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Neurology Flashcards

1
Q

Where is the most common location for TIA embolus? (1)

What symptoms do patients with this present with? (3)

A

Anterior circulation - originating from atherosclerotic plaque in the carotid artery.

Hemiparesis, dysphasia, amaurosis fugax

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2
Q

How do patients with posterior circulation TIAs present? (4)

A 
Bilateral motor and sensory dysfunction
Loss of consciousness
Binocular blindness
Vertigo
Diplopia
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3
Q

What vessel is typically involved in a posterior circulation stroke? (1)

A

Vertebrobasilar

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4
Q

What is the pharmacological management following TIA? (3)

A

300 mg aspirin for 2 weeks
Longterm - Clopidogrel
Statin

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5
Q

What are the features of an anterior circulation stroke, what is the difference between a total and partial anterior circulation stroke? (4)

A

Unilateral weakness/hemiparaesis
Homonymous hemianopia
Higher cerebral dysfunction - dysphasia, visuospatial disorder

Partial will only have 2 of the 3 features. Partial typically affected the anterior cerebral artery, with middle being total.

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6
Q

How does the paralysis vary in middle cerebral artery strokes compared to anterior?

A

In anterior - lower limbs are affected more than the upper limbs and there is less sensory loss

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7
Q

Which artery is most commonly affected in ischaemic stroke? (1)

A

Middle cerebral artery

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8
Q

What is the function of Broca’s and Wernicke’s areas? (2)

A

Broca’s - Production of speech

Wernicke’s - comprehending speech

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9
Q

What is Weber’s syndrome? (3)

A

Midbrain stroke
Affects CNIII (Occulomotor)
With contralateral hemiplegia/paresis

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10
Q

What is a lacunar stroke? What is the most common type? (3)

A

A stroke of a penetrating artery
There is an absence of cortical signs
Pure motor

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11
Q

What is required before treatment in a stroke? (1)

A

Head CT - differentiate between ishcaemic and haemorrhagic

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12
Q

What is the treatment for ischaemic stroke? (4)

A

ABCDE
IV alteplase thrombolysis within 4.5 hours of symptom onset
Aspirin 24 hours following thrombolysis
VTE prophylaxis and early mobilisation

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13
Q

What are causes of intracerebral haemorrhage? (5)

A 
Hypertension
Cerebral amyloid angiopathy
Ruptured AV malformation
Coagulation disorders or use of anticoagulants
Vasculitis
Neoplasms
Traumatic brain injury
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14
Q

What is the main cause of subarachnoid haemorrhagic strokes? (1)

A

Berry aneurysms in the circle of Willis

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15
Q

What are risk factors for subdural haematoma? (5)

A

Head injury
Cerebral atrophy/increased age
Alcohol misuse
Anticoagulation medication

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16
Q

What is the typical delay between injury to symptoms in subdural versus extradural haematoma? (2)

A

Subdural - Days to weeks

Extradural - Minutes to hours followed by a lucid period then relapse in hours to days

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17
Q

What is seen on CT in a subdural haematoma? (1)

A

Crescent-shaped mass

Density decreases the older the bleed is

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18
Q

What is seen on CT in an extradural haematoma? (1)

A

Hyperdense biconvex shape

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19
Q

What is the management of subdural and extradural haematoma? (3)

A

ABCDE
Mannitol for raised ICP
Stabilise and refer to neurosurgery

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20
Q

Name some red flags in a patient presenting with migraine (4)

What should be done if a patient presents with red flags? (2)

A

Onset > 50 years old
Change in pattern
Abnormal neurological exam
Posteriorly located headache

Neuroimaging (MRI) and lumbar puncture

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21
Q

What is used to manage migraines acutely? (2)

A

Triptans (Sumatriptan)

Simple analgesia

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22
Q

What is used for migraine prophylaxis? (3)

A

1) Propranolol or Topiramate

2) Amitryptaline

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23
Q

What is the management for acute cluster headache? (2)

A

Oxygen and triptans

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24
Q

What is used for cluster headache prophylaxis? (1st and 2nd line) (2)

A

1) Verapamil

2) Lithium

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25
What is used in the acute management of trigeminal neuralgia? (1)
Carbamazepine (anticonvulsant)
26
What condition must be excluded in trigeminal neuralgia? (1)
Temporal arteritis
27
Name causes of peripheral neuropathy (4)
``` Diabetes Alcohol misuse Vitamin deficiency - B12 Infective/Inherited - Lyme disease, EBV, Shingles Drugs - Isoniazid, cisplatin, phenytoin ```
28
What are the mechanisms that can lead to peripheral neuropathy? Give an example of a condition in each. (6)
Demyelination (damage to Schwann cells) - Guillan Barre Syndrome Axonal degeneration - Multiple sclerosis Wallerian degeneration - Infarction Compression - Carpal tunnel syndrome Infiltration - Leprosy, inflammation, malignancy
29
What organisms typically lead to Guillain Barre syndrome? (3)
Campylobacter EBV CMV
30
How does Guillain Barre present? (5)
``` 1-3 weeks post infection. Symmetrical, ascending muscle weakness +/- numbness Loss of reflexes Autonomic dysfunction Neuropathic pain Can be respiratory involvement ```
31
What tests should be done in suspected Guillain Barre syndrome?
``` Nerve conduction study Lumbar puncture Spirometry - to monitor resp function LFTs - elevated indicates higher severity Serology - antiganglioside antibodies ```
32
What is seen on lumbar puncture in Guillain Barre? (1)
Elevated proteins | Normal cell count
33
What is the management for Guillain-Barre syndrome? (2)
Plasma exchange and IV immunoglobulins
34
What is the most common inheritance pattern in Charcot-Marie-Tooth? (1)
Autosomal dominant
35
How does Charcot-Marie-Tooth present? (4)
Foot drop Loss of sensation Loss of reflexes Peroneal muscle atrophy and 'inverted champagne bottle' appearance
36
What is the triad of Parkinsonism? (3)
Rigidity, bradykinesia, resting tremor
37
What is the pathology behind Parkinson's disease? (4)
Progressive degeneration of dopaminergic receptors in the substatia nigra of the basal ganglia. Lewy bodies develop. There is loss of dopamine and melanin in the striatum.
38
What do Lewy bodies consist of? (2)
Ubiquitin and alpha-synuclein
39
What are the features of a Parkinsonian tremor? (6)
``` Pill rolling Micrographia Improves with activities Postural instability Cog-wheeling Brisk reflexes ```
40
Name some non-motor symptoms of Parkinson's (4)
``` Depression Anosmia Visual hallucinations Constipation Urinary frequency/urgency ```
41
Describe a Parkinsonian Gait (4)
Stooped Small, shuffling gait Narrow base Reduced arm swing
42
What is the gold standard management for Parkinson's? (2) | How do the drugs work? (2)
Levodopa + Carbidopa Levodopa is a precursor to dopamine that crosses the blood brain barrier Carbidopa is decarboxylase inhibitor that prevents Levodopa being converted to Dopamine in the peripheral circulation.
43
What is used to delay starting levodopa in Parkinson's? (2)
Monoamine Oxidase Inhibitors - Rasagiline | Dopamine agonists - Pramiprexole, Ropinirole
44
What are limitations/disadvantages of Levodopa? (3)
Decreased efficacy and duration of action over time On/Off effect Levodopa induced dyskinesia
45
What are the symptoms of progressive supranuclear palsy? (4)
Early postural instability Vertical gaze palsy Cognitive impairment NO tremor
46
What are the symptoms of multiple system atrophy? (4)
Early autonomic dysfunction - Postural hypotension, bladder dysfunction Cerebellar signs
47
What are the Parkinson-plus syndromes? (3)
Progressive Supranuclear Palsy Multiple system atrophy Lewy-body dementia
48
How are Lewy body dementia and Parkinson's differentiated clinically? (1)
In Parkinson's motor symptoms occur a year or more before dementia In Lewy body the two occur closer together or at the same time
49
What is the cause of Huntington's Disease? (2)
A mutation of chromosome 4 with an extended glutamine sequence consisting of multiple CAG repeats
50
What are the first symptoms of Huntington's? (1)
Prodromal phase - mild psychotic and behavioural changes
51
In which areas is neuronal loss seen in Huntington's? (2)
Caudate nucleus and putamen of the basal ganglia
52
How are neurotransmitters affected in Huntington's? (3)
GABA and ACh are reduced | Normal Dopamine
53
What can be used for symptom management in Huntington's? (3)
Benzodiazepines Sodium valproate Tetrabenazine Antidepressants, antipsychotics
54
What are the variants of motor neurone disease? What nerves are affected in each one? (4)
Amyotrophic lateral sclerosis - UMN and LMN Primary lateral sclerosis - UMN Progressive muscular atrophy - LMN Progressive bulbar palsy - UMN and LMN of lower cranial nerves
55
What dementia is amyotrophic lateral sclerosis associated with? (1)
Frontotemporal dementia
56
What is the management of motor neurone disease? (4)
Riluzole - extends life by approximately 3 months Baclofen for muscle spasms Non-invasive ventilation PEG tube feeding
57
What imaging is used to visualise the plaques in multiple sclerosis? (1)
MRI
58
What are the clinical features of Multiple Sclerosis? (4)
Unilateral optic neuritis UMN signs - Spasticity, weakness, hyperreflexia Symptoms are worse in the heat or after exercise (Uthoff's phenomenon) Cerebellar signs
59
What is Lehrmitte's sign in multiple sclerosis? (2)
Neck flexion leads to an electric shock sensation down the trunk and limbs
60
What investigations should be order in suspected multiple sclerosis and what would be seen in each? (6)
MRI brain and spinal cord - Periventricular lesions, cervical spinal cord lesions Lumbar puncture - Raised protein, oligoclonal bands FBC, TSH, metabolic panel, B12 - exclusionary
61
How are relapses treated in multiple sclerosis? (1)
IV methyprednisolone
62
What is the most common cause of death in multiple sclerosis? (1)
Aspiration pneumonia
63
What antibodies are associated with Myasthenia Gravis? (2)
AChR antibodies | anti-muscle-specific tyrosine kinase (MuSK) antibodies
64
What muscles are affected first in Myasthenia Gravis? (1)
Extraoccular muscles
65
What is Lambert-Eaton Myasthenic syndrome? (1)
Presents similarly to Myasthenia Gravis but is associated with small cell lung cancer
66
What investigations are done in suspected Myasthenia Gravis? (4)
Serum antibodies (MuSK, antiACh) CT chest - Thymic hyperplasia Tensilon test - IV endrophonium increases power Neurophysiology
67
What class of drug is used for symptom control in Myasthenia Gravis? (1) Name two examples (2)
Acetylcholinesterase inhibitors - Pyridostigmine, neostigmine
68
What surgery can improve symptoms in Myasthenia Gravis? (1)
Thymectomy
69
What is the management for a Myasthenic crisis? (3)
Intubation and mechanical ventilation Plasmapheresis and IV immunoglobulins Corticosteroids
70
What is seen on blood tests in Duchenne muscular dystrophy? (1)
Elevated creatinine kinase
71
Which cancers metastasise to the brain? (5)
Lung, breast, prostate, colorectal, melanoma and kidney
72
What is the most common high grade brain tumour? (1)
Astrocytoma
73
What is the diagnostic criteria for brainstem death? (4)
1) Patient must suffer from a condition that has lead to irreversible brain damage 2) Potentially reversible causes have been excluded 3) There is coma, apnoea and absence of brainstem reflexes that have been formally demonstrated The diagnosis must be made by two doctors
74
What are the brainstem reflexes examined in suspected brainstem death? (6)
``` Pupils unresponsive to light Absent corneal reflex Absent oculovestibular reflex No cranial nerve motor response No gag or cough reflex ```
75
What lobe is affected in this seizure presentation - | A sense of deja vu and strange smells followed by repetitive, non-purposeful movements (1)
Temporal lobe
76
What lobe is affected in a seizure with Jacksonian march? (1)
Frontal lobe
77
What is first line for generalised tonic-clonic seizure prophylaxis? (2)
Sodium Valproate or Lamotrigine
78
What is first line prophylaxis for absence seizures? (2)
Sodium Valproate or Ethosuximide
79
What is the management for status epilepticus?
IV or rectal benzodiazepines (IV Lorazepam, Rectal diazepam)
80
What is first line prophylaxis for partial seizures? (2)
Carbamazepine or Lamotrigine
81
What is seen on EEG in West syndrome? (1) | How is this syndrome managed? (2)
Hypsarrhythmia | Corticosteroids and vigabatrin
82
What genetic syndrome is West syndrome associated with? (1)
Tuberous sclerosis
83
What are the cerebellar signs? (6)
``` Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred, staccato speech Homonymous hemianopia ```
84
What is used to manage subarachnoid haemorrhage? (4)
Nimodipine - Calcium channel blocker that stops vasospasm Dexamethasone NaCl Fluids Neurosurgery referral
85
What artery is affected most commonly in extradural haemorrhage? (1)
Middle meningeal artery
86
What are the triad of symptoms of normal pressure hydrocephalus? (3)
Dementia Gait dyspraxia Urinary incontinence
87
What is the treatment for normal pressure hydrocephalus? (1)
Ventriculo-peritoneal shunting
88
What is the most common genetic mutation in Alzheimers? (1)
apoE4
89
What is the pathophysiology of Alzheimers? (3)
Amyloid plaques develop in the grey matter of the brain and intracellular neurofibrillary tangles made up of tau proteins develop. There is atrophy and overall reduction in cholinergic function.
90
Which parts of the brain are affected first in Alzheimers? (2)
The hippocampus and medial temporal structures
91
How is vascular dementia managed? (3)
Decrease vascular risk - aspirin, warfarin, blood pressure control Anticholinesterases - Donepezil Memantine
92
What are Pick bodies? (2)
Pathological intracellular inclusion bodies caused by mutations in tau proteins
93
How does frontotemporal dementia present? (2)
Early behavioural changes - apathy, disinhibition, impulsivity Initial preservation of cognitive function
94
What is used to manage frontotemporal dementia? (2)
SSRIs | Atypical antipsychotics
95
How are Pick bodies identified? (1)
Silver staining
96
What are Lewy bodies? (1)
Alpha synucelin and ubiquitin deposits
97
Name some visual signs of multiple sclerosis (4)
Blurred vision OR reduced visual acuity Blurred vision OR reduced visual acuity on exposure to heat e.g. a hot shower (Uthoff’s phenomenon) Colour desaturation (e.g. seeing the colour red as orange or grey) Eye pain at rest Painful ocular movements Oscilopsia (a visual disturbance in which objects in the visual field appear to oscillate)
98
Name three tests done in suspected multiple sclerosis and the results expected (6)
MRI Head +/- spine - Multiple sclerotic plaques (most commonly seen in periventricular white matter) with finger-like radial extensions (Dawson's fingers) Lumbar puncture - Lymphocytic pleocytosis Oligoclonal bands Evoked potential testing - usually visual, shows a slowed response
99
Where are sclerotic plaques most commonly seen in multiple sclerosis? (1)
Periventricular white matter
100
What histological changes are expected in neurones in multiple sclerosis? (3)
Demyelination Variable oligodendrocyte loss Hypercellular plaque edge due to infiltration of tissue with inflammatory cells Perivenous inflammatory infiltrate (mainly macrophages and T-lymphocytes) Older plaques may have central gliosis
101
What drug can delay progression of disease in multiple sclerosis? (1)
Beta interferon
102
What class of drugs is first line for treating Alzheimer's disease? Give an example (2)
Anticholinesterase inhibitors - Rivastigmine, Donepezil

Phase 3A (6 decks)

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