Rest of acute neuro Flashcards by Wasim Silmi

A 62-year-old woman presents back pain and difficulty walking. On examination there is increased tone and hyper-reflexia in both legs. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier. Which is the most likely diagnosis?

Spinal cord compression

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A 20-year-old woman presents with pins and needles in both legs. Her symptoms rapidly progress over 4 days to include lower extremity weakness to the point that she is unable to mobilise her lower extremities. She reports gastrointestinal symptoms 2 weeks ago. Lumbar puncture reveals mildly elevated protein with no cells and normal glucose.Given the most likely neurological diagnosis which organism is most likely to have caused the gastroenteritis?

Salmonella
Campylobacter Jejuni
E. Coli 0517
Rotavirus
Entamoeba histolytica

Campylobacter jejuni

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Define GBS

Acute autoimmune demyelinating polyneuropathy

affecting the PNS

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What is the pathophysiology of GBS

AI process attacking myelin sheath or Schwann cells in sensory and motor peripheral nerves

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Cause of GBS?

Unknown but 2/3rds preceded by an URTI or gastroenteritis 2-3 weeks previously

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Which type of cell produces myelin

Schwann cells

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What are the viral causes of GBS (5)

CMV, EBV, HepB/C, HIV

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What are the bacterial causes of GBS (2)

campylobacter jejuni, mycoplasma

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What is the triad in Miller-Fischer syndrome and the one thing it is without

ophthalmoplegia, areflexia & ataxia but NO muscle weakness. In Miller-Fisher syndrome there are antibodies against a specific ganglioside (GQ1b)

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What is the triad of: ophthalmoplegia, areflexia & ataxia but NO muscle weakness known as

Miller-Fischer syndrome

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Signs of GBS (4)

Hypotonia
Flaccid paralysis ( = weakness/paralysis & ↓ muscle tone)
Altered sensation/numbness
Fasciculations

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Symptoms of GBS (6)

Peripheral neuropathy
Progresses acutely
Ascending paraesthesia & pain
Symmetrical limb weakness
Can also cause facial nerve palsy
Can also have autonomic symptoms (urinary retention, ileus)
If this progresses to resp. paralysis, patients might need ventilatory support

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Ix for GBS (4)

Nerve conduction studies
Lumbar puncture
Spirometry
Bloods

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How often should you perform spirometry in a GBS patient

Every 6 hours

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What do you see in the nerve conduction study of a GBS patient

Decreased nerve conduction

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What do you see in the lumbar puncture of a GBS patient (3)

Albuminocytological dissociation (a hallmark of demyelinating polyneuropathies)
↑ protein (reflects CNS inflammation)
normal glucose & cell count (due to no infection)

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What are you looking for in the bloods of a GBS suspected patient

Anti-ganglioside AB’s (Miller-Fischer variant)

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Which AB is present in Miller-Fischer variant GBS

anti-ganglioside

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Define hydrocephalus

Excessive accumulation of CSF in the ventricular

system in the brain.

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Epidemiology of hydrocephalus

Bimodal distribution (affects the young &amp; 
elderly)

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Pathophysiology of hydrocephalus

Bc you have excess CSF, the ICP increases. CSF also permeates through the ependymal lining into the periventricular white matter. This results in white matter damage and gliotic scarring.

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What is the difference between a communicating and non-communicating hydrocephalus

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Non-communicating
/Obstructive - Caused by CSF flow obstruction

Communicating
↓ absorption, ↑production of CSF

What is a normal pressure hydrocephalus

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Idiopathic chronic ventricular enlargement but without significantly elevated CSF pressure measured via lumbar puncture

What is a hydrocephalus ex vacuo

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ventricular expansion 2ary to to compensate for brain atrophy (eg in AD)

What are the four types of hydrocephalus

Communicating non-communicating normal pressure ex vacuo

Causes of non-communicating hydrocephalus (5)

Stenosis of the cerebral aqueduct Stenosis of the interventricular foramina Lesions in 3rd, 4th ventricle Posterior fossa lesions (tumour, blood) compressing the 4th ventricle These cause an obstruction in the flow of the CSF flow

Causes of communicating hydrocephalus (3)

Tumours Meningitis (typically TB) Normal pressure hydrocephalus

What is a communicating hydrocephalus

: the problem is outside the ventricular system – for example, it can be due to reduced absorption or blockage of the venous drainage system or due to increased CSF production

Acute onset presentation of hydrocephalus (4)

Nausea & vomiting Headache Papillooedema

Chronic onset presentation of hydrocephalus (4)

Cognitive impairment Unsteady gait Double vision CN palsies

Normal pressure hydrocephalus presentation (3)

Cognitive impairment Gait apraxia Hyperreflexia

Hydrocephalus Ix (2)

``` CT/MRI Head – 1st line Ventricular enlargement Might show the cause (eg tumour) CSF analysis From ventricular drain May show infection ```

What must you assess before a LP

ICP

What is a radiculopathy

Compression of a nerve root as it exits the spinal cord

Causes of spinal cord compression (7)

``` Trauma Tumours Osteoporosis, Corticosteroid Tx Osteomalacia, Osteomyelitis Intervertebral disc disease (disc herniation) ```

Presentation of spinal cord compression (motor 3, sensory 2, autonomic 3)

Motor Limb weakness (hemiplegia/paraplegia) UMN symptoms below the level of the lesion LMN symptoms at the level of the lesion Sensory Sensory loss below a specific level Back pain Autonomic Constipation Urinary retention Erectile dysfunction

Ix for cord compression (8)

MRI or CT (MRI is Definitive) Bloods - FBC, U&Es, calcium, ESR, immunoglobulin electrophoresis (multiple myeloma) Urine - look for Bence Jones proteins (multiple myeloma)

What do you look for in the urine in multiple myeloma

Bence Joyce proteins

What is a Bence Joyce protein

Protein found in urine in MM

What do you do to investigate MM (2)

Urine Bence Joyce protein and Ig electrophoresis

Define cauda equina syndrome

Lumbosacral nerve roots that form the cauda | equina in the spinal canal become compressed

Causes of cauda equina (3)

Lumbar disc herniation Tumours Epidural abscess

Presentation of cauda equina (4)

LMN symptoms Perianal anaesthesia Bladder retention Leg weakness

What is sciatica

Lumbosacral nerve root impingement

Presentation of sciatica (motor and sensory)

Motor: LMN symptoms for the muscles innervated by this spinal root Sensory: DERMATOMAL pattern Pain, numbness

Causes of radiculopathy (5)

Degenerative disc disease, osteoarthritis, spondylolisthesis, tumours, infection

Define spondylolisthesis

forward displacement of a vertebra on the one below producing pain by compression of the nerve roots

What is forward displacement of a vertebra on the one below producing pain by compression of the nerve roots known as

Spondylolisthesis

How to diagnose sciatica

straight leg raise test: If pain in the distribution of the sciatic nerve is reproduced on passive flexion of the straight leg at the hip between 30-70 degrees then it is considered a positive sign (Lasegue's sign) This test is sensitive but not very specific

A 21-year-old woman presents to A & E with acute onset of left-sided body twitching, lasting for 5 minutes, after a minor accident in which she hit her head. She reports 3 similar episodes in the past month, after her boyfriend broke up with her. Past-medical history includes IBS for which she takes laxatives. Physical examination, laboratory investigations and imaging studies are normal. What is the most likely diagnosis? ``` Dissociative seizure Simple partial seizure Vasovagal episode Todd’s palsy Myoclonic seizure ```

Dissociative seizure

What is a dissociative seizure

can resemble epileptic seizures | but have NO biological correlate.

When should you suspect dissociative seizure (4)

Suspect Dissociative seizures if: Prolonged duration Hx of abuse, psychological or emotional precipitants

Explain GCS scoring

``` Eyes 4 spontaneous 3 to speech 2 to pain 1 no response ``` ``` Verbal response 5 oriented to time, person and place 4 confused 3 inappropriate words 2 incomprehensible sounds 1 no response ``` ``` 6 obeys command 5 moves to localised pain 4 flex to withdraw from pain 3 abnormal flexion 2 abnormal extension 1 no response ```

Rest of acute neuro Flashcards

(53 cards)