Neurology Presentations Flashcards
(84 cards)
1
Q
How would a patient describe a tension headache?
What can trigger tension headaches?
A
Band distribution - frontal-occipital Associated with neck pain Mild to moderate pressure pain No N&V or aura Last a few hours
stress, poor posture, depression and anxiety
2
Q
How are tension headaches managed?
A
Reassure
Aspirin, paracetamol or NSAIDs all first line
Acupuncture
3
Q
What is the diagnostic criteria for migraine?
A
At least 5 headaches that:
- Last 4-72 hours
- Are severe, unilateral, pulsating and interrupt daily activity
- Are associated with N&V or photo/phonophobia
- Are not due to a secondary cause
4
Q
What are some migraine triggers?
A
Oestrogen (COCP and menstruation) Foods (cheese, red wine, citrus fruits) Stress Bright lights Alcohol
5
Q
How are migraines managed?
a) Acute
b) prophylaxis + when is prophylaxis offered?
c) menstrual induced
A
ACUTE:
- oral triptan + NSAID or paracetamol
- prochlorperazine + nasal triptan
PROPHYLAXIS if >2/month:
- propranolol (preferred in women) or topiramate (teratogenic)
- acupuncture
MENSTRUAL MIGRAINE
frovatriptan
6
Q
Describe the aura associated with some migraines
A
- transient hemianopic disturbance
- spreading scintillating scotoma
7
Q
Describe the signs and symptoms of a cluster headache and the timing/ frequency of attacks
A
Severe, sudden onset, unilateral pain around the eye
Ipsilateral autonomic features - rhinorrhoea, sweating, partial horner’s, lacrimation, lid swelling
Typically occur at night
1-2 hour bouts daily over 6-12 weeks
8
Q
What can trigger cluster headaches?
A
Triggers - alcohol, histamine, heat, exercise
9
Q
How are cluster headaches managed?
A
Acute - subcutaneous sumatriptan, 100% O2
Prophylaxis - verapamil (some evidence for prednisolone)
Surgery - trigeminal nerve blockade
10
Q
How would you investigate headaches?
A
BP
Optic fundi
Temporal artery palpation if >50
11
Q
What are the red flags for headaches?
A
Systemic symptoms: fever, vomiting, LOC Thunderclap Immunocompromised Precipitated by Valsalva Focal neurological deficit Positional Personality change Cognition change Malignancy known to give brain mets
12
Q
What are the features of medication induced headache?
A
> 15 headaches a month
History of opioid or triptan use
13
Q
What secondary causes of headaches would you consider?
A
V: temporal arteritis I: meningitis, sinusitis, malaria, HIV T: head injury, SAH A: M: hypothyroid I: N: brain metastasis, primary tumour D: medication induced, CO poisoning
Other: dental/ jaw
14
Q
What would you ask about in a history for loss of consciousness?
A
Before - triggers? prodromes - visual, auditory, palpitations? change of colour?
During - Duration? convulsions? continence? tongue biting?
After - time for recovery
15
Q
What are the 5P’s and 5C’s of loss of consciousness
A
Precipitant Prodrome Palpitations Position Post event
Colour Convulsions Continence Cardiac hx FH of sudden cardiac death
16
Q
What investigations would you request for a patient who has come in with loss of consciousness?
A
FBC, U&E, Blood glucose BP - lying and standing EEG ECG - 24hr Imaging with MRI Carotid sinus massage Table tilt test
17
Q
What 3 things characterise syncope?
A
Loss of consciousness
Transient - recover by themselves
Global cerebral hypoperfusion
18
Q
What are your differentials for LOC?
A
NEURO: RICP, epilepsy, Parkinson’s, Lewy Body dementia
CARDIAC: arrhythmias, HOCM, aortic stenosis
METABOLIC: diabetic autonomic failure, uraemia, hypoglycaemia
DRUGS: diuretics, antihypertensive
OTHER: hyperventilation induced, carotid hypersensitivity
19
Q
What is vertigo? and what causes it?
A
Spinning
Rotatory
20
Q
What are the central causes for vertigo?
A
vertebrobasilar ischaemia posterior circulation stroke Acoustic neuroma MS Alcohol
21
Q
What are the peripheral causes for vertigo?
A
Viral labyrinthitis Vestibular neuronitis BPPV Meniere's Ototoxic drugs
22
Q
Nystagmus that is what? likely indicates a central cause of vertigo?
A
- Bidirectional
- Purely horizontal or vertical or torsional
23
Q
What are some bedside examinations you’d want to do in a patient presenting with vertigo? Describe the results in terms of where the lesion is
A
Rombergs
- proprioception or vestibular system issue
- they fall towards the side of the lesion
- normal if cerebellar cause
Uttunberg
- march on spot with eyes shut
- rotate towards the side of a labyrinthine lesion
Head impulse
- patient fixes eyes and examiner moves head
- catch up saccade will occur when head rotated to side of lesion if peripheral lesion
Skew deviation
- cover eyes and if central lesion then vertical correction will occur when eye uncovered
Dix-hallpike - BPPV
24
Q
What is ataxia?
Describe an ataxic gait
A
Disorder of co-ordination, balance and speech
Wide based, appear drunk, can’t stand with feet together
25
Where can a lesion be to cause ataxia?
What type of ataxia would you get at these locations?
Cerebellar vermis = gait ataxia
Cerebellar hemisphere = peripheral ataxia (finger-nose test)
Can also be due to poor proprioception:
- peripheral sensory neuropathy
- DCML
26
What can cause a bilateral ataxia? What would you seen on examination of ataxia was bilateral?
- Alcohol (cerebellar degeneration)
- B1 and B12 deficiency
- MS
- CJD and other intracranial infections
- Drugs
Patient veers from side to side
27
What can cause a unilateral ataxia? What would you seen on examination of ataxia was bilateral?
- Cerebellar or brainstem stroke
- SOL
Patients veers to the side of the lesion
28
What is friedreich's ataxia? What pattern of inheritance does it show?
AR trinucleotide repeat disorder that does not exhibit anticipation
29
What are the signs, symptoms and associated diseases of Friedreich's ataxia?
At age 10-15:
- cerebellar ataxia
- kyphoscoliosis
- absent ankle jerks but extensor plantars
- optic atrophy
Associated with HOCM and diabetes
30
What is ataxic telangiectasia and what are the signs, symptoms and associated diseases?
AR inherited combined immunodeficiency disorder:
- cerebellar ataxia
- telangiectasia (including ocular)
- recurrent chest infections
Associated with lymphoma and leukaemia
31
What is athetosis? What can cause it?
Slow involuntary writhing movements affecting the extremities
Asphyxia, neonatal jaundice, Huntington's and cerebrovascular disease
32
What is dystonia?
Sustained muscle contraction frequently causing twisting movements or abnormal postures because of con-contraction of antagonistic muscles
33
How is dystonia managed?
Focal - botulinum injections
| Generalised - L Dopa if <40, Anticholinergics, tetrabenazine, deep brain stimulation
34
What is chorea?
Continuous, irregular, jerky movements occurring at random locations
35
What can cause chorea?
Hereditary - Huntington's, benign hereditary, Wilson's
Infection - syndenham's , HIV, meningitis/encephalitis
Vascular - infarct, polycythaemia
Metabolic - glucose, hyperthyroid, hypocalcaemia
Immune - SLE, anti-phospholipid, pregnancy
Drugs - Dopamine antagonist, oral contraceptive, amphetamines and cocaine
36
What is spasmodic torticollis?
Shortened sternocleidomastoid means the head is tilted and chin tilted the opposite way
37
What is myoclonus?
Sudden shock like muscle jerks that are frequently repetitive
38
What are tics?
Rapid repetitive stereotyped movements
Can be voluntarily suppressed - lead to internal tension
Triggered by stress or boredom
39
What are the types of tics?
Motor - eye blinking, head jerk, nose twitch, shoulder shrug, facial grimace
Vocal - throat clear, grunting, coughing, sniffing
Other - vulgar words, repeating words, vulgar gestures
40
What is a tremor? What are the types and what could cause them?
Rhythmical oscillatory movement of body part
Resting: Parkinson's
Postural: anxiety, alcohol, thyroid, essential, Wilsons
Action: cerebellar disease
41
What is an essential tremor? Describe the tremor seen in this disorder
Autosomal dominant postural tremor
- Symmetrical
- affects UL (+/- head)
- Low amplitude
- High frequency
- Not present in sleep
- Improve with alcohol
42
How are essential tremors managed?
Propranolol and Primidone
43
What would you investigate when determining the cause for a tremor?
```
Neurological exam
Type of tremor
Medication history
Thyroid function
LFT
Copper levels
Imaging
```
44
What is characteristic of polyneuropathies?
Motor and/or sensory disorder of multiple peripheral or cranial nerves
Symmetrical
Widespread
Worse distally
45
What would be a typical history of someone with a sensory peripheral neuropathy?
- glove and stocking distribution of paraesthesia
- problem with small objects like buttons
- burning their fingers
46
What would be a typical history of someone with a motor peripheral neuropathy?
- becoming clumsy handed
- falling more
- wasting hand muscles
- high stepping gait
47
What are the autonomic signs of polyneuropathy?
Postural hypo
Reduced sweating
Ejaculatory failure
Horner's
```
Constipation
Nocturnal diarrhoea
Urine retention
Erectile dysfunction
Holmes-adie pupil
```
48
What can cause primarily sensory polyneuropathy?
```
Diabetes
Uraemia (renal failure)
Alcohol
Reduced B1
Reduced B12/folate
Leprosy
```
49
What can cause primarily motor polyneuropathy?
- Guillain-Barre
- Chronic inflammatory demyelinating polyradiculoneuropathy
- Charcot-marie tooth
- Lead poisoning
- Diptheria
50
What causes mixed polyneuropathy i.e. sensory and motor?
Hypothyroid/glycaemia
Malignancy - paraneoplastic (SCLC), polycythaemia vera
Autoimmune: polyarteritis nodosa, RA, sjogrens, sarcoid
Infection - lyme, HIV
Drugs: isoniazid, phenyotin, metronidazole
51
What are your differentials for motor weakness?
```
V: stroke
I: GBC, sepsis, encephalopathy
T: cord injury, RICP
A: MS, myasthenia, poly/dermatomyositis, cushings, thyroid dysfunction, SLE, Duchenne
M: hypoglycaemia, hypokalaemia, hypercalcaemia
I:
N: MSCC, hypercalcaemia
D: statins, alcohol, steroids
```
52
What is the neurological disturbance in fibular neuropathy?
Lateral leg and dorsal foot sensation loss
| Foot drop
53
What causes meralgia paraesthetica? In whom and how does it present?
Compression of the lateral femoral cutaneous nerve anywhere along its course (L2/L3 and around ASIS)
RF: obesity, pregnancy, tense ascites
- Tingling/burning in upper antero-lateral thigh
- Worse on standing
54
Which body parts are most affected by diabetic sensory neuropathy?
Feet > hands
55
How would a polyneuropathy as a result of B1 deficiency present?
Feet > Hands
Burning and shooting pains
Reduced reflexes
Muscle weakness
56
What is the sensory disturbance in B6 excess/deficiency?
PATCHY sensory loss of extremities
57
What is the sensory disturbance in B12 deficiency?
Transient and MIGRATORY
| Loss of proprioception and vibration
58
What drugs can cause sensory disturbance?
```
Chemotherapy agents
Antiretrovirals
Phenytoin
Metronidazole and nitrofurantoin
Isoniazid
```
59
What is the sensory disturbance in migraine with aura?
Acute spreading loss
Typically from hand up ipsilateral arm to face and tongue
Last <1hr
60
What primary care investigations would you want to do for someone presenting with a polyneuropathy?
```
HBA1C
TFTs
LFTs (alcohol abuse)
Vitamin levels
CRP, WCC (infection?)
```
61
Which side of the brain are the speech centres found?
Dominant hemisphere
| Left (most of the time even if left handed people)
62
Where is Broca's area?
Which artery supplies it?
What is the function?
Next to motor cortex in frontal lobe
Superior MCA
Production of speech
63
Where is Wernicke's area?
Which artery supplies it?
What is the function?
Next to auditory cortex in superior temporal lobe
Inferior MCA
Interpretation of language
64
What connects Broca's and Wernicke's areas? Where is this found?
Arcuate fasciculus
| Supramarginal gyrus of parietal lobe
65
What is the difference between dysarthria and dysphasia?
Dysarthria is a MOTOR disorder of speech - articulation and pronunciation
Dysphasia is a disorder of language - problem in thoughts becoming spoken
66
What can cause dysarthria?
UMN lesions of the brainstem or hemisphere
| LMN of the brainstem affecting bulbar muscles
67
What can cause dysarthria?
Briefly, how would they classically present?
Pseudobulbar palsy
- slurred speech with weak voice
MS
- can be slurred, staccato etc depending on lesion location
Parkinson's
- quiet and monotonous
MND
- indistinct and nasal
68
Compare the presentation of Brocas, Wernkicks and conductive aphasia
BROCA
- non-fluent slow and halting, comprehension intact, insight
WERNICKE
- fluent, no comprehension, no insight, neologisms, may of may not be able to repeat
CONDUCTIVE
- fluent, insight, unable to repeat strings of words
69
What is cognition?
Process of acquiring knowledge and understanding through thought, experience and senses
70
What can affect cognition?
Demenia, Parkinson's, Huntington's
Metabolic - hypoglycaemia, toxins, hypothyroid
CVS - Stroke, hypo perfusion, decreased folate, B6 or 12
Other - infections, drugs, trauma, menopause, tumour
71
What is neuropathic pain?
| How does it present?
Pain due to a dysfunctional nervous system
Shooting, electrical burning pain
Can be continuous or intermittent
Spontaneous
72
What are some causes of neuropathic pain?
Peripheral:
- diabetes, alcohol, herpes, radiculopathy, tumour infiltration, trigeminal neuralgia
Central:
- MS, post-stroke, chemotherapy
73
How is neuropathic pain managed?
1. amitriptyline, duloxetine, gabapentin, pregabalin
2. switch drugs don't add
```
Flare: tramadol
Localised area (e.g. herpes): capsaicin cream
```
74
What are the CI's and ADR's associated with neuropathic pain meds?
Amitriptyline
- CI in arrhythmia, heart block, post MI
- ADR - Anticholinergic syndrome, drowsiness, long QT
Duloxetine ADR - GI upset, drowsy, dry mouth
Gabapentin
- Caution in diabetes
- ADR - dizzy, drowsy, unsteady
Pregablin ADR - headache, dizzy, drowsy
75
What is first line management for trigeminal neuralgia?
Carbamazepine
76
Where can lesions be to affect bladder control?
What conditions would typically affect bladder control at each of these levels?
CENTRAL:
- Stroke, MS, head injury, dementia, parkinsons
SUPRASACRAL (often about T12)
- spinal cord injury, MS, spina bifida, cervical spondylosis
SACRAL (S2,3,4) and PERIPHERAL
- spinal cord injury, spina bifida, cauda equina, peripheral neuropathy eg diabetes
77
Describe the bladder and sphincter dysfunction in someone with a lesion above T12
- overactive/spastic bladder so that bladder volume is low and there are involuntary contractions
- the sphincter control is uncoordinated with bladder contraction
- patient gets urge incontinence
78
Describe the bladder and sphincter dysfunction in someone with a lesion at S2,3,4 or peripheral
- flaccid and underactive bladder so that bladder volume is high
- underactive sphincter control
- patients get urinary retention
79
Describe a hemiplegic gait and state what would cause it
Knee is extended and the foot dropped
Circumduct the leg to compensate
Cause: contralateral brain lesion
80
Describe a diplegic/ paraplegic gait and state would would cause it
Legs adducted giving a scissoring movement
Circumduct legs to compensate
Cause: bilateral brain lesion (CP), spinal cord lesion, MND
81
Describe a neuropathic gait (due to peripheral neuropathy)
High steppage and then slam the foot down in order to sense when it's on the floor
82
Describe a myopathic gait and state what would cause it
Waddling - laterally flex torso away and circumduct the leg
Cause: polymyalgia rheumatica, muscular dystrophy
83
Describe an antalgic gait
Shortened stance phase on affected leg
84
Describe a frontal gait and state what would cause it
Wide based and a normal arm swing are what differentiate it from Parkinonism gait as everything else is the same i.e. shuffling, hesitation to start, en bloc turning
Cause: frontal lobe pathology
