Neurology notes Flashcards
(154 cards)
1
Q
3 big causes of TLOC?
A
Epileptic seizure, syncope and psychogenic non-epileptic seizure
2
Q
What is a seizure? Types of epileptic seizures?
A
An abnormal and excessive discharge of cerebral neurones
Focal- simple partial (aura)
Complex partial–> LOC, some motor manifestation, lip smacking, fiddle with buttons/ fingers
Secondary generalised tonic clonic seizures
3
Q
Generalised onset of epileptic seizures? Causes?
A
Generalised tonic clonic seizures - GTCS, myoclonic jerks, absences
Idiopathic/ genetic cause, early morning seizures, worse with sleep deprivation/ alcohol, photosensitivity
4
Q
Different syncope types?
A
Reflex- neurally mediated, vasovagal, situational, carotid sinus hypersensitivity, cardiogenic, orthostatic hypotension- drugs, autonomic failure
5
Q
Conditions predispose to transient tachyarrhythmias? These have an abnormal what between events?
A
Bradyarrhythmias, cardiac ischaemia, structural heart disease
ECG- cause sudden death in young people, do ECG in patients with TLOC
6
Q
Heart block types that have a high risk of progression to asystole?
A
Complete (3rd degree) heart block, Mobitz type II 2nd degree heart block, incomplete trifascicular block- RBBB, LAD, 1st degree heart block
7
Q
Why does acute ischaemia cause syncope? Blackout during exercise= what until proven otherwise?
A
Arrhythmia, output failure/ acute mitral regurgitation
Cardiogenic
8
Q
PNES= associated with what?
A
Comorbid psychopathology and childhood sexual abuse
9
Q
Rarer causes of TLOC? Useful past medical hx features? Drug hx? Social hx? Family hx?
A
Hypoglycaemia and acute hydrocephalus
Birth- premature/ SCBU, febrile seizures, CNS infections/ head injury, psychological comorbidity
Antidepressants, tramadol
Psychological comorbidity, alcohol and drugs, driving
Seizures, sudden cardiac death, evidence of psychological comorbidity
10
Q
Hx for GTCS?
A
No trigger, may have aura, stiffening, jerking of limbs, vocalisation/ grunting breathing, cyanosis, eyes open, 1-2 minutes long, profound confusion for about 20 minutes, lateral tongue bite, urinary incontinence, injury
FH- seizures, tramadol e.g., head injury
11
Q
Hx for syncope?
A
Triggers for vasovagal/ none for cardiac, typical fainting syndrome, may have jerks if maintained upright posture, pallor, brief, rapid recovery, previous events, cardiac hx, hypotensive meds, family hx of sudden cardiac death
12
Q
Hx for PNES?
A
May be situational, symptoms= discussed sparingly, eyes often closed, may be emotional/ partially responsive, often very prolonged, apparent status epilepticus, variable post-ictal phase- almost always tired/ washed out
Psych comorbidity, other functional illness, antidepressants, psychosocial deprivation/ domestic abuse, trauma, FHX
13
Q
All patients with TLOC should have what? CT not in syncope unless what? Epilepsy patients neuroimaging unless diagnosis of what? Ix of choice?
A
A 12 lead ECG
Acute hydrocephalus suspected
Genetic generalised epilepsy
MRI
14
Q
Normal EEG does not do what? Gold standard diagnosis for PNES?
A
Exclude epilepsy
Video EEG recording in hospital
15
Q
6 types of neurological emergencies?
A
Coma, sudden/ subacute new headache
Weakness a) generalised +/- resp failure, acute/ subacute paraplegia/ quadriplegia, acute hemi/ monoplegia
Visual loss
Status epilepticus
Other- bladder function loss, hemiballismus, status dystonicus, severe chorea, severe dysphagia, acute dysphasia
16
Q
Common coma causes? Uncommon? Rare?
A
Drugs, toxins, anoxia, mass lesions- bleeds, infections, infarcts, metabolic, SAH, epilepsy
Mass lesions- tumours, venous sinus occlusions, hypothermia, psych- catatonia
Pituitary apoplexy, fat embolism
17
Q
Examination in coma?
A
GCS, pupils- size, reactions, movements, corneal reflexes, focal deficits- asymmetry motor function, tendon reflexes, plantar responses, meningism
18
Q
Assessing coma?
A
Blood tests, imaging- CT, MRI, lumbar puncture, EEG
19
Q
What is status epilepticus?
A
Persistent seizure activity for 30 mins/ more, continuous, intermittent without recovery of consciousness
20% cases= fatal, increased CNS metabolic consumption, rhabdomyolysis, renal failure, metabolic acidosis, hyperthermia, heart and other organ effects
20
Q
What is sudden onset headache with third nerve palsy/ painful 3rd CN palsy until proven otherwise? Causes of sudden severe headaches?
A
SAH
Cerebral venous sinus thrombosis, dissection- carotid/ vertebral, infection, acute haemorrhage/ acute infarcts, pituitary apoplexy
21
Q
Presentation spontaneous SAH? On examination?
A
Acute severe localised headache, meningism, double vision, droopy eyelid
Sometimes seizures, low GCS, sudden death
Normal/ reduced GCS, subhyaloid haemorrhage, 3rd nerve palsy, bilateral extensor plantar responses, severe meningism, focal neurological deficit
22
Q
Investigations for SAH?
A
Immediate- CT, CT angiogram/ MRI angiogram, lumbar puncture- 12 hours after for xanthochromia, catheter angiogram
23
Q
Features of GBS? GBS mimics?
A
Acute/ subacute, demyelinating> axonal, immune mediated, multifocal polyradiculo-neuritis
Numbness starting distally, progressive ascending weakness, bifacial weakness+ other cranial neuropathies, flaccid tetra/ paraparesis, areflexia
Spinal shock syndrome secondary to cord compression, botulism, MG
24
Q
Ix for GBS? Tx?
A
CSF- elevated protein, fewer <3/ no cells
Monitor vital capacity, DVT prophylaxis, BP, ECG, monitor swallow- low threshold for NG feeding
IVIG- 2g/ kg total dose, over 5/7, plasma exchange-less available, alternate days for 5-7 exchanges
25
What are the descending (motor tracts)?
Anterior and lateral corticospinal tracts, medial and lateral reticulospinal tracts, vestibulospinal tract, oliviospinal tract, tectospinal tract, rubrospinal tract, tectospinal tract
26
Ascending (sensory tracts)?
Fasciculus gracilis, fasciculus cuneatus, anterior and posterior spinocerebellar tracts, spinotectal, lateral and anterior spinothalamic tracts
27
Causes of spinal cord disorders?
Traumatic- whiplash, gunshot, stab, haematoma, degenerative- cervical and lumbar spondylosis, inflammatory- MS, transverse myelitis, neoplastic- ependymoma/ meningioma, infective- HIV, vascular- anterior spinal cord artery occlusion, spinal dural fistula, granulomatosis- sarcoidosis, metabolic- vit B12 deficiency, hereditary, neurodegenerative- ALS, other- syringomyelia
28
Symptoms of a spinal cord emergency? Need to rule out what?
Acute/ subacute onset: bladder- bowel weakness, saddle anaesthesia, leg weakness, constant sensory deficit, significant pain--> acute imaging of spine (MRI)
Cord compression
29
Investigating traumatic spinal cord disorders? Degenerative? Inflammatory? Neoplastic?
MRI
MRI, CT spine
MRI spine, then brain with contrast, LP- OCB and cells
MRI W/ contrast
30
Investigating infective spinal disorders? Vascular? Granulomatous? Metabolic? Hereditary? Other neurodegenerative? Other?
```
MRI, ESR, BBV, FBC
MRI, angiography, vasculitis screen
Serum ACE level, MRI, CXR
B12, folate MMA and fasting homocysteine
Genetic panel
EMG and genetics
MRI
```
31
Lesion of dorsal lesion-->? Common causes? Below T6, only what is present?
Ipsilateral loss of light touch, vibration and position sense in right leg, generalised below the lesion level
MS, penetrating injuries, compression from tumours
Fasciculus gracilis
32
Lesion of right fasciculus cuneatus at C3? Common causes?
Absence of light touch, vibration and position sensation in right arm and upper trunk
MS penetrating injuries, compression from tumours
33
Lesion of right lateral corticospinal tract at L1? Right lateral spinothalamic tract at L1?
UMN signs in right leg
| Absence of pain and temperature sensation in left leg
34
Damage to anterior gray and white commissures (central cord syndrome) at C5-C6 causes what? Causes?
Absence of pain and temperature sensation in C5 and C6 dermatomes in both upper extremities
Post traumatic contusion and syringomyelia, intrinsic spinal cord tumours
35
Complete transection of right half of spinal cord at L1?
Absence light touch, vibration and position sense in right leg, UMN signs in right leg, absence of pain and temperature sensation in left leg
36
Complete transection of spinal cord at L1?
UMN signs in both legs (paraplegia,) absence of pain, temperature sensation, light touch, vibration and position sense in both legs
37
Complete transection of dorsal columns bilateral in cervical region (posterior cord syndrome)?
Absence of light touch, vibration and position sense from neck down- below lesion level
38
Anterior cord syndrome in cervical region?
UMN signs bilaterally below lesion level, LMN signs bilaterally at lesion level
Absence pain and temperature sensation bilaterally below lesion
Light touch, vibration, position sense= intact throughout
39
Causes of anterior spinal artery occlusion?
Vasculopathy- stroke risk, accidental occlusion of artery of Adamkwich during AAA repair
40
Common causes of transverse myelitis? Hemi-section of the cord?
MS, post infectious transverse myelitis, ADEM, other inflammatory- sarcoidosis
Intervertebral disc protrusion, spinal cord tumours, metastatic deposits, abscess
41
Causes of cauda equina?
Compressive- discs+ tumours, non-compressive- inflammatory, infiltrative, granulomatous, vascular- spinal dural fistula
42
Management of spinal cord disorder?
Manage the cause and complications- weakness, bladder and bowel dysfunction, spasticity, pain, pressure areas, mobility
43
Symptoms of carotid territory stroke? Posterior circulation?
Weakness of face, leg, arm, amaurosis fugax, impaired language
Dysarthria, dysphagia, dysarthria, diplopia, dizziness, ataxia, diplegia
44
All 3 symptoms needed for diagnosis of a TACS? 2 symptoms needed for what diagnosis?
Homonymous hemianopia, unilateral weakness and/ or sensory deficit of face, arm and leg, higher cerebral dysfunction- visuospatial disorder/ dysphasia
PACS
45
One of what symptoms needed for a POCS diagnosis?
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia
46
One of what symptoms needed for a LACS diagnosis?
Pure sensory stroke
Pure motor stroke
Sensori-motor stroke
Ataxic hemiparesis
47
Time-window for mechanical thrombectomy for anterior circulation stroke?
6 hours- can be used alongside IV thrombolysis
48
Medical management of strokes?
VTE assessment, hydration, NG feeding +/- PEG feeding, spasticity- physio, botox, monitoring for infection
49
Secondary prevention in strokes?
Antiplatelets- 300mg aspirin 2 weeks, clopidogrel lifelong
Anticoagulation- in AF, HASBLED and CHADSVASC scores
BP< 130/80 in HTN
Cholesterol- statin therapy, 40% reduction in non-HDL cholesterol
50
Surgical tx of stroke?
Extracranial carotid stenosis= USS carotid dopplers+/- CTA/MRA, carotid endarterectomy/ stenting
Malignant MCA syndrome- decompressive hemicraniectomy
Posterior circulation= EVD/ posterior fossa decompression
51
Stroke mimics?
Seizures, tumours/ abscess, migraine, metabolic, functional, spinal cord/ peripheral nerve/ cranial nerve
52
Muscle weakness hx?
Onset- instant/ gradual
Distribution- proximal/ distal, symmetrical/ asymmetrical, mono/ poly
Cranial nerve involvement, variability
Sensory symptoms, recent illness, PMH, FH, drugs, alcohol
53
Peripheral neuropathy more motor loss?
GBS, CIDP, C-M-T disease, diptheria, porphyria
| Deficiency states, diabetes, alcohol/ toxins/ drugs, metabolic abnormalities, leprosy, amyloidosis
54
Presentation of MG?
Generalised, fatiguable weakness, proximal limbs, neck and face, extraoccular, bulbar particularly elderly, occular= 10-25%
55
Investigation for MG? Tx?
Tensilon test, AChR antibodies, EMG, CT thorax
ACHesterase inhibitors e.g. pyridostigmine
Immunosuppressants- steroids, azathioprine, thymectomy
56
MND presentation?
No sensory/ visual/ B/B involvement, asymmetric weakness, bulbar/ limb onset, survival= usually 2-5 years
57
Common muscle disorders? Uncommon?
Steroid myopathy, statin myopathy, metabolic and endocrine myopathies, myotonic dystrophy
Duchenne, Becker, polymyositis, mitochondrial disorders
58
Investigation muscle disorders? Tx?
CK, EMG, ESR/ CRP +/- genetics, +/- biopsy
| Remove causal agent, supportive, immunosuppress if inflammatory
59
Red flags for headaches? Weakness?
New headache> 60 y/o, thunderclap, infective sx, hx of malignancy
Loss of sphincter control, sudden onset, progressive, respiratory/ swallowing issues
60
Approach when the patient is alert/ orientated? Drowsy/ confused/ unconscious?
Hx and neuro-examination
| Collateral hx, gen app, vital signs and mini-neurologic exam: GCS, lateralising signs, pupils
61
Use what if patient can give a history? Can't give a hx?
'Pain tool,' 'domain tool,' and standard background history headings with neuro-examination= general appearance, vital signs and core examinations based on possible syndromes
Collateral hx, exam= general appearance, vital signs and mini-neurologic exam= GCS, pupils and lateralising signs
62
Sub-headings for best motor response out of 6? How do this? How long post-ictus?
6= obeys commands, 5= localises to pain, 4= flexes to pain, 3= withdrawal, 2= extends to pain, 1= none
Groove behind ears both sides top of the bed
1 hour
63
Sub-headings for best verbal response out of 5?
5= orientated in time, place and person, 4= confused, 3= inappropriate words, 2= incomprehensible sounds, 1= none
64
Sub-headings for best eye opening response out of 4? Can only do what after giving anaesthetic?
4= eyes open spontaneously, 3= eyes open to speech, 2= eyes open to pain, 1= none
Pupils
65
About identifying what in a pupil examination? Usually represents what?
'Fixed and dilated pupil'
Compression from the brain above, on the PARASYMPATHETIC fibres on the outside of the third nerve as it passes over the apex of the petrous part of the temporal bone, due to some life-threatening brain swelling process
66
How long once unilateral fixed and dilated pupil developed to provide lifesaving surgical intervention? This time window can be maximised by what and time to do what?
A 3-4 hour window before contralateral pupil fixes and dilates and death is inevitable
IV mannitol administration, have the patient intubated/ ventilated, scanned and transferred to a neurosurgical centre
67
What does a lateralising sign reflect? They tend to be obvious during what process? Such signs include what?
A problem with one hemisphere versus the other
During the process of doing the GCS assessment
Inattention to one side, gaze paresis (unable to look) to one side
An upper limb drift in an individual who can hold out his arms with eyes closed i.e. obeys commands, slower localising/ flexion response of one upper limb versus the other when both are either localising/ flexing, asymmetric motor response of one upper limb versus the other e.g. one side flexing, the other extending
68
Pain tool in history taking?
Site, radiation, onset- sudden/ gradual, precipitating factor, duration, course, progression, character, severity, disturbing sleep, alleviating/ exacerbating factors, associated symptoms, had before, response to conservative measures, significantly interfering with lifestyle
69
Domain tool to explore impact on person's lifestyle?
Mobility, communication, interpersonal relationships, school/ work/ hobbies, continence/ sexual function/ personal hygiene, sleep, eating/ drinking/ nutrition
70
What appears first in general- signs or symptoms? 2 exceptions? How to neuro-examine a child?
Symptoms
Watch them as you lead them through structured play and then do 'core examination' and vital signs at end to minimise distress
71
What is a secondary brain problem? Primary? What's important in looking to identify primary brain problems?
Where the pathological process disrupting brain function= outside the brain e.g. hypovolaemia/ hypotension/ shock, hypoxia
Within the brain
Vital signs- e.g. pyrexia for CNS infection, irregular pulse (AF) in context of a stroke
72
What's involved in the core neurologic examination?
General appearance, vital signs, gait, fundoscopy, long tract signs and vibration sense with 125 Hz tuning fork
73
Long tract signs useful in screening for what? What are they?
Myelopathy
Spastic gait, hypertonia, hyper-reflexia, Babinski's, clonus, cross-abductors, Hoffman's sign, loss of fine finger movements, deltopectoral reflex
74
Headings for neuro-exam beyond the core exam?
```
Head/ cranial nerves
Upper limbs
Lower limbs
Trunk: 1. Spinal deformity
2. Sensory level
3. Surgical wounds
4. Paraspinal mass
5. Truncal flexion
6. Paravertebral muscle spasm
7. NF1 skin lesions, e.g., cafe au lait
8. Palpable/percussable bladder
9. Patulent anal sphincter
10. Urostomy, colostomy
11. Perineal sensation
12. Dysraphism, e.g., any dimple, pit, hairy patch or swelling in midline down spine
```
75
Format for presenting findings?
Name, age, PC, when started
Described pain as...
Smoker, allergies, living condition, past surgery, occupation, clinically- well/ unwell, general appearance, vital signs, positive findings, negative findings
76
What is a benign essential tremor?
A fine tremor affecting all the voluntary muscles- symmetrical, most notable in the hands, but affects many other areas e.g. head tremor, jaw tremor and vocal tremor
Worse when tired, stressed/ after caffeine, improved by alcohol, absent during sleep
77
What is an intention tremor?
Broad, coarse and low frequency tremor evidence during deliberated movement, usually perpendicular to the direction of movement
78
What is an essential tremor? What is an action tremor?
Involuntary and rhythmic shaking, during drinking from a glass/ tying shoelaces- both hands and arms, often more noticed more in dominant hand as it is an action tremor
Occurs with the voluntary movement of a muscle e.g. intention
79
What to check with essential tremor? % responds to medication? What meds?
U&Es, LFT, TFT, calcium
50%
Propanolol, primidone, pregabalin, gabapentin, clonazepam
80
Which tremors should be referred?
All new ones not essential tremor, diagnostic uncertainty, essential requiring further management, with other neurological symptoms: ataxia, cerebellar signs, parkinsonism
81
E.g. of Parkinsonism?
Rigidity, bradykinesia, gait shuffling, tremor: idiopathic Parkinson's, vascular, NPH, Parkinson's plus, iatrogenic
82
Stages of Parkinson's?
Early 'honeymoon period', middle period- wearing off, late period- dyskinesias, chorea, fluctuations, cognitive impairment
83
Drugs used in Parkinson's? What is entacapone?
Co-careldopa/ co-beneldopa, CR preparation, dispersible prep- resuce/ morning, Stalevo= co-careldopa plus entacapone
A COMT inhibitor- prevents levodopa breakdown in brain and periphery
84
Non-ergot and ergot dopamine agonists for Parkinson's? What do ergot drugs require?
Ropinirole, pramipexole, rotigotine
Bromocriptine, pergolide, cabergoline
Monitoring
85
Pros and cons of dopamine agonists over levodopa?
Less dyskinesia, longer acting
| More risk of hallucinations, compulsive behaviour, postural hypotension, daytime sleepiness, specific ergot SEs
86
E.g. of MAOIs? Beware of what? CIs?
Selegiline, rasagiline- NICE= SSRI best avoided, citalopram relatively safe
Serotonin syndrome with SSRI and tricyclics
Tramadol, pethidine, methadone
87
What is apomorphine?
Water soluble dopamine agonist- rescue tx in pen form, continuous daytime infusion- helps smooth motor fluctuations, less hallucinogenic than other dopamine agonists
88
Amantadine can help what? New drugs? Drug with most improvement of motor symptoms? Intermediate? Least? Most best on comb of what?
```
Dyskinesia
Safinamide, opicapone
Levodopa
Dopamine agonists
MAOIs
Levodopa and a dopamine agonist
```
89
NICE recommendations for Parkinson's?
Refer to specialist for diagnosis untreated, if motor fluctuations- manage according to specialist advice
Point of contact to specialist services
Review every 6-12 months
Document impulse control disorder, sleep attacks and hallucinations, consider DAT Spect in atypical tremors
Access to physio, OT, SALT, dietician, advise vit D supplementation, palliative care referral and end of life
90
Parkinson's non-motor symptoms?
Mood, sleep, cognitive disorders, impulse control, autonomic dysfunction, presymp symptoms
91
Manage who as non-PD patients? Sleep issues? Tx? Causes?
Anxiety and depression
Insomnia, daytime sleepiness, disruptions during sleep, REM sleep behaviour disorder
Clonazepam, melatonin
Lack of muscle and mental relaxation, stiffness, restless, tremor, meds wear off
92
Daytime sleepiness requires what? Night time akinesia?
Med review- modafinil
| Med review- CR levodopa, rotigotine patch
93
What to do with cognitive disorders in PD?
Review triggering factors and non PD medication and refer to neurology
Mild-moderate PD dementia= cholinesterase inhibitors, referral to dementia pathway, memantine if not tolerated
94
What to do with psychotic Parkinson's patient?
Provoking factors, refer to neurology, specialist can discontinue drugs, initiate quetiapine, clozapine, cholinesterase inhibitors
95
AN symptoms of Parkinson's? Tx?
Orthostatic hypotension, constipation, nausea, vomiting, heat intolerance, urinary frequency and incontinence, urinary urgency, nocturia, sweating, hypersalivation, drooling, seborrhoea, sexual dysfunction in men and women
Anti-emetics, stop anti-HTs, anticholinergics, botulinum/ hyoscine
96
Clinical syndromes?
1) Proximal myopathy
2) Myasthenic syndrome
3) Mononeuropathy
4) Peripheral neuropathy
5) Radiculopathy
6) Anterior horn cell syndrome
7) Myelopathy
8) Vertebral pain syndrome
9) Cerebellar syndrome
10) Cranial neuropathy
11) Lobe syndrome
12) Parkinsonism
13) Chorea
14) Parasellar syndrome
15) Dementia
16) Acute confusional state
17) S+S of raised ICP
18) Epilepsy
19) Stroke
20) Meningism/ meningeal irritation
21) MS
22) Somatisation
97
Pattern and cause of proximal myopathy? O/E?
```
Progressive pattern (hair, stairs and chair,) secondary to corticosteroid use
Balance and single leg squat
```
98
Most common upper limb mononeuropathies? Lower limbs? Investigations?
```
Carpal tunnel (thumb, index and middle finger,) ulnar nerve and axillary due to shoulder dislocation/ relocation, radial neuropathy due to spiral fractures of the radius
Common peroneal nerve= rare cause, meralgia paraesthetica in obese people
EMG/ nerve conduction studies
```
99
Causes of peripheral neuropathy?
Diabetes mellitus and leprosy- mixed motor and sensory
100
What is a radiculopathy? Symptoms of radiculopathy? Commonly affected upper and lower limb?
Pinching of a nerve root in the spinal column
| Radiating limb pain often in the pattern of the dermatome- sharp/ shooting, C6/7= common, L5/S1
101
What is spinal claudication and what is it associated with?
Radiculopathic subsyndrome- bilateral radiating leg pain/ paraesthesia that comes on with walking and they have to stop and rest for a number of minutes before walking on again, often relieved by leaning forward i.e. cycling is not an issue
102
Red flag symptoms for a radiculopathy?
Constant bilateral radiating leg pain, perineal numbness, foot weakness, and urinary symptoms
103
Myotomes and dermatome for C6? Reflex?
Biceps
Thumb
Biceps jerk
104
Myotomes and dermatome for C7? Reflex?
Triceps
Middle finger
Triceps jerk
105
Myotomes and dermatome for L5?
Dorsiflexion (stand on heels), dorsum of foot/ big toe
106
Myotomes and dermatome for S1? Reflex?
Plantarflexion- stand on toes
| Ankle, lateral foot/ sole of foot/ little toe
107
What is a residual radiculopathy?
No active nerve root compression, left with deficit
108
Underlying disease entities for anterior horn cell syndrome?
MND, spinal muscular atrophy and poliomyelitis
| Areflexia, flaccid paralysis, sensation= preserved, LMN signs
109
What is a myelopathy? Causes and commonest cause? Important to screen for what?
Injury to the spinal cord caused by severe compression- from spinal stenosis, disc degeneration, disc herniation, AI disorders/ other trauma
Disc-osteophyte cord compression
Long tract signs
110
Who should be screened for myelopathy? What will they complain of? Where is the lesion in a C5/6 myelopathy?
Anybody attending with neck pain/ back pain or radiating arm or leg pain
Clumsy hands, stiff legs/ not their own
C6
111
What will a patient complain of with vertebral pain syndrome? O/E? Underlying disease entity?
Localised aching pain with limited radiation, stiffness/ restriction of movement, worse with activity, absence of associated neurologic symptoms
Visible/ palpable paravertebral muscle spasm, tenderness and movement restriction
Wear& tear degenerative changes, rare= TB, bacterial discitis/ osteomyelitis, osteoporotic fractures/ metastatic disease (part thoracic vertebral pain.)
112
Signs and symptoms of cerebellar syndrome?
Patient feels drunk, S+S= ipsilateral to side of lesion
| Gait apraxia, ataxia on finger nose testing, and nystagmus
113
Symptoms of frontal lobe syndrome? Parietal lobe?
Contralateral limb weakness, motor dysphasia for dominant frontal love(Broca's area), personality only affected in bilateral frontal lobe process
Non-dominant= contralateral sensory disturbance- NO limb pain, dominant= as per non+ higher sensory processing- associated issues e.g. dyslexia, dysgraphia, dyscalculia and astereognosis
114
Temporal lobe syndrome? Occipital?
Dominant= understanding of speech(superior temporal gyrus) and memory, no for non-dominant temporal lobe
Contralateral visual field loss
115
What does parasellar syndrome include?
Hypopituitarism and bitemporal hemianopia
116
Non-dementia causes of dementia? Difference with acute confusional state?
NPH, large frontal/ subfrontal or dominant hemisphere meningioma and subdural haematoma
Acute= often caused by secondary brain problem, lasts hours/ days, dementia= primary and lasts months/ years
117
What will the patient complain of regarding raised ICP? O/E? Possible cause?
Gradual onset, progressive headache, nausea/ vomiting, double vision, blurred vision, general deterioration in cognitive functioning and mobility and LOC
Drowsiness, papilloedema, paralytic squint, fixed dilated pupil, reduced LOC
Hydrocephalus, CNS bacterial infection- brain abscess, empyema, meningitis
118
3 categories of stroke?
SAH, ischaemic stroke, spontaneous brain parenchymal haemorrhage
119
Who go to neurosurgery for surgical decompression of an ischaemic stroke?
Those with a major intracranial vessel stroke with a large stroke of secondary brain injury and swelling--> critically raised ICP
Common= small artery--> internal capsule= taken out, no large volume of brain tissue injury/ swelling
120
Indications for surgical decompression in ischaemic stroke?
Cerebellar infarction- tight posterior fossa and secondary hydrocephalus on imaging, can be from vertebral artery dissection, MRI can confirm
Infarction in territory of MCA- in at least 50% MCA territory, patient <60 y/o, deteriorating LOC, referral within 24 hours symptom onset, surgery within 48 hours
121
Carotid endarterectomy in ischaemic stroke associated with what? What should be done within one week of symptom onset? Consider in who? Surgery within how long in TIA/ minor stroke?
Carotid arter stenosis in the neck- 75% patients, Carotid imaging
Symptomatic carotid stenosis 50-99%
2 weeks
122
Clinical syndrome presentation in supratentorial haemorrhage? Infratentorial? Angiographic investigations if what planned and possibility of what? Blood tests?
Lobe syndrome, meningeal irritation, raised ICP
Cerebellar syndrome, meningeal irritation, raised ICP
Surgery, underlying AVM/ aneurysm
Platelet count and clotting factors
123
Management of a stroke?
Reverse anticoagulation/ address bleeding diathesis, uncontrolled HTN= titrated in critical care setting with IV labetalol and monitor, significant haemorrhage discussed with neurosurgeon, reducing LOC (mass effect/ secondary hydrocephalus)= surgery, brainstem= poor prognosis, surgical evacuation= no benefit in limb weakness/ neurological deficit
Exclude any underlying causative lesion such as tumour/ AVM
124
SAH presents how? Investigations?
Occipital headache- worst ever, vomiting, photophobia and neck stiffness
CT head- negative= lumbar puncture for xanthochromia, +ve= CT angiography and/ or catheter cerebral angiography
125
Classification of SAH? RFs for aneurysm formation? Where are aneurysms usually? Rare causes? Angiogram -ve in what %?
```
Intracranial berry aneurysm 80-90%
Family history, HTN, smoking
At junction points around circle of Willis/ at main MCA bifurcation
AVM, arterial dissection, tumour
10%
```
126
Management of SAH?
Dealing with comps of aneurysmal SAH and securing causative berry aneurysm at an appropriate time point
127
How is an intracranial berry aneurysm secured? Reason for securing? Depends on what factors?
Surgical craniotomy and applying sprung titanium clip to neck of aneurysm with intra-op microscope/ endovascular placement of fine platinum coils inside lumen of aneurysm
Risk of rebleed and risk of further risk to life
Timing of the bleed with respect to presentation, background general health, SAH clinical grade- based on GCS, angiographic appearances, presence of angiographic arterial spasm
128
Complications of SAH? Given pre-emptively in vasospasm? Management?
Hydrocephalus requiring insertion of external ventricular drain
Haematoma needing craniotomy and evacuation
Hyponatraemia- from cerebral salt wasting
Vasospasm--> infarction
Lower RTI
Nimodipine, driving BP with IV fluids and inotropes with arterial and central venous lines in situ, unless infarction on imaging
129
What will patient complain of with meningeal irritation? O/E? Underlying disease entities?
Severe headache, vomiting, photophobia, neck stiffness, sudden onset if SAH
Drowsy, pyrexia if bacterial meningitis, photophobic, neck stiffness
SAH and bacterial meningitis= serious, CT then lumbar puncture
130
Patients presenting to neurosurgery with otherwise unexplained symptoms should have a what to exclude MS?
MRI- discharged from neurosurgical follow-up
131
% referred to neuroscience clinics have non-organic cause to neurologic symptoms? Further % have somatisation component?
10%
| 20%
132
UMN issues with bladder? LMN? What tumour can cause brachial plexus issues?
Urgency and frequency
Cannot tell need the toilet, numbness
Those in the lung apex
133
What two things can cause rhabdomyolysis? Colour of urine? Complications?
Drugs e.g. statins, corticosteroids and dehydration
Tea-coloured
Electrolyte imbalances, DIC
134
Who would you give a CT head to?
In facial trauma, determine inflammation, plan radiation therapy for cancer, assess aneurysms, AVMs, assess bleeding/ clots, tumours and brain cavities- hydrocephalus
135
Why over 65s scanned more readily? Primary and secondary brain injuries?
Tend to be on more drugs
Injury to scalp, fractures, haematomas, vascular injury
Hypoxia- ischaemia, swelling
136
What is the Monro- Kellie doctrine?
Increase in brain tissue/ CSF/ blood must reduce the volume of another
137
Look at what on CT head?
The scout film- fracture of upper cervical spine/ skull
Brain asymmetry
Sulci, Sylvian fissure and cisterns to exclude SAH
Change windows to look for subdural collection
Bone windows- fractures
Mass- intraaxial (in brain) or extraaxial
138
Acute blood on CT head? Becomes isodense after how long? Then hypodense after?
Bright (hyperdense)
1 week
2+ weeks
139
Extradural haematoma shape? Tx?
Boomerang
| 30cm 3 should be evacuated
140
Subdural haematoma shape? White spot is what?
Crescent-shaped
| Calcium calcification
141
Look where for SAH on CT? See what?
Interpeduncular cistern and Sylvian fissure
| Streaky blood into sulci of brain
142
What is a contre-coup injury?
Opposite side to where trauma was
143
Headaches+ other symptoms could be what? Often treated with what?
Venous sinus thrombosis
| Heparin
144
In acute stroke, initially tone is what? Becomes what? How do reflexes change?
Reduced, become increased
| Areflexia--> hyperreflexia
145
If can't do MRI of the spine, do what?
CT myelography
146
Start with what if acute head presentation? Worried about blood in the head? MS, sinus thrombosis or arterial dissection? Excluding/ better visualising pathology in posterior fossa?
CT head
CT
MRI
MRI
147
Non acute head presentation? Spine presentation? Infection/ tumour?
MRI
MRI- CI--> CT myelogram
Include post-contrast
148
2 golden rules for CNS imaging?
Always ensure a patient is 'stable' before transferring to the radiology department for scan- airway secure, vital signs= normal, scalp laceration= sutured
CT before LP
149
4 Qs when viewing a CT scan?
Is there: 1) an intracranial mass- dimensions in three planes, surrounding oedema, loss of normal sulci/ gyri, loss of basal cisterns, ventricular effacement, midline shift in mm
2) Hydrocephalus- 3rd ventricle lost and temporal horns obvious?
3) Intracranial blood- patterns of haemorrhage, appearance of blood over time, white on 'soft tissue window', goes from white--> grey--> black
4) Skull and extracranial soft tissues
150
10 common CT scan scenarios?
SAH, intraventricular haemorrhage, intracerebral haemorrhage, chronic subdural haematoma, extradural haematoma, acute subdural haematoma, brain abscess, malignant brain tumour, meningioma, obstructive hydrocephalus
151
CSF colour in T2 MRI? Contrast that is given? Sequence for stroke/ abscess?
White
Gadolinium
DWI
152
Seen on MRI for MS? To show spinal degenerative disease?
Axial, periventricular 'high signal' lesions on T2/ proton density
Sagittal T2 then axial T2
153
4 concepts for looking at CT scans?
1) A simple matrix- of small squares that determine the resolution of the image and contain a value that represents amount of XR radiation by that square of tissue
2) Hounsfield units: bone= +1000, water=0, air= -1000
3) Grey scale: 'soft tissue window'= brain/ blood/ CSF and 'bone window'= skull detail
4) Neuroanatomy
154
Two key Qs for patients and MRI?
Metal/ implants, is the patient claustrophobic
