Pathology Flashcards
(295 cards)
1
Q
What is the normal volume of CSF
A
120-150ml at one time
500ml is produced per day so lots of turnover
2
Q
What does CSF usually contain
A
Should be clear with some protein and glucose
No RBC, neutrophils and only a small number of lymphocytes
3
Q
What suggests an infection in the CSF
A
Increase in the number of neutrophils or lymphocytes
4
Q
What causes hydrocephalus
A
Obstruction to flow of CSF - tumour, pus etc
Decreased reabsorption of CSF - post SAH or meningitis
Overproduction of CSF - tumour in the choroid plexus (rare)
5
Q
What is hydrocephalus
A
Accumulation of excessive CSF within the ventricular system of the brain
6
Q
what is the difference between communicating and non-communicating hydrocephalus
A
Non-com - obstruction to CSF is within the ventricular system
Com - obstruction to flow is outside of ventricle (e.g. in the subarachnoid space)
- all of the ventricles will dilate
7
Q
How can hydrocephalus present in very young children
A
If hydrocephalus occurs before the sutures close, then the head enlarges
8
Q
What is hydrocephalus ex vacuo
A
When the ventricles dilate due to loss of brain parenchyma and there is a compensatory increase in CSF volume
Seen in Alzheimer’s
9
Q
What can lead to raised ICP
A
Hydrocephalus - increase in CSF Space occupying lesion Idiopathic Intracranial Hypertension Oedema Cerebral venous sinus thrombosis Increased venous volume Physiological - hypoxia, hypercapnia and pain
10
Q
What effects does raised ICP have on the brain
A
Intracranial shifts and herniation
Pressure on the cranial nerves and vital brain centres
Impaired blood flow
reduced consciousness
11
Q
How do you work out cerebral perfusion pressure
A
MAP-ICP
12
Q
What would a subfalcine herniation cause
A
Results in weakness and/or sensory loss on the opposite side (particularly in legs)
13
Q
What would a tentorial herniation cause
A
Pupil dilation on that side
14
Q
What would a cerebellar herniation cause
A
Death = life-threatening as causes brain stem compression
15
Q
What is a transcalvarial herniation
A
Swollen brain will herniate through any defect in the dura and skull if there is damage (post-trauma)
16
Q
What are the early clinical signs of raised ICP
A
Papilloedema – pressure on the optic nerve
Pupillary dysfunction and vision changes
N and V – due to pressure on the vomiting centre in the brain
Headache – worse when lying down, due to pressure on the dura
Neck stiffness
Decreased consciousness - drowsy
17
Q
Where do single brain abscesses tend to come from
A
Local extension - infection in nearby area such as mastoiditis
Direct implantation - due to skull fracture
18
Q
Where do multiple brain abscesses tend to come from
A
Haematogenous spread - often from lungs (pneumonia) or heart (endocarditis)
Usually occur at boundary between grey & white matter
19
Q
What lifestyle factor increases risk of brain abscess
A
IV drug use
20
Q
What effect does a brain abscess have
A
Can cause a mass effect and also leads to oedema
Toxic injury can occur
21
Q
How does a brain abscess present clinically
A
Fever
Symptoms of raised ICP
May also have symptoms of the underlying cause
22
Q
How do you diagnose a brain abscess
A
CT or MRI
Can aspirate to determine organism and therefore treatment
23
Q
How do you treat a brain abscess
A
Weeks of antibiotics
Depends on organism
24
Q
What is meningitis
A
Inflammation of the meninges and CSF within the subarachnoid space
25
What would you see on an LP of someone with meningitis
Abundant polymorphs
| Decreased glucose
26
What features must you ask about in a neuro history
```
Date of onset
Nature of main symptom (e.g. weakness)
Associated neurological symptoms
Exacerbating / relieving factors
Evolution
Recurrence
```
27
Where can neurological deficits/injury arise from
CNS
PNS
NMJ
or the muscle itself
28
Which area tends to be affected by a CNS issue
Often whole limb - larger area
| Hemi or paraplegia
29
Which area tends to be affected by a PNS issue
Usually causes distal/peripheral problems
Often localised
Can affect whole limb though
30
Which area tends to be affected by a NMJ issue
Ocular - vision
Bulbar - speech and swallow
Proximal limb
31
Which area tends to be affected by a muscle issue
Proximal muscles
| usually symmetrical
32
How does weakness present in a CNS issue
Feeling of heaviness
Due to a combination of numbness and weakness
Pyramidal pattern: arms have weaker extensors and legs the flexors are weaker
Therefore have flexed arms and hyperextended legs
Weakness will be contralateral if brain, below level of lesion if spinal
33
How does weakness present in a PNS issue
Usually positional - e.g. when asleep
Ascending - works its way up from glove and stocking
Affects distal areas - may be some wasting
34
How does weakness present in a NMJ issue
As fatiguable
Weakness gets worse when you've used to muscle - worse at the end of the day or on repeated movement
Pattern is variable
35
How does weakness present in a muscle issue
```
May have insidious onset
Muscle wasting
Symmetrical and in proximal muscles
May be accompanied by aching (myalgia)
Hard to rise from chair without using arms
```
36
Are sensory symptoms seen in CNS issues
Yes
If in brain it is hemisensory and contralateral to the lesion
If in spinal cord the issue will be below the level of the lesion
(spinothalamic on contralateral side and dorsal column on ipsilateral)
37
Are sensory symptoms seen in PNS issues
Yes
Pain is often prominent
Typically glove and stocking distribution - peripherals
38
Are sensory symptoms seen in NMJ issues
No
39
Are sensory symptoms seen in muscle issues
No
40
What are the additional features of a CNS pathology
Spasms or jerks
| May have sphincter involvement
41
What are the additional features of a PNS pathology
```
Cramp
Twitching - e.g. fasciculations
Distal wasting
Loss of grip
Tripping up
Unsteady when eyes are closed
```
42
What are the additional features of a NMJ pathology
```
Swallowing and speaking difficulty
May struggle with lots of chewing/talking
Diplopia and ptosis
Opthalmoplegia
Orthopnoea
Worse later in the day
```
43
What are the additional features of a muscle pathology
Myalgia - pain
Cramp
May struggle with specific movement - e.g. getting up from a low chair
44
What physical signs of CNS pathology might you see on inspection
Abnormal limb posture
Upper limb fixed flexion
Lower limb hyperextension
45
What physical signs of PNS pathology might you see on inspection
Muscle wasting - distal
Fasciculations
Pes cavus
46
What physical signs of NMJ pathology might you see on inspection
Ptosis
| Ophthalmoplegia
47
What physical signs of muscle pathology might you see on inspection
Proximal wasting
48
How is tone affected in CNS pathology
Increased
| Spasticity or clonus
49
How is tone affected in PNS pathology
Decreased
| Particularly distally
50
How is tone affected in NMJ pathology
Either the same or slightly decreased if very long standing
51
How is tone affected in muscle pathology
Either the same or slightly decreased if very long standing
52
How are reflexes affected in CNS pathology
Increased
53
How are reflexes affected in PNS pathology
Decreased or absent
54
How are reflexes affected in NMJ pathology
Usually the same
| May be slightly decreased if very long standing
55
How are reflexes affected in muscle pathology
Either the same or slightly decreased
| Reflexes usually retained until pathology is very advanced or long standing
56
What is the plantar response like in CNS pathology
Get an extensor response
| Toes splay out and extend
57
What is the plantar response like in PNS pathology
Flexor response - normal
| Toes curl down
58
What is the plantar response like in NMJ pathology
Flexor response - normal
| Toes curl down
59
What is the plantar response like in muscle pathology
Flexor response - normal
| Toes curl down
60
What is clonus
Continued jerking after sharp, fast movement
| 3 beats is abnormal, 6 is pathological
61
Pathology in the cervical spinal cord will affect which area of the body
The hands and arms
62
Pathology in the thoracic spinal cord will affect which area of the body
The legs
63
What kind of disease pattern is seen in CNS inflammatory conditions
Tend to come and go symptom wise
| Relapsing and remitting seen in MS
64
What kind of disease pattern is seen in CNS vascular conditions
Normally a sudden deficit that slowly gets better
65
What kind of disease pattern is seen in CNS space occupying lesions
Gradual increase in the deficit
66
What kind of disease pattern is seen in disc prolapse
Disc prolapse issue can come on and get gradually worse or a sudden event can lead to a more intense deficit that stays at that level
67
How can you test for a bulbar deficit in NMJ pathology
Ask them to count out loud - may decline as goes on
| Say tough phrase at the start and end ‘West Register Street
68
How can you test for a ocular deficit in NMJ pathology
Get them to fix their gaze on a set horizontal point and ask if they develop diplopia
69
How do you test for ptosis
Get patient to look up for 30secs and see if their eyes start to droop (ptosis)
70
Ocular issues in a suspected NMJ problem is suggestive of what
Myasthenia Gravis
71
What causes myasthenia gravis
Autoimmune disease where there are antibodies against the acetylcholine receptors on the post-synaptic membrane
Fewer ACh receptors means transmission becomes inefficient and causes weakness
Loss of action potential leads to lack of muscle contraction
Affects the NMJ
72
Are you unconscious when asleep
Technically not
| It is a state between conscious and unconscious as you can be awoken when stimulated
73
What is REM sleep
Rapid eye movement
Mostly occurs at the end of the night
EEG will show fast brain activity - similar to being awake
Muscles will be atonic (except diaphragm and eye muscles)
74
What is Non-REM sleep
Occurs at the start of the night
EEG activity is synchronised and rhythmic
Heart rate, BP and cerebral blood flow are reduced
There is partial relaxation of the muscles
75
What are the differences between dreams in REM and non-REM sleep
REM dreams – act out a story that you remember (narrative dreaming)
A non-REM dream you will not remember but may feel a strong emotion upon waking
76
What is the function of deep sleep (non-REM)
This is essential sleep
| Allows the cortex to recover after a busy day
77
What is the function of REM sleep
Mainly for early brain development - important for kids
Adults can cope without
Consolidates memory and possibly deletes unnecessary memory
78
What role does emotion play in sleep
Brain has to feel ready to go to sleep
| States of anxiety will make it feel like you haven't slept as the brain isn't rested
79
Describe the circadian rhythm
This is our 'body clock'
Has 2 peaks at 4am and 2pm = most tired at these points
Lasts 25 hours
Also controls appetite, hormone secretion, temperature
Varies with age - kids and elderly wake/sleep early whilst teenagers sleep late
80
What is suspected to reset the circadian rhythm
Light - specifically blue light which is picked up by retinal cells
This is why its harder to wake up in winter when its dark
81
What are the risks of chronic sleep deprivation
Loss of inhibition and sense of danger
Leads to poor judgement and decision making
Can cause irritability, suspiciousness and even visual illusions
Will end up having lapses in concentration and microsleeps
82
Missing out on which type of sleep will cause sleep deprivation
Non-REM (deep) sleep
| Can get by without REM
83
Which area of the brain is most effected by lack of sleep
The cortex
It can only rest during sleep
Therefore a lot of the symptoms of sleep deprivation are pre-frontal
84
How can sleep deprivation kill you
No cases of dying just due to lack of sleep but it would probably kill you
Most common cause is RTA - spikes early hours of the morning
85
How much sleep do we need
Around 7-7.5 hours a night minimum
86
Can you catch up on sleep
Nope
| Long lie at weekend will not make up for sleep deprivation in the week
87
What is a REM sleep disorder
People will act out dreams (e.g. kick, running)
Will shout out in sleep
Only an issue if it occurs regularly
Seen in Parkinson's
88
List some common parasomnias
```
REM or non-REM
Sleep walking
Restless legs
Sleep terrors
Sleep paralysis
```
89
How does narcolepsy present
Daytime sleepiness - may fall asleep during conversations/meals
Cataplexy - sudden loss of muscle tone triggered by strong emotion
If people get very angry or laugh a lot they can suddenly slump to the ground
Hallucinations occurring at sleep onset - hypnagogic
90
How would you investigate narcolepsy
Overnight polysomnography
Multiple sleep latency test - assess how quickly someone falls asleep
narcoleptics will fall asleep almost immediately and go straight into REM sleep
LP will show low CSF hypocretin
91
What are the complications of narcolepsy
Job impairment - struggle to stay awake
| Increased risk of death in car accidents - shouldn't drive if not controlled
92
How does decorticate rigidity present
Upper limb flexed
| Lower limb extended and internally rotated
93
How does decerebrate rigidity present
Arms are extended and pronated
Wrists flexed
Plantars flexed
94
How does a central cord syndrome present
Affects the medial corticospinal fibres
| Get a cape like loss of sensation
95
What commonly causes a central cord syndrome
Common in the elderly who have cervical injuries or overextension
96
How does an anterior cord syndrome present
DCML is intact but other tracts affected
| Bilateral loss of spinothalamic sensation
97
What commonly causes an anterior cord syndrome
Usually due to interruption of blood supply in the anterior artery
Can present as spinal shock
98
How does brown-sequard syndrome present
Ipisilateral loss of motor below the level of the lesion
| Loss of sensation on opposite side
99
What is a common cause of brown-sequard syndrome
Penetrating injury to the back or neck
| Stab wound is buzzword
100
Syringomyelia is a type of what cord syndrome
Central cord syndrome
| Due to increased CSF pressure around the cord
101
What investigation would give you a definitive diagnosis in suspected brain cancer
Biopsy
102
What investigation would give you a definitive diagnosis in suspected extradural haemorrhage
CT scan
103
What investigation would give you a definitive diagnosis in suspected SAH
CT angiography
104
What are the symptoms of cerebral herniation
Cause by raised ICP
Extensor responses - upgoing plantars
Cushing's triad - hypertension, bradycardia and irregular breathing
Unreactive pupil
105
What type of herniation is most likely to cause unresponsive pupil
Uncal
106
What type of back pain gets better when walking uphill
That caused by lumbar stenosis
| The lean forward opens up the canal
107
What type of back pain gets worse with sitting or turning over
Mechanical
108
How does an anterior circulation stroke present
Higher cerebral dysfunction (e.g. dysphasia).
Homonymous visual field defect
Contralateral motor and/or sensory deficit
109
How does a posterior circulation stroke present
Cerebellar dysfunction
Isolated homonymous visual field defect
Cranial nerve dysfunction
110
How does a lacunar stroke present
Purely motor or sensory symptoms
111
What are sunset eyes a sign of
Hydrocephalus
| Upward gaze will be impaired
112
What are the symptoms of normal pressure hydrocephalus
Ataxia - shuffling gait like Parkinson's but no stopping issues
Incontinence
Dementia
113
Disorders of the pyramidal tracts present with what symptoms
Pyramidal weakness
| Spasticity
114
Disorders of the basal ganglia present with what symptoms
Can be hyperkinetic: dystonia, tics, myoclonus, chorea
| Or Hypokinetic = rigidity, bradykinesia
115
What is the Babinski reflex
When you drag a pointer up the sole of the foot the plantar reflex is increased
Toes splay outward
116
Describe the pattern of upper motor neuron disease
Increased tone - stiffness and spasticity
Minimal muscle wasting
No fasciculations
Clonus present
Brisk reflexes
Extensor plantar reflex - Babinski present
Pyramidal/ corticospinal pattern of weakness (= weak extensors in the arm, weak flexors in the legs)
Central pattern of sensory loss
117
Describe the pattern of lower motor neuron disease
```
Muscle wasting - early atrophy
Fasciculations
Decreased power
Decreased tone - flaccid
Decreased or absent reflexes
No clonus
Flexor plantar reflex - normal (no Babinski)
```
118
Describe the neurological pattern of functional disorders
No wasting
Normal tone and reflexes
Erratic changes in muscle power - e.g. able to walk but power on the couch is much lower
Migrating and fluctuating sensory patterns
119
What causes upper motor neuron lesions
Strokes
Space occupying lesions
Spinal cord problems
120
What causes lower motor neuron lesions
Motor neuron disease
Spinal muscular atrophy
Peripheral nerve issues - diabetes, toxic or metabolic insult
Nerve compression - carpal tunnel etc
121
What causes neuromuscular junction disorders
Myasthenia gravis - ACh receptor antibodies
| Lambert-Easton paraneoplastic syndrome - interferes with calcium channels
122
What nerve roots are responsible for the ankle jerk reflex
S1 and S2
123
What nerve roots are responsible for the knee reflex
L3 and L4
124
What nerve roots are responsible for the biceps reflex
C5 and C6
125
What nerve roots are responsible for the triceps reflex
C7 and C8
126
What does a glove and stocking distribution of sensory loss suggest
Length dependant neuropathy
| Can range from mild to severe
127
What does a sensory level distribution of sensory loss suggest
Spinal cord lesion
128
What does loss of temp/pain sensation but preserved light touch suggest
Hemicord damage
129
What does the cerebellar gait look like
Broad based
Unsteady
Cannot walk heel to toe (tightrope) - very unsteady
130
What is dysdiadochokinesis
Clumsy when attempting fast, alternating movements
131
What are signs of cerebellar disorders
```
Dysdiadochokinesis
Ataxia - cerebellar gait
Nystagmus
Intention tremor
Speech issue - dysarthria
Hypotonia
```
132
List the key extra-pyramidal symptoms seen in Parkinsonism
```
Bradykinesia
Rigidity
Resting tremor
Impaired gait and posture - stooped and small steps
Impaired postural reflexes
Reduced arm swing
Hypophonia - slow speech
```
133
Are motor symptoms in Parkinson's disease symmetrical
Nope
They are asymmetrical in Parkinson's
Symmetry suggests drug induced or atypical parkinsonism
134
What are the symptoms of large motor fibre damage
weakness, unsteadiness and muscle wasting
Reduced power
Absent reflexes
135
What are the symptoms of large motor fibre damage
Numbness, paraesthesia, unsteadiness
Reduced vibration sensation
Absent reflexes
136
What is a high stepping gait suggestive of
Peroneal nerve palsy - causes a foot drop
Often due to an L5 issue - e.g. prolapse
They have to lift their feet up high due to foot drop
Front of shoe may be scuffed
137
What is mononeuritis multiplex
Neurological issue affecting one side of the body
Can be due to an underlying inflammatory disorder
Lose function quickly
Patchy sensory loss
Can present with wrist or foot drop
138
What is a radiculopathy
When the nerve root is damaged
| Can be due to a disc prolapse or inflammation
139
What is a plexopathy
Affects a nerve plexus
Traction injuries common cause (especially in kids)
Causes a lot of pain
140
What is the most common cause of peripheral nerve demyelination?
Guillain-Barre syndrome
141
How can nerves be damaged (underlying process)
Axonal loss
Demyelination
Trauma
142
How does demyelination present on nerve conduction studies
Slow conduction
| Amplitude is preserved
143
How does axonal loss present on nerve conduction studies
Loss of amplitude
| Can also determine severity
144
What can cause demyelinating neuropathy
Acute - Guillain-Barre syndrome
| Chronic - CIDP or hereditary sensory motor neuropathy
145
How does Guillain-Barre Syndrome present
Progressive paraplegia over days up to 4 weeks.
Will quickly go 'off legs' and lose reflexes
Associated sensory symptoms proceed weakness - tingling or numbness
Peripheral glove and stocking pattern mainly
Severe pain is common
Can lead to breathing difficulty
146
Describe how Guillain-Barre syndrome progresses
Usually preceeded by some form of infection - e.g. food poisoning
Progressive symptoms over days to weeks
Peak symptoms are usually 10-14 days of onset
Sensory symptoms usually precede weakness
Can lead to breathing problems and death
147
How can Guillain-Barre syndrome cause death
Through cardiac arrhythmia as the autonomic nerves also become demyelinated
The breathing problems can kill if not dealt with - muscle weakness affects the respiratory muscles too
DONT miss this presentation
148
How do you treat Guillian-Barre syndrome
Immunoglobulin infusion
or
Plasma exchange
Mechanical ventilation if breathing affected
149
How do hereditary neuropathies present
Pure motor, sensory, sensorimotor, small fibre and autonomic variants
May get orthopaedic complications - HMSN type 1
Can be axonal loss or demyelinating
Hundreds of possible mutations
Genetic testing is available for the most common types
150
What can cause axonal neuropathies
```
Idiopathic - age related
Vasculitic - RA or ANCA
Paraneoplastic
Infections - HIV, syphilis, HB/C
Drugs and toxins - alcohol included
Metabolic - diabetes, b12, porphyria
```
151
Which neuropathies can affect the autonomic nerves
Acute - GBS or porphyria
| Chronic - Diabetes, amyloidosis or hereditary
152
How do you treat axonal neuropathies
Treat underlying cause
| Symptomatic - physio, orthotics, pain relief
153
How do you treat neuropathies caused by vasculitis conditions
Pulsed IV methylprednisolone + cyclophosphamide
154
What is Lambert Eaton Myasthenic Syndrome
Condition where there are antibodies to presynaptic calcium channels which cause less vesicle release
Associated with small cell carcinoma
May present like myasthenia but need to look for underlying cancer
155
How do you treat Lambert Eaton Myasthenic Syndrome
3- 4 diaminopyridine.
156
Which part of the nerve pathway is affected in myasthenia gravis
It is a post-synaptic disorder
157
Name 2 pre-synaptic NMJ disorders
Botulinum toxicity
| Lambert Eaton Myasthenic Syndrome (LEMS)
158
How does myasthenia gravis present
Muscle weakness and FATIGUE - worse at end of day
Weakness is extraocular (ptosis), facial and bulbar
Limb weakness is typically proximal
Can have rapid onset respiratory issues
Bilateral facial weakness makes it hard to smile
159
How is the thymus related to myasthenia gravis
75% of patients will have either thymus hyperplasia or a thymoma
Therefore always get a CT chest to look for thymoma if MG is suspected
160
Who gets myasthenia gravis
2 peaks - Females in 3rd decade and Males in 6/7th decade
Slightly more common in women
Lots of patients will have another autoimmune condition
161
How do you treat myasthenia gravis
Acetylcholinesterase inhibitor – pyridostigmine (prevents ACh breakdown)
Steroids or steroid sparing agents - slow intro to avoid side effects
Intravenous immunoglobulin - given IV short term
Thymectomy
162
What drug should you avoid in people with myasthenia
Gentamicin
| Precipitates myasthenia crisis in many people – go into respiratory failure
163
What are fasciculations
Visible, fast, fine , spontaneous twitch
May be seen in normal muscle after stress, caffeine or in fatigue
Occurs in denervated muscles - has become hyper excitable
Usually a sign of disease in the motor neurone
164
What is myotonia
Failure of muscle relaxation after use
Will look very stiff
e.g. they will shake your hand but be unable to let go as muscle wont relax
165
What causes myotonia
An issue with the chloride channels
| Usually hereditary
166
Give examples of some immune mediated muscle disorders
Polymyositis - symmetrical and progressive proximal weakness
Dermatomyositis - similar but with skin lesions
167
How do you grade muscle power
0 – no movement at all
1 - flicker of movement when attempting to contract muscle
2 – some muscle movement if gravity removed but none against gravity
3 - movement against gravity but not against resistance
4 – movement against resistance but not full strength
5 – normal strength
168
What is myotonic dystrophy
Commonest muscular dystrophy
Autosomal dominant - inherited muscle disorder
Multisystem involvement
Myotonia, weakness, cataracts, ptosis, frontal balding, cardiac defects
Trinucleotide repeat disorder with anticipation
169
Why must you screen family members if someone presents with myotonic dystrophy
Some other members may only have the heart defects which need to be found before they cause a real issue
170
Which common drug class is a major cause of myopathy
Statins
| lots get myalgia and some get myopathy
171
What is rhabdomyolysis and how does it present
Breakdown or dissolution of skeletal muscle
Triad of myalgia, muscle weakness and myoglobinuria
Complications of acute renal failure and DIC
172
What can cause rhabdomyolysis
Damage to skeletal muscle causes leakage of large quantities of toxic intracellular contents into plasma.
This can occur due to crush injuries, toxins, post-convulsions or after extreme exercise - marathons
173
Is chronic pain considered a disease
Yes it is officially recognised
| This hopes to improve coordination and management
174
What is the definition of pain
An unpleasant sensory and emotional experience, associated with actual tissue damage, or described in terms of such damage
175
How is pain received
Painful stimulus is recognised
A-delta and C fibres carry it from receptor to spinal cord
This is then sent up to the thalamus which passes them on to the somatosensory cortex
This is the sensory path
The emotional response is cause by the impulse also being sent to the amygdala and hypothalamus
This brings it to attention
176
What is peripheral sensitisation
Change that occurs in the nervous system after tissue injury
There is a reduction in the threshold of peripheral afferent nociceptors
177
What is central sensitisation
Change that occurs in the nervous system after tissue injury
There is increased excitability of spinal neurons
Rewiring in the spinal cord and changes in the brain
May be that more pain signals are able to be received
178
What are the signs of chronic regional pain syndrome
```
Allodynia - pain caused by a non-painful stimulus
Hyperalgesia - increased pain response
Swelling
Hair and nail changes
Osteopenia
```
179
What is allodynia
Pain caused by a non-painful stimulus such as being touched by cotton wool
180
What is nociceptive pain
Pain from injury relayed through a normal nervous system
181
What is neuropathic pain
Pain generated within the nervous system
182
How does neuropathic pain present
Burning, shooting, tingling and increased sensitivity
| Allodynia and hyperalgesia
183
What can cause neuropathic pain
Shingles or post-herpetic neuralgia
Surgery
Trauma
Diabetic neuropathy
184
What medication can be used to treat neuropathic pain
```
Tricyclic antidepressants - amitriptyline (most common)
Anticonvulsant - gabapentin
Opioids
NMDA antagonists - ketamine
Na channel blockers such as lignocaine
Capsaicin
GABA agonists
```
185
What can cause chronic pain in cancer survivors
```
Post surgical pain
Chemotherapy induced painful peripheral neuropathies
Chronic graft vs host disease
Radiation induced pain syndromes
Hormonal therapy and arthralgias
```
186
Does the NICU increase risk of chronic pain
YES
If we keep injuring the nervous system (through procedures etc) then they are more likely to have chronic pain
The nervous system develops differently than a term baby
187
Is chronic pain genetic
Some twin studies suggest a genetic influence but very complex
188
Which type of ion channels have an effect on pain reception
Voltage gated sodium channels
Many channelopathies that lead to pain disorders
Can cause people to be unable to express pain or leads to extreme pathological pain
189
What type of amputation leads to more chance of chronic pain
If there is prolonged damage to the limb and a delay to amputation there is more chance of chronic pain
190
Describe sensory remapping
Common after amputation
Sometimes sensation can be remapped so that areas of the brain responsible for sensation the hand (for example) will redirect and instead when stimulated they feel it in another area (as well as the phantom area)
191
What is the risk with prescribing opioids for chronic pain
Addiction and potential for overdose
| Commonly only used for malignancy pain
192
Give examples of degenerative diseases of the cerebral cortex
Alzheimer's
Pick Disease
CJD
193
Give examples of degenerative diseases of the basal ganglia and brain stem
Parkinson Disease
Progressive Supranuclear Palsy
Huntington Disease
194
Give examples of degenerative diseases of the motor neuron disease
Motor Neuron disease
195
Which cancers are most likely to metastasise to the brain
Breast, bronchus, kidney, melanoma, colon
196
What can lead to central herniation through the foramen magnum
SOL
| Haemorrhage
197
What is the most common posterior fossa tumour in children
Medulloblastoma
| Can lead to hydrocephalus by compressing the ventricular system and causing CSF to build up
198
What cellular processes occur after brain tissue is damaged
Macrophages come in and clear up the dead cells (this leads to liquefaction)
After this all that is left is a space
199
What takes up the majority of the space in the skull
The brain - 80%
| CSF and blood make up the rest
200
Describe the Monroe-Kellie principle
There are 3 intracranial components (brain, blood and CSF) if one of them increases in volume or you add a 4th (tumour, abscess) then the ICP must rise
201
What can cause a physiological rise in ICP
Coughing
Bending forward
Straining
202
Can ICP ever be negative
Yes
| Seen in new-borns, sedated patients or when standing vertically
203
What is the immediate compensation for raised ICP
CSF is pushed out of the foramen magnum into the spinal canal
Sinuses can become squeezed to reduce blood volume
204
How do you calculate the cerebral perfusion pressure
MAP-ICP
205
What will obstruction to CSF flow lead to
Hydrocephalus
206
What cerebral perfusion pressure will lead to a loss of consciousness
Below 20
| Patient will become comatose
207
What is the effect of high CO2 in the blood
CO2 is a potent dilator – high CO2 in blood will cause vasodilation
208
What can affect the blood flow to the brain
pressure changes, metabolic changes, stretch response or CO2 levels
Cerebral flow is autoregulated
209
What is chiari syndrome
Cerebellar tonsils protrude into the foramen magnum and block CSF flow
Leads to obstructive hydrocephalus
210
What type of brain tumour can produce CSF
Choroid plexus papilloma
| Usually only seen in children
211
What is the normal ICP in adults
7-15mmHg
212
What are the late clinical signs of raised ICP
```
Coma
Fixed, dilated pupils
Can have hemiplegia
Bradycardia (Cushing’s triad)
Hyperthermia
Increased urinary output (BP trying to compensate)
```
213
How do you manage raised ICP or hydrocephalus
Maintain CPP and prevent ischaemia
Maintain head in the midline to facilitate blood flow
Loosen jewellery, collars etc
Set the head of the bed to 30-45 degrees
Avoid anything that could lead them to raise ICP – coughing, gagging etc
Decrease environmental stimuli
Treat the hyperthermia
Maintain the fluid balance and normalise electrolytes Keep CO2 at normal level
214
What medications can be used in the treatment of raised ICP
```
Use diuretics (mannitol, furosemide etc)
Anti-epileptics
Barbiturate coma (reduces brain function to a minimum)
```
215
What surgery can be used in the treatment of raised ICP
Surgical decompression - remove part of the skull to allow pressure to escape
Remove any mass lesions and drain abscesses
CSF shunts - from ventricles to peritoneal space
216
What is the risk of craniotomy
Leads to disfigurement and the cranioplasty to repair carries a large risk
217
What can cause communicating hydrocephalus
Meningitis
Trauma
SAH
218
What can cause non-communicating hydrocephalus
Colloid cyst
Tumours
Chiari syndrome
219
What are the physical signs of hydrocephalus
Sunset eyes – unable to look up due to midbrain pressure
Broad, flat face is a sign in kids
Enlarged head in very young children
220
How does normal pressure hydrocephalus present
Abnormal gait - wide based and shuffling
Urinary incontinence
Dementia - mild
Called Hakim's triad
221
Who gets normal pressure hydrocephalus
The elderly
| Its idiopathic
222
How does normal pressure hydrocephalus appear on scans
Large sylvian fissure
Enlarged ventricles
Crowned brain (a lot of brain up at the top of the skull – pushed up by pressure)
Angle between the lateral ventricles is 90’ or less
223
How do you treat normal pressure hydrocephalus
VP shunt, medium or low-pressure valve
224
Who gets idiopathic intracranial hypertension
Usually young and common in women of child-bearing age
Some will develop it in pregnancy and get better after birth
Mainly in western civilisations
Usually overweight - biggest risk factor
225
What are the symptoms of idiopathic intracranial hypertension
```
Debilitating headaches
Double vision and blurriness
Reduced visual acuity
Tinnitus (often pulsatile)
Radicular pain (affects arms)
Papilloedema
Unsteadiness
```
226
What is the main complications of idiopathic intracranial hypertension
Permanent visual loss
| Seen in 25% of patients
227
How does the CT scan appear in idiopathic intracranial hypertension
CT will be normal
| These patients never have enlarged ventricles
228
What causes idiopathic intracranial hypertension
Exact cause is unknown
| May be due to CSF imbalance, hormones (oestrogen) or venous pressure
229
What investigations are done for idiopathic intracranial hypertension
LP
CT/MRI head
CTV - venogram
Fundoscopy
230
How can you treat idiopathic intracranial hypertension
Reduce pressure with LP and drainage
Weight loss
Carbonic anhydrase inhibitors - acetazolamide, topiramate
Diuretics
CSF diversion - shunt
Interventional radiology - venous stents
ONSF (optic nerve sheath fenestration)
231
What is mechanical pain
Pain on movement
232
If a problem presents acutely what are the likely causes
Trauma
| Vascular
233
If a problem presents over days or weeks what are the likely causes
Infection
234
If a problem presents over weeks to months what are the likely causes
Tumour
| Degenerative disease
235
What is cervical myelopathy
Compression of the upper MN
Leads to hyperreflexia and hypertonia
Will have a spastic gait and positive Hoffman's test
236
Which type of haemorrhage has a lucid interval
Extradural
237
What is pronator drift
Get the patient to hold their arms out with their eyes closed
If one side is weaker it will slowly drop
Seen in upper MN conditions
238
What are the signs of cerebellar pathology
```
Dyskinokinesia
Ataxia
Nystagmus
Intention tremor
Staccato speech
Hypotonia
```
239
Spastic gait can be seen in which conditions
Cervical myelopathy - unilateral
| Cerebral palsy
240
Which gait is seen in cerebral palsy
Spastic
| Scissoring - legs are so stiff that they almost end up crossing them when swinging forward
241
Those who have had a stroke can present with which type of gait
Flexed arm - flexors stronger
Stiff and straightened leg - extensors stronger
Will swing leg round in a circular motion to stop foot scraping
242
How are reflexes affected by UMN lesions and LMN lesions
UMN - hyperreflexia
| LMN - hyporeflexia
243
How can timescale help you diagnose the underlying cause of a neuro issue
Acute - infection or vascular
Days/weeks - infection
Weeks/months - tumour or degenerative
244
Night pain is a red flag for which cause of back pain
Cancer
| Focal tenderness may be elicited over the site of mets
245
Night sweats are a red flag for which cause of back pain
TB
246
A trendelenberg gait is seen in which conditon
In someone which weak hip abductors
| e.g. osteoarthritis
247
How does cervical myelopathy present
Spastic gait
Increased tone in hands - struggle with fine motor skills
Clumsiness - dropping things a lot
Legs jump at night - hyperreflexia
Poor balance if they shut eyes - loss of proprioception
248
How does lumbar claudication present
Commonly in the elderly - degenerative
Bilateral tingling, numbness, heaviness and occasionally pain
Decreased walking distance
Improves on leaning forward - e.g. when walking uphill or leaning on shopping trolley
249
Why does lumbar claudication improve on leaning forward
It is in part caused by a thickened ligamentum flavum which narrows the spinal canal
When you lean forward this ligament changes shape and gets thinner - opening canal and improving symptoms
250
What makes the headache caused by raised ICP worse
Worse on waking, lying down, bending forward, coughing, vomiting
251
What initial test would you do in clinic if you suspect raised ICP
Fundoscopy to exclude papilloedema
252
List general red flags for neurology
Focal neurology
Change in behaviour
New onset seizure
253
How does cauda equina present
Saddle paresthesia
Genital numbness
Erectile dysfunction
Painless urinary retention with urinary incontinence.
254
How does functional weakness present
Variable power with normal bulk, tone & reflexes
May have collapsing weakness - before you put any pressure on them their limb collapses back down
Power may vary depending on how distracted the patient is - i.e. normal on the 'trick' tests such as Hoovers
255
Acute unilateral weakness is usually due to what
Stroke
256
What conditions can cause acute generalised weakness
Guillain-Barre syndrome,
Myasthenia
Myopathy
Cord pathology.
257
What is the pyramidal pattern of power changes
weak extensors in the arm, flexors in the leg
258
Glove and stocking sensory loss is common in which condition
Peripheral neuropathy
| Starts in toes and works up to knees before hands become involved
259
What is a resting tremor
A tremor which is no worse with action
| Seen in Parkinsons
260
What is a pill-rolling tremor
A subtype of resting tremor seen in the index and thumb only
Looks like they are rolling something in their fingers
Seen in Parkinson's
261
What is a postural tremor
Tremor most obvious in outstretched hands
| Comes on with certain positions
262
What can cause a postural tremor
May be physiological
Increases with anxiety, hyperthyroidism and medication eg
thyroxin, lithium and sympathomimetics
263
What is an intention tremor
Tremor which is worse during movement, especially when moving towards a target when past-pointing may occur
264
Intention tremors are seen in which conditions
It is typically
associated with cerebella disorders, although severe forms occur with
ischaemia or demyelination of the red nucleus.
265
What are the most common causes of peripheral neuropathy
Diabetes
Alcohol - nutrition and toxicity
Idiopathic - generally age related
266
Are peripheral neuropathies typically asymmetrical or symmetrical
Symmetrical
267
What is the difference between occular and generalised myasthenia
Ocular myasthenia is purely eye involvement
| Generalised will include limbs, neck, bulbar symptoms
268
How do you diagnose myasthenia gravis
Antibody testing
Electrophysiology test
Always get a CT chest - look for thymoma
269
How do essential tremors present
Postural
Generally symmetrical
No change in tone
Often have family history
270
How does a cerebellar tremor present
Action/intention tremor
Can be symmetrical or asymmetrical depending on pathology
May have reduced tone
271
How might eyes be affected in cerebellar pathology
Nystagmus
| Eyes may also goes past the point and have to come back - kinda like an intention tremor
272
How can you test for fatiguable muscle weakness
Shoulder abduction before and after repetitive movement (flap arm 20x then test again)
273
How do extra-pyramidal tremors present
Resting tremor
Can be brought out by distracting the patient, may come with cog-wheeling
Asymmetrical
Will have rigidity
274
What features in a history make a swallowing problem more likely to be neurological
Dysphagia to liquids then solids
275
Do steroids have a role in the treatment of Guillian-Barre syndrome
No
| Unlike many neurological disorders, there is no evidence for steroids in GBS
276
How do you diagnose Guillian-Barre syndrome
Neurophysiology
- Generally a demyelinating picture (decreased conduction velocity but normal amplitude of AP)
Lumbar puncture
- high protein with no cells
- excludes infective mimics
Antiganglioside antibodies
- Seen in 60% of cases
277
Those presenting with functional disroders may complain of which symptoms
Migrating and fluctuating sensory patterns
Motor symptoms - lack of control over limbs, heavy limbs, collapsing limbs
Memory problems are usually exaggerated - persistent and more pronounced
Often lots of fluctuation - some days very distressed and cant remember anything, other days are fine
Often have balance issues - not vertigo or lightheadeness, mainly internal feeling
278
What is a conversion disorder
When a psychological trauma in past is not dealt with and presents as a neurological deficit
Now considered to be different to FND
279
How do you manage a functional disorder
- Explaining a functional disorder to patients can be usuful - e.g. Hardware vs software issue
Don't go overboard as it is very confusing
May scan them to look for any underlying issue - usually normal
Neuropsychology can help with cognitive symptoms
280
How can Hoover's test be used to find a functional disorder
If you ask them to push their 'weak' leg into the bed they will often lack power
However, then tell them you are testing the other side and ask them to lift the 'unaffected' leg up
In order to do they you unconsciously press down with the other leg - therefore you know the nerves are intact and power is in fact normal
281
What is a benign essential tremor
A sporadic and slower subtype of resting tremor
| Typically maximal in the upper limbs, head, jaw and tongue
282
When might an upper motor neurone issue present with flaccidity
When associated with spinal shock
| Initial flaccidity
283
List general causes of somatosensory disturbance
Pathology affecting peripheral nerves, nerve roots, or the CNS sensory
pathways from the spinal cord to the cerebral cortex.
Physiological stimuli affecting a normal nervous system, such as hyperventilation, transient pressure on a nerve, transient ischaemia
or drug treatment
Transient dysfunction of sensory cortex in epilepsy and in migraine
Psychiatric or psychological illnesses
284
What is parasthesiae
A burning or prickling sensation
| Pins and needles
285
What is hyperpathia
Where the pain threshold of one area is much lower
| Painful stimuli are much more painful than usual
286
How does functional weakness present
Variable power with normal bulk, tone & reflexes
287
Acute unilateral weakness is typically caused by which pathology
Stroke
288
What is polyradiculopathy
Diffuse disease of the nerves causing generalised weakness
289
List UMN causes of weakness in all 4 limbs
Cervical cord lesion
Brainstem lesions
Bilateral cerebral lesions
MND - affects both UMN and LMN
290
List LMN causes of weakness in all 4 limbs
Polyradiculopathy
Peripheral neruopathy
MND - affects both UMN and LMN
291
List UMN causes of weakness in both legs
spinal cord lesion
292
List LMN causes of weakness in both legs
cauda equina lesion
293
List UMN causes of weakness in one leg
lesion above highest level
294
List LMN causes of weakness in one leg
single nerve = monotherapy
| single root = radiculopathy
295
List causes of patchy weakness
multiple CNS lesions
polyradiculopathy
multiple single nerves
mononeuritis multiplex
