Neurology Flashcards
(245 cards)
1
Q
WHAT IS A TRANSIENT ISCHAEMIC ATTACK?
A
Blood flow to part of the brain TEMPORARILY stops
Lasts for less than 24 HOURS
NO lasting damage
Usually caused by emboli
2
Q
What are the risk factors for TIAs?
A
Non-modifiable risk factors
Age
Sex
Family history
Race/ethnicity
Modifiable risk factors
Smoking
Hypertension
Diabetes
Hyperlipidemia
Activity level
3
Q
What are the causes of TIAS?
A
Thromboembolism
From carotid
Cardioembolism
Post-MI or AF
Hyperviscosity
Polycythaemia,
4
Q
What are the signs and symptoms of a TIA?
A
Mimic a stroke in the same vessel
5
Q
What are the tests for TIAs?
A
Carotid Doppler
Angiography
Fundoscopy (amaurosis fugax)
Listen for carotid bruits because of atherosclerosis
Aim to find the cause and define vascular risk
FBC + prothromibin (test for bleeding/hypercoaguable conditions)
ESR
U&Es
Glucose (if low could cause altered mental state)
lipids (risk for atherosclerotic disease)
6
Q
What is the treatment for TIAs?
A
-
Reduce risk factors
Blood pressure/diabetes/cholesterol -
Antiplatelet drugs
Clopidogrel or aspirin - Warfarin/DOAC (if cardiac emboli)
- Carotid endarterectomy (if >70% stenosis)
7
Q
What is the ABCD2 scale?
What are the values?
A
Scale to determine risk of having a future stroke. 2/7 days
Age ≥60 yrs old 1 point
Blood pressure ≥140/90 1 point
Clinical features
Unilateral weakness 2 points
Speech disturbance without weakness 1 point
Duration of symptoms
Symptoms lasting ≥1h 2 points
Symptoms lasting 10–59min 1 point
Diabetes 1 point
8
Q
What does the scores indicate in ABCD2?
A
More than 6 strongly predicts a stroke
More than 4 should be seen by a specialist in 24 hours
9
Q
WHAT IS AMAUROSIS FUGAX?
A
Painless progressive loss of vision in one or two eyes
“like a curtain descending over my field of view”
10
Q
What causes amaurosis fugax?
A
Emboli passing into the retinal artery
11
Q
What are the tests for amaurosis fugax?
A
Ultrasound
MRI and CT
Fundoscopy
12
Q
What is the treatment for amaurosis fugax?
A
- Atherscleoric lesion = ASPIRIN or CLOPIDOGREL
- Cartoid atherscleosis = Carotid endarterectomy
- Cadiac cause = warfarin/correct AF
13
Q
WHICH IS THE MORE COMMON STROKE?
A
ischamemic
14
Q
WHAT IS AN ISCHAEMIC STROKE?
A
Interupption of the blood supply to the brain
15
Q
What causes ischaemic stroke?
A
- Thromobsis
- Embolism
- Systemic hypoperfusion
- Cerebral venous sinus thrombosis
16
Q
What are the signs and symptoms of a stroke?
A
Depends on location of the stroke
Symptoms affected the contralateral side of the brain area
Cerebral (contralateral sensory loss or hemiplegia—initially flaccid)
Brainstem (quadriplegia, dis- turbances of gaze and vision, locked-in syndrome)
Lacunar (ataxic hemiparesis, pure motor, pure sensory, sensorimotor, and dysarthria/clumsy hand)
17
Q
What are the investigations for a stroke?
A
Clinical examination - NIHSS (national institues of health stroke scale)
-
Risk factors
Hypertension -
Cardiac cause
Echo/ECG -
Carotid
Ultrasound/bruits
CT/MRI/Angiography
18
Q
What is the treatment for an ischaemic stroke?
A
1st line: Thrombolysis
IV alteplase
2nd line: Antiplatelets
Clopidogrel 75mg OD
Stroke therapy long term
S+L
Physio
OT
19
Q
When must thombolysis be given in an ischaemic stoke and what are the contraindications?
A
Less than 4.5 hours
- Surgery in last 3 months
- Patient on warfarin
- Hx of active malignancy
- Platelets <100,000/mm3
20
Q
WHAT IS A HEMORRHAGIC STROKE?
A
Rupture of a blood vessel or abnormal vascular structure
21
Q
What are the different types of hemorrhagic strokes?
A
Intracerebral hemorrhage
Subarachnoid hemorrhage
22
Q
What are the causes of haemorrhagic strokes?
A
- Hypertensive haemorrhage
- Ruptured aneurysm
- Ruptured AV fistula
- Drug induced bleeding
23
Q
What are the signs and symptoms of a stroke?
A
Depends on location of the stroke
Symptoms affected the contralateral side of the brain area
- Cerebral (contralateral sensory loss or hemiplegia—initially flaccid)
- Brainstem (quadriplegia, disturbances of gaze and vision, locked-in syndrome)
- Lacunar (ataxic hemiparesis, pure motor, pure sensory, sensorimotor, and dysarthria/clumsy hand)
24
Q
What are the investigations for a stroke?
A
Clinical examination - NIHSS (national institues of health stroke scale)
-
Risk factors
Hypertension -
Cardiac cause
Echo/ECG -
Carotid
Ultrasound/bruits
CT/MRI/Angiography
25
What is the treatment for a haemorrhagic stroke?
- _Control BP_
B-blocker
- Beriplex if warfarin-related bleed
- Clot evacuation
26
How do you distinguish between a haemorrhagic and ischaemic stroke?
CT head
27
WHAT ARE THE DIFFERENT INTER-CRANIAL HAEMORRHAGE?
Extradural haemorrhage
Subdural haemorrhage
Subarachnoid haemorrhage
Intracerebral haemorrhage
28
WHAT ARE SOME EXAMPLES OF INTRACEREBRAL HAEMORRHAGE?
Lobar haemorrhage
Thalamic haemorrhage
Pontine haemorrhage
Cerebellar haemorrhage
29
What are the different layers of the meninges?
Dura, usually firmly adherent to the inside of the skull
Arachnoid, more adherent to the brain
Pia, on the surface of the brain and cannot be separated from the brain
30
Where are the meningeal vessels? What veins cross the subdural space?
Meningeal vessels are in the Extradural space
Bridging veins cross the subdural space
31
In which space does the circle of willis lie?
The circle of Willis lies in the subarachnoid space
32
Are there any blood vessels below the pia?
There are no vessels deep to the Pia, the Pia forms part of the blood brain barrier
33
WHAT IS A SUBARACHNOID HAEMORRHAGE?
Rupture of the arteries forming the circle of Willis
Often because of ‘Berry aneurysms’
34
What are the causes of subarachnoid haemorrhages?
Trauma
Berry aneurysm
Arteriovenous malformations
Idiopathic
35
What are the signs and symptoms of a subarchanoid haemorrhage?
What is the headache called which they call a warning sign of a leaky vessel?
**Symptoms**
Sudden onset severe headache (‘Thunderclap headache’)
Photophobia
Reduced consciousness
Vomiting
Collapse
Seizures
**Sign**
Kernig's sign
Terson syndrome (retinal, subhyaloid and vitreous bleeds)
3rd oculomotor palsy (posterior communicating artery)
Sentinel headache
36
What are the investigations for a subarchanoid haemorrhage?
**_CT_**
Spider sign
**_LP_**
CSF bloody early
Becomes xanthochromic (yellow), breakdown of haem to bilibrubin
**_Angio_**
To determine location
37
What is the treatment for subarchanoid haemorrhage?
Neurosurgery!!!!
Keep blood pressure low
Keep hydrated and nutrition
Nimodipine (recued vasospasm)
If anneurysm deteced either coil or clipping.
38
WHAT IS A SUBDURAL HAEMORRHAGE?
Bleeding between the dura on the skull and the arachnoid layer
39
What is the cause of subdural haemorrhages?
Where is the bleeding from? Who is it most common in?
Trauma
Bleeding from bridging veins
Commonest where the patient has a small brain (alcoholics, dementia)
Occurs in ‘shaken babies’
**_GRADUAL_**
Gradual rise in ICP over many weeks
40
What are the symptoms of a subdural haemorrhage?
**_Fluctuating level of consciousness_**
Slow physical or intellectual slowing
Sleepiness
Headache
Personality change, and unsteadiness.
Neurological symptoms happen later
41
What investigations can you do for a subdural haemorrhage?
CT/MRI shows clot ± midline shift
Look for crescent-shaped collection of blood over 1 hemisphere.
42
What is the treatment for a subdural haemorrhage?
1. Evacuation 1st-line
2. Craniotomy is 2nd-line
43
Where does bleeding occur in subdural haemorrhage?
Between arachnoid and dura
44
WHAT IS AN EXTRADURAL HAEMORRHAGE?
Bleed between skull and dura membrane
45
How is an extradural haemorrhage caused? What artery bleeds in extradural?
Traumatic
Fractured skull
Bleeding from Middle Meningeal Artery and vein
Also dural venous sinus
46
What normally happens to the pressure during an extradural bleed?
What period is seen?
Rapid rise in inter-cranial pressure (ICP)
Conscious level falls or is slow to improve
Lucid period
Coning and death if not treated
47
What symptoms does an extradural haemorrhage show?
Increasingly severe headache
Vomiting
Confusion, and fits follow
Brainstem compression later on
48
What investigations for an extradural haemorrhage can you do?
**_CT_**
Haematoma
Often biconvex/lens-shaped
**_X-ray_**
Fractures
49
How can you treat a extradural haemorrhage?
Clot evacuation ± ligation of the bleeding vessel.
Care of the airway in an unconscious patient
50
What is the difference in CT shape for extradural and subdural haemorrhage?
Biconvex/lens-shaped in extradural
the blood forms a more rounded shape
Compared with the sickle-shaped
Subdural haematoma as the tough dural attachments to the skull keep it more localized
51
WHAT IS EPILEPSY?
https://www.youtube.com/watch?v=L0XqL2I35n8
Seizure diorder
Recurrent and unpredictable seizures
52
What is the definition of an epileptic seizure?
Paroxysmal event
Caused by excessive, hypersynchronous neuronal discharges
Behaviour, sensation or cognitive processes change
53
What is the treatment of focal epilepsy?
How do they work?
Carbamazepine (inhibits Na+ channels)
Lamotrigine (inhibits glutamate release)
54
What is the first line of therapy for generalised epilepsy?
Sodium Valproate
Lamotrigine
55
What is the main excitatory transmittor in the brain? What is the receptor for it?
Glutamate
NMDA
56
What are the patinet only signs of a seizure?
Fear
Certain smells
57
What is the main inhibitory transmittor in the brain? What is the receptor?
GABA
GABA receptors
58
What are the outward signs of a seizure?
Jerking
Moving
Losing consciousness
59
What is it called when a seizure starts focal and becomes generalised?
Focal onset bilateral tonic-clonic
60
What is it called when both hemispheres of the brain are affected?
**_Generalised_**
Can start as focal and become generalised
61
What is a jacksonian march?
Which lobe is this most common in?
When jerky movements affect one area then move to other areas
Most common in frontal lobe
62
What are the focal seizures divided into?
_**Simple partial
Without impaired awareness**_
Small area
Strange sensation - hearing or tasting
Jerky movements
Awake and alert
_**Complex partial
With impaired awareness**_
Loss of awareness
May not remember
63
What is it called when the effect of a seizure is limited to one hemisphere or single lobe
Focal or partial seizure
64
What is the treatment of a staticus epilepticus?
Open + maintain airway
Community - Diazepam
Hospital - Lorazepam
Give phenytoin if seizures continue
65
What is a seizure called if it lasts longer than 5 minutes ongoing or without returning to normal?
What type of seizure is it normally?
Status epilepticus
Usually tonic-clonic
MEDICAL EMERGENCY
66
What are generalised seizures divided into?
**_Tonic_**
Muscles stiff and flexed
Fall backward
**_Atonic_**
Suddenly relaxed muscles
Fall forward
**_Clonic_**
Violent muscle contractions
Convulsions
**_Tonic-Clonic_**
**_Myoclonic_**
Short muscle twitches
**_Absence_**
Spaced out, unresponsive
67
What are the different parts of seizure?
Prodrome
Aura
Ictal symptoms
Post-ictal symptoms
Prodrome= mood/behaviour change
Aura = part of seizure patient is aware of
Ictal symptoms = dependent on part of brain affected
Post-ictal symptoms = headache, confusion, amnesia, etc.
68
Where do complex partial seizures always start?
Temporal lobe
69
WHAT IS PARKINSON'S?
Movement disorder where the dopamine producing neurons in the substantia nigra of the brain die
70
What is the cause of parkinson's?
Usually no known cause
**_Sometimes_**
Genetic with environment
71
What are the direct and indirect pathways?
_Control movement_
Direct = movement
Indirect = no movement
_Direct_
Striatum
Global pallidus interna
Substantia nigra pars reticularis
Thalamus
_Indirect_
Striatum
Global pallidus externa
Subthalamic nucleus
https://www.youtube.com/watch?v=NcIWYCkKwVA
72
What happens in parkinson's to the substantia nigra?
What do the remaining neurons contain?
Blackened areas gradually disappear
**_These form_**
Lewy bodies containing alpha-synuclein protein
Present in the dopamine neurons before they die
73
What are the signs and symptoms of parkinsons?
Resting tremor (Pill roll)
Rigidity (cog-wheel)
Bradykinesia
Postural instability
Also non motor symptoms (dementia)
**_NO WEAKNESS_**
74
What are the investigations for parkinsons?
Medical history and examination
Give levodopa and improvement in symptoms helps with diagnosis
MRI and CT to rule out other causes
75
What is the management for Parkinson's?
**_Increase dopamine_**
_Co-careldopa_
L-DOPA (levodopa) + carbidopa
_Dopamine receptor agonists_
Ropinirole
_**Decrease dopamine breakdown**
MAO-B inhibitor_
Selegiline
_COMT inhibitor_
Entacapone
**_Motor symptom treatment_**
Amantadine and anticholingergics
**_Surgery_**
Deep brain stimulation
76
How does levodopa work?
Levodopa crosses blood brain barrier
Converted to dopamine
By dopa decarboxylase
Within nigrostriatal neurons
77
What does the no weakness of parkinson's tell you?
Not a disease of motor cortex or corticospinal pathway diseases
78
What does the resting tremor of parkinson's tell you?
Not a cerebellar disase
As would be action or intention tremor
79
WHAT IS HUNTINGTON'S DISEASE?
Cell loss within a specific set of neurons in the basal ganglia and cortex
80
What is the cause of huntingtons disease?
What does it cause the death of and where?
1. Autosomal dominant
2. CAG repeated sequece of DNA
3. Abnormal protein produced
1. Death of GABA (inhibitory) neurons particularly
2. Striatum
81
What gene is involved with what is the code?
How many is need for huntingtons disease?
Huntingtin gene
Contains triplet repeat CAG
Normal person has 10-35
HD has \>36
82
What is anticipation?
What does more repeats mean?
When is anticipation more likely?
CAG repeats increase with generations.
More repeats means an earlier onset.
Anticipation more likely if parent affected is the father.
83
What are the symptoms of huntingtons disease?
When is the normal onset?
Chorea
Psychiatric/behavioural changes
Cognitive decline and dementia
30-50
84
What are the investigations forhuntingtons disease?
**_History_**
Confirm chorea
**_Imaging_**
Bicaudate diameter
**_Exclude differentials_**
**_Genetic testing_**
**_Histology_**
Identify huntington
85
How can you treat huntingtons disease?
**_Chorea_**
Tetrabenazine
**_Agression_**
Risperidone
86
WHAT ARE THE DIFFERENT TYPES OF HEADACHES?
And give some examples for each?
**_Primary_**
Tension, cluster, migraine, sins
**_Secondary_**
Meningitis, encephalitis, GCA, medication overuse, venous thrombosis, tumour, SAH
**_Other_**
Trigeminal neuralgia
87
What are secondary headaches?
Red flag headaches
88
WHAT IS A MIGRAINE?
Recurrent headache associated
Visual & GI disturbance
89
What is the location of a migraine?
Unilateral
90
What are the features of a migraine?
How long does it last?
Gradual onset
Crescendo pattern
Moderate-severe intensity
Duration 4-72 hours
91
What are migraine's associated symptoms?
Nausea
Vomiting
Photophobia
Phonophobia
Aura - feeling something about to happen
92
What is the treatment for migraines?
Acute and prophylaxis?
**_Acute_**
Oraltriptan e.g. Sumatriptan
+ NSAID e.g. Ketoprofen
**_Prophylaxis_**
B-blocker e.g. Propanolol
93
What are the triggers of migraines?
Chocolate
Hangobers
Orgasms
Cheese
Oral contraceptives
Lie-ins
Alcohol
Travel
Exercise
94
WHAT IS A TENSION HEADACHE?
More muscular
Most common reason why over the counter analgesics are bought
95
What is the location of a tension headache?
Bilateral eyebrow region
96
What is the character of tension headaches?
Pressure or tightness which waxes and wanes
Duration is variable
97
What are the associated symptoms which a tension headache?
None
98
WHAT ARE CLUSTER HEADACHES?
Hyperactivity to 5HT
99
Where is the pain in a cluster headache?
Rapid onset severe unilateral, orbital, supraorbital or temporal pain
100
What is the character of cluster headaches?
How long do they last?
Pain begins quickly, deep, continuous pain, excrusiating and explosive in quality
Duration 30 mins to 3 hours
101
What are the associated symptoms of cluster headaches?
Pain
Hornems
Ptosis
Drooping of eyelid
Miosis
Unable to dilate pupils
Lacrimation
Nasal discharge
102
What is the treatment for a cluster headache?
How can you prevent them?
100% oxygen
Sumatriptan
Verapimil
Lithium
103
WHAT IS GIANT CELLS VASCULITS?
Vascultis that affect the carotid artery
When they affect the temporal artery
They cause headaches
104
Who does giant cell arteries affect?
Older than 50 year olds
Women more than men
105
What does giant cell arteritis cause?
What does it lead to high amount in, in the blood?
Lots of inflammation
Leading to high ESR and CRP
106
What does a biopsy look like of an affected giant cell arteritis artery?
Giant cell infiltration of elastic lamina between tunica intima and media
107
What does segmental giant cell mean?
Only sections of the artery are affected
Could take out unaffected part of vessel
108
What are the treatments for giant cell arteritis?
Corticosteroids
109
What condition is GCA associated with?
POLYMYALGIA RHEUMATICA
110
What are the symptoms for GCA?
Headache
Scalp tenderness (egon combing hair)
Jaw claudication
Amaurosis fundax
111
What drugs do you need to prescribed with steroids?
PPI (gastric protection) & bisphosphonate(bone protection)
112
What does the trigeminal nerve do?
What are the branches called?
Sensation to the face
**Three branches**
1. Opthalmic
2. Maxillary
3. Mandibular
113
What are sinus headaches?
Associated with sinusitis
114
WHAT IS TRIGEMINAL NEURALGIA?
| (this quesiton inside headaches)
115
What is the epidemology of trigeminal neuralgia?
Man
50-60
116
What is the treatment for trigeminal neuralgia?
1st line Carbamazapine
2nd line Lamotrigine, phenytoin or gabapentin
Surgery
117
What is the diagnosis of trigeminal neuralgia?
1. ≥3 attacks of unilateral facial pain
2. Pain in ≥1 division of trigeminal nerve with no radiation
3.Pain must have 3 of the following:
Paroxysmal attacks lasting from 1-180 seconds
Severe intensity
Electric shock-like/shooting/stabbing/sharp
Precipitated by innocuous stimuli to the affected side of the face (vibration, washing/shaving, brushing teeth, etc.)
4. No neurological deficit
118
What are the symptoms of trigeminal neuralgia?
Sudden severe pain
Sharp, stabbing, piercing
Comes and goes
More when chewing or mouth movemnts
119
What side of the face will be affected?
Only one side
120
WHAT IS CAUDA EQUINA SYNDROME?
Where is the damage?
Compression of nerve roots
Spinal damage distal to L1
121
What vertebrae are involved with cauda equina?
L4 and L5
122
What are the symptoms of cauda equina?
Foot drop
Numbness
Saddle anesthesia
Bladder and Bowel incontinence
123
What are the tests for cauda equina syndrome?
1. MRI
124
What is the treatment for cauda equina?
1. Surgical decompression by full laminectomy
125
What is the anatomy of the spine?
What happens in cauda equina?
Nucelus pulposus surrounded by annulus fibrosis
Herniates out and compresses spine
126
What is the difference between cauda equina and sciatica?
In cauda equina you get
1. Saddle anaesthesia
2. Bladder dysfunction
3. Sexual dysfunction
4. Decreased anal tone
Sciatica is just
1. Back pain
127
WHAT IS SCIATICA?
Pain in the distribution of the sciatic nerve, ie felt in the thigh and, MOST IMPORTANTLY, below the knee
A pain that is not felt below the knee is not sciatica
128
What are the risk factors for sciatica?
**Personal factors including:**
1. Age (peak 45-64 years)
2. Increasing risk with height
3. Smoking
4. Psychological stress
**Occupational factors include:**
1. Strenuous physical activity - for example, frequent lifting, especially while bending and twisting
2. Driving
3. Vibration of the whole body
129
What are the cuases of sciatica?
1. Disc herniation:
Common sites of herniation are L4-L5 and L5-S1
2. Malignancy
3. Infection
4. Vascular compression
130
What are the investigations for sciatica?
1. MRI
2. Check for red flags
e. g. malignancy, fractures, cauda equina syndrome
131
What is the treatment for sciatica?
1. Conservative treatment for 6-8 weeks.
Keep active
Provide - paracetamol, NSAIDs, codiene, morphine
2. Steroid injections
If pain doesn't improve after 6-8 weeks then you should refer to MSK
1. Surgery
Laminectomy
Discetomy
132
What is a radiculopathy and what causes it?
What is the treatment?
Radiculopathy= NERVE ROOT gives LMN
Disc prolapse
Osetoarthrits
Conservative
133
What is a myelopathy and what causes it?
What is the treatment?
Myelopathy= CORD gives UMN
Oseophytes
Disc prolapse (slower onset)
Tumour (slow onset)
Surgical decompression
134
WHAT IS MULTIPLE SCLEROSIS?
https://www.youtube.com/watch?v=yzH8ul5PSZ8
Inflammatory, demyelinating disease.
Specific to the central nervous system.
Has relapsing and remitting symtptoms.
135
When does MS begin?
Between the ages of 20-40
136
What is the cause of MS?
**_Vit D deficiency_**
**_Genetics_**
Female
HLA DR2
**_Environment_**
Infections
137
What are the symptoms of MS?
What is the sign seen in MS?
Optic neuritis (impaired vision and eye pain)
Nystagmus, double vision and vertigo
Bladder and sexual dysfunction
Spasticity and other pyramidal signs
Sensory symptoms and signs
Lhermitte's sign (electric shock-like sensation that occurs on flexion of the neck.)
138
What is the diagnostic criteria for MS?
Two or more CNS lesions disseminated in time and space
Exclusion of conditions giving a similar clinical picture
139
What are the investigations for MS?
**_History_**
E.g. brief unexplained visual loss.
**_CSF_**
Oligoclonal bands of IgG
**_MRI_**
Plaques
**_Visual evoked potential_**
Measures nervous system response to visual stimuli
140
What is the treatment for MS?
How would you treat the symptoms?
E.g. tremor and spasticity?
What do you give for an acute relapse?
**_Chronic - reduce relpase rate_**
1. 1st line = **Beta Interferon**
2. 2nd line = **Glatiramer acetate**
3. 2nd line = **Natalizumab**
**_Symptom management_**
1. Tremor = **Beta blocker**
2. Spasticity = **Baclofen**
**_Acute relapse_**
1. Steroids = IV Methylprednisolone 5 days
141
What are the differential diagnosis of MS?
SLE
Lyme disase
AIDS
142
What is the criteria for MS?
McDonald
143
What are the characterisitcs of fatigue specific to MS?
What is this phenomenom called?
Exacerbated by heat
Improved by cool temperatures
Called Uthoff's
144
What does all this destruction of nerves leave behind in MS?
Fibrosis
Plaques or sclera
145
What happens in MS?
Pathology (Start with T cell)
What does this lead to?
T cell ligand on BBB wall
It then gets activated by myelin
Causes more expression of surface ligands on BBB
Also releases cytokines, vasodilation and damage to oligodendrocytes
B cells mark myelin, macrophages eat it
Regulatory T cells stop this eventually
Sensory, motor and cognitive problems
146
What type of hypersensitivity reaction is MS?
Type 4 (cell mediated)
147
What are the different types of MS?
Relapsing remmiting MS
Secondary progressive MS
Primary progressive MS
Progressive relapsing MS
148
What is charcot's neurological triad?
What is it described in?
Dysarthria
Nystagmus
Intention tremor
MS
149
WHAT IS MYASTHENIA GRAVIS?
https://www.youtube.com/watch?v=bYGxGdu9MsQ
Autoimmune disease of acetylcholine receptors
150
What type of sensitivity reaction is myasthenia gravis?
1. Type 2
2. IgG Cytotoxic injury
3. Damage or lysis to host cells medaited by autoantibodies
151
What do the B cells release?
| (Two antibodies)
**_Release IgG antibodies_**
Bind to the nicotinic receptors
Unable to bind acetylcholine
No contractions
Antibodies can also affect complement pathway
**_Muscle receptor specific tyrosine kinase antibodies_**
Attack inside cells
CAUSE INFLAMMATION
152
What is the epidemology of myasthenia gravis?
BIMODAL!!!!!
Women in 20-30s
Older men 60-70s
153
What are the symptoms of myasthenia gravis?
When do the symptoms get worse?
Muscle weakness
**_Ptosis_**
Drooping eyelid
**_Diplopia_**
Double vision
Towards the end of the day
154
How is myasthenia gravis diagnosed?
**_Bedside test_**
Arm outstretched, count to 50
**_Antibodies_**
Anti-AChR antibodies increase in 90%
MuSK antibodies (muscle specific tyrosine kinase)
**_Neurophysiology_**
Decremental muscle response
**_Imaging_**
CT of thymus
155
What is the treatment for myasthenia gravis?
**_Acetylcholinesterase inhibitors_**
Pyridostigmine
**_Immunosupressive drugs_**
Prednisone
**_Surgical removal of thymus_**
Reduce helper T cells
156
What is a myesthemic crisis?
Life threatening part of the disease
Affect muscles of breathing
157
What is associated with myasthenia gravis in 10% of cases?
Thymic neoplasm
158
WHAT IS MOTOR NEURON DISEASE?
Cluster of major degenerative diseases
Selective loss of neurons in motor cortex
Cranial nerve nuclei, and anterior horn cells
159
What are the lower motor neuron symptoms?
1. Hypo-reflexia
2. Hypo-tonia
3. Denervation atrophy
4. Babinski -ve
5. FASCICULATIONS
160
What are the upper motor neuron symptoms?
1. Hyper-reflexia
2. Hyper-tonia
3. Spasticity
4. Babinski +ve
5. NO fasiculations
161
What does ALS result loss of?
Motor neurons in motor cortex and the anterior horn of the cord
162
What is the most common type of MND?
What gene is affected?
ALS/amyotrophic lateral sclerosis
SOD-1 gene
163
How is MD different from myasthenia?
MND never affects eye movements
164
How is motor neuron different to MS and polyneuropathies?
No sensory loss or sphincter disturbance
165
What are the investigations for motor neuron?
**_Neurophysiology nerve conduction studies_**
Electromyography
**_Blood tests_**
Creatine Kinase
**_MRI head/spine_**
**_Lumbar puncture_**
Exclude differentials
166
What is the treatment of motor neuron disease?
**_Antiglutamatergic drugs_**
Riluzole
Slows progression
**_Baclofen, diazepam_**
Spasicity
**_Amitriptyline_**
Drooling
**_Pallative_**
Tracheostomy
167
What are the different onset of symptoms of ALS?
**_Limb onset_**
Dropped foot, awkwardness running
**_Bulbar onset - worse prognosis_**
Dysphagia
Slurred speech
Difficulty speaking
Progress to same symptoms
168
What are characteristic of motor neurons?
Fasciculations
169
What are the different types of motor neuron disease?
Do they do upper or motor neuron damage?
ALS (Amyotropic Lateral sclerosis) (Both)
Progressive bulbar Palsy
Progressive muscular atrophy (Only LMN)
Primary lateral sclerosis (Only UMN)
170
WHAT IS GUILLAIN-BARRE SYNDROME?
Acute neuropathy
171
What are the symptoms of guillain-barre syndrome?
Symmetrical
Rapid ascending paralysis and sensory deficits
Absent reflexes
NO WASTING
172
What type of neuropathy is it?
Demyelinating
**_Two types_**
Axonal motor
Axonal sensorimotor
173
What is the most likely cause of guillain-barre syndrome?
Infection
**_Campylobacter jejuni_**
2-4 weeks following GI or resp infection
174
What is the treatment of guillain-barre?
1. **Plasmaphoresis (plasma exchange)**
2. **IV - Ig**
Clear debris
3. IV antibiotics
175
What are the tests for guillain-Barre syndrome?
**_LP_**
High protein and low WBC in CSF
**_Nerve conduction studies_**
Slower conduction
**_Electromyography_**
Decreased muscle involvement
176
WHAT ARE PERIPHERAL NEUROPATHIES?
Any disorder of the peripheral nervous system
177
Where can a peripheral neuropathy affect?
The receptors at the skin, to the peripheral nerve, to the spinal nerve or selectively affects the dorsal root ganglia where the cell bodies of the first sensory neuron are.
178
What are the demyelinating neuropathies normally?
Genetic or inflammatory
179
What is an example of an acute neuropathy?
Guillain-Barre syndrome
180
How can peripheral neuropathies be calssified?
Acute and chronic
181
What is the pattern of nerve involvement called for symetical sensorimotor neuropathy? What nerves are involved first?
Length-dependent
Initially sensory, but eventually sensorimotor
| (longer fibers are affected first)
182
What are the common causes of polyneuropothies?
**_DAVID_**
Diabetes
Alcohol
Vitamin deficiency (B12)
Infective (GB)
Drugs (isoniazid)
183
What are the common mononeuropathies?
Carpal tunnel syndrome (median nerve)
Ulnar neuropathy (entrapment at thecubitaltunnel)
Peronealneuropathy (entrapment at the fibular head)
**_Cranial mononeuropathies(III or VII cranial nerve palsy)_**
idiopathic
immune mediated
ischemic
184
How can you distinguish axonal neuropathies, what groups?
Symmetrical Sensorimotor
Asymmetrical Sensory
Asymmetrical Sensorimotor
185
What are the two different types of neuropathy in terms of number of nerves?
Mononeuropathy: problem with one nerve
Polyneuropathy : problem with many nerves
186
What is affected first in symetrical senori-motor neuropathies?
Initially with sensory symptoms affecting the
**_Toes and fingers_**
187
What are the motor symptoms of neuropathies?
1. Muscle cramps
2. Weakness
3. Fasciculations–muscle twitches
4. Atrophy
**_High arched feet (pes cavus)_**
188
What is ataxia?
Poor balance
Sensory (loss of proprioception) or cerebellar
189
What is asymetical sensorimotor also called?
Mononeuritis multiplex
190
What nerves are affected in asymetical sensory neuropathy?
Dorsal root ganglon exclusively
191
What is the most common neuropathy?
Symetrical sensorimotor
192
What would each type of neuropathy tell you in nerve conduction studies?
Demyelinating --\> slow conduction velocities
Axonal --\> reduced amplitudes of the potentials
193
What are nerve conduction tests useful for?
Telling the type of neuropathy
194
What are the first steps in diagnostic approach for peripheral neuropathies?
**_History_**
**_Clinical examination_**
Reduced or absent tendon reflexes
Sensory deficit
Weakness –muscle atrophies
**_Neurophysiological examination (i.e. NCS/QST)_**
195
What are the causes of axonal peripheral neuropathies?
Associated with systemic diseases
Inflammatory–immune mediated (mainly acute)
Infectious (i.e. hepatitis, HIV, Lyme)
Ischemic (i.e. vasculitis)
Metabolic (i.e. Fabry’s, porphyria)
Hereditary (CMT, HLPP)
Toxins (pharmaceuticals, environmental toxins, B6)
196
WHAT IS CARPAL TUNNEL SYNDROME?
Compression of the median nerve in the carpal tunnel in wrist
197
What is the treatment for carpal tunnel?
1. Splinting
2. Corticosteroids injections
3. Surgery of ligament
198
What are the tests for carpal tunnel?
Electrophysiological testing
Description of symptoms
**_Phalen's moneuver_**
Flex wrist down for 1 min - tingling
**_Tinel's sign_**
Tap nerve
199
What are the risk factors for capal tunnel?
Typing
Obesity
Pregnancy
Rheumatoid
200
What causes carpal tunnel syndrome?
Inflammation of nearby tendons and tissues
Causing oedema
Causing compression
201
What are the symptoms of carpal tunnel syndrome?
Pain, numbness and tingling
Thumb
Index
Middle
RIng finger(thumb side)
Wasing of abductor policisbrevis and thenar eminence
202
WHAT ARE THE COMMON PRESENTATIONS OF A BRAIN TUMOUR?
Why do these occur?
Headache, worse in morning
N+V
Seizures, focal neurological deficits
**_Papiloedema_**
Symptoms of a raised ICP
203
What is the treatment of a brain tumour?
Oral steroids (dex) can help to relieve symptoms
Surgery
204
When are the features of raised ICP worse and better?
Worst on waking from sleep in the morning.
Increased by coughing, straining, and bending forwards
Sometimes relieved by vomiting
205
Where are the sites that cancers to the brain metastisise from?
Lung (most common)
Breast
Bowel
206
What are the investigations for a brain tumour?
CT with contrast/MRI.
Brain biopsy
207
WHAT IS MENINGITIS?
https://www.youtube.com/watch?v=gIHUJs2eTHA
Inflammation of the meninges (membrane covering the brain)
Leptomeninges
208
What are most types of primary brain tumours?
The majority are glial cell in origin:
Astrocytoma (85-90%)
Oligodendroglioma’ (~5%)
209
What are the grades of brain tumours?
Grade 1 resectable
Grade 2 10 years
Grade 3 and 4 12 months
210
What are the red flag symptoms of a brain tumour?
Headache with history of malignancy
New onset focal seizure
Cluster headache
Rapidly progressing focal neurology
Papilloedema
211
What are the leptomeninges?
Inner two layers
212
What are the clinical signs of meningitis?
What signs are associated with meningitis?
What is the rash from?
Fever
Headache
Neck stiffness
Photophobia
Phonophobia
Kernig’s sign
Brudzinski’s sign
**_Petechial rash (non-blanching)_**
Meningococcal septicaemia
213
What are the differential diagnosis of meningitis?
Malaria
Encephalitis
Septicaemia
Subarachnoid
214
What are the main investigations for bacterial meningitis?
**_Blood cultures_**
FBC, U&E, CRP, serum Glucose, lactate
**_Lumbar puncture_**
Glucose decrease, protein increase, WBC
**_CT Head_**
**_Throat swabs_**
Pneumococcal and Meningococcal serum PCR
215
What is the management of bacterial meningitis?
**IM benzylpenicillin**
**\<3 months**
Cefotaxime + Amoxocillin
**\>3 months**
Ceftriaxone
Sometimes dexamethosome added to help inflammatory response
216
What meningitis prophylaxis do you give to people who were in contanct with a patient with meningitis??
Rifampicin
217
What are the viral causes of meningitis?
Herpes
HIV
EBV
Mumps
218
What are the bacteria causing meningitis?
**0 - 3 months**
1. Group B Streptococcus (most common cause in neonates)
2. E. coli
3. Listeria monocytogenes
**3 months - 6 years**
1. Neisseria meningitidis
2. Streptococcus pneumoniae
3. Haemophilus influenzae
**6 years - 60 years**
1. Neisseria meningitidis
2. Streptococcus pneumoniae
219
WHAT IS ENCEPHALITIS?
Swelling of the brain
220
What causes encephalitis?
**_Herpes simplex virus - 1 - in 95% of cases_**
Virus
Autoimmune
221
What are the signs and symptoms of encephalitis?
Bizarre encephalopathic behaviour or confusion
Decreased GCS or coma
Fever
Headache
Focal neurological signs
Seizures
History of travel or animal bite.
222
What are the investigations for encephalitis?
**_LP - CSF_**
Increased CSF protein and lymphocytes, and decreased glucose. PCR for HCV
**_Bloods_**
Cultures
**_Contrast-enhanced CT_**
Focal bilateral temporal lobe involvement is suggestive of HSV encephalitis.
**_EEG_**
lateralised periodic discharges at 2 Hz
223
What is the management of encephalitis?
What would you give for seizures?
IV Acyclovir
**_Phenytoin_**
Seizures
224
What happens to the brain in encephalitis?
Brain swells causing oedema and may destroy the nerve cells
May cause bleeing and brain damage
225
WHAT IS HERPES ZOSTER?
Shingles
226
What is the treatment for shingles?
What is the treatment for post-herpetic neuralgia?
**_Acyclovir_**
**_Amitriptyline_**
Post-herpetic neuralgia
227
What is the diagnosis of shingles?
The rash
Quality of pain
Location
228
What are the symptoms of shingles?
Rash across a dermatome that doesn't cross the midline
Stabbing, piercing pain
229
How is herpes zoster caused?
Varicella zoster virus reactivates
It lays dormant in dorsal root ganglion
230
WHAT IS DEMENTIA?
A clinical syndrome with many underlying causes
231
What is dementia characterised by?
Decline in memory, intellect or personality severe enough to intere with daily life
232
What are the clinical features of Alzheimer’s?
Memory Loss
Visuospatial problems
Reasoning and language problems
Psychiatric features
Death
233
What are the risk factors for Alzheimer’s?
Increased Age
Female
Poor socioeconomic status
ph of head injury
Down syndrome
234
What is the pathophysiology of Alzheimer’s?
Presence of extracellular plaques in the cortex composed of
**_beta amyloid peptide_**
Intracellular
**_neurofibrillary tangles composed of tau._**
235
What is the treatment for Alzheimer’s?
Acetylcholinesterase inhibitors
(Donepezil, rivastigmine) can give modest benefit
NMDA-Receptor antagonist
(Memantine) may also help
236
What is dementia with lewy bodies?
1. A type of dementia with characteristic
2. Alpha-synuclein cytoplasmic inclusions (Lewy bodies)
3. In the substantia nigra, paralimbic and neocortical areas
237
What are the clinical features of Lewy body dementia?
1. **Progressive cognitive impairment**
In contrast to Alzheimer's, early impairments in attention and executive function rather than just memory loss
Cognition may be fluctuating, in contrast to other forms of dementia
Usually develops before parkinsonism
2. **Parkinsonism**
3. **Visual hallucinations** (other features such as delusions and non-visual hallucinations may also be seen)
238
What are the investigations for Lewy body dementia?
1. Usually clinical
2. Single-photon emission computed tomography (SPECT) is increasingly used
239
What is the management for Lewy body dementia?
1. **Both acetylcholinesterase inhibitors** (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's
2. **Neuroleptics should be avoided** in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism.
240
What is FTD dementia?
Selective degeneration of the frontal and temporal lobes
Onset typically in middle age
FH present in 40%
241
What are the clinical features of FTD dementia
1. Progressive deterioration in behaviour, personality and language
2. Disinhibition
3. Increased appetite
242
What are the investigations for FTD?
SPECT Scan
1. Atrophy of the frontal and temporal lobes
2. Pick bodies - spherical aggregations of tau protein (silver-staining)
3. Gliosis
4. Neurofibrillary tangles
5. Senile plaques
243
What is the management for FTD?
1. No helpful drugs
Focus on managing symptoms
1. SSRI for aggitation and disinhibition
2. Antipsychotics for behaviour
244
How much of dementia does vascular make up?
What its risk factors
10% dementia
RFs: Increased BP, Smoking, PH of stroke/IHD, obesity, diabetes, cholesterol
245
How can you distinguish vascular dementia from alzeihmers?
1. Mood changes more prominent
2. Degree of memory loss less obvious
3. Focal neurological symptoms
4. Imaging: patches rather than overall
