Neurology Flashcards
1
Q
What does DANISH stand for?
A
DANISH Dysdiadokochinesia/Dysmetria Ataxic gait Nystagmus Intention tremor Slurred staccato speech Hypotonia
2
Q
What are some causes of cerebellar syndrome?
A
DAISIES Demyelination Alcohol Infarction SOL Inherited (wilsons, friedrichs) Epilepsy medications (phenytoin) Systemic: MSA
3
Q
Cerebellar signs are ipsi or contralateral?
A
Ipsilateral
4
Q
Lesion of the cerebellar vermis causes what picture?
A
Ataxic trunk and gait with normal arms
5
Q
Cerebellar nystagmus versus vestibular nystagmus?
A
Cerebellar nystagmus: fast phase towards the lesion
Vestibular nystagmus: Fast phase away from the lesion
6
Q
Hx questions for cerebellar syndrome?
A
MS - parasthesia, visuals, weakness Alcohol Infarction (onset, RFs) Schwannoma - hearing loss, tinnitus, vertigo FH DH
7
Q
Ix for cerebellar syndrome?
A
ECG - arrhythmia Bloods - Etoh (FBC, U&E, LFT), thrombophilia (clotting), Wilsons (low caeruloplasmin) CSF - oligoclonal bands MRI Pure tone audiometry
8
Q
Mx for cerebellar syndrome?
A
General: MDT, CV risk management, reduce ETOH
Specifics:
MS - methylpred
EtOH - Pabrinex, tapering chlordiazepoxide
Infarct - thrombolysis
Schwannoma - surgery
Wilson’s - penicillamine
9
Q
What causes Lateral Medullary Syndrome (LMS)?
A
Vestibular artery or PICA occlusion
10
Q
What are the signs of LMS?
A
DANVAH Dysphagia Ataxia Nystagmus Vertigo Anaesthesia Horner's (miosis, ptosis, anhidrosis)
11
Q
With which neurocutaneous syndrome are vestibular schwannomas associated
A
Neurofibromatosis type 2
12
Q
How might a vestibular schwannoma present?
A
Unilateral SN hearing loss, tinnitus, vertigo
Headache (raised ICP)
Ipsilateral CN 5,6,7,8 palsies and cerebellar sign
13
Q
What is the investigation of choice for vestibular schwannomas?
A
MRI of the cerebellopontine angle
14
Q
Von Hippel-Lindau key points?
A
Renal cysts Bilateral RCC Haemangioblastomas (cerebellar) Phaeochromocytomas Islet cell tumours
15
Q
What are the main features of Friedrich’s ataxia?
A
Pes cavus
Bilateral cerebellar ataxia
Leg wasting with areflexia
Loss of vibration and proprioception
16
Q
What are the features of Wilson’s disease?
A
CLANK Cornea - Kaiser Fleischer rings Liver - CLD Arthritis Neuro - PD, ataxia, psych Kidney - Fanconi's synd
17
Q
What gaits would you see in patients with a) Unilateral UMN signs and b) Bilateral UMN signs?
A
a) Circumducting (ex>flex)
b) Scissoring
18
Q
Causes of bilateral UMN signs (spastic paresis)
A
MS
Cord compression/trauma
Cerebral palsy
19
Q
Causes of unilateral UMN signs?
A
Stroke MS SOL Cerebral palsy Cord compression
20
Q
Diagnosis if mixed UMN and LMN signs?
A
MND
Rarely: Friedrichs, Subacute combined degeneration of the cord (B12 deficiency)
21
Q
Hx questions in UMN signs?
A
MS - tingling, eye probs, ataxia, other weakness
Cord compression - back pain, fever, weight loss
Trauma
FH
22
Q
Ix in UMN signs
A
MRI - cord and brain
MS - LP
Compression - FBC (infection), CXR
SCDC - B12, pernicious anaemia antibodies
23
Q
Mx for UMN signs?
A
Supportive - MDT, orthoses, mobility aids, baclofen for contractures
24
Q
Differentials for bilateral, symmetrical, distal neuropathy?
A
Charcot Marie tooth
Paraneoplastic
GB syndrome
25
Proximal myopathy differentials?
```
Inherited: Muscular dystrophy
Inflammation: Dermato/polymyositis
Endocrine: Cushings, acromegaly, thyrotoxicosis, osteomalacia
Drugs: EToH, statins, steroids
Malignancy: Paraneoplastic
```
26
Differentials for hand wasting?
```
Syringomyelia
MND
Klumpke's
Charcot Marie Tooth
Diabetes
```
27
Stroke secondary prevention protocol?
Start atorvastatin after 48 hours
Asp 300 for 2 weeks
Clopi 75 or Asp 75 or ticagrelor 200 used for maintenance
Warfarin/DOAC if AF
28
What might you find on examination of a patient with diabetic neuropathy?
Inspection: Finger pricks, PVD, Charcot joints
Motor: Bilateral loss of ankle jerks, foot drop (mononeuritis multiplex)
Sensory - Stocking distribution
29
Ix for diabetic neuropathy?
Full exam - fundi, CN, upper limb
Urine - glucose, ACR
Blood - HbA1c, glucose, U&Es
30
Mx for diabetic neuropathy?
MDT, good glycaemic control, neuropathic pain management (amytryptilline, gabapentin, capcasin cream etc)
31
What might you find on examination of a patient with Charcot Marie Tooth (CMT) disease?
Insp - pes cavus, distal muscle wasting, thickened nerves
Motor - high stepping gait, weak dorsiflexion, absent ankle jerks
Sensory - stocking
32
Ix for CMT?
Nerve conduction studies
| Genetic testing
33
Facial palsy syndromes accompanied by other CN involvement?
Pons -> Millard Gubler Syndrome (CN 6, 7, corticospinal tracts)
CPA (CN 5,6,7,8 + cerebellar signs)
34
Facial palsy differentials?
```
75% idiopathic Bell's
Vascular
MS
SOL
CPA mass
Parotid tumour
Ramsay Hunt (zoster) /Cholesteatoma
```
35
Hx questions to ask in facial nerve palsy/
Sx: Eye dryness, drooling, hyperacusis, ageusia
Cause: Onset (rapid in bells), rash or ear pain, DM, SOL signs, vertigo, tinnitus, diplopia, weakness, fever
36
Ix for facial nerve palsy?
```
Urine dip - glucose
Bloods - DM, VZV, Lyme, anti-ACh receptor antibodies
MRI of Posterior cranial fossa
LP
Audiometry
Nerve conduction studies
```
37
Mx of facial nerve palsies?
Prednisolone within 72 hours for 10 days + artificial tears and tape eyes closed at night
Valaciclovir if Ramsay Hunt suspected
38
What is a distinguishing feature of cholesteatoma?
Foul smelling white ear discharge
39
What else might you find on examination of a patient with facial anaesthesia?
Weak masseter and temporalis
Jaw jerk may be brisk (UMN) or absent (LMN)
Loss of corneal reflex (CN5)
40
What are some causes of facial anaesthesia?
Supranuclear, nuclear, peripheral
Supranuclear: Demyelination, Stroke, SOL
Nuclear: CPA lesion, LMS
Peripheral mononeuropathy: DM, sarcoid, vasculitis, cavernous sinus
41
What are the signs of Horner's syndrome?
```
PEAS
Ptosis
Enophthalmos
Anhydrosis
Small pupil
```
42
What are the differentials for Horner's syndrome?
Central, pre-ganglionic, post-ganglionic
Central - MS, LMS
Pre-ganglionic - Pancoast's tumour (T1), trauma (CVA insertion/endarterectomy)
Post-ganglionic - Cavernous sinus thrombosis
43
Causes of CN3 palsy?
Medical vs. Surgical
Medical: DM, MS, Weber's syndrome (CN3 + Contralateral hemiplegia)
Surgical: Raised ICP (uncal herniation), cavernous sinus thrombosis, PICA (+pain)
44
What are the salient points and important causes regarding the Argyll Robertson pupil?
Small irregular pupils which accomodate but dont react to light
Causes: Quaternary syphillis, DM
45
Salient features and important causes of RAPD/Marcus Gunn pupil?
Minor constriction to direct light with dilatation on moving light from normal to abnormal eye.
Causes: MS, glaucoma
46
Difference in field defect between pituitary adenoma and craniopharyngioma?
Pit adenoma: superior quadrantopia
| Craniopharyngioma: inferior quadrantopia
47
What might you find on examination of a patient with internuclear opthalmoplegia?
Failure of ipsilateral adduction
Nystagmus in contralateral abductin eye
Convergence preserved
48
What are some causes of internuclear opthalmoplegia?
MS (most common)
Infarction
Syringomyelia
Phenytoin toxicity
49
How would you interpret the results of Rinne's test?
Positive (normal) = AC>BC
| Negative = BC>AC, where true is conductive deafness and false is complete SNHL
50
How would you interpret the results of Weber's test/
Central= normal
| SNHL lateralises to normal ear
51
Interpret:
Weber - lateralises to the right
Rinne - positive bilaterally
Left sided sensorineural hearing loss
52
Interpret:
Weber - lateralises to the right
Rinne - negative on the right
Right sided conductive hearing loss
53
Interpret:
Weber - no lateralisation
Rinne - positive bilaterally
Normal OR bilateral sensorineural hearing loss
54
Interpret:
Weber - no lateralisation
Rinne - negative bilaterally
Symmetrical conductive hearing loss
55
What are some causes of a conductive hearing loss?
WIDENING
```
Wax/foreign body
Infection
Drum perforation
Extra (otosclerosis/trauma)
Neoplasia
INjury
Granuloma (sarcoid)
```
56
What are some causes of sensorineural hearing loss?
DDIVINITY
```
Developmnetal (Alports, TORCCH)
Degenerative - presbyacusis
Infection - VZV, measles, meningitis
Vascular - Stroke
Inflammation - Vascitis/Sarcoid
Neoplasia - CPA tumours
Injury
Toxins - Gent, Vanc, Furosemide, Aspirin
lYmph - Meniere's
```
57
Define the following terms:
Dysphonia
Dysarthria
Dysphasia
Dysphonia: Impaired sound production
Dysarthria: Impaired articulation of sounds into words
Dysphasia: Impairment of language
58
How do you test each of:
Dysphonia
Dysarthria
Dysphasia
```
Dysphonia: Bovine cough, soft voice
Dysarthria: Yellow lorry, baby hippopotamus, the Leith police dismisses us
Dysphasia:
Name three objects - nominal
Three stage command - receptive
Repeat back - conductive
```
59
What are the following tracts responsible and where do their fibres decussate?
a) Dorsal columns
b) Lateral spinothalamic
c) Lateral corticospinal
a) Fine touch, vibration, proprioception - Decussation in medulla
b) Pain and temperature - Decussation at entry level
c) Motor - Pyramidal decussation at ventral medulla
60
What is Beck's syndrome?
Anterior spinal artery infarction affecting the ventral 2/3 of the cord, resulting in para/quadraparesis (depending on spinal level), impaired pain and temperature but touch and proprioception are preserved
61
Differentials for muscle weakness?
Work anatomically from brain to muscle
Brain - Vascular, MS, SOL, infection
Cord - Vascular, MS, trauma
Anterior horn - MND, polio
Roots - Spondylosis, cauda equina, carcinoma
Motor nerves - compression, GBS, CMT
NMJ - GBs, Myasthenia, botulism
Muscle - Steroids, poly/dermatomyositis, inherited musculodystrophies
62
Differentials for hand wasting?
Work anatomically from cord to muscle
Cord - MND, polio, syringomyelia
Roots (C8, T1) - compression
Brachial plexus - compression (cervical rib, Pancoast), klumpke's palsy
Neuropathy- General (CMT), mononeuritis (DM), compressive
Muscle - RA (through disuse), myotonic dystrophy, cachexia
63
Differentials for gait disturbance?
Motor vs sensory
Motor
Basal ganglia - shuffling (Parkinsonism)
Bilat UMN - scissoring (cord comp/trauma or CP/MS cerebrally)
Unilat UMN - circumducting (CVA, MS, SOL)
Bilat LMN - (footdrop) (CMT, GBS, corda equina)
Unilat LMN - high stepping (common peroneal lesion, L5 root lesion, DM)
UMN + LMN =MAST (MND, ataxia (Friedrichs), SCDC, tabes dorsalis)
Sensory
Vestibular - Romberg +ve (Meniere's, labyrinthitis, brainstem lesion)
Cerebellar - ataxic (EtOH, infarction)
Proprioceptive loss (B12 deficiency, peripheral neuropathy)
Visual loss
Other
Myopathy, MG/LEMS, postural hypotension, arthritis
64
What are the differentials for black out?
CRASH
Cardiac: Stokes Adams attack
Reflexes: Vagal - vasovagal, cough, micturation, effort etc. or Sympathetic underactivity (hypovolaemia, drugs, autonomic neuropathy, pooling)
Arterial: Vertebrobasilar insufficiency (CVA, TIA), shock, hypertension (phaeo)
Systemic: Metabolic (hypoglycaemia), resp (hypoxia/hypercapnia), blood (anaemia)
Head: Epilepsy, drop attacks
65
What is the definition of a postural drop?
Anything greater than 20/10 after 3 minutes
66
What investigations might you do after a collapse?
ECG (+24hr ECG/BP), bloods (UNE, FBC, glucose), tilt table, EEG, echo, CT
67
CRASH
C
Trigger, before, during, after, Ix
```
Trigger - Exertion, drug
Before - palps, chest pain, dyspnoea
During - pale, slow/absent pulse, some clonic jerks
After - rapid recovery
Ix - ECG + 24hr ECG, Echo
```
68
CRASH
R
Trigger, before, during, after, Ix
Trigger - prolonged standing, heat, stress, fatigue
Before - gradual onset, nausea, pallor, sweating, CANNOT occur when lying down
During - pale, grey, clammy, clonic jerks and incontinence may occur but no tongue biting
After - rapid recovery
Ix - tilt table
69
CRASH
A
Trigger, before, during, after, Ix
Trigger - arm elevation, migraine, nothing
Before - gradual onset, nausea, pallor, sweating
During - pale, grey, clammy, clonic jerks and incontinence may occur but no tongue biting
After - rapid recovery
Ix - imaging
70
CRASH
S
Trigger, before, during, after, Ix
```
Trigger - hypoglycaemia
Before - tremor, hunger, sweating, light headedness
During - as for vasovagal
After - as for vasovagal
Ix - BM
```
71
CRASH
H - epilepsy
Trigger, before, during, after, Ix
Trigger - flashing lights, fatigue, fasting
Before - aura, strange feeling deja vu, smells, lights, automatisms
During - tongue biting, incontinence, stiffness, jerking, eyes open, cyanosis, hypoxia
After - headache, confusion, drowsy
Ix - EEG, raised prolactin at 10-20 minutes
72
CRASH
H - drop attacks
Trigger, before, during, after, Ix
Trigger - nil
Before - no warning
During - sudden weakness of legs causes older woman to fall to ground
After - no post ictal phase
73
Differentials of vertigo?
IMBALANCE
Infection/injury - Ramsay hunt, labyrinthitis, trauma
Meniere's - recurrent vertigo with fluctuating SNHL + tinnitus
BPV
Aminoglycosides/furosemide
Lymph
Arterial - migraine, CVA
Neoplasm - vestibular schwannoma
Central lesion - demyelination, tumour, infarct
Epilepsy - complex partial
74
What are the different types and causes of tremor?
RAPID
Resting: Abolished on movement, PD, Da agonists
Action/Postural: Worse on movement, causes inc BET, endocrine, ETOH withdrawal, beta-agonists, anxiety
Intention: Irregular, past pointing, cerebellar damage
Dystonic: mostly idiopathic
75
What would you give to treat acute dystonia?
Procyclidine (antimuscarinic)
76
What are some reversible causes of dementia?
```
Infective (HSV, cysticercosis)
Vascular (chronic subdural)
Inflamm (SLE, sarcoid)
Neoplasia
Nutritional (thiamine, B12/fol, B3)
Hypothyroid
Hypoadrenal
Hypercalcaemia
Normal pressure hydrocephalus
```
77
What are the differentials for delirium?
DELiRIUMS
```
Drugs: opioids, sedatives, ldopa
Eyes, ears, etc
Low O2 states (MI, CVA, PE)
Infection
Retention
Ictal
Under hydration/nutrition
Metabolic (DM, post op, sodium, uraemia)
Subdural haemorrhage
```
78
What investigations would you do for delerium?
Bloods: FBC, LFT, U&E, CRP, glucose, ABG
ECG
Urine dip
Septic screen
79
Acute headache differentials?
VICIOUS
Vascular - haemorrhage, infarction, venous (sinous thrombosis)
Infection - Men/enceph/abscess
Compression - Tumour, pituitary
ICP - Spontaneous intracranial hypotension (worse on standing)
Ophthalmic - Acute glaucoma
Unknown
Systemic - HTN, infection (sinusitis), toxins
80
Chronic headache differentials?
MCD TINGS
Migraine
Cluster headaches
Drugs - analgesia, caffeine
```
Tension Headaches
ICP
Neuralgia (trigeminal)
Giant cell arteritis
Systemic (HTN, uraemia)
```
81
What are the features of venous sinus thrombosis?
Headache, vomiting, seizures, vision impairment, papilloedema
82
What is the acute and prophylactic management of cluster headaches?
Acute: 100% O2 + sumatriptan
Prophylaxis: Verapamil, topiramate
83
What are the signs and management of temporal arteritis?
Unilateral scalp pain/tenderness with thickened, pulseless temporal artery. May also have jaw claudication, amaurosis fugax. Raised ESR.
Management is with 60mg PO pred for 5-7 days guided by symptoms and ESR. Also give PPI with bisphosphonate
84
What is the acute and prophylactic management of migraines?
```
Acute:
1st - Paracetamol + metoclopramide
2nd - NSAID + metoclopramide
3rd - Rizatriptan (CI in IHD and with SSRIs)
4th - Ergotamine (5-HT1b block)
```
Prophylaxis:
1st - Avoid triggers
2nd - Propranolol, topiramate
3rd - valproate, gabapentin
85
What are Berry aneurysms associated with, and what type of haemorrhage do they cause when they rupture?
PKD, CoA, Ehlers Danlos
| Subarachnoid
86
What investigations would you do to diagnose a SAH?
CT - detects 90% in first 48hrs
| LP - Xanthochromia
87
What is the management of a SAH?
Frequent neuro obs
Maintain SBP > 160
Nimodipine for 3 weeks to reduce cerebral vasospasm
Endovascular coiling
88
What are the complications of a SAH?
Rebleeding - 20%
Cerebral ischaemia
Hydrocephalus (arachnoid granulation blockage)
Hyponatraemia - common
89
What is the Miller Fischer variant of GB syndrome?
Opthalmoplegia + ataxia + areflexia
90
What are some common infective causes of GB syndrome?
Campylobacter, mycoplasma, CMB, EBV, vaccines
91
What are the salient features of GB syndrome?
```
SYMMETRICAL, ascending flaccid weakness with lower motor neuron signs.
Proximal > distal
Breathing and bulbar problems
Back pain is common
Parasthesia in extremities
Autonomic neuropathy
```
92
What is the management of GB syndrome?
Supportive: Airway, analgesia, autonomic (inotropes/catheter), antithrombotic
Immunosuppression: Plasmapheresis and IVIG
Physiotherapy to prevent contractures
93
What is the prognosis of GB syndrome?
85% make a complete recovery
94
What are the clinical features of Charcot Marie Tooth disease?
Nerves: Thickened, enlarged
Motor: Foot drop, weak dorsiflexion, absent ankle jerks, symmetrical distal muscle atrophy, pes cavus
Sensory: Stocking loss, some experience neuropathic pain
95
What are the salient points regarding polio?
RNA virus affecting anterior horn cells causing fever sore throat and myalgia.
0.1% develop paralytic polio characterised by:
Asymmetric LMN paralysis with NO sensory involvement
96
What are the clinical features of myasthenia gravis?
Increasing muscle fatigue (ptosis, diplopia, voice softening, myasthenic smile, head droop, foot drop)
Normal tendon reflexes
97
What investigations would you do if myasthenia is suspected?
(Tensilon test - edrophonium IC should improve power) Still done?
Anti-AChR Abs in 90%
EMG - reduced response to a train of impulses
Reduced FVC
TFTs
98
What is the management of myasthenia?
Symptom control - Pyrostigmine
Immunosuppression - pred if relapse
Thymectomy - in young people
99
What should be done in the event of a myasthenic crisis?
Plasmapheresis and IVIg
| Monitor FVC and provide support if <20
100
What antibodies are characteristic of myasthenia and Lambert Eaton syndrome?
Myasthenia - anti nAChR
| LEMS - anti VGCaC
101
What are the salient features of botulism?
Toxin which prevents ACh vesicle release
Sescending flaccid paralysis with no sensory change
Rx - BenPen and antiserum
102
Describe Brown-Sequard syndrome
Hemisection of the spinal cord resulting in ipsilateral UMN signs, fine touch and proprioceptive loss with contralateral loss of pain and temperature sensation
103
What is the strongest risk factor for an acute ischaemic stroke?
Hypertension
104
What are the features of a total anterior circulation stroke?
ALL 3 of the following:
1. Contralateral hemiplegia/paralysis
2. Contralateral homonymous hemianopia
3. Executive dysfunction (dominant= dysphasia, non-dominant= hemispatial neglect)
105
What are the features of a partial anterior circulation stroke?
Two of the 3 TACS criteria
106
What are the features of a posterior circulation stroke?
Any of the following:
1. Ipsilateral cerebellar signs
2. Contralateral homonymous hemianopia
3. Brainstem syndrome
107
What are the features of a lacunar infarct?
Crucially, there is absence of cortical dysfunction, visual dysfunction, drowsiness or brainstem signs.
There may be one of 5 syndromes:
1. Pure motor (commonest)
2. Pure sensory
3. Mixed sensorimotor
4. Dysarthria
5. Ataxic hemiparesis
108
What are the features of a brainstem infarction, and what structures do they correlate to?
```
Hemi-quadriparesis - corticospinal tracts
Conjugate gaze palsy - CN3
Horner's syndrome - sympathetic trunk
Facial weakness - CN7
Nystagmus, vertigo - CN8
Dysphagia/dysarthria - CN9+10
Dysarthria/ataxia - Cerebellum
Reduced GCS - RAS
```
109
What are some alternative differentials for strokes?
```
Head injury +- haemorrhage
Abnormal glucose control
SOL
Hemiplegic migraine
Encephalitis
Opiate overdose
```
110
What is the acute NON-medical management of stroke?
```
ABCDE approach
Plce NBM
Maintain glucose between 4-11
Keep BP below 185/110 (caution)
Frequent neuro obs
Urgent CT/MRI (DW if poss)
```
111
What is the acute medical management of acute ischaemic stroke?
If CT confirms ischaemic stroke and within 4.5 hrs of symptom onset, perform thrombolysis with alteplase
Also give 300mg aspirin + PPI
112
What is the secondary prevention protocol following an acute ischaemic stroke?
Start statin after 48 hours
Ssp/clopi 300mg for 2 weeks followed by
1st line; Clopi 75
2nd line; Asp 75 + ticagrelor 200mg BD
Use Warfarin instead if cardioembolic stroke, or patient has chronic AF
Consider carotid endarterectomy if good recovery and ipsilateral stenosis >70%
113
What is involved in stroke rehabilitation?
MENDS
MDT - physio, SALT, dietician, OT, spec nurses, neurologist, family
Eating - regular screening swallows, screen for malnutrition
Neurorehab - physio and speech therapy
DVT prophylaxis
Sores - avoid avoid avoid
114
What investigations would you do following a suspected TIA?
```
Bloods - FBC, U&E, LFT, BM, ESR, lipids
CXR
ECG
Echo
?Brain imaging
Carotid doppler +_ angiography
```
115
What is the management plan following a TIA?
1. Anticoagulate - same protocol as for stoke
2. Cardiac RF control - BP, lipids, DM, smoking, exercise, reduce salt intake
3. ABCD2 to assess risk of subsequent stroke
116
What is the ABCD2 score and when is it used?
Used to predict risk of subsequent stroke following a TIA
Age>60
BP>140/90
Clinical Fx (unilateral weakness or speech disturbance)
Duration (>1hr scores 2 points, 10mins-59 mins scores 1)
Diabetes
117
Which vessels are affected in a subdural haemorrhage?
Bridging veins between the cortex and venous sinuses
118
What is the management approach to an extradural haematoma?
1. Provide neuroprotective ventilation (100% O2 aiming for CO2 3.5-4)
2. Consider mannitol 1g/kg IV
3. Craniectomy
119
How might a venous sinus thrombosis present?
Insidiously over days-weeks, with signs of raised ICP, and proptosis/eyelid oedema/opthalmoplegia in the case of cavernous sinus thrombosis
120
How might a cortical vein thrombosis present?
Over days, typically with stroke like focal symptoms. May also have thunderclap headache and focal seizures
121
What are some causes of intracranial venous thrombosis?
```
Pregnancy
COCP
Trauma
Dehydration
Malignancy
Thrombophilia
```
122
What are Kernig's and Brudzinski's signs in the context of meningitis?
Kernigs - pain on hip flexion
| Brudzinskis - neck flexion instigates lifting of legs
123
What is the antibiotic management of bacterial meningitis?
Community - 1.2g BenPen IM
If <50 - Ceftriaxone 2g IM/IV BD
If >50, add ampicillin
If ?viral -> aciclovir
124
How might an encephalitis present?
Infectious prodrome followed by bizarre behaviour, confusion, reduced GCS, headache, focal signs, seizures etc
125
What investigations would you do for a suspected encephalitis?
Bloods - FBC, cultures, viral PCR, malaria film
Contrast CT - bilateral temporal lobe involvement suggests HSV
LP - Raised protein, lymphocytes
EEG
126
What is the management of encephalitis?
Aciclovir infusion stat
Supportive measures in HDU
Phenytoin for seizures
127
What are some predisposing factors for a cerebral abscess?
```
Prev infection
Skull fracture
Congenital heart disease
Endocarditis
Bronchiectasis
Immunosuppression
```
128
What are some causes of epilepsy?
2/3 are idiopathic
Congenital - NF, TS, CP
Acquired - Infection, vascular, trauma, SOL, MS, sarcoid
Non-epileptic - withdrawal, metabolic, raised ICP, infection, eclampsia, pseudoseizures
129
What do the terms simple and complex refer to regarding seizures?
```
Simple = awareness unimpaired
Complex = awareness impaired
```
130
What are the 5As of complex partial seizures?
```
Aura
Autonomic
Awareness lost
Automatisms
Amnesia
```
131
What are the features of a petit mal seizure?
ABSENCES
```
ABrupt onset
Short - <10s
Eyes - glazed
Normal - investigations
Clonus/automatisms
EEG - 3Hx spike and wave
Stimulated by hyperventilation
```
132
What are some localising features to seizures arising from each of the cortical lobes?
Temporal - automatisms, deja vu, delusions, hallucinations
Frontal - motor Fx (Jacksonian march, arrest, Todd's palsy)
Occipital - Visual phenomena
Parietal - numbness, parasthesia
133
What investigations might you do following an unprovoked seizure?
```
Bloods - FBC, UnE, glucose, prolactin (raised @10-20 mins if true seizure), AED levels
Urine - toxicology
ECG
EEG - supportive not definitive
MRI - not routine
```
134
What are first and second line drug managements for the following types of epilepsy?
1. Tonic clonic
2. Absence
3. Tonic/atonic/myoclonic
4. Focal +-2 gen
1. Valproate ->Lamotrigine
2. Valproate/Ethosuximide -> Lamotrigine
3. Valproate -> Levetiracetam
4. Lamotrigine -> Carbamazepine
135
What AEDs may be used in pregnancy?
Lamotrigine or carbamazepine
| 5mg Folic acid
136
What are 3 side effects of lamotrigine?
Skin rash ->SJS
Hypersensitivity reaction
Diplopia
137
What are the side effects of valproate?
ALPROATTTE
```
Appetite increase
Liver failure
Pancreatitis
Reversible hair loss
Oedema
Ataxia
Tremor, Teratogenicity, Thrombocytopaenia
Encephalopathy
```
138
Wha are 3 side effects of carbamazepine?
Aplastic anaemia
Skin reactions
SIADH ->hyponatraemia
139
What are 4 side effects of phenytoin?
Gingival hypertrophy
Hirsutism
Cerebellar syndrome
Peripheral sensory neuropathy
140
What is the first thing to do in status epilepticus?
Check BMs
141
What is the immediate management following head injury?
```
A-E approach
Look for lacerations, fractures, CSF leak, signs of skull base fracture, blood behind TM
C-spine tenderness
Head to to examination
Log roll
```
142
What are the indications for CT head in the context of head trauma?
BANGS LOC
```
Break in bone
Amnesia >30 mins
Neuro deficit/seizure
GCS <13 @any time or <15 2 hours after event
Sickness - more than one vomit
LOC
```
143
What are the two ways in which IIH may present?
As a SOL
| Visual - blurring, CN6 palsy, enlarged blind spot
144
What is the management of IIH?
```
Weight loss number 1
Acetazolamide
Loop diuretics
Prednisolone
LP shunt if necessary
```
145
What is the acute management of raised ICP?
```
A-E approach
Treat seizures and correct hypotension
Elevate bed to 40 deg
Neuropreotective ventilation
Mannitol or hypertonic saline
```
146
How might each of the types of brain herniation present?
Tonsillar - CN6 palsy, UMN signs, apnoea
Transtentorial/uncal - CN3 palsy, contralateral hemiparesis
Subfalcine - May compress ACA causing a stroke
147
What are the characteristic features of each of the Parkinsons- plus syndromes?
PSP - Postural instability, Speech disturbance, Palsy of vertical gaze
CBD - Aphasia, akinetic rigidity, dysarthria, apraxia
MSA - Autonomic dysfunction, cerebellar signs
LBD - Fluctuating cognition, visual hallucinations
148
What are some other causes of parkinsonism?
```
Dementia pugilistica
Infection: Syphillis, HIV, CJD
Vascular infracrtions
Antipsychotics, metoclopramide
Wilson's disease
```
149
What are the features of Parkinson's disease
TRAPPS PD
```
Tremor
Rigidity
Akinesia
Postural instability
Postural hypotension
Sleep disorders
Psychosis
Depression/Dementia
```
150
What are the side effects of L-DOPA?
DOPAMINE
```
Dyskinesia
On-off effect
Psychosis
Arterial BP decrease
Mouth dryness
Insomnia
Nausea
Excessive daytime somnolescence
```
151
What is the management of Parkinson's disease?
If biologically fit:
1. Da agonists e.g. ropinirole
2. MOA-B inhibitors e.g. rasagiline, selegiline
3. L-DOPA - co-careldopa
If biologically frail:
1. L-DOPA
2. MOA-B inhibitors
Other therapies
COMT inhibitors reduce end dose effect - e.g. Entacapone
Apomorphine is a potent Da agonist
Amantidine is useful for iatrogenic dyskinesias
Atypical antipsychotics where relevant
SSRIs
152
What is Lhermitte's sign and when is it seen?
Neck flexion causing shooting pains in trunk/limbs in MS patients
153
What is the acute management of an MS attack?
Methylpred 1g for 3 days
154
What is the role of steroids in the management of MS?
Used in acute scenarios to speed recovery but not alter the extent of recovery
155
What is the longterm prophylactic management of MS?
IFN-beta - reduce relapse freq
Glatiramer - as above
Natilzumab - as above
Alemtuzumab
156
What are some good prognostic signs in MS?
```
Female
Under 25 yo
Sensory signs at onset
Long interval between relapses
Fewer MRI lesions
```
157
What are the clinical features of cord compression?
Deep local spinal pain in dermatomal distribution
Sensory, reflex and motor level with progressing weakness and sensory loss
Painless urinary retention
Faecal incontinence
158
What are the causes of cord compression?
Trauma
Infection
Malignancy (mostly mets)
Disc herniation
159
What is the management of acute cord compression?
Neurosurgical emergency
For malignancy give dexamethasone IV and consider laminectomy
For abscess give Abx and surgical decompression
160
What are the signs of conus medullaris lesions?
Early constipation and retention
Mixed UMN/LMN weakness
Back pain
161
What are the signs of cauda equina syndrome?
```
Saddle anaesthesia
Back pain
Poor anal tone
Radicular pain down legs
Bilateral Flaccid, Areflexic lower limb weakness
Incontinence
```
162
What are some causes of spondylosis?
Trauma
Ageing
Disc/Vertebral collapse
Osteophytes
163
How might a cervical spondylosis present?
Mostly asymptomatic
Neck stiffness
Arm pain with motor and sensory disturbances
Lhermitte's sign
Hoffman's sign (flicking middle finger pulp causes pincer grip response)
164
What deficits are seen in a C5 root lesion?
Motor: Deltoid and supraspinatus weakness
Sensory: Numb elbow
165
What deficits are seen in a C6 root lesion?
Motor: Biceps and brachioradialis weakness, with reduced biceps reflex
Sensory: Numb thumb and index finger
166
What deficits are seen in a C7 root lesion?
Motor: Triceps and finger extension weakness with reduced triceps reflex
Sensory: Numb middle finger
167
What deficits are seen in a C8 root lesion?
Motor: weak finger flexors and intrinsic hand muscles
Sensory: Numb little and ring fingers
168
What is the management of cervical spondylosis?
Conservative: Collar, analgesia
Medica: Steroids
Surgical: Decompressive laminectomy
169
How might lumbosacral spondylosis present? and which nerve roots are affected most commonly?
L5 and S1 most commonly affected
| Presents with severe lower back pain +- sciatic pain, limited spinal flexion
170
What deficits are seen in L5 root lesion?
Weak hallux plantarflexion +- foot drop, reduced sensation over dorsum of foot
171
What deficits are seen in S1 root lesion?
Weak foot plantarflexion and eversion, loss of ankle jerk, calf pain, loss of sensation over sole of foot and back of calf
172
How might spinal stenosis present?
Spinal claudication: Aching on walking, rapid onset, +-parasthesia
Pain alleviated on leaning forward
173
What are some causes of mononeuritis multiplex (2 ore more peripheral nerves affected)
Diabetes
Amyloid
Rheumatoid
Sarcoid
174
What are the features of NF 1?
CAFE NOIR
```
Cafe au lait spots (>6 in adults)
Axillary freckling
Fibromata (subcut - may compress local structures)
Eye - Lisch nodules are brown hamartomas of the iris
Neoplasia - various inc. CNS and phaeos
Ortho - kyphoscoliosis
IQ reduction
Renal - RAS dysfunction ->HTN
```
175
What are the features of NF 2?
Cafe au lait spots
Bilateral ventricular schwannomas
Bilateral cataracts
176
What is the mean survival of NF2?
15 years from diagnosis
177
What are the causes of intrinsic cord disease?
DIVINITY
```
Degenerative - MND
Developmental - Friedrich's
Infection - HIV, Syphillis
Vascular infarction
Inflammation - MS, transverse myelitis
Neoplasia
Injury
Toxin - B12 def
sYringomyelia!!!
```
178
What is the clinical history (symptom progression) of syringomyelia?
May be stable for years then worsen suddenly e.g. on coughing as pressure increase leads to lesion extension
179
What are the major causes of syringomyelia?
Arnold- Chiari malformation
Masses (these two block CSF flow)
Spina bifida
secondary causes
180
What are the cardinal signs of syringomyelia?
1. Sensory loss: absent pain and temperature but preserved touch, proprioception and vibration as ventral tracts are affected. CAPE distribution
2. Wasting of hands (claw)
3. Loss of upper limb reflexes
4. Charcot joints in shoulder and elbow
181
What are the features of a median nerve (C6-T1) palsy?
Motor: LOAF muscle weakness and thenar wasting
Sensory: Radial 3.5 fingers and palm sensory loss, pain, imp proprioception, Tinels and Phalens positive
182
What are the features of an ulnar nerve (C7-T1) palsy?
Motor: Partial claw, hypothenar wasting
Sensory: Ulnar 1.5 fingers sensory loss
183
What are the features of a radial nerve (C5-T1) palsy?
Motor: Finger/wrist drop
Sensory: Snuff box sensory loss
184
What are the features of a phrenic nerve (C3-C5) palsy?
Orthopnoea and raised hemidiaphriagm
185
What are some causes of polyneuropathy?
Metabolic: DM, renal, B12, hypothyroid
Inflammation: GB synd, sarcoid
Vasculitis: RA, Wegener's
Drugs: Isoniazid, EtOH, Phenytoin
186
How would you investigate a polyneuropathy?
Bloods - FBC, LFT, UnE, B12, BM, Ca, ANA/ANCA, TFT, ESR
Nerve conduction studies
EMG
187
What are the main causes of sensory neuropathy?
ABCDE
```
Alcohol
B12
CKD
DM
Every vasculitis
```
188
What are the main causes of motor neuropathy?
GB syndrome
CMT
Paraneoplastic
Lead
189
What are the main causes of autonomic neuropathy?
```
DM
HIV
SLE
GBS
LEMS
```
190
What are some features of autonomic neuropathy?
```
Postural hypotension
ED
Reduced sweating
Constipation and urinary retention
Horners
```
191
What are three cardinal negative features of MND
Never any sensory loss
Never any sphincter involvement
Never affects eye movement
192
How would you investigate potential MND?
Brain/cord MRI and LP - both for exclusion
| EMG shows denervation
193
What is the picture of MND?
Mixed UMN and LMN signs
Speech or swallowing impairment
FTD
194
What are the management options for MND?
Riluzole - prolongs life by 3
| Supportive measures: Drooling, dysphagia, resp failure, pain, spasticity Rx
195
What are the 4 types of MND and a distinguishing feature of each one
ALS - commonest
Bulbar palsy - most severe
PMA - LMN signs only
PLS - Mainly UMN signs
196
What is the difference between bulbar and pseudobulbar palsy in terms of its presentation?
Bulbar = LMN so flaccid fasciculating tongue, quiet speech, reduced jaw jerk
Pseudobulbar = UMN so spastic tongue, hot potato speech, brisk jaw reflex
197
How would you distinguish between a myopathy and a motor neuropathy?
Myopathy is slower onset and causes proximal rather than distal weakness. Dystrophies also tend to affect specific muscle groups and have preserved tendon reflexes
198
How would you investigate a ?myopathy?
```
ESR
CK
AST
LDH
EMG
```
199
What are the features (and findings) of Duchenne's?
Presents early (~4), Gower's sign, calf pseudohypertrophy, respiratory failure
Ix: V raised CK
200
How does Becker's compare with Duchenne's?
Presents later and is less severe
