Neuro Flashcards

Question

Management of SAH?

Answer 1

**GENERAL** * Continuous observation, IV access, analgesia **PREVENTING ISCHAEMIA** * Nimodipine (calcium antagonist) **DEFINITIVE** * Surgical - clipping (11-14 days after) Antifibrinolytics reduce bleeding

Answer 2

Seizure lasting for \>30 minutes, or repeated seizures without intervening consciousness

Answer 3

* Open and maintain airway * Recovery position * Oral/nasal airway * Oxygen * IV access if possible * **Lorazepam** * IV 2-4mg (2nd dose if no response in 10 min) * **Phenytoin** * 15-20mg/kg IVI at \<50mg/min * Maintenance - 100mg/6-8h * OR **Diazepam** 100mg in 500mL of 5% glucose - infuse at 40mL/h

Answer 4

Diazepam 10-20mg PR Midazolam 10mg buccal

Answer 5

Common = aneurysm, diabetes, MS, tumour, trauma/surgery, stroke Rare = vasculitidies, sarcoidosis Infection = Lyme disease, syphilis, HIV, Wernicke’s encephalopathy

Answer 6

glacucoma, retinitis pigmentosa, stoke, retinal occulsion, detached retina

Answer 7

Papilloedema

Answer 8

* Medial, superior, and inferior recti, and inferior oblique muscles * Lateral rectus and superior oblique take over --\> down and out. * Ptosis – due to ↓response of levator palpebrae superioris

Answer 9

* Superior oblique * Eye turns up and out, and elevates more as it moves medially

Answer 10

* Lateral Rectus * Eye medially deviated and movement lateral from midline is not possible

Answer 11

* Inability to raise eyebrows, open eyes against resistance, do facial movements etc. * Forehead sparing in UMN lesion, not so in Bell’s palsy. * Lacrimation, salivation impaired (lesion proximal to geniculate ganglion) * Taste impaired (anterior 2/3 tongue – lesion above chorda tympani) * Hyperacusis (lesion above nerve to stapedius)

Answer 12

Sensorineural deafness * Patient will report a quieter sound in the ear with the sensorineuronal hearing loss Conductive hearing loss * Sound lateralises to affected ear - ear with the conductive hearing loss is only receiving input from the bone conduction and no air conduction, and the sound is perceived as louder in that ear

Answer 13

Posterior 1/3 of the tongue

Answer 14

MINDMATT * Meniere's * Infective * Neoplastic (acoustic neuroma) * Degenerative * Metabolic * Autoimmune * Toxic * Trauma

Answer 15

* Hand of benediction on trying to make a fist * Paraesthesiae in thumb, index and middle fingers – relieved by dangling hand over edge of bed and shaking it (‘wake and shake’) * Sensory loss and weakness of abductor pollicics brevis +/- wasting of thenar eminence

Answer 16

Splinting; local steroid injection +/- decompression surgery.

Answer 17

(C6-T1) Swelling/compression in tunnel myxoedema, prolonged flexion (Colle’s splint), acromegaly, myeloma, local tumours (lipoma, ganglion), RA, amyloidosis, pregnancy, sarcoidosis.

Answer 18

(C7-T1) * Weakness/wasting of medial (ulnar) wrist flexors, interossei and medial two lumbricals * Cannot cross fingers in good luck sign/claw hand * Hypothenar eminence wasting, weak 5th digit abduction, 4th/5th DIP joint flexion * Sensory loss over medial 1½ fingers and ulnar side of hand

Answer 19

C5-T1 * Opens the fist * muscles involved = **BEAST** --\> brachioradialis, extensors, abductor pollicis longus, supinator & triceps.

Answer 20

Compression against humerus

Answer 21

Wrist/finger drop with elbow flexed and arm pronated Sensory loss variable – anatomical snuff box mostly

Answer 22

Klumpke's palsy (lower) and Erb's palsy (upper)

Answer 23

(C3-5) Orthopnoea & raised hemidiaphragm on CXR

Answer 24

(L4-S1) * Foot drop, weak ankle dorsiflexion/eversion * Sensory loss over dorsal foot.

Answer 25

(L4-S3) Inability to stand on tiptoe (plantarflexion), invert the foot, or flex the toes, with sensory loss over the sole.

Answer 26

* Numbness; pins and needles/paraesthesiae; ‘glove and stocking’ distribution, * Difficulty handling small objects like buttons * Signs of trauma (finger burns) or joint deformation may indicate sensory loss * Diabetic and alcoholic neuropathies are typically painful

Answer 27

A = alcohol B = B12/folate deciciency C = Cancer/Connective Tissue/Collagen D = Diabetes E = Endocrine e.g. hypothyroid

Answer 28

Guillain-Barré, Lead Poisoning, Charcot-Marie-Tooth * Often progressive (may be rapid) * Weak or clumsy hands; difficulty in walking (falls, stumbling) * Difficulty in breathing (↓vital capacity) * Signs = LMN lesion - wasting/weakness in distal muscles of hands/feet – reflexes are reduced/absent

Answer 29

DM, amyloidosis, Guillain Barré, Sjogren’s Syndrome, HIV, Leprosy, SLE * Postural hypotension, decreased sweating, ejaculatory failure, Horner’s syndrome * Constipation, nocturnal diarrhoea, urinary retention, erectile dysfunction

Answer 30

* Bloods * FBC, ESR, glucose, U+E, LFT, TSH, B12, electrophoresis, ANA, ANCA * Urinalysis * Imaging * CXR * Other * LP +/- specific genetic tests; nerve conduction studies

Answer 31

* Treat cause; involve physio and OT. * Foot care and shoe choice [Symbol] minimise trauma. * Splinting * IV immunoglobulin in Guillain-Barré and demyelinating polyradiculoneuropathy * Steroids/immunosuppressants may help in vasculitic causes * Neuropathic pain --\> amitriptyline, duloxetine, gabapentin and pregabalin

Answer 32

* Cortical bridging veins * Connect the venous system of the brain to the large intradural venous sinuses and lie relatively unprotected in the subdural space

Answer 33

* Any factor that stretches bridging veins --\> cerebral atrophy, low CSF pressure after shunting * Alcoholism * Coagulation disorder/anticoagulation

Answer 34

* **Fluctuating conscious level** * History of gradual onset headahces, memory loss, personality change, dementia, confusion, drowsiness * Symptoms vary from day to day with intervening lucid periods * **Focal neurological signs** * Often hemiparesis on the side ipsilateral to the lesion (false localising sign) * **Aphasia** * If lesion on the left side

Answer 35

Shows clot +/- midline shift. Crescent-shaped collection of blood (increased density) over 1 hemisphere.

Answer 36

Irrigation/evacuation (via burr twist drill and burr hole craniostomy) = 1st line Craniotomy = 2nd line

Answer 37

Middle meningeal - typically after trauma to temple

Answer 38

* Hemiparesis +/- brisk reflexes and upgoing plantars * Ipsilateral pupil dilates --\> coma deepens --\> bilateral limb weakness * Breathing becomes deep and irregular (brainstem compression) * Bradycardia and raised BP (Cushing’s response) are late signs

Answer 39

Haematoma (biconvex/lens-shaped are of increased density); blood forms more rounded shape (dural attachments to skull keep it more localised.

Answer 40

Presence of multiple neurological deficits which are separated in time and space.

Answer 41

* Optic neuritis – usually unilateral * Transverse myelitis - acute episode of bilateral weakness of legs, with loss of control of bowels and bladder. * Neurogenic bladder dysfunction – urgency +/- incontinence and frequency * Impotence * Sensory deficits – tingling in restricted distribution, trigeminal neuralgia, Lhermitte’s phenomenon (electricity sensation down spine on neck flexion) * UMN deficit – spastic weakness of legs * Cerebellar damage – ataxia, dysarthria, nystagmus * Vertigo * Dementia in later stage

Answer 42

* **Bloods** * FBC, CRP, ESR, U&Es, LFTs, TFTs, glucose, HIV, calcium and B12 levels * **MRI** * 95% have periventricular lesions * 90% discrete white matter abnormalities * Focal demyelination – plaques in optic nerve, brainstem and spinal cord * Gadolinium enhancement improves sensitivity * **CSF** * Oligoclonal bands of IgG on electrophoresis that are not present in serum suggest CNS inflammation. * **Visual Evoked Potentials** * Show conduction changes consistent with demyelination – increased latency in patients with optic neuritis.

Answer 43

1. Steroids 2. Disease-modifying 3. Symptomatic

Answer 44

Methylprednisolone – shortens acute relapses (use sparingly) – doesn’t alter overall prognosis.

Answer 45

**Interferons (IFN-1β and IFN-1α)** * ↓Relapses 30% and ↓lesion accumulation on MRI. Modest role in delaying disability. **MABs** * Alemtuzumab/Natalizumab – better than interferons. **Non-immunosuppressive** * Glatiramer, mioxantrone **Others** * Azathioprine is good for relapsing remitting.

Answer 46

**Spasticity** * Baclofen, diazepam, dantrolene, tizanidine. **Tremor** * Botulinum toxin A **Urgency/Frequency** * Intermittent self-catheterisation/tolterodine

Answer 47

1. **Tremor** * Worse at rest; often 'pill rolling' 2. **Rigidity/↑Tone** * ****'*Cogwheel ridigity*' - jerky resistance to passive movement- felt by rapid pronation/supination * '*Lead pipe rigidity*' - sustained resistance to passive movement throughout the whole range of motion, with no fluctuations 3. **Bradykinesia/Hypokinesis****** * Slow to initiate movement and slow, low amplitude repetitive actions (low blink rate, monotonous hypophonic speech, migrographia). * Gait: ↓arm swing, festinance, freezing at obstacles or doors * Expressionless face (hypomimesis)

Answer 48

* Sense of smell reduced * Constipation * Visual hallucinations * Frequency/urgency * Dribbling of saliva * Depression and dementia

Answer 49

Usually clinical diagnosis SPECT scan

Answer 50

**_Levodopa_** * Co-beneldopa/Co-careldopa (combined with dopa-decarboxylase inhibitor) * Variable response (unpredictable freezing) and reduced end of dose response. * Key decision = when to start. Cons = ↓efficacy over time, dopamine-induced dyskinesias (5-10 years), psychosis, visual hallucinations, N+V (domperidone) **_Dopamine Agonists_** * Ropinirole/pramipexole (transdermal). * Drowsiness, nausea, hallucinations, compulsive behaviour * Apomorphine = potent DA (continuous SC infusion) – evens out end-of-dose effects **_Anticholinergics, MAO-B inhibitors, COMT inhibitors_**

Answer 51

**_Neuropsychiatric_** * Deep brain stimulation **_Surgical_** * Surgical ablation of overactive basal ganglia circuits (subthalamic nuclei)

Answer 52

1. **Prodrome** = Change in mood/ behaviour (hrs -days) 2. **Aura** = Simple partial seizure (temporal) which may precede 3. **Partial (focal)** = Features referable to part of one hemisphere 4. **Primary generalised** = No warning/aura. Discharge throughout cortex w/o localising features 5. **Simple** = awareness unimpaired 6. **Complex** = awareness impaired 7. **Secondary generalised** = focal seziure --\> generalised (e.g. aura --\> ton-clon)

Answer 53

2/3 are idiopathic (often familial) * **Congenital** * NF, tuberous sclerosis, TORCH, perinatal anoxia * **Acquired** * Vascular (CVA), cortical scarring (trauma, infection), SOL, SLE, PAN, MS, sarcoidosis * **Non-Epileptic Seizures** * Withdrawal (EtOH, opiates, benzos), metabolic (glucose, Na, Ca, urea, NH3), ↑ICP, infection, eclampsia, pseudoseizures

Answer 54

Focal motor, sensory, autonomic or psychic symptoms

Answer 55

_5 As (usually from temporal lobe)_ * **A**ura * **A**utonomic (skin colour change, temperature, palpitations) * **A**wareness lost (motor arrest, motionless state) * **A**utomatisms (lip-smacking, fumbling, chewing, swallowing) * **A**mnesia

Answer 56

ABSCENCES * **AB**rupt onset/offset * **S**hort (\<10s) * **E**yes (glazed, blank stare) * **N**ormal (intelligence, examination, brain scan) * **C**lonus (or automatisms) * **E**EG (3Hz spike and wave) * **S**timulated by hyperventilation and photics

Answer 57

* LoC * ***Tonic*** = limbs stiffen; ***Clonic*** = rhythmic jerking of limbs * Cyanosis; incontinence; tongue biting (lateral) * Post-ictal confusion and drowsiness

Answer 58

Sudden jerk of limb, face or trunk

Answer 59

Sudden loss of muscle tone à fall (no LoC)

Answer 60

Clusters of head nodding and arm jerks (EEG shows hypasarrhythmia)

Answer 61

* Bloods – FBC, U+E, LFT, calcium, glucose * Urine toxicology * ECG * Imaging – MRI (focal onset, adult epilepsy, seizures in spite of treatment) * EEG – to support diagnosis and help classification

Answer 62

Advise against driving, swimming, bathing alone until Dx is established Diagnosis --\> no driving until seizure free for 1 year (HGV 10 years seizure and medication free)

Answer 63

* Avoid valproate (lamotrigine or CBZ instead) * 5mg folic acid daily if child-bearing age * CBZ and phenytoin are inducers and ↓efficacy of OCP

Answer 64

INDUCERS (reduce concentration) * Carbamezapine * Phenytoin * Barbituates INHIBITORS (increase concentration) * Valproate

Answer 65

* Skin rash * Rash * Diplopia/blurred vision * Levels affected by inducers/inhibitors

Answer 66

* Leukopenia * Skin reactions * Diplopia/blurred vision * SIADH --\> hyponatraemia

Answer 67

ALPROAT³E * **A**ppetite↑ * **L**iver failure * **P**ancreatitis * **R**eversible hair loss * **O**edema * **A**taxia * **T**eratogenicity, **T**remor, **T**hrombocytopenia * **E**ncephalopathy (due to ammonia)

Answer 68

* Gingival hypertrophy * Hirsutism * Cerebellar signs (ataxia, nystagmus, dysarthria) * Peripheral sensory neuropathy * Diplopia * Tremor

Answer 69

Bilateral - may have photophobia and phonophobia No nausea/vomiting or significant systemic upset/neurological deficit

Answer 70

* Avoid overwork/stress, excess alcohol, lack of exercise. Strategies to counteract stress. * Treat clinical depression. * Avoid analgesic abuse – max 12 doses per week. * Headache diary * Reassurance

Answer 71

If \<2 days a week – **OTC analgesics**. * Paracetamol – not great * NSAID or aspirin * Avoid codeine If frequent/chronic --\> aim for long term remission (**prophylaxis**) * Low dose amitriptyline * 3 week course of naproxen BD Alternative = acupuncture

Answer 72

Syndrome characterised by periodic headaches with complete resolution between attacks. * **Vascular theory** = aura due to vasoconstriction, headache due to vasodilation * **Neuronal theory** = aura associated with spreading neuronal inhibition

Answer 73

25% prevalence in women, 8% in men Usually first attack before age 30 Migraine without aura 3x more common than migraine without aura

Answer 74

At least 5 attacks, all fulfilling following criteria * **Frontotemporal headahce** lasting 4-72 hours with at least 2 of the following characteristics * **Unilateral** location * **Pulsating**/throbbing quality * **Moderate to severe** pain intensity * Causing problems/avoidance of **routine physical activity** * With **_at least one of_** * N+V * Photophobia/phonophobia * Not attributable to another disorder

Answer 75

Usually gradual - peak after 2-12 hours, gradually subsiding. Often begin in morning, possibly waking them from sleep

Answer 76

* Symptoms * Anorexia, blurred vision, impaired concentration, nasal stuffiness, hunger, tenesmus, diarrhoea, abdominal pain, polyuria, pallor, sweating, and sensations of heat or cold * Signs * Localized oedema of the scalp, face, or under the eyes; scalp tenderness; prominence of temporal blood vessels; or neck stiffness and tenderness

Answer 77

Diagnosis = at least 2 attacks. Aura has at least one of the following characteristics (but no motor weakness) * Fully reversible visual symptoms (flickering lights, spots or lines, loss of vision) * Fully reversible sensory symptoms (paraesthesiae, numbness) * Less common --\> usually starts in the hand, migrates up the arm, then involves the face, lips, and tongue. Numbness may follow the paraesthesia. * Sensory auras rarely occur alone, and usually follow visual auras

Answer 78

During the aura or follows the aura within 60 mins

Answer 79

1. ↑Risk of ischaemic stroke (RR = 2.16) * More so in migraine with aura – OCP + migraine with aura = NO (8x risk) 2. ↑Risk of depression, BAD, anxiety, panic disorder 3. Status migranosus – debilitating migraine that lasts more than 72 hours 4. Migrainous infarction – cerebral infarction occurring during course of typical attack of migraine with aura.

Answer 80

1. Primary headache - tension, cluster 2. Secondary - intracranial tumour 3. Others = depression, sinusitis, dental caries, epilepsy, TIA, arteriovenous malformations, phaeochromocytoma

Answer 81

**_Pharmacological_** * Combination Therapy * Oral triptan (5HT agonist - rizatriptan, sumatriptan) + NSAID or paracetamol * Antiemetics (metoclopramide) – relieves nausea and enhances efficacy of analgesics **_General_** * Identify and avoid trigger factors * Regular sleep and dietary measures

Answer 82

* IHD * Coronary spasm * Uncontrolled BP * Recent lithium * SSRIs

Answer 83

**_5HT agonists_** Constrict cranial arteries and inhibit release of substance P/pro-inflammatory neuropeptides --\> block transmission from trigeminal nerve.

Answer 84

**_General_** * Identify and avoid trigger factors = most important. * If migraine recurring 4 or more times per month --\> treat prophylactically **_1st Line_** * Topiramate or Propranolol * Amitriptyline **_2nd Line_** * Pizotifen (can cause weight gain) - triptan * Gabapentin, pregabalin * Valproate

Answer 85

Can cause foetal malformations and impair effectiveness of hormonal contraceptives

Answer 86

1. Ipsilateral upper motor neurone signs (weakness) 2. Contralateral spinothalamic signs (no pain/temp) 3. ipsilateral dorsal column signs (no vibration/proprioception) Results from an injury to one side of the spinal cord resulting in hemisection of the cord - damage to corticospinal tract, spinothalamic tract and dorsal columns

Answer 87

female sex, middle age, low income household, divorced, low educational status

Answer 88

1. **Pain** – chronic (\>3 months) and widespread (involves left and right sides, above and below the waist, and the axial skeleton. * *_Allodynia_* = pain in response to non-painful stimulus. * *_Hyperaesthesia_* = exaggerated perception of pain in respon=se to a mildly painful stimulus. 2. **Profound fatigue** – unrefreshing sleep, significant fatigue and pain with small increases in physical exertion. 3. **Additional Features** – morning stiffness, paraesthesiae (without underlying cause), headaches (migraine and tension), poor concentration, low mood, sleep disturbance. ## Footnote **All investigations normal.**

Answer 89

Autoimmune disease mediated by antibodies to nicotinic acetylcholine receptors on post-synaptic membrane of neuromuscular junction. Associated with AI disease (RA, SLE)

Answer 90

Slowly increasing or relapsing muscular fatigue. Muscle groups affected (in order): * Extraocular * bulbar (swallowing, chewing) * face * neck * limb girdle * trunk Symptoms exacerbated by: * Pregnancy, hypokalaemia, infection, over-treatment, change of climate, emotion, exercise, gentamicin, opiates, tetracycline, quinine, beta-blockers

Answer 91

* Ptosis; diplopia; * Myasthenic snarl on smiling; * ‘Peek sign’ or orbicularis fatigability (eyelids begin to separate after manual opposition to sustained closure) * On couning to 50, the voice fades * Tendon reflexes normal

Answer 92

Anti-AChR antibodies (90%) Ptosis improves by \>2mm after ice application to eyelid for \>2 min

Answer 93

Treated with anticholinesterases, immunosuppression (steroids, azathioprine, ciclosporin)

Answer 94

* Post-meningitis * SAH * Trauma * Neoplastic * Dural sinus thrombosis

Answer 95

* Features of raised ICP * Impaired upward gaze * Mental impairment * Gait apraxia; up going plantars, tendon jerks exaggerated * Urinary incontinence due to sphincter dysfunction * Hypopituitarism due to enlargement of 3^rd ventricle into posterior fossa.

Answer 96

* Macrocephaly – anterior fontanelle enlarged and tense * Scalp veins are prominent * Irritability * Poor feeding/FTT * Developmental delay * Convulsions/mental impairment * ***Setting sun appearance*** - lids retracted, eyes depressed forwards and downwards, upward gaze is impaired

Answer 97

* Treat cause * Ventriculoperitoneal shunt – burr hole à silicone tube in lateral ventricle --\> drains CSF subcutaneously into peritoneum.

Answer 98

Amyotrophic Lateral Sclerosis (ALS) * Selective loss of neurons in motor cortex, cranial nerve nuclei and anterior horn cells * Combined UMN and LMN signs - no sensory loss or sphincter disturbance - ***different from MS/polyneuropathies*** * Never affects eye movements - ***different from Myasthenia*** * Closely linked with FTD

Answer 99

* \>40 yrs * Stumbling spastic gait * Foot drop +/- proximal myopathy * Weak grip (door-handles don’t turn) and shoulder abduction (hair washing is hard)

Answer 100

**_UMN_** * Spasticity, brisk reflexes, ↑plantars **_LMN_** * Wasting, fasciculation of tongue, abdomen, back, thigh. * Speech and swallowing sometimes affected (bulbar signs)

Answer 101

* Usually viral = HSV1/2, CMV, EBV, VZV, arboviruses, HIV * Non-viral = any bacterial meningitis, TB, malaria, Lyme disease

Answer 102

* Infectious prodrome à fever, rash, LNs, cold sores, conjunctivitis, meningeal signs * Bizarre behaviour or personality change * Confusion, ↓GCS --\> coma * Fever, headache * Focal neurology --\> seizures * Hx of travel or animal bite

Answer 103

Lesions cause ipsilateral signs _DANISH_ * **D**ysdiadochokinesis, **D**ysmetria (past-pointing) * **A**taxia (limb, truncal) * **N**ystagmus * **I**ntention tremor * **S**lurred speech, **S**canning dysarthria * **H**ypotonia

Answer 104

_PASTRIES_ * **P**osterior fossa tumours * **A**lcohol * **S**troke * **T**rauma * **R**are (paraneoplastic syndromes) * **I**nherited (Freidrich's ataxia) * **E**pilepsy drugs (phenytoin) * **S**clerosis (multiple)

Answer 105

Astrocytoma, Glioblastoma, Oligodendrocytoma, Ependyoma, Meningioma * Signs of raised ICP * Seizures * Evolving focal neurology (localising signs) * Personality change

Answer 106

Peek sign - Myasthenia Gravis

Answer 107

* Bloods – cultures, viral PCR, malaria film * Contrast CT – focal bilateral temporal involvement = HSV * LP - ↑protein, lymphocytes, PCR Treat with IV Aciclovir; supportive management in HDU/ICU.

Answer 108

* With abnormal scans * **Tumours** – fluctuating gradual onset * **Abscess** – fever, fluctuating onset * **Haematomas** – subdural, extradural * With normal scans * **Todd’s paresis** – focal weakness in a part of the body after a seizure. This weakness typically affects appendages and is localized to either the left or right side of the body. It usually subsides completely within 48 hour * **Migraine** * **Neuroglyopenia** (low blood sugars) ## Footnote **Seizures, spreading depolarisation, subdural, sugars, sepsis**

Answer 109

* Aspirin 300mg PO (600mg PR) 14 days à switch to clopidogrel 75mg afterwards * Admit to stroke unit care * Monitor BP \<150/90 * O2 \>93% * Early SALT assessment * 40-80mg atorvastatin * If anterior circulation – carotid endarterectomy (doppler à if 50% stenosed within 2 weeks, or \>70% stenosed within 12 weeks, consider surgery).

Answer 110

* Not until TWO WEEKS AFTER – consider if AF. * Warfarin, DOACs * CHADVASc in AF/HASBLED * Relative risk reduction in stroke is 2/3 * Questions about lifestyle and other drugs and liver disease * Counsel on lifestyle!! – 5 a day, fishy oils, less salt, cut down on booze, cut out the fags. * Vocational stuff – can you return to work? Driving?

Answer 111

1. **_Problems after stroke_** * Immobility * Pressure sores * Contractures – physio, botulinum, baclofen * PE/DVT – compression stockings * UTI/aspiration pneumonitis 2. **_Prognosis_** * Haemorrhage = poor prognosis (long term disability if survive) * Ischaemic = if dense, poor (50% mortality at 30 days, long term disability) if smaller, is better (lower recurrence) 3. **_Difficult decisions_** * Long term feeding (NG, PEG etc) * EOL care – palliation, second opinions, withholding/withdrawing care

Neuro Flashcards

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