Neurology Flashcards
1
Q
Extraoccular muscles
A
SR: move eye up - CN3 IR: move eye down - CN3 LR: abduct eye - CN6 MR: adduct eye - CN3 IO: up and out - CN3 SO: down and out - CN 4
2
Q
Brown sequard
A
Hemisection of spinal cord
contralateral spintholamic loss - pain, temp, fine touch
ipsilateral loss of motor, vibration, deep touch, proprioception
3
Q
M.G.
A
Px - known
Typicially nictonic acetylcholine receptor antibodies
4
Q
M.S. symptoms
A
Diagnosis based on clinical signs, evidence of relapsing and evidence of a lesion (MRI dissemination in space and new lesion)
Visual sx:
- optic neuritis
- optic atrophy
- uhtoffs phenomenon: worsening vision following rise in body temp
Sensory sx
- puns and needles
- numbness
- trugeninal neuralfia
- Llhermittes syndrome: parsthesia of limbs on neck flexion
Motor:
- spastic weakness - legs
Atxia
Urinary incontinence
5
Q
Visual field defects
A
Homonyous hemianopia:
- incongruous defects: optic tract
- congruous defects: optic radiation or occipital cortex
Homonymous quadrantanopias:
- superior- temporal lobe
- inferior - parietal lobe
Bitemoral hemianopia:
- optic chiasm
- upper quad - inf chiasmal compression - pituitary
- lower quad - superior chiasmal compression - craniopharyngioma
6
Q
Phenytoin
A
Bunds to sodium channel and increases refractory period.
Adverse effects: PHENYTOIN
P-450 interaction Hirsuitism/Heamorrhagic dx of the new born Enlarged gums Nystagmus Yellow skin Teratogenic Osteomalacia Inteference with vitamin b12metabolism Neuropathies - vertigo, ataxia
7
Q
Myasthenia crisis exacerbating factors
A
Penicillamine Procainimide, quinidine Lithium Phenytoin Abx - macrolides, quinolone, gentamicin, tetracyclines
8
Q
Gingival
Hyperplasia causes
A
Phenytoin
CCB - nifedipine
Ciclosporin
Non-drug -AML
9
Q
Acute disseminated encephalomyelitis
A
Autoimmune
Occurs typically a few weeks after viral illness or vaccination
Px: Encephalopathy Motor weakness Seizure Coma
INX:
MRI with T2 weighted —> poorly defined hyper intensities in the subcortical
White matter
Mx:
IV glucocorticoid —> fx —> IVIg
10
Q
Essential tremor management
A
Propranolol
Second line or CI (Asthma) —> primidone
11
Q
Aphasia
A
Wernickes:
- superior temporal gurus lesion
- fluent speech without meaning
- word substitution and neoglism
- impaired comprehension
Brocas;
- inferior frontal gyrus lesion.
- non fluent, effortful soeech
- comprehension normal
Conducting aphasia:
- Arcuate fasiculus
- fluent speech but poor repetition- they are aware
- comprehension normal
Global Aphasia:
- large lesion affectinf all 3 of above
12
Q
Anterior spinal
Artery syndrome
A
Bilateral spastic paresis with loss of spinothalamic.
Lateral spinothalamic
And lateral corticopspinal
13
Q
Subacute combined degeneration of spinal cord
A
Vitamin B12 and vitamin E deficiency
Lateral corticospinal, dorsal column and spinocerbellar - affected
B/L PERIPH NEUROPATHY & MIX OF UMN/LMN SIGNS
Bilateral spastic paresis
Bilateral loss of prioooception and vibration sensation
Bilateral limb ataxia
14
Q
Friederichs ataxia
A
Px same as SCDC
- A.R. trinucleotide repeat
Px:
- Absent knee and ankle reflex
- Extensor plantar response
- Cerebellar symptoms
- Optic nerve atrophy
15
Q
Syringiomyelia
A
Spinothalamic tract bellow + LMN at level
Flaccid paresis
16
Q
Peripheral nueropathies causes
DAM IT BICH
A
Drugs and chemicals - Pb, phenytoin, metronidazole, vicristine, isoniazid
Alcohol and amyloid
Metabolic - DB, uraemia, hypoglycaemia
Infection - GBS, HIV, leprosy, lime dx, syohillis
Tumor - paraneoplastic syndrome (lung, lymphoma,
Melons)
B12 and other deficiencies
Idiopathic
CTD/ vasculitis
Hereditary/hypothyroidism
17
Q
Ramsay hunt syndrome
A
Reactivation of VZV —> geniculare ganglion of CNVII
Ft:
- auricular pain (1st ft)
- cN7 palsy
- vesicular Tash around ear (as well as ant 2/3 of tongue)
- other ft - vertigo and tinnitus
Mx
- PO aciclovir and corticosteroids
18
Q
Restless legs syndrome
A
TEST FOR FERRITIN
Akathisia
Paratheasia
Periodic movement in sleeps
Assoc
- FHx
- IDA
- Uraemi
- DB
- Pregnancy
Mx:
- simple measures such as stretching and massage
- tx IDA
- DA agonist = 1st LINE - R-opinirole, pramipexole
- BZD
- Gabapentin
19
Q
Alzheimer’s disease
A
Frontal lobe sparing
Pathological findings:
- extracellukar B- amyloid
- hyperphisphorylated tau proteins
- neurofibrillary tangles
- loss of cholinergic fn
Temporal and parietal loves
APOE —> e2,e3,e4 alleles on chromosome 19
Early onset —> presenellin 1& 2 and amyloid precursor protein
Tx:
1) donepezile - cholinesterase inhib
2) memantime NMDA - for moderate to sev Alzheimer’s
20
Q
Lea body dementia
A
> 65yrs
Accumulation of LBs in brain stem
And cortex
NT dysfunction
Loss of visuospatial awareness + hallucinations.
Fluctuating
Tx:
Donepezil
Tx PD
EXTREME SENSITICITY TO NEUROLEPTICS- deterioration of PD
21
Q
FT DEMENTIA
A
2nd most common in <65 (behind early onset AD)
Cognition intact
Change in behaviour and personality —> DISINHIBITED
Decreased language production
22
Q
Primary progressive Aphasia
A
Non fluent - left inf temporal
Semantic - left anterior temprorak
Logopenic - posterior temporal
And parietal
23
Q
Prion disease - cJD
A
Transmissible spongiform encephalopathy.
Prions - misfplded proteins- transmitted —> propagation
Prions - resistant to standard sterilisation
Sporadic CJD:
- 45–>75yr
- PRNP GENE
- myoclonus, ataxia And rapidly progressive dementia
Variant CJD:
- 20s age of onset
- psychiatric prodrome —> painful sensory sx
Inx MRI.
24
Q
Normal P hydrocephalus
A
Wobbly + whacky + wet
Inx —> MRI
Mx:
- large volume CSF removal by LP
- VP shunt
25
M.S.diagnosis
Clinical picture
MRI - lesion disseminated in Time and space
Impaired oligoclonal bands on CSF
26
MS subtypes
Relapsing - remitting
Secondary progressive (secondary to R-R)
Primary progressive - deterioration from outset
Progressive relapsing - primary progressive with superimposed R-R
27
MS - relapse treatment
Relapse - period lasting 24-48 hrs, when previously stable for 30 day, and other cause especially infection is excluded
Tx: high dose steroids with an oral taper:
1g methylpred—> 500mg PO methyl pred
28
DMARD therapy in MS
Indicated iff
RRMS:
- =>2 in last two years —> IFN-B
- IFN-beta Or galtiramer resistant —> fingolimod
- => 2 disabling relapses —> natalizumab
Secondary progressive
- tx with IFN-B
Adverse effects:
Natalizumab: PML
Fingolimod: transient AV slowing, macula oedema and Herpes reactivation
Alemtuzumab: autoimmune disease. - ITP and Goodpasteures
29
Autoimmune encephalitis - non paraneoplastic
Most common
Extracellukar targets
Steroid responsive
30
AI encephalitis - paraneoplastic
Lung and breast ca
Intracellular targets
Not steroid responsive
Limbic encephalitis is an example:
- seizure
- amnesia
- confusion
31
Wernicke’s Encephalitis
Low thiamine vitamin B1
Confusion
Ataxia
Abnormal eye movements
Assoc with:
-
32
Cortical blindness
Severe/complete blindness
Pupil reflexes present
Macular soaring
Bilateral occipital infarct
33
Marcus Gunn Pupil
Seen on RAPD
Lesion anterior to optic chiasm = optic nerve or retina
Causes:
- Renital detachment
- optic berve - neuritis (MS)
34
Causes of small pupil (mitosis)
Senile miosis
Pontine haemorrhage
Horner syndrome
Argyll Robertson: bilateralx assymetrical. Small irregular pupils - NORMAL ACCOMODATION NOT REACTIVE TO LIGHT.
Drugs- opiates/pilocarpine
Myotonic dystrophy
35
Horner syndrome
Miosis
Ptosis
Anhidrosis
Vasodilation and enopthalmos
36
Horner syndrome investigation
Hydroxyamphetamine - distinguishes between 1st and second order VS 3rd
- 1 and 2 order pupil dilation
- 3rd order - no dilation
37
Intranuclear opthalmoplegia presentation
Impaired ipsilateral addiction
Abducting nystagmus contralat
Convergence normal
No Diplopia
38
Causes of INO
BILATERAL INO = MS
Demyelinative disease - young
Vascular - >60
Trauma
Basilar artery occlusion
Miller fisher syndrome
Vascukitis
Overdose - barbiturates, phenytoin, amtryptilline
39
Supranuclear opthalmoplegia
Disorder in cerebral hemispheres, cerebellar and brainstem
DOLLS HEAD MOVEMENT - increased movement on reflex than voluntary
Examples:
PSP
Gaze palsy
Midbrain syndrome
40
Coma
interruption of ARAS
41
Persistent vegetative state
CNS intact
Roving eye movements.
Sleep wake cycle intact
Still have stable BP/Resp drive
42
Decorticate vs decerebrate
decorticate:
- Flexor response
- Upper brainstem
Decerebrate
- Extensor
- B/L midbrain or pontine.
43
Brain stem lesions and pupils
Normal - lesion is bellow pons or above thalamus
(P)inpoint - Opiate or (P)ontine lesion
Fixe (m)idpoint - (m)idbrain
Dilated pupil - Midbrain, sympathomimetic, CN3
44
Eye movements
Spont eye movement - Bihemispheric dysfunction
Horizontal deviation:
- Non status epileptic
- Ipsi hemispheric stroke
- Contralat pontine stroke
Roving eye movements:
- Toxic/metabolic
- Brainstem ifarct
- B/L hemispher.
Skew Deviation - Post fossa lesion
45
BRainstem death
Brainstem reflexes + Motor responses + Respiratory drive are absent in commatosed pt with irreversible known cause.
Must have satisfactory O2/Temp and no hypercapnia or pharmacological influence and no metobolic disturbance or reversible cause.
46
Encephalitis causes
```
Viral
- HSV1 - most common
VZV
Enterovirus
Adenovirus
```
```
Bacteria
mTB
Streptococcus - menngitis
meningococcus - meningitis
Syphillis
```
Other:
Cryptococcus
toxoplasmosis
nnon-infective
47
Encephalitis - indications for urgent CT before LP
```
low GCS
Focal neuro
uncontrolled seizures
Cushing triad (raised ICP) - high BP, Low pulse, High RR
Clotting abnormality
sepsis
immunocomp
```
48
Encephalitis Mx:
MRI/LP (CT if indicated)
Start Aciclovir straight away.
49
Meningitis - causes
Bacterial:
Meningococcus
Pnemococcus
mTB
```
Viral:
- Enterovirus
HSV
HIV
VZV
Mump
CMV
```
Other:
Cryptococcus
Toxoplasmosis
50
MEningitis - CSF findings
```
Bacteria:
- High opening P
- Neutrophils
Low PRotein
Low Gluc
```
```
Viral:
- Normal opening P
- Lymphocytes
- Normal/high prtein
Normal Gluc
```
Tb:
- High/V.High opening P
- Lymphocytes
- V.high protein
- VV. Low Glucose
Fungal:
- VVVHigh opening P
- Lymphocytes
- VVVhigh protein
- V. Low gluc
51
MEningitis management;
<3mnth or >50 - Cefotaxime + amoxicillin
3 mnth - 50 yrs - Cefotaxime
Meningococcus - IV Benpen + Cefotax
Strep - Cefotaxime
- H.influenza - Cefotaxime
Listeria - IV Amox + gent
Contacts:
- streptococc - no prophylaxis
- meningococc - Rifamp
52
Infectious myelitis
Px: PAIN + FEVER + MENINGIM + MIXED UMN/LMN signs.
Viral
- Entero
- HIV
- HTLV-1
- VZV/ HSV/ CMV
BActerial:
- Syphillis
parasitic causes.
- Schistosomiasis --> Acute transverse myelitis + Raised Eosinophills.
53
Migraine w/o Aura criteria
```
A - => 5 attacks
B - Headache lasts 4-->72 hr
C- Headache with 2/4 of:
- Unilat
- pulsating
- worsened by activiy
- Mod sev
D => one of:
- N/V
- photo/phonophobia
E - not explained by other diagnosis
```
54
Migraine w/ Aura
```
A - =>2 attacks
B- =>1 of:
- Visual
- Sensory
- brainstem
- Motor
- Retinal
C - =>2 of:
- =>1 aura sx spreading over 5 mins or >1 in succession
- Each sx asts 5-60mins
- => 1 is unilat
- Aura = accompanied by or followed within 60 mins be headache
```
55
Migraine Mx
Acute:
1st line - Po Triptan + NSAID or Paracetamol
Fx --> Non-po prochlorperazine + metoclop + Nasal triptan
Prophylaxis:
- 1st line = Propanolol or Topiramate
- Fx --> accupuncture or Gabapentin
Advise suplement with Riboflavin
Menstrual migraine --> Frovatriptan or Zolmitriptan
56
Migraine Mx in Preg
Acute:
1st line = paracetamol
2nd line = ASA or NSAID (not 3rd trimester)
Prophylaxus - Propanolol
57
Cluster headache diagnostic criteria
A - =5 attacks
B - Sev/v.sev unilat orbital/supraorbital/temporal pain
- lasts 15 --> 180mins
C - Either or Both of:
1) => 1 of the following:
- conjunctival injection/lacrimation
- nasal congestion
- Eyelid oedema
- Forehead/facial swelling
- " " " " flushing
- Fulness in ear
- miosis/ptosis
2) Sensation of restlesness/agitation
D - Attacks have freq of every other day to 8/day for >1/2 time of cluster period
58
Cluster headache - Mx
Acute Mx:
- O2 + S/C Triptan
Prophylaxis
1st lie - Verapamil
59
MS vs NMO
NMO-IgG + in NMO
60
Caroticocavernous fistula
High flow is between intracavernous artery and cavernous sinus
Secondary to trauma
Pulsation proptosis and CN3/4/6
Raised IOP
61
Foster Kennedy syndrome
Ipsilateral optic atrophy
Contralat papilloedema
Direct damage if SOL - FRONTAL LOBE
62
Friederichs ataxia
A.R.
Trinueotide repeatbdisorder - GAA
CARDIACCC
Absent ankle jerks/extensor plantars
Cerebellar ataxia
Optic atrophy
Mixed LMN/UMN
Pea cavus
63
Valproate side effects
VALPROATE
```
Vomiting
Alopexia
Liver toxicity
Pancreatitis/pancytopenia
Retention of fat - weight gain
Oedema
Ataxia
Teratogenic/ tremor
Enzyme inhibition
```
64
GBS vs CIDP
CIDP > 8/52 History
65
Congenital nystagmus causes
```
Idiopathic
X-linked or AD
Secondary to visual impairment:
-albinism
Optic nerve hypoplasia
-retinal dystrophy
```
66
Acquired Nystagmus causes
Downbeat - foramen magnum lesion
- Arnold chiari malformation
- spinocerebellar degen
- demyelinative
- platybasia
Upbeat
- intrinsic brainstem dx
- cerebellar vermis lesion
- organiphosphates
- wernickes enceph
Pendular:
-demyelinative disease
67
Neuroleptic malignancy syndrome
Atypical antipsychotics Or dopaminergic drugs
Seen in first 10
Days of tx
Young male
Pyrexia
Rigidity
Tachycardia
Mx:
IV FLUIDS AND DANTROLENE
68
Migraine affects on GI
Delays gastric emptying during attack
Therefore combine with a pro kinetic such as metoclopramkde
69
Trigeninal neuralgia
Brief lancet pain
Women >50
Unilateral and trigger points
Can be presenting symptom of MS
Tx
```
Carbamazepine/phenytoin
Clonazepam
Backpfen
Thermocoagulation of trigeminal ganglion
Surgical micro vascular decompression
```
70
Vertigo causes
Peripheral - labyrinthine
- BPPV
- Trauma
- Ménière’s disease
- acute viral infection
- chronic bacterial OM
- occlusion if internal auditory artery
Central:
- vascular disease
- ms
- SOL
- alcohol or drugs
- hypoglycaemia
71
Ménière’s disease
Vertigo
Tinnitus
Sensorineural HL
72
Drug induced Parkinson’s
Rigidity and tremor are uncommon !!
73
Vestibular schwannoma
Vertigo + SNHL + Absent corneal reflex
Tumour of CN8
Corneal reflex absent
Facial sensation abnormal
Inx MRI or high res CT
Mx- surgical removal
74
Lateral medullary syndrome
PIKACHU and mark whallberg with a horn on a hot sunny day
PICA - can’t - CHew
Posterior inferior cerebellar artery
CHew - dysphasia
Mark - Wallenberg syndrome
Big horn - Horners syndrome
Sun - tempersrion problems
- ipsilateral OM face
- contralat in body
75
Facial nerve paralysis
Supplies face, ears Tate and tear
Can present with
Forehead sign
Hyperacusis - due to paralysis of stapedius muscle
Facial expression
Loss of Tate
76
MMSE
Normal 30-27
Mild 26-22
Mod 21-10
Sev 9-0
77
Variant CJD
HOCKEY STICK SIGN
progressive dementia
Mycoclonus
78
Polyneuropathies
Acute - inflamm, toxic, vasculitic
Chronic - genetic or metabolic
Symmetrical distal weakness and sensory lows - lower>upper limb
79
IIH
YOung obese female
Headache + Paoilloedema w/o focal neuro or lesion
No neuro signs.
Normal neuro imaging
normal CSF appearance
INCREASED LP OPENING P (>25cmH2O)
Iatrogenic causes:
OCP, steroids, tetracyclin, vit A, Nitrofurantoin, Nalidic acid
```
Mx:
- WL
- Acetozolamid or topiramat
- Can use rpt LP
VP SHUNT or optic Nerve fenestration
```
80
Gersstmann syndrome
Acalculia, Right to left disorientation, finger agnosia and agrapgia.
Dominant parietal lobe is affected
81
syringomyelia
collection of CSF in spinal cannal.
Causes:
- Chairi malformation
- trauma
- tumour
- idiopathic
Patter of Px:
spinothalmic tracts cross i th anteriro commisure of spinal cord --> therefore symptoms first.
CAPE LIKE loss of spinothalamic
preserved lght touch, vibrationa nd propriooception
Inx - MRI with contrast - xcl tumour and MRI bran to excl. chiari.
Untreated --> scoliosis
Mx:
- Tx cause
- symptomatic --> shunt
82
5-HT3
Acts on CTZ of medulla oblongata
Ondansetron
Side effects - constipation
83
CN3 palsy
Pupil down and out
Ptosis
Pupil maybe dilated
Causes:
PAINFUL PALSY R/O POST COMMUNICATY ARTERY ANEURYSM
- DB
- vasculitis
- invaluable hernition/raised ICP
- cavernous sinus thrombosis
- Weber’s syndrome (midbrain strikes) - ipsilateral CN3 palsy and contralat hemiplegi
Amyloid and MS
84
Stopping AED
Stop it seizure free for >2 years and stop over 2-3 months
85
Craniopharyngioma
Most clmmons upratentorial lesion in children
Originates from
Rathke pouch in ventromedisl area of hypothalamus
Px:
- bitemporal hemianopia inferior quadrant
- hypopituitary
- motor oil like fluid in tumour
Inx —> CT - calcification
Tx - surgical resssction
86
Narcolepsy
Associate hla DR2
Low level of ore in (hypocretin) control sleep / appetite
Early onset REM
```
FT:
- inset in teens
- hypersolmonence
Cataplexy
Sleep paralysis
Vivid hallucinations on SLEEPING AND WAKING
```
Inx
Sleep latency eeg
87
Heniballism
Damage to subthalmic nucleus
Contralat proximal sudden jerking movements - basilic movement (choreoform is distal)
Sx - whilst patient ASLEEP
Mx - antidopaminergic - haloperidol
88
Complex regional
| Pain syndrome
CR 1 - no demonstrable nerve lesion
CR2- demonstratable nerve lesion
Ft:
Progressive disproportionate symptoms
Temp and skin changes
Oedema and sweaty d
Mx:
Early PT
Neuropathic analgesia
Pain team
89
Epilepsy management
Generalised --> Na Valproate
Focal --> Carbamazepine
Generalised T-C:
- Na Valproate
- Carbmazepine/Lamotrigine
Abscence:
- Na Valproate
- Ethosux
Myoclonic:
- Na Valproate
- 2nd clonazepam and lamotrigine
90
Epilepsy Childhood syndromes
West's syndrome - Infantile spasms:
- 1st few months
- Progressive mental handicap \
- EEG _ Hypsoarrythmia
- Vibagatran
Absence:
- EEG - 3Hz spike
- Na Valproate/Ethosux
```
Lennox-Gustaut:
- Hx of absence
SEV MENTAL HANDICAP
- EEG - Slow spike
- Ketogenic diet
```
Benign Rolandic Epilepsy:
- Parasthesia
- M>F
Juvenile myoclonic Ep:
- Seizures in the a.m.
- Daytime somnolence
- Na Valproate
91
Localising Epilepsy
Temporal lobe - H.E.A.D:
- Hallucionations
- Epigastric rising
- Automatism - lip smacking/hand rubbing
- Deja Vu/Dysphagia
Frontal lobe:
- Motor
- Head-leg
- Jacksonian march
Parietal:
- Parasthesia
Occipital:
- Flashes and floaters
92
Epilepsy when to start treatment
after 2nd seizure
or
1st seizure if:
- Structural abnormsality
- EEG unequivocal
- Neuro deficit
- PT/family thyink a second is unnaceptable.
93
Epilepsy in pregnancy
All can be used - Na Valproate is only cobtraidicated
Folic Acid 5mg
- Carbezapine = least teratogenic
Breatsfeeding is safe
94
Epilepsy and DVLA
1sts eizure - 6/12 off if no structural and no EEG findings (if present 12/12 off)
Epilepsy/multiple seizures --> 12/12 seizure free. IF >5yr seizure free --> drive until 70
Cant drive whilst stopping AED + 6/12 after last dose.
95
TIA
<24 hours
now no longer time based but tissue based = A transient epilepsy of neuro dysfunction caused by Brain, S.cord, retina ischaemia - w/o infarction - w/o infection
ABCD2 no longer used
Mx:
- ASA 300mg -- after exclusion of haemorrhgagic
LT Mx:
- Clopidogrel
- 2nd line - Dipyradimole + ASA
96
TIA - referral
Crescendo TIA or Cardioembolic --> urgent referral
TIA in last 1/52 --> urgent referral
Prev TIA >1/52 --> referral in 1/52
97
Carotid endarterectomy
Recommended if Stenosis >70%
98
Stroke Features and anartomical location
Anterior Cerebral A --> Typical Ft
Middle Cerebral A --> Typical ft + Homonious hemianopia
Post cerebral A --> Homonyous hemianopia w/ macula sparing
Basillar A --> Locked in syndrome
Opthalmic A --> Amurosis Fugax
99
Stroke assesmment in hospital - ROSIER
ROSIER - exclude BGL then:
LOC (-1)
Seixure (-1)
```
unilat facial weakness (+1)
unilat arm weakness (+1)
unilat leg weakness (+1)
Speech disturbance (+1)
Visual field defect (+1)
```
>0 --> stroke likely
100
MX - Thrombolysis
<4.5 hours
absolute - CI:
- Prev haemorrhage
- Seizure @ onset
- Neoplasm
- suspected SAH
- Stroke or TBI in last 3/12
- Prev GI haewmorrgage in last 3/52
- LP prev 7/7
- Active bleed
- PREG
- varices
- malignnast HTN
101
Stroke - secondar precention
Clopidogrel life long
2nd line or cantr tolerate : Dipyradimole and ASA
AF post stroke:
- Warfarin or FXa inhib - start 2/52 after stroke
102
Degenerative cervical myelopathy
Rf:
- Smoking]
- Genetics
- Occupation
- Asians have different aetiology as increased occification of posterior longitudinal ligament
Px sx unknown
Px:
- Pain - neck or limbs
- Hoffmans sign
- loss of motor f/dexterity
- loss of sensory
- loss of autonomic fn
Inx --> MRI C spine
Mx:
- urgewnr eferral for spinal decompression - early tx within 6 months
103
Trigeminal neuralgia management
1st line - Carbamezapine
104
S.A.H - Risk factors
PCKD
Ehlers-danlos
Fibromuscular dysplasia
medium vessel vasculitis
Aortic coarctation
105
SAH inx
CT immed.
LP at 12 hours - Xanthochroia - Bili
106
SAH poor prognostic factor + Mx
- low GCS
- >65
- Bleed on CT
```
Mx:
- Nimodipine 60mg 4hrly
-Urgent for clipping/coiling
\
Prevention if => 2 relatives w/ SAH or PCKD --> Refer
```
107
SAH complications
Neurological
- Rebleed
- Hydrocephalus
- Ischaemia - secondary to vasopasm
Systemic
- Fever
- Tachy - secondary to catcholamine releasse
- SIADH
- Neurogenic pulm edema.
108
Primary CNS vasculitis
can occur as systemic or primary neuro
primary CNS presents as 3 types:
- MS with atypical ft - seizure, stroke like
- Acute/subacute encephalopathy like - Acute confusional state
- mimik an intracranial lesion
inx - R/O other cause
Mx:
- High dose steround --> Taper with PO
- once ion remission --> Azathioprine
109
Central venous thrombosis
Young fat female.
Suspect if:
- pregnancy in 3rd trimester
- Hx VTE
- PRogressive new neuto decloine
- Ischaemic stroke that crosses arterial territories
Inx:
- CT / CT Venogram
Mx:
- Anticoag w. LMWH
- Antiepileptics.
110
Reversibel vasoconstrinction syndrome
recurrent sev thiunderclap headache
Post partum
Angiography --> String of bead appearence --> rpt imaging shows resolution
Mx acutely with nimodopine
111
Neuromyelitis optica (NMO)
MS like - mopre severe
Px:
- Optic neuritis + Transverse myelitis (sev - "sawn off")
Can be triggered by MS DMARDS
IgG AQP4
Mx:
- Steroids +/ plasmophoresis +/- IV Ig
112
Neurosarcoidosis
Non spec px
inx - ACE levels
CT
CXR - BHL
CSF - high ACE/Lympogocytes, low gluc, oligoclonal bands
Mx --> immunosupression
113
CNS tumours
Adults:
- Glioma & MEt dx - 60% - brai between tumour and skull
- MEningioma - no brain between tumour and skull
- Pit lesion 10%
Child:
- Astrocytoma
- medulloblastima
Inx: MRI
Mx
Surgery
- curati e in meningioma
- Glioma - lots of invasion - sx tx
114
MND
Px Assymetrical progressive motor degen and mix of UMN/LMN
2 types:
1) ALS - UMN lower limbs and LMN upper limbs
2) Bulbar palsy - worst prognosis - FEV1
3) Progressive muscular atrophy - LMN in one limb - BEst prognosis
Inx:
- R/O other cause - imaging
- EMG - chronic dennervation/ N sensory/ Preserved velocity
```
Mx:
- Riluzole - monitor LFT and BM supression
- MDT
- SALT
- PT
Nutionin - PEG
- Resp NIPPV
```
115
Parkinson's dx
lew body depsoitis in substansia nigra pars compacra --> decrease DA inpout into basal ganglia.
Triad:
- Bradykinesia
- Resting tremor (3-5Hz)
- Rigidity
other - Mask face/micrographia/ flexed ppsture/ depression/ sleep disorder. bowel dysfn.
116
PD management
Levodopa:
- Good for motor symptojs
- On + Off perdios.
- dyskinesias
- less effective with time
DA Agonist:
- Ropinerole/ Rigotine patch/ Apomorphin/ PRamipexole
- More hallucinations + IMPULSE control
- Apomorphin e good if motor fluctuation
- Ergot derivatives: Carbegoline/bromocriptine --> Retroperitoneal fibrosis --> prior to start Echo/ESR/CXR
MAO-B:
- Selegeline
- more On-time
- less hallucination
- fewer S.E
COMT-I
- Entacapone
- increase on time
- less hallucnations
NMDA- R - antage:
- Amantadine
- improved dyskinesia
117
Causes of parkinsonism
```
PD
Drugs - antipsychotic/metoclop
wilsons
psp
msa
post encephalitis
dementia pugilistica
toxins - CO/MPTP
```
118
PArkinsons plus
LBD
MSA - autonomic
PSP - Vertical upgaze - down>up - cant walk dow stairs - poor response to lefvodopa
CBD - disorder of movement and cognition - alien hand syndrome
119
Huntingtons diseaser
AD trinucleotide rpt disorder --> complete penetransce and anticipation
Loss of D2 in cortex + Striatum
Px:
- Chorea
- YOUNG PT WITH PD
- slow saccadic ieye movements
inx - MRI
Mx
- Symptomastic
- SSRIs
- Chorea --> Tetrabenazine
120
Wilson's disease
A.R. - chromosome 13 - decreased biliary copper exceretion
Child --> hepatic manifestion
late teen --> psychiatric --> exec dysfn/impulsivity./emotinally labile
```
other ft:
kayser-flaischer rings
wing beating trremor
chorea
dyskinesia
```
inx - MRI
Mx - Cu chelating wih Penicillamine
121
tabes dorsalis
post column --> loss of dorsal column
122
anterior horn cell syndrome
LMN signs
seen in poliomyelitis
123
combined anterior horn + pyramidal
UMN lesions bellow and LMN @ lesion - ALS
124
anterior spinal artery syndrome
supply anterior 2/3 of SC
Flaccid paralysis + loss of spinothalamic + preserved dorsal.
125
Cauda equina vs connus medullaris syndrome
see notes essentiall
C.E - assymetrical LMN
CMS - symmetical UMN signs - motor preserved. - Early bladdder/biwel
126
Mononeuropathies
Median nerve (C6 - T1):
- Carpal tunnel
- L.O.A(d).F
- sensory thenar eminence
Ulnar (C7-T1):
- Claw hand
- Sensation - ulnar border of hand
- distal compression --> Preserved palmar sensation
```
Radial N (C5-T1)
- wrist + finger drop
Sensation loss dorsum of hand and 1st web.
```
Common peroneal
- Foot drop+ weak eversion
- Lateral shin + dorsum of foot sensation.
127
Mononeuritis multiplex
WARDS PLC
```
Wegners
amyloidosis
RA
DB
Sarcoidposis
PAN
Leprosy/lyme
Carcionmatosis/churg straus
```
128
GBS
Flaccid paralysis + polyneuropathy
Follows URTI/GI infection - campylobacter
NADIR 14 dayts
can cause areflexia + Respiratory comprise (FVC)
EMG - Demyelinating dx therefore SLOW CONDUCTION
CSF - high protein otherwise normal
Mx - self terminates
if non-ambulant --> IVIg/Plasma exhange
129
MG
ACH-R and MUSK (bulbar) . - POST SYNAPTIC
Assoc:
- THYMOMA - CT Chest
- AI disorder - pernicious anaemia/AI Thyroid. Rhwum/SLE
- Thymic hyperplasia
```
Inx:
- EMG
- CT Chest - thymoma
CK
- Tensilon test - IV edrophonium
```
Mx:
- Pyridiostigmine - long acting acetylcholinesterase inhib
- PRed
130
MG exac factors
- Penicillamine
- Procainamide/quinidine
- Betablocker
- Li
- phenytoin
- Abx - gent/macrolide/quinolonews/tetracyclines
131
Myasthenia crisis
increased commen in MUSK Ab + --> May req ventilation
Triggers: - Stressors/sterpods.withdrawl of pyridostigmine/ low K+ or PO4-/ anaemia
Mx:
- Monitor FVC --> <1 --> ITU
- IVIg + plasmophoresis
132
LEMS
PRESYNAPTIC VOLTAGE GATED Ca channels
Assoc. SCC
rpt contractions --> STRENGTHEN
inx - EMG - shows strength with rpt
Tx
- underlying cause
- =3,4-DAP +/- pyridostigmine
- I.S - pred + Aza
133
Myopathies
Symmetrical PROXIMAL weakness - difficulty rising from chair or getting uo
Sensation/refleces all normal
Causes:
- imflamm = polymoyositis
- inherited - DMD/BMD.myotonic dystrophy
- Endo - cushings/thyrotoxicosis
- EtOH
inx - MUSCLE BIOPSY
134
Myotonic dystrophy
20-30 yrs
Think of the Ds for DM1
- Distal weakness
- A.D.
- DB --> glycosuria
- Dysarthria
two types : DM1 and DM2
- DM1 - distal >prox
- DM2 - prox >distal
Ft:
- myotonic facies - haggered
- frontal balding
- B/L ptosis
- catracts --> LOSS OF RED REFLECX
- dysarthric
135
DMD and BMD
A.R.
Mutuation --> DYSTROPHIN GENE
DMD>BMD severity
DMD:
- 1st 5yrs
- calf pseudohypertophy
- gowers sign
- IQ DOWN
BMD:
- 10yrs
- IQ NORMAL
136
fascioscapulohumeral dystrophy
A.D.
Affects what it says - facial/scapula/ upper arm
Px at 20yrs
137
Dermatomyositis
```
Prox muscle symmetrical weaskness
Gottrens papuoles
heliotrope rash - purple rash on face + eyelids
Photosensitive
macula rash on back + shoulder
```
```
Inx: - CK!!!!!!
ANA
Others Jo-1
SRP
MI-2 Ab
```
EMG
CK
MUSCLE BIOPSY
Mx - PRednisolone
138
Polymyositis
symmetrical proximal weakness
Raynauds
Resp muscle weakness/ILD
Inx: - CK!!!!!!
JO-1 - esp assoc with raynauds !!!!
- EMG
Muscle biopsy
Mx - pred
139
inclusion body myositis
insidious weakness @ 60yrs
PROX L.L AND DISTAL U.L.
Dysphage
Inx:
- Muscle biops
- Ck can be N
140
Mitochondrial dx
exclusively maternally inherited
poor phenotype:genotype
Histology - RED RAGGED FIBRES
Examples:
- Leber's optic atrophy -= B/l painless LOV
- MELAS - Stroke like episodes in <40
- MERRF - Myoclonus/seizures/myopathy
- KEarnes Sayres - ext opthalmoplegis + Retinitis pigmentosa + Ptosis
141
Neurofibramotosis
NF1 - chromosome 17
- Cafe au lait spots
- axillary groin freckles
- peripheral neurofibromas
- lisch nodules
- phaechromacytomas
NF 2 - Chromosome 22
- Bilateral vestibular schwannomas
- multiple intracranial schwannommas, ependyomas, meningiomas
142
Tuberous sclerosis
Epilepsy + developmental problems
```
Shagreen patch
ashleaf spot
subungal fibromata
adenoma sebaceoum
Retinal harmartomas
```
143
Absence seizure - CI AEDs
CARBAMEZAPINE
Phenytoin, vabigitran, gabapentin
144
paraneoplastic syndromes affecting nervous system
LEMS
Anti-Hu
- Painful sensory neuropathy
anti-yo:
- Cerebellar syndrome
- assoc with Ovarian Ca and Breast Ca - Y looks like a vagina and (Y) looks like cleavage
Anti - Ri
- Ri Ri - woman - breast cancer
- Rhianna has great eyes
- occular opsiclonus-myoclonus
Anti-GAD
- stiff man syndrome
- Oh My GAD im so stiff
145
Triptan (5HT-1) Contraindication
Cerberovascualr disease
| Ischaemic heart dx
146
Miller fisher syndrome
typeof GBS
opthalmoplegia + Ataxia + Areflexia
Descending paralysis (Ascending in GBS)
147
Risks of epilepsy on fetus
Birth defects
new botn epilepsy - 10% if one first degree 25% =>2
Neonatal coagulopathy - Phenytoin.phenobarbital/primidone - Give Vitamin K
148
Anti-NMDA RECEPTOR encephalitis
Paraneoplastic syndrome - Ovarian tumour
Px - encephalitis and psychiatric features
Tx - immunosupress
149
Ménière’s disease
Sensorineural deafness + tinnitus + vertigo
Mx:
ENT
DVLA - cease until sx control
Acute - prochloroerazine
Prevention -betahistine
150
Neuropathic pain
Amitryptilline gabapentine pregabalin duloxetine
Fx —> tramadol
151
Ataxia telangectasia
AR
Cerebellar ataxia
Telangectasia
IgA deficiency —> recurrent chest infections
- malignancy lymphoma leukaemia
152
Friederichs atxia vs ataxia telangectasia
Both:
AR
CEREBELLAR ATAXIA
ONSET IN CHILDHOOD
friederichs - DONT get infections
153
Guillian barre syndrome
Flacid weaknes
Hyporeflexia
Tachycardia
154
VHL
Retinal and cerebral hemangiomas --> px/fhx of ICH or suddent blindness
Renal cysts --> renal ca
Phaeochromacytoma
155
stroke secondary prevention
Clopidogrel + statin
156
LEMS
Small cell lung ca
presynataptic voltage gated Ca channels
PROXIMAL weakness --> can repsond to STEROIDS
157
Absence seizure - what % seizure freee >16 yrs
90-95%
158
Pergolide - used in Parkinsons - complication
Can cause pulmonary fibrosis
159
Pituitary apoplexy
Hypopituitarism (hypotension, low hormones and can mimic SAH
160
Raised protein in CSF
GBS
TB/Fungal/Bacterial meningitis
Froin's syndrome - Raised protein bellow blockage "tumour, disc infection"
Viral encephalitids
161
Otitis media mx
Topical abx + stewroid
162
Facial nerve palsy
Hyper acusis due to paralysis of stapedius
Facial nerve paralys
loss of supply to ant 2/3 tongue
loss of tears
163
most common complication following meningitis
Sensorineural Hearing loss
164
DVLA + NEuro
Stroke/ TIA - 1/12
Multiple stroke/TIA in short period - 3/12
Craniotomy for meningioma - 1 year
Craniotomy for pituitary - 6/12
Transphenoidal - drive once no no impairment
Simple faint - no
1 ep syncope explained + trated - 4/52
1 ep unexplained - 6/12
>1 Ep - 12/12
Narcolepsy/cataplexy - cease on diagnosis
165
MND - MX
Riluzole:
- prevents stim of glutamate receptors
- used in ALS
- 3/12 prolonged survival
NIV:
- bets for survival - 7/12
166
Transient global amnesia
Retrograd and antegrade amnes + Repetitive questions - w/o other neuro or cognitive sign
lasta <24 hrs
167
Menieres dx
tinnitus
SNL HL
VErtigo
nystagmus
mx:
- Acute = prochlorperazine - IM or buccal
- prevention = betahistine
168
Hemiballism
Damage to Subthalmic nucleus.
contralat Involuntary jerking movements - Prox>dista
Sx better when sleep
Tx:
- Antia DA - Haloperidol
169
Neuroleptic malignant syndrome
Occurs hrs or days after starting antipsychotic or in PD agter suddenlt stopping Dopaminergic drugs
Ft:
- High Temp
- High BP/HR/RR
- Muscle Rigidity
- Confudion/delirium
Tx:
- Stop Antipsychotic
- IVI
- Dantrolene
170
VEstibular neuronitis vs viral labyrinthitis
VN:
- No HL or tinnitus
- Vertigo
Horizontal nystagmus
VL:
- Vertigo + HL
171
Horners syndrome - distinguishing between causes
Heterochromia = congenital hroners
1st order - Central lesion - think of S's :
- Syringiomyelia
- stroke
- Multiple Sclerosis
- tumour
- enceph
- Anhydrosis to fce + arm + trunk
2nd order - Preganglionic - think Ts:
- Anhydrosis to face
- Pancoast Tumour
- Thyroidectomy
- Trauma
3rd order - Pos-gananglionic - think of Cs:
- Carotid aneurysm
- Carotid dissection
- Cavernous sinus thrombosis
- Cluster headache
172
Stroke - ant cerebral artery vs middle cerebral artery
Ant:
- Lower extremity > upper extremity
MCA:
- Upper extremity > Lower
- Contralat homonymous hemianopia
- Aphasia
173
CLuster headache RF / Triggers
RF:
- men
- smoekrs
Trigger = EtOH
174
What parkins medication can lead to pulmonary fibrosis
Pergolide
175
Medication overuse headache mx
Simple analgesics - stop abruptly
| Opiods - withdraw gradually
176
Ataxia telangectasia
Cerebellar Ataxia - falling over
Ig-A- leads to recurrent chest infections
Telangectasia
177
Damage to what structure causes chorea
Damage to the caudate nucleus of the basal ganglia
178
Myotonic dystrophy - Think of the Ds
DM1
- Dyarthria
- Distal weakness
- A.D
- DB
179
MS good prognostics
```
Female
young age
R-R
sensory sx only
long interval between episodes
full recovery between episodes.
```
180
Botulinism
Clostridia = G+ anaerobic bacillus
Seen in IIVDU / contaminated food
Block og ACh release
FLACCID PARALYSIS
Mx - anti-toxin only effective if given earluy
181
Meningitis bacterial causes
0-3 months:.
- grpup B strep
- e. Coli
- listeria
3months - 6years
- meningococcus
Pneumococcus
H. Influenzae
6-60 yrs:
- meningococcus
- Pneumococcus
>60:
Meningococcus
Pneumococcus
Listeria
Immunodeficiency - listeria
182
Bells oalsy vs ramsey hunt
Both cause LMN facial nerve palsy
Ramsey hunt - HZV - RASH around ear
Bells - NO RASH - often vira
Ramsey hunt - give aciclovir
Bells palsy - pred only
183
Palatale myoclonus SOL - what ate affected?
Olivary nucleus
184
Types of nstagmus and site of lesion
See-saw = occipital
Alternating + jerky - Cerebelum
Convergence-retraction - Midbrain
Downbeat = medulla
Up-beat = pons
185
Nerve conduction results
Conduction block - ddue to segmenyal demyelination - seen in GBS
Axonal demyelination - normal conduction Velocity with low AP
Global demyelination - no conduction block
Wallerian degeneration - axonal + myelin degeneration distal to axonal damage - MY INJURY
186
How to control Droolng in Parkinsons pt
consider gylocpyronium bromide
187
Pyramidal tract lesion pattern of weakness
Upper limb extensor lower limb flexor
188
Medication overuse headache
NSAIDs/paracetamol - stop ABRUPTLY
Opiates - withdraw SLOW
189
Factors that affect rate of LP induced headache
Size of needle
Direction of bevel
not replacing stylet
Inc number of ttempts.
190
Miller Fisher vs GBS
Miler - Fisher syndrome is a variant of GBD which STARTS with CNS
therefore often start with eye signs
anti-G1qb
191
Strokke - Alexia but able to write - What area of the brain?
Corpus callosum
192
GBS poor prognostics
```
>40yrs
Preceeding diarhoeal illness
Upper limbs affected
High anti-GM1 titre
Need for ventilatory support
```
193
Subcortical vs cortical dementia
Cortical:
- Memory + language
Subcortical:
- Frontal lobe - planning, verbal fluency, personality
- psychomotor slowing, reduced verbal output, reduced response.
194
Which AED is contraindicated in absence seizures?
Carbamezapine - can worsen seizures
195
Myasthenia crisis
FvC measuring
Plasmaphoresiss and IV Ig
