neurology Flashcards
(146 cards)
1
Q
mx of tension-type headache?
A
acute- aspirin, paracetamol, NSAID
prophylaxis- acupuncture
amitriptyline
2
Q
features of migraine?
A
severe, unilateral throbbing headache
associated with nausea, photophobia, phonophobia
3
Q
diagnostic criteria for migraine? ABCDE
A
At least 5 attacks fulfilling criteria B-D:
B- attacks lasting 4-72 hours
C- 2 of the following characteristics:
- unilateral location
-pulsating quality
- moderate or severe pain headache
- aggravation by or causing avoidance of routine physical activity
D- during headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E- not attributed to any other disorder
4
Q
triggers for migraine
A
Chocolate Hangovers Orgasms Cheese Oral contraceptives- CI'd if aura Lie-ins Alcohol Tumult Exercise
5
Q
mx of acute migraine?
A
1st line- oral triptan and NSAID or paracetamol
metoclopramide or prochlorperazine
6
Q
prophylaxis of acute migraine?
A
if 2+ attacks a month
Topiramate or propranolol
acupuncture
riboflavin
7
Q
what is wrong with topiramate?
A
cleft palate and reduces effectiveness
8
Q
RFs for cluster headache?
A
male, smokers
9
Q
features of cluster headaches?
A
Unilateral pain around one eye- episodes last 15 minutes-2 hours
Restless and agitation
Eye- redness, lacrimation, lid swelling, miosis, ptosis
Rhinorrhoea
10
Q
mx of cluster headaches?
A
100% O2
sub cut triptan (sumatriptan)
prophylaxis- verapamil, short course prednisolone may help
11
Q
what is trigeminal neuralgia?
A
a pain syndrome characterised by severe unilateral pain
majority are idiopathic but could have serious underlying cause such as tumour
12
Q
features of trigeminal neuralgia?
A
a unilateral disorder of brief electric-shock like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve
triggers= washing, shaving, brushing teeth
13
Q
RFs for trigeminal neuralgia?
A
hypertension, >50
14
Q
Ix of trigeminal neuralgia?
A
MRI
15
Q
mx of trigeminal neuralgia?
A
1st line= carbamazepine
failure to respond needs prompt referral to neurology
16
Q
RFs of GCA?
A
over 50s, associated with polymyalgia rheumatica
17
Q
features of GCA?
A
scalp tenderness jaw claudication pulseless temporal arteries temporal pulsating headache amaurosis fugax
18
Q
ix of GCA?
A
ESR
raised CRP, platelets, alk phos, reduced Hb
temporal artery biopsy
19
Q
mx of GCA?
A
Steroids- prednisolone 60mg
PPI and bisphosphonates
20
Q
complications of GCA?
A
Visual loss
21
Q
signs of raised ICP?
A
Worse walking, bending forwards, lying down, coughing associated with vomiting papilloedema focal signs seizures
22
Q
layers of meninges of the brain
A
Dura mater
Arachnoid mater
Subarachnoid space
Pia mater
23
Q
causes of SAH?
A
Berry aneurysm- associated with adult PKD, Ehlers Danlos syndrome, coarctation of the aorta AV malformation Pituitary apoplexy Arterial dissection Mycotic aneurysms
24
Q
features of SAH?
A
Thunderclap headache N&V Meningism: photophobia, neck stiffness Coma seizures
25
Ix of SAH?
CT head
LP- done if CT is negative, perform 12 hours after symptom onset to allow development of xanthochromia (RBC breakdown)
refer to neurosurgery as soon as SAH confirmed
26
Tx of SAH?
CT intracranial angiogram
clipping of aneurysm
vasospasm is prevented with nimodipine
external ventricular drain for hydrocephalus
maintain cerebral perfusion with dexamethasone to decrease cerebral oedema
27
causes of subdural haemorrhage?
tearing of bridging veins between the venous sinuses and the cortex
causes increased ICP
28
RF for subdural haemorrhage?
traumatic head injury
cerebral atrophy/increasing age
alcoholism
anticoagulation meds
29
Signs and symptoms of subdural haemorrhage?
acute- raised ICP, confusion, seizure
| chronic- cognitive decline, personality change, headache
30
Ix of subdural haemorrhage?
CT- gold standard
| diffusely spreading crescent shaped mass
31
mx of subdural haemorrhage?
neurosurgery- monitor ICP and decompressive craniotomy
| if chronic and no neuro deficit- can be managed conservatively
32
what is an extra dural haemorrhage?
collection of blood between the dura mater and bone
33
symptoms of extra dural haemorrhage?
briefly consciousness after a low impact injury then lucid interval:
then altered consciousness, severe headache, N&V, confusion, seizures
may lead to rapid increase in intra-cranial pressure- ipsilateral pupil dilatation, signs of brainstem injury/ compression
34
Ix of extradural haemorrhage?
CT- hyperdense biconvex (lemon shape) adjacent to skull
35
mx of extradural haemorrhage?
craniotomy and clot evacuation
| give mannitol if raised ICP
36
causes of encephalitis?
viral infection- HSV 1&2, VZV, EBV, CMV, HIV, measles and mumps
Secondary to bacterial meningitis, TB, malaria, listeria etc
37
symptoms of encephalitis?
features of a viral infection
LOC
behavioural change
focal neurological deficit
38
Ix of encephalitis?
LP and CSF studies (PCR)- moderate increase in protein level. lymphocytes and decreased glucose
bloods and cultures
39
mx of encephalitis?
if viral- aliclovir IV high dose for 14 days
IM benpen in meningitis
anti-seizure meds
40
what is guillain barre syndrome?
an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically campylobacter jejuni)
41
features of GBS?
```
Progressive weakness in all 4 limbs
some sensory signs
history of gastroenteritis
areflexia
CN involvement e.g. diplopia
autonomic involvement e.g. urinary retention, diarrhoea
```
42
Ix of GBS?
LP- rise in protein found with a normal WCC
nerve conduction studies
if resp muscle involvement -> ITU admission
43
mx of GBS?
IVIG for 5 days
44
causes of epilepsy?
```
idiopathic
CP
tuberous sclerosis
mitochondrial diseases
head injury
```
45
types of epilepsy?
primary generalised- LOC, bilateral discharges, no ofcal brain abnormality
partial/focal- one hemisphere involved.
**partial seizure is focal structural abnormality until proven otherwise**
46
types of primary generalised epilepsy?
-tonic-clonic- stiffness and rigidity followed by rhythmic jerking. can have tongue biting and incontinence. post-ictal confusion and todd's paralysis
- tonic
- clonic
- absence
- myoclonic
- atonic
47
name some non-epileptic causes of seizures?
febrile convulsions
Alcohol withdrawal seizures
Psychogenic non-epileptic seizures
48
types of focal seizures?
focal aware
focal impaired awareness
awareness unknown
focal to bilateral seizure (secondary generalised)
49
features of temporal lobe seizure?
```
HEAD
Hallucinations (auditory, olfactory, gustatory)
Epigastric rising/emotion
Automatisms (lip smacking)
Deja vu/ dysphasia (Wernicke's area)
```
50
features of frontal lobe seizure? (motor)
head/leg movements
posturing
post-ictal weakness
Jacksonian march (up and down motor homunculus)
51
features of parietal lobe seizures? (sensory)
paraesthesia
52
features of occipital lobe seizures? (visual)
floaters/flashes
53
Ix of epilepsy?
EEG and MRI
54
mx of epilepsy?
1st line for generalised seizures- sodium valproate 2nd line lamotrigine
1st line for partial seizures- carbamazepine
55
driving and epilepsy?
cannot drive for 6 moths following a seizure, 12 months if established epilepsy
56
How can epilepsy meds contraindicate other meds e.g. warfarin?
they can induce/inhibit the P450 system affecting metabolism of other drugs
57
epilepsy and pregnancy?
sodium valproate is teratogenic
| breastfeeding is generally considered safe
58
epilepsy and contraception?
they both reduce the effectiveness of eachother
59
how does sodium valproate work and AEs?
increases GABA activity
AEs- weight gain and increased appetite, alopecia, ataxia, tremor, hepatitis, pancreatitis, thrombocytopenia, P450 enzyme inhibitor
60
how does carbamazepine work? and AEs
binds to sodium channels increasing their refractory period
| AEs- P450 inducer, dizziness and ataxia, drowsiness, agranulocytosis, SIADH, visual disturbances
61
SE of lamotrigine?
stevens- johnson syndrome
62
how does phenytoin work?
binds to sodium channels and increases their refractory period
AEs- P450 inducer, dizziness and ataxia, drowsiness, hirsutism, megaloblastic anaemia, peripheral neuropathy, osteomalacia, lymphadenopathy
63
management of status epilepticus?
ABCDE
check BG levels
benzodiazepines e.g. diazepam (rectally or intranasally or sublingual) or lorazepam (IV) 4mg
wait 10 mins
phenytoin, sodium valproate and phenobarbital IV
GA in no response within 30 mins
64
what should be checked to rule out other causes of status epilepticus?
BG
| PaO2
65
what is Parkinson's disease?
degeneration of the dopaminergic neurons in the substantia nigra
symptoms are classically symmetrical
development of lery bodies
66
features of PD?
Bradykinesia
tremor- 3-5Hz, most at rest
rigidity- cog wheel or lead pipe
```
mask-like facies
flexed posture
micrographia
fatigue
REM sleep behaviour disorder
psych disturbance
```
67
diagnosis of PD?
clinical
| MRI will be normal initially but then show atrophy
68
mx of PD?
If motor symptoms are affecting QOL-> 1st line levodopa
if they aren't -> dopamine agonist e.g. ropinirole or MAOB inhibitor
Combine drugs
Can add COMT inhibitor
69
what is levodopa?
usually combined with a decarboxylase inhibitor to prevent peripheral metabolism of levodopa to DA to reduce AEs
- reduces effectiveness with time (usually by 2 years)
70
AEs of levodopa?
```
dyskinesia (involuntary writhing movements)
on-off effect
dry mouth
anorexia
palpitations
postural hypotension
psychosis
drowsiness
```
Don't stop suddenly -> can cause acute dystonia
71
AEs and monitoring of dopamine receptor agonists?
bromocriptine, ropinirole
prior to tx- ECHO, ESR, CXR, creatinine
AEs- impulse control disorder, excessive daytime sleepiness, hallucinations, nasal congestion, postural hypotension
72
how do MAO-B inhibitors work?
e.g. selegiline
inhibits the breakdown of DA
AEs- postural hypotension, AF
73
how do COMT inhibitors work?
e.g. entocapone, tolcapone
stops breakdown of DA
AEs- can cause liver damage
74
name some parkinson plus syndromes?
Progressive supra-nuclear palsy
Multiple system atrophy
Corticobasal degeneration
Lewy body dementia
75
features of progressive supra-nuclear palsy?
```
early postural instability and falls
vertical gaze palsy
rigidity of limbs < trunks
no tremor
symmetrical
```
76
features of multiple system atrophy?
early autonomic features (postural hypotension, bladder dysfunction)
cerebellar signs
no tremor
77
features of corticobasal degeneration?
akinetic rigidity involving one limb
78
features of lewy body dementia?
dementia before motor symptoms= LBD
| dementia one year after motor symptoms= PD
79
what is huntington's disease?
AD neurodegenerative condition
trinucleotide repeat disorder: CAG
results in degeneration of cholinergic and GABAergic neurons in the striatum of the basal ganglia
80
features of huntington's disease?
```
typically after 35 years of age
chorea
personality change
dystonia
saccadic eye movements
```
81
diagnosis of huntington's disease?
CT/MRI
clinical
genetic testing
82
mx of huntington's disease?
no cure
| chorea- benzodiazepines, valproic acid, tetrabenazine
83
what is motor neuron disease?
cause is unknown
| presents with upper and lower motor neuron signs
84
clues which point towards a diagnosis of MND?
Fasisculations
the absence of sensory S&S
mixture of LMN and UMN signs
wasting of the small hand muscles/ tibialis anterior is common
85
types of MND?
1) Amytrophic lateral sclerosis- (50%)- typically presents with LMN signs in arms and UMN signs in legs. Associated with fronto-temporal dementia
2) Primary lateral sclerosis- UMN signs only
3) Progressive muscular atrophy- LMN signs only, affects distal muscles before proximal, carries best prognosis
4) progressive bulbar palsy- palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei
- carries worse prognosis
86
diagnosis of MND?
Clinical
nerve conduction studies
EMG
MRI to exclude cervical cord compression and myelopathy
87
mx of MND?
Riluzole- prevents stimulation of glutamate receptors. Used mainly in amytrophic lateral sclerosis. Prolongs life by about 3 months
Resp care- NIV e.g. BiPAP at night
Spasms- baclofen
88
prognosis of MND?
50% die within 3 years
89
what is MS?
Chronic cell-mediated autoimmune disorder characterised by demyelination in the CNS
90
epidemiology of MS?
3x more common in women
age 20-40 years
more common at higher altitude
91
types of MS?
- Relapsing-remitting disease- (85%) acute attacks (last 1-2 months) followed by periods of remission
- secondary progressive disease- neurological S&S between relapses
- primary progressive disease (10%)
92
diagnosis of MS?
2 OR MORE RELAPSES AND EITHER
OBJECTIVE CLINICAL EVIDENCE OF 2 OR MORE LESIONS OR
OBJECTIVE CLINICAL EVIDENCE OF 1 LESION TOGETHER WITH REASONABLE HISTORICAL EVIDENCE OF A PREVIOUS RELAPSE
93
Features of MS?
Visual- optic neuritis, optic atrophy, Uhthoff's phenomenon (worsening symptoms following increased body temp), internuclear ophthamoplegia
Sensory- pins and needles, numbness, trigeminal neuralgia, Lhermitte's syndrome (paraesthesia in limbs on neck flexion)
Motor- spastic weakness
Cerebellar- ataxia, tremor
Others- urinary incontinence, sexual dysfunction, intellectual deterioration
94
Ix of MS?
MRI- periventricular plaques
CSF- oligoclonal bands, IgG
Visual evoked potentials- delayed, but well preserved waveform
95
mx of MS?
Acute relapse- oral or IV methylprednisolone for 5 days
Disease modifying drugs- DMARDS (beta-interferon), glatiramer acetate, natalizumab, fingolimod
96
mx of specific problems of MS- fatigue, spasticity, bladder dysfunction?
fatigue- CBT, mindfulness, amantadine
spasticity- baclofen and gabapentin, PT, diazepam, cannabis and botox
bladder dysfunction- self-catheterisation, anticholinergics e.g. doxizosin
97
what is myasthenia gravis?
an autoimmune affecting the neuromuscular junction
| affects acetylcholine receptors- antibodies against them
98
associations with myasthenia gravis?
```
thymomas
autoimmune antibodies (pernicious anaemia, thyroid, RA, SLE), thymic hyperplasia
```
99
features of myasthenia gravis?
```
muscle fatiguability
extraocular muscle weakness: diplopia
ptosis
dysphagia
peek sign= can't keep eyes closed for long
```
100
Ix of myasthenia gravis?
```
single fibre electromyography
CT thorax to exclude thymoma
CK normal
auto-antibodies- anti-AChR or anti-MuSK
Tensilon test- IV edrophonium reduces muscle weakness temporarily
```
101
mx of myasthenia gravis?
long-acting anticholinesterase inhibitors e.g. pyridostigmine
immunosuppression e.g. prednisolone initially
thymectomy
102
mx of myasthenic crisis?
plasmapheresis
| IVIG
103
exacerbating factors for myasthenic crisis?
```
beta blockers
penicllamine
lithium
phenytoin
Abx
```
104
causes of dementia?
```
alzheimer's disease
CV disease- multi-infarct dementia
lewy body dementia
huntingtons
CJD
Pick's disease
HIV
```
105
assessment of dementia?
6CIT, 10-CS
GP setting- MMSE, GPCOG
Blood screen to exclude reversible causes- FBC, U&E, LFT, Ca, glucose, TFT, vit B12 and folate
Neuroimaging to excluse organic causes
106
genetics of Alzheimer's disease?
most cases are sporadic
5% of cases are inherited as an autosomal dominant trait
mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome 14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form
apoprotein E allele E4 - encodes a cholesterol transport protein
risk factors include Down's syndrome
107
macroscopic changes of AD?
Widespread cerebral atrophy, particularly involving the cortex and hippocampus
108
microscopic changes of AD?
```
Cortical plaques (due to deposition of type A-Beta amyloid protein)
Intraneuronal neurofibrillary tangles (caused by anbormal aggregation of the tau protein)
```
109
mx of alzheimer's disease?
non-pharmacological- exercise, group therapy, cognitive rehab
pharmacological-
-3 acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine) 1st line
- memantine (NMDA receptor antagonist) 2nd line
* donepezil contraindicated in bradycardia, can cause insomnia*
110
features of fronto-temporal lobar dementia?
onset before 65
insidious onset
relatively preserved memory and visuo-spatial skills
personality change and social conduct problems
111
3 types of fronto-temporal lobar dementia?
1. Pick's disease
2. Progressive non-fluent aphasia/ CPA-non-fluent speech
3. Semantic dementia- fluent progressive aphasia
112
features of pick's disease?
```
personality change
impaired social conduct
hyperorality
dis-inhibition
increased appetite
```
113
macroscopic changes associated with pick's disease?
atrophy of frontal and temporal lobes
114
microscopic changes associated with pick's disease?
aggregation of tau proteins
gliosis
neurofibrillary tangles
plaques
115
features of lewy body dementia?
associated with PD
progressive cognitive impairment
parkinsonism
visual hallucinations (other features such as delusions and non-visual hallucinations may also be seen)
116
Ix of lewy body dementia?
clinical
| SPECT (DAT scan)
117
tx of lewy body dementia?
both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's
118
RF of brain tumours?
ionising radiation
immunosuppression
genetic syndromes- neurofibromatosis
119
types of brain tumours?
high grade- gliomas- astrocytomas or oligodendromas
- primary cerebral lymphoma
- medulloblastoma
low grade- meningioma, acoustic neuromas, neurofibromas, pituitary adenoma, pineal tumour
120
features of brain tumours?
increased ICP
neurological focal symptoms- personality change, cognitive or behavioural symptoms, confusion
Coning can occur- herniation of cerebellar tonsils through foramen magnum -> resp depression, bradycardia, death
121
diagnosis of brain tumours?
CT/MRI
122
tx of brain surgery?
neurosurgery
123
cause of extra dural haemorrhage?
fracture of temporal or parietal bone causing laceration of the middle meningeal artery
ususally young adults
124
causes of cerebellar disease?
```
PASTRIES
Paraneoplastic
Alcohol
Stroke
Trauma
Rare- Gluten's ataxia, Friedrich's ataxia
Iatrogenic- drugs e.g. phenytoin
Endocrine
SOL/MS
```
125
what is a neurofibromatosis?
a genetic condition that causes nerve tumours (neuromas) to develop throughout the nervous system
2 types- NF1 most common
126
features of neurofibromatosis type 1?
at least 2 of CRABBING.
C – Café-au-lait spots (6 or more) measuring ≥ 5mm in children or ≥ 15mm in adults
R – Relative with NF1
A – Axillary or inguinal freckles
BB – Bony dysplasia such as Bowing of a long bone or sphenoid wing dysplasia
I – Iris hamartomas (Lisch nodules) (2 or more) are yellow brown spots on the iris
N – Neurofibromas (2 or more) or 1 plexiform neurofibroma
G – Glioma of the optic nerve
127
mx of neurofibromatosis type 1?
There is no treatment of the underlying disease process or to prevent the development of neurofibromas or complications.
Management is to control symptoms, monitor the disease and treat complications.
128
complications of neurofibromatosis type 1?
Migraines
Epilepsy
Renal artery stenosis causing hypertension
Learning and behavioural problems (e.g. ADHD)
Scoliosis of the spine
Vision loss (secondary to optic nerve gliomas)
Malignant peripheral nerve sheath tumours
Gastrointestinal stromal tumour (a type of sarcoma)
Brain tumours
Spinal cord tumours with associated neurology (e.g. paraplegia)
Increased risk of cancer (e.g. breast cancer)
Leukaemia
129
what is Neurofibromatosis type 2 commonly associated with?
acoustic neuromas
These are tumours of the auditory nerve innervating the inner ear.
bilateral almost always indicates NF2
mx= surgery
130
mx of benign essential tremor?
propranolol
| primidone
131
features of benign essential tremor?
```
Fine tremor
Symmetrical
More prominent on voluntary movement
Worse when tired, stressed or after caffeine
Improved by alcohol
Absent during sleep
```
132
what is lambert eaton myasthenic syndrome?
similar to myasthenia gravis
| damage to NM junction causes progressive muscle weakness
133
common cause of lambert eaton myasthenic syndrome?
small cell lung cancer
| antibodies against voltage-gated calcium channels in SCLC cells
134
medical mx of lambert eaton syndrome?
amifampridine allows more ACh to be released in the NM junction
135
what is charcot marie tooth disease?
an inherited disease that affects the peripheral motor and sensory nerves
136
features of charcot marie tooth disease?
- high foot arches (pes cavus)
- distal muscle wasting causing inverted champagne bottle legs
- weakness in lower legs (ankle dorsiflexion)
- weakness in hands
- reduced tendon reflexes
- reduced tone
- peripheral sensory loss
137
differentials of peripheral neuropathy?
```
A – Alcohol
B – B12 deficiency
C – Cancer and Chronic Kidney Disease
D – Diabetes and Drugs (e.g. isoniazid, amiodarone and cisplatin)
E – Every vasculitis
```
138
mx of charcot marie tooth disease?
neurologists
PT, OT, podiatrists
ortho surgeons to correct disabling joint deformities
139
What is tuberous sclerosis characterised by?
harmatomas- benign neoplastic growths of the tissue (skin, brain, lungs, heart, eyes)
can cause epilepsy
140
skin features of tuberous sclerosis?
```
ash leaf spots
shagreen patches
angiofibromas
café au lait spots
poliosis
```
141
where does the facial nerve exit the brainstem?
cerebellopontine angle
| passes through the temporal bone and parotid gland
142
what are the 5 branches of the facial nerve?
```
temporal
zygomatic
buccal
marginal mandibular
cervical
```
143
functions of the facial nerve?
motor- muscles of facial expression, stapedius (ear), some neck muscles
sensory- taste anterior 2/3 tongue
parasympathetic- submandibular and sublingual salivary glands and lacrimal gland
144
why is the forehead not spared in a LMN lesion?
each side of the forehead only has innervation from one side of the brain therefore in a lesion it can't be supplied by the other side of the brain
145
examples of unilateral and bilateral UMN lesions of the facial nerve?
Unilateral- CVAs, tumours
Bilateral- pseudobulbar palsies, MND
146
causes of LMN facial nerve palsies?
Infection- otitis media, malignant otitis externa
Systemic disease- DM, sarcoidosis, leukaemia, MS, GBS
Tumours- acoustic neuroma, parotid tumour, cholesteatomas
Trauma
