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neurology Flashcards

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1
Q

What are the roots of the ulnar nerve

A

C7-T1

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2
Q

Causes of unilateral ptosis

A

Horners
3rd nerve palsy
Myasthenia

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3
Q

Causes of a proximal weakness

A

Unable to stand from a chair. Reduced power in shoulder abduction

Neurological - myasthenia, muscular dystrophy, ALS
Muscle disease - myopathy or myositis (Polymyositis and dermatomyositis)
Endo - diabetes, thyrotoxicosis, Cushings
Polymyalgia (apparent weakness due to stiffness and pain, not objectively weak)
Drugs - steroids, alcohol
Electrolyte disturbance
Malignancy
Renal failure
Osteomalacia
Rhabdomyolysis

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4
Q

How to distinguish between cerebellar disease and sensory ataxia

A

Cerebellar - will have eye signs (nystagmus) and speech change (scanning dysarthria)

Sensory ataxia - sensory change (vibration and joint position sense), pseudoathetosis, able to perform finger-nose testing with eyes open, but not eyes closed

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5
Q

Indications for surgery for carotid artery stenosis

A

Occlusion between 50-99%
Occlusion >70% according to ESCT criteria (S = seventy)
Occlusion >50% according to NASCET criteria

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6
Q

Inheritance of myotonic dystrophy

Mutation and chromosome

A

AD with anticipation

Due to trinucletide repeat expansion on chr19 - myotonin protein kinase gene

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7
Q

Jumping vision

A

Oscillopsia

Cerebellar disease

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8
Q 
Friedrich's ataxia
Features
Inheritance
Onset
Complications
A

Features
Cerebellar sx - cerebellar ataxia, scanning dysarthria, nystagmus
Dorsal column loss - Sensory ataxia, upgoing plantars with decreased reflexes, loss of proprioception and vibration sense
UMN signs - Leg wasting & spastic paraparesis
Pes cavus

Inheritance
AR
Onset during teenage years
Prognosis ~20yrs

Complications  
Cardiac disease - HOCM
Optic atrophy (30%)
Diabetes mellitus (10%)
Sensineural deafness
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9
Q

Holmes Adie pupil

A

Benign condition
Pupil dilated, but slowly accommodates to light and accommodation
Usually chronic, can be acute with photophobia and blurriness
Syphilis negative (vs Argyll Robertson)

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10
Q

Investigations for peripheral neuropathy

A

Bloods - FBC (macrocytosis - B12), LFTs for derangement (alcohol)
Immunoglobulins and serum protein electrophoresis (myeloma)
Vitamin deficiencies - B1/6/12
HbA1c

Nerve conduction studies and EMG - determine length-dependent nature and axonal vs demyelinating pattern

Demyelinating pattern and non-length dependence are more in keeping with an underlying inflammatory cause eg CIDP

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11
Q

Ddx of cerebellar gait

A

S - SOL, stroke, MS
Malignancy related - paraneoplastic
Alcoholic degeneration
Other cerebellar degeneration - Friedrich’s ataxia

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12
Q

What CN are affected in cerebellopontine angle tumours

A

V, VI, VII, VIII and cerebellum

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13
Q

Causes of sensory ataxia

A

Central
Friedrich’s ataxia

Spinal
Cervical myelopathy (compression at cervical level)
Subacute combined degeneration of the cord - B12 deficiency 
Tabes dorsalis (neurosyphilis) - check for A-R pupil (accommodates but doesn't react to light)

Peripheral neuropathy - Diabetic neuropathy, alcohol

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14
Q

Causes of nystagmus

A

Cerebellar (ipsilateral lesion)
Vestibular (contralateral lesion)
Peripheral vestibular - Meniere’s, acoustic neuroma, labyrinthitis, vestibular neuritis (vertigo without deafness or tinnitus)
Central vestibular - Stroke/SOL/MS, encephalitis

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15
Q

Investigations for a stroke

A

CT head for consideration of thrombolysis
ECG for AF (+/- 24hr tape for paroxysmal AF)
Echo for structural heart disease
Carotid doppler for stenosis and consideration of carotid endarterectomy

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16
Q

Contraindications for thrombolysis

A

Onset of sx >4.5hrs ago (unless also considering thrombectomy)
Seizures at presentation
Ischaemic stroke or head injury in the last 3 months
BP >180/110
Previous intracranial bleed
Active bleeding;
Surgery or major trauma (incl CPR) within last 2wks
Non-compressible arterial puncture within last wk
LP in prev 7/7

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17
Q

Causes of a proximal myopathy

A

Endocrine - Cushings

Polymyositis / dermatomyositis

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18
Q

Indications for thrombectomy

A

Thrombectomy with thrombolysis: sx onset of acute ischaemic stroke within past 6hrs and confirmed occlusion of proximal anterior circulation seen in CTA/MRA

Thrombectomy +/- thrombolysis: for people last known to be well within 6-24hrs with sx of acute ischaemic stroke and confirmed occlusion of proximal anterior circulation seen in CTA/MRA AND potential to salvage brain tissue as assessed by MRI DWI or CT

Those with previously good function (pre-stroke functional status of less than 3 on the modified Rankin scale and a score of more than 5 on the National Institutes of Health Stroke Scale (NIHSS))

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19
Q

Indications for a decompressive hemicraniectomy

A

Within 48hrs of sx onset for people with acute stroke who meet all of the following criteria:

large infarction in MCA territory (>50% on CT)
Score above 15 on the NIHSS

Decreased GCS (score of 1 or more on item 1a of the NIHSS (rousable by minor stimulation, or worse)

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20
Q

What are the features of Friedrich’s ataxia

A 
Cerebellar sx
Sensory ataxia 
Cardiac disease
Ophthalmoplegia 
Nystagmus
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21
Q

Unilateral foot drop
Causes
Other features to look for

A

Other features:
Pes cavus
Wasting
Areflexia

Levels - spine, sciatic, common peroneal, peripheral neuropathy

Causes:

L4/5 radiculopathy - weakness of inversion and eversion - trauma, disc herniation

Sciatic nerve damage - hip surgery

Common peroneal nerve palsy - trauma, compression, leprosy, polio

Peripheral neuropathy - DM, CIDP, GBS, Charcot Marie Tooth disease

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22
Q

Contraindications for rapid BP lowering in stroke

A

Underlying structural cause (for example, tumour, arteriovenous malformation or aneurysm)

GCS <6

are going to have early neurosurgery to evacuate the haematoma

have a massive haematoma with a poor expected prognosis

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23
Q

Roots of the median nerve

A

C6 - T1

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24
Q

Causes of a bilateral foot drop

Causes
Other features to look for

A

Other features:
Pes cavus
Wasting
Areflexia

Levels - spine, sciatic, common peroneal, peripheral neuropathy

Causes:
1 - peripheral neuropathy - DM, CIDP, Charcot Marie Tooth, leprosy

2 - neuromuscular - inclusion body myositis, MND, myotonic dystrophy - distal weakness

3 - Cauda equina

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25
Mx of myasthenia
ACEi - pyridostigmine SE - anticholinergic - dry mouth, urinary retention Steroids followed by steroid sparing agents Acutely - FVC monitoring with steroids +/- IV Ig
26
Features of ataxia telangiectasia
Ataxia - cerebellar Telangiectasia Delayed motor development
27
Causes of peripheral neuropathy
Diabetes mellitus Alcohol Drugs - nitrofurantoin, amiodarone, isoniazid, vincristine Vitamin deficiencies - B1/6/12 Immune - CIDP, GBS, ANCA positive vasculitis, Sarcoidosis CTD - SLE, Sjogrens, RA Amyloidosis Paraneoplastic - either solid tumour or paraproteinaemia related (myeloma) Hypothyroidism and uraemia Rare / heritable causes - HSMN
28
Features of spinocerebellar ataxia
Cerebellar signs Peripheral neuropathy UMN signs Ophthalmoplegia AD inheritance - CAG trinucleotide repeat expansion
29
Ddx of chorea like movements
``` Sydenhams chorea SLE Vasculitis Huntingtons Hyperglycaemia Polycythaemia ```
30
Causes of a bilateral LMN VIIth nerve palsy | What else should be checked for
``` Bilateral Bells GBS Sarcoidosis Myaesthenia gravis MND Lyme disease ```
31
``` GBS What antibody is present Causes Pattern of CF Important ix Mx ```
Anti-GM1 Post-infection, malignancy, vaccination Ascending weakness and parasthesiae, autonomic dysfunction FVC LP - normal WCC but raised protein Nerve conduction studies IVIg / plasma exchange acutely Supportive mx
32
Features of Frierich's ataxia
``` Sensory loss due to loss of dorsal root ganglion cells and peripheral nerve fibres Motor impairment (loss of motor pathways) - bilateral spastic paraparesis Cerebellar signs (degeneration of spinocerebellar tracts) ``` ``` Young onset Wasting, deformities - pes cavus Broad gait Cerebellar features UMN signs due to spinal motor degeneration Sensory loss (dorsal columns) Decreased reflexes with upgoing plantars ``` Other features: Optic atrophy HOCM - murmur
33
Causes of bilateral ptosis
``` Myasthenia gravis Myotonic dystrophy Oculopharyngeal dystrophy Chronic progressive external ophthalmoplegia (a/w Kearns Sayre) Congenital Bilateral Horners Syringomyelia ```
34
What is the distribution of signs in Wallenberg syndrome Which vessel is affected
Lateral medullary syndrome Posterior inferior cerebellar artery ``` Ipsilateral: Horners - SNS loss Facial sensation loss (CN5) Vertigo (CN8) Dysphagia (CN 9 and 10) Ataxia (cerebellum) ``` ``` Contralateral: ST loss (decussates lower down) ```
35
Causes of absent ankle reflex with upgoing plantars
SACD Hereditary cerebellar ataxia - Friedrich's Spinocerebellar ataxias MND Taboparesis (neurosyphilis) Mixed conditions - eg DM with cervical myelopathy
36
What are the features of myotonic dystrophy
Long drooping face Unilateral or bilateral ptosis Frontal balding Muscle wasting of the face and shoulders. Cataracts Slurred speech - dysphagia and dysarthria. Poor ability to relax post contraction (myotonia) Hypo-reflexia Distal muscle weakness (although type II disease presents later with proximal weakness) Cardiac features - heart block, cardiomyopathy Diabetes mellitus Gonadal atrophy with preserved secondary sexual characteristics
37
Red flags for non-length dependence of peripheral neuropathy
Proximal weakness with preserved distal power Asymmetry in sensation and motor function Suggests inflammatory cause (GBS / CIDP) over length dependent processes such as alcohol or diabetes
38
Causes of predominantly sensory peripheral neuropathy
D - diabetes D - deficiencies (B vitamins) D - drugs - linezolid, chemotherapeutics (vincristine) D - drink (alcohol)
39
What does weakness with normal reflexes indicate
Lesion at the level of the NMJ or muscle itself NMJ - myasthenia Muscle - myopathy
40
What features can be looked for in the CN exam in support of myasthenia
Bilateral fatiguable ptosis | Complex ophthalmoplegia
41
Name given to syndrome of ipsilateral CN3 palsy and contralateral hemiparesis
Webers | Mid-brain stroke
42
Features of pseudo bulbar palsy Causes
``` Monotonous slurred speech, dysarthria Dribbles from mouth Cannot protrude tongue Absent palatal movement Emotionally labile Exaggerated jaw jerk ``` ``` Causes: Bilateral stroke of internal capsule (commonest) MS MND SOL - brainstem tumour Traumatic head injury ```
43
Txs for Parkinsons disease
L-dopa in combination with peripheral DOPA decarboxylase inhibitors carbidopa or benserazide Entacapone (peripheral COMT inhibitor) DA agonists - ropinerole MAOi - selegiline For PD dementia - rivastigmine or amatadine For tremor predominant PD - add on anticholinergic procyclidine
44
Causes of chorea (5)
Rheumatic fever - syndenhams chorea (ask about sore throat) Huntingtons - ask about FHx Drugs - anti-psychotics Vascular lesions / SOL in subthalamic nucleus (tends to be unilateral) SLE
45
Mx of MND
MDT - PT/OT and neurologist Communication aids SALT with assessment for feeding support Spirometry and early morning ABG for respiratory support Riluzole is only disease-modifying tx
46
Causes of a unilateral LMN VIIth nerve palsy | What else should be checked for
``` Bells palsy Ramsay Hunt syndrome Acoustic neuroma / meningioma (look for involvement of Vth, VIth, VIIth, VIIIth nerves, cerebellar signs and loss of taste on anterior 2/3 of the tongue). Parotid tumour Pontine lesion ``` Any cause of mono neuritis multiplex - DM, vasculitis, sarcoid Check ipsilateral ear for signs of Herpes Zoster
47
Perioral fasciculations are pathognomonic of which condition
Kennedys disease Hereditary spinomuscular atrophy due to X-linked recessive mutation in androgen receptor gene LMN affected only - proximal weakness and fasciculation May be signs of androgen insensitivity - gynaecomastia
48
Causes of bulbar palsy
LMN lesion ``` MND Syringobulbia GBS Poliomyelitis SOL - skull base or retropharyngeal ```
49
Investigations for myasthenia
Anti-AChR antibodies If negative, anti-MUSK antibodies Nerve conduction studies for decremental response CT chest for thymoma
50
Causes of wasting of the small muscles of the hands | Other features o/e
Wasting - thenar and hypothenar eminence Ext at MCP joints, flexion at IP joints Dorsal guttering Causes: Anterior horn cells of C8/T1: cord compression, MND, syringmyelia, CMT disease, old polio Root lesion at C8/T1: Cervical spondylosis, tumour at C8/T1 (neurofibroma) Brachial plexus: Cervical rib, Pancoast's tumour, trauma (Klumpke's palsy) Combined ulnar and median nerve lesions Arthritis causing disuse atrophy (RA) Cachexia
51
Features and causes of a spastic paraparesis
Bilateral increased tone and weakness Hyper-reflexia, upgoing plantars and clonus Brain Cerebal palsy, parasaggital meningioma Spinocerebellar degeneration ``` Spine MS (and transverse myelitis) Cord compression - SOL, disc B12 deficiency - SACD Trauma MND Hereditary spastic paraparesis Tropical spastic paraparesis (HTLV1) ```
52
Causes of mono neuritis multiplex
``` DM Vasculitis - Churg Strauss, Wegener's Sarcoid Polyarteritis nodosa SLE Amyloidosis ```
53
Features of a common peroneal nerve palsy
Inspection Wasting of anterior and peroneal parts of the leg Motor Achilles reflex spared (via S1) Weak dorsiflexion - ask to walk on heels Foot eversion lost, foot inversion spared Weakness of first toe dorsiflexion - extensor hallux longus Sensory Anaesthesia over the anterior (dorsal) surface of the leg and foot (deep and superficial peroneal nerves) Sparing of sensation over the medial side of the foot (saphenous branch of the femoral nerve) and lateral side of the foot (sural branch of the tibial nerve)
54
Features of Miller Fisher syndrome | Antibody
Ophthalmoplegia Ataxia (cerebellar) Areflexia Anti-GQ1b antibodies
55
Ddx of isolated LMN signs with normal sensation
Motor neurone disease Multifocal motor neuropathy (extremities tend to be affected first - anti-GM1 antibodies, treatable with IVIg) Progressive muscular atrophy (distal weakness before proximal) Hereditary spinal muscular atrophies Kennedy disease (rare) - androgen insensitivity
56
Acute mx of MS
High dose IV steroids | Consider SE - hyperglycaemia, gastric ulcer (give PPI), warn of sleep disturbance
57
Causes of bulbar speech
MND Bulbar palsy Pseudo-bulbar palsy (incl vascular disease and MS) Brainstem vascular disease and brainstem stroke
58
Causes of an asymmetric spastic paraparesis
Looks for contralateral sensory change - consider Brown Sequard syndrome Check for sensory level ``` Ddx: Compression - disc profusion, tumour MS Vasculitis - SLE, sarcoid Trauma MND Infection - HIV Nutrition - B12, Cu Rare - hereditary spastic paraparesis ```
59
What is the most important ddx for MND
Cervical cord compression
60
What features are suggestive of Progressive Supranuclear Palsy
Axial rigidity and imbalance - falls (without postural hypotension) Impairment of vertical saccades Confusion / dementia
61
Indications for rapid BP control in stroke
Haemorrhagic stroke with sx onset within last 6hrs - lower BP if >150 Haemorrhagic stroke with sx onset beyond last 6hrs Aim systolic 130-140
62
Symptoms of thalamic syndrome | What vessel is affected
Vessel: posterior cerebral artery Signs: Hemisensory loss of face and body contra laterally - all modalities Increased pain sensation over the same distribution
63
What are the causes of cerebellopontine angle syndrome What is the correct ix
Acoustic neuroma - unilateral tinnitus or deafness Meningioma Ix - MRI
64
Causes of Horners What else should you examine for Key ix
Sympathetic trunk damage causing Anhidrosis, ptosis, miosis Causes: Central (hypothalamic / brainstem) - stroke (Wallenberg syndrome), SOL, MS, trauma, encephalitis, syringomyelia Will cause anhidrosis of the face, neck, arm and trunk Neck (cervical cord and T1; pre-ganglionic) - trauma (to brachial plexus), cervical rib, Pancoast tumour, thyroidectomy Anhidrosis of face only Carotid (post-ganglionic) - aneurysm, endarterectomy, dissection, cavernous sinus thrombosis No anhidrosis What else to examine for: Apical chest signs Neck - scars, aneurysm Hands - wasting Key ix: MRI head and arotid
65
What features in addition to Parkinsonism are suggestive of specific Parkinsons plus syndromes
Gaze paresis - PSP Autonomic dysfunction and cerebellar signs - MSA Cognition and visual hallucinations - LBD
66
Causes of a predominantly sensory peripheral neuropathy
Diabetes Toxic - alcohol Drugs - abx, chemotherapy, antiviral B vitamin deficiencies
67
Ix to send in suspected myasthenia gravis
``` Anti-AChR and anti-MUSK antibodies TFT CK to exclude myopathies Spirometry Nerve conduction / EMG Imaging for thymoma ```
68
Cervical myelopathy
Compression at cervical cord level causing mixed LMN and UMN in the upper limbs, depending on the level Causes: Cervical spondylosis Spinal cord SOL
69
Tx of MS
MDT approach ``` Symptomatic tx Bladder - anticholinergics Spasticity - baclofen Neuropathic pain Depression Fatigue ``` ``` Disease modifying therapy Beta inferon Glatiramer Fingolimod Natalizmab Cladiribine ```
70
Non motor sx of Parkinsons
``` Anosmia Sleep disturbance and REM sleep disorder Constipation Autonomic symptoms - postural hypotension, erectile dysfunction, urinary incontinence Depression ```
71
Features on examination to help diagnose cause of cerebellar ataxia
Associated PN - alcohol or spinocerebellar disease Upgoing plantars - spinocerebellar disease Vascular risk factors Features of malignancy - paraneoplastic syndrome Medications FHx
72
Causes of parkinsonism
``` Drugs - antipsychotics, antiemetics Idiopathic Parkinson's disease Progressive supra nuclear palsy Multisystem atrophy Lewy body dementia ```
73
Features of a syringobulbia
Cerebellar signs - Nystagmus, ataxia Facial dissociated sensory loss Bulbar palsy - speech, dysarthria, wasted faciculating tongue, weakness of sternomastoids and trapezius
74
Causes of a spastic paraparesis and features on examination
``` Features: Bilateral increased tone Weakness Hyper-reflexic and upgoing plantars Scissoring gait ``` ``` Causes - brain and spinal cord: Cerebal palsy MS Cord compression - check for sensory level, back pain, no signs above level Cervical spondylosis Trauma MND Disc prolapse ``` ``` Rarer: Spinal artery thrombosis HTLV - tropical spastic paraparesis Hereditary spastic paraplegia Vasculitis ```
75
What are the modes of sensation and what do they sense
Spinothalamic - sharp touch / pain, temperature | Dorsal column - vibration and proprioception, light touch
76
Completing PD exam
Cerebellar signs Autonomic signs Cognition - Lewy body dementia Assess whether under or over medicated
77
Causes / associations of carpel tunnel syndrome
``` Idiopathic Occupational RA and OA Pregnancy Acromegaly Hypo-thyroid and diabetes Trauma ```
78
Ix of carpel tunnel
Nerve conduction studies | HbA1c, IGF1, TFT
79
Causes of a proximal weakness
``` Polymyositis / dermatomyositis Cushings and steroid use Malignancy associated Alcoholism Diabetic amyotrophy Muscular dystrophy ```
80
Multifocal motor neuropathy Features Tx
Features: Progressive LMN signs, starting distally - demyelination No sensory involvement Responds to IV Ig and immunosuppression
81
Kennedy disease
X-linked mutation in androgen receptor causing androgen insensitivity Features: LMN signs, classically affecting proximal and bulbar muscles Perioral fasciculation Signs of androgen insensitivity - gynaecomastia and testicular atrophy
82
Primary lateral sclerosis
UMN signs only
83
Primary muscular atrophy
LMN signs only, typically distally

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