1
Q
Pres of frontal lobe lesion?
A
- Personality change
- Anosmia
- Motor aphasia
- Contralat hemiparesis
2
Q
Pres of parietal lobe lesion?
A
- Hemiparesis
- Atereognosis
- Inattention (draws half clockface)
3
Q
Gersmann’s syndrome?
- which lobe
- 4 features
A
- parietal
2. dysgraphia, acalculia, finger agnosia, inability to distinguish L and R side of body
4
Q
Pres of occipital lobe lesion?
A
contralat homonymous hemianiopia
5
Q
Pres of midbrain lesion?
A
- Unequal pupils
- Inability to move eyes up/down
- short term amnesia + confabulation
- Somnolence
6
Q
Cerebellar lesion?
- pres
- causes
A
- DANISH [dysdiadochokinesia, ataxia, nystagmus, intention tremor + dysmetria, staccato speech]
- CVE, SOL, infection, wernickes
7
Q
Cerebellar pontine angle
- which tumour here
- pres
A
- Acoustic neuroma
2. ipsilat deafness/tinnitus, facial/trigeminal palsy, cerebellar
8
Q
Vision in X –> lesion
- R optic nerve
- optic chiasm (central)
- R optic tract
A
- blindness of R eye
- bipolar hemianopia
- left homonymous hemianopia
9
Q
GCS /15
A
BEM /4
BVR /5
BMR /6
10
Q
DDx of headache
A
- Subarachnoid
- migraine
- meningitis/encephalitis
- tension
- medication-induced
- GCA
- raised ICP
- CVE/TIA
- IIH
- Cervical spondylosis
- glaucoma
11
Q
Red flags of headache
A
- Change in pattern
- New onset >50yo
- Seizures
- Systemic illness
- Personality change
- Worst headache ever
- scalp tenderness/jaw claudication
- focal neuro signs
- raised ICP eg vomiting
12
Q
Triad of meningism
- symptom
- signs
A
- headache, photophobia, nuchal rigidity
- kernigs [hip flexion + knee extension = pain]
Brudzinski [lift head off couch = invol lifting of legs]
Nuchal rigidity [inability to flex neck]
13
Q
Meningitis
- rfs
- usual cause
- non infective
A
- CSF shunt, spinals, DM, EtOH, IVDU, malignancy
2. Viral [mumps, HSV, HIV] Fungal [crytococcus] Bacterial [neonate=GBS, young children= HIb, adults= S.pneumoniae, HIb, N.meningitidis immunocomp=listeria]
- malignancy, sarcoid, SLE
14
Q
Pres of meningitis
A
- meningism
- fever
- bulging fontanelle
- opisthotonos
- altered mental state
- shock
15
Q
Ix in menigitsi
A
- LP
- bloods [FBC, CRP, culture, coag, U+E, ABG]
- urine, nasal swab, stool culture
16
Q
Sx of raised ICP
A
- vomiting
- reduced consciousness
- headache
- fits
17
Q
CI to LP
A
- raised ICP
- shock
- Coag abnorm
18
Q
Complications of LP
A
- post LP headache
- infection
- bleeding
- herniation
19
Q
Mx of meningitis
A
- fluids, antipyretic, antiemetic
- Meningococcus –> IV ceftriaxone
- Pneumococci –> vancomycin + ceftriaxone
- GBS –> IV cefotaxime
- Listeria –> IV amox + gent
+dexamethasone in children
20
Q
Comps of meningitis
A
- sepsis, septic shock, DIC
- seizures, coma, raised ICP
- septic arthritis
- haemolytic anaemia
- SIADH
- deafness
- Friedrichsen-Waterhouse
21
Q
Prevention of meningitis
A
- vaccination
- Prophylaxis –> ciprofloxacin/rifampicin
22
Q
Meningococcal septicaemia
1. usual organism
2 type
A
- Neisseria meningitidis
- Gram -ve diplococcus
[often found in nasopharynx]
23
Q
- Pres of meningococcal septicaemia
2. pres hosp mx
A
- non-blanching petechial rash + sepsis
2. IV/IM benpen
24
Q
Meningococcal septicaemia Ix
A
- Blood cultures
- FBC, U+E, LFT, CRP
- Coag
- LP +/- CT
25
Hospital mx of meningococcal septicaemia
-Resus
-<3m [cefotaxime + amoxicillin]
>3m [ceftriaxone]
26
Comps of meningococcal septicaemia
- seizure
- raised ICP
- DIC
- adrenal failure (F-W syndrome)
- deafness
- hydrocephalus
27
Encephalitis
1. what
2. usual cause
3. pres
1. inflam of brain parenchyma
2. HSV
3. headache, altered mental state, seizures
[in neonate --> + lethargy, irritable, poor feeding, bulging fontanelle]
28
Encephalitis
1. ix
2. mx
3. risk
4. comps
1. bloods, CT head, LP (+PCR), EEG, MRI
2. IV aciclovir
3. IV fluids good but risk of cerebral oedema
4. SIADH, DIC, cardiac arrest, epilepsy, personality change
29
SAH
1. causes
2. RF
3. pres
1. berry aneurysm, AV malform, vasculitis
2. HTN, smoking, cocaine, ADPKD, Ehlers-Danos, Marfans, NF
3. sudden onset severe headache, vom, confusion, seizure
30
Places for berry aneurysm?
- junction of AComA + ACA
- bifurcation of MCA
- junction of PComA + IC
31
Signs of SAH
- meningism (6hr post headache)
- altered GCS
- Intaoccular haemorrhage
- focal neuro
32
ix for SAH
- CT Head (non-contrast)
- LP [xanthocromia after 12h]
- cerebral angiography
- ECG
33
1. Where is CSF prod?
2. Which layer of meninges?
3. Absorbed where?
1. choroid plexus in Vs
2. flows into subarachnoid space
3. dural venous sinuses
34
mx of SAH
- resus
- nimodipine
- labetalol
- coiling / clipping
35
comps of SAH
- rebleeding
- ischaemia
- hydrocephaleus
36
raised ICP causes
- neoplasm
- haematoma
- oedema
- hydrocephalus
- cerebral venous thrombosis
- idiopathic intracranial hypertension
37
mets to brain from where
- lung
- breast
- colon
- melanoma
38
pres of raised ICP
- headache (worse on waking / coughing / bending forward)
- papilloedema
- vomiting (no nausea)
- altered mental state
39
ICP
1. ix
2. mx
1. CT/MRI
| 2. resus, anticonvulsant, CSF drainage, analgesia, sedation, mannitol
40
Cause of extradural haematoma
- fracture of temporal/parietal bone
| - causing damage to middle meningeal artery
41
pres of extradural
1. trauma + LOC
2. lucid interval
3. deterioration
headache, N+V, seizures, CSF otorrhoea/rhinorrhoea, altered GCS
42
extradural
1. ix
2. mx
1. bloods, XR skull, CT head
| 2. resus, mannitol , clot evacuation (craniotomy)
43
Subdrual haematoma
1. usual cause
2. pres
3. chronic
1. tear in bridging vein
2. acute, decreasing GCS --> LOC
3. gradual decline, headache, can be aSx
44
subdural
1. ix
2. mx
3. comps
1. CT non contrast, FBC, U+E, LFT, coag
2. resus, clot evacuation
3. raised ICP, oedema, recurrence, seizures,
45
Migraine triggers
```
CHeese
OCP
Caffeine
AlcohOl
Anxiety
Travel
Exercise
```
46
Types of migraine (5)
1. w/ aura
2. w/o aura
3. migraine aura w/o headache
4. hemiplegic
5. menstrual
47
pres of migraine
- fatigue, irritable
- aura in 1/3 [visual, somatosensory, paraesthesia]
- headache = u/l, pulsating, severe 4-72h
- photo/phonophobia
48
migraine
1. acute mx
2. prophylaxis
1. triptan
| 2. propanolol/topiramate
49
CI to triptan
- uncontrolled HTN, angina
| - triptan = 5-hydroxytryptamine agonist
50
how many migraines before prophylaxis
>=2 attacks/month
| medication >2d/w
51
COCP CI in migraine?
risk of ischaemic stroke in migraine with aura
52
Cluster headache
1. who
2. pres
3. acute mx
4. prophylaxis
1. young men (smokers)
2. headache, sharp, around eye + autonom fts, restless
3. O2 + SC triptan
4. verapamil
53
Tension headache
1. pres
2. mx
1. headache, b/l like band
| 2. NSAID / pcm, amitriptyline
54
Trigeminal neuralgia
1. what
2. who in
3. pres
4. ix
5. mx
1. neuropathic disorder of trigeminal nerve
2. F 50-60y
3. sudden sharp/shock like, facial pain 'tic doloureux'
4. MRI r/o 2dary cause
5. carbamazepine
55
GCA
1. pathology
2. who in
3. pres
4. ix
5. mx
6. comps
1. vasculitis (m,l)
2. > 60 yo
3. headache severe, scalp tenderness, jaw claudication, visual disturbance
4. ESR, CRP, temporal artery biopsy
5. prednisolone high dose
6. loss of vision
56
mx of TIA
- aspirin 300mg
- statin
- carotid endartectomy
- no driving for 1m
57
signs of stroke
1. ischaemic
2. haemorrhagic
1. carotid bruit, AF, hx of TIA
| 2. meningism, severe headache, coma
58
mx of stroke
1. acute
2. LT
1. o2, glucose, bp
ischaemic [aspirin 300, clopidogrel 75, alteplase in 4.5h, thrombectomy in 6h]
2. 2dary prevention
59
prevention of stroke
- lifestyle
- BP
- AF - anticoag
- aspirin/clopidogrel/dipyridamole
- statin
60
Cause of delirium
- acute infection
- drugs (inc withdrawal)
- post-op
- vascular (CVE, IHD)
- metabollic (hypoxia, glycaemia, hypercalcaemia)
- Vit deficiency
- endo
- trauma
- malignancy
61
pres of delirium
-acute onset + fluctating course
-DELIRIUM
Disordered thinking
Euphoric/fearful
Language (gabbling, rpt)
Illusions/delusion/hallucination
Reversal of sleep/wake
Inattention
Unaware
Memory deficit
62
2 types of delirium
- Hypoactive (apathy, quiet, confusion)
| - Hyperactive (agitation, delusion, disoreintation)
63
Delirium
1. ix
2. mx
1. bloods, urine dip, blood culture, ecg, cxr
| 2. supportive, environmental, stop drugs
64
groups of sx in dementia (3)
- Cognitive impairment [ST memory, language, attention, orientation]
- Psych disturb [depression, delusion, hallucination]
- Difficulty with ADLs [driving, dressing etc]
65
Dementia
1. assessment
2. ix
3. mx
1. GPCOG, MMSE, AMT
2. bloods, CXR, MRI head
3. Advanced directives, LPAs, therapy, routines, palliative care,
benzos in challenging behaviour
66
Alzheimers pathology
- progressive degen of cerebral cortex --> widespread cortical atrophy
- beta amyloid plaques
- neurofibrillary tangles
67
RF for dementia
- age
- FH
- head injury
- vascular RFs
68
Pres of dementia
1. early
2. later
3. late
1. ST memory loss, difficulty finding words
2. apraxia, confusion
3. disorientation, apathy, depression, disinhibition, aggression
69
Ddx of dementia
- normal ageing
- NPH
- PD
- hypothyroid
- Vit B12 deficiency
- Depression
- delirium
70
Ix in dementia
- MRI
| - HMPAO SPECT (differentiate AD vs VD vs FTD)
71
Vascular Dementia
1. pathology
2. cause
3. RF
1. cognitive impairment due to ischaemia from CVD
2. stoke related (multiple tiny infarcts
3. hx of stroke/TIA, HTN, DM, smoking, obesity
72
Vascular demntia
1. diagnosis
2. ix
3. mx
1. based on clinical/brain imaging. Stepwise decline
2. MRI
3. adress CVRFs, donepezil/galatamine
73
Dementia with Lewy-Bodies
1. pathology
2. pres
3. ix
4. mx
1. LB = eosinophilic intracytoplasmic neuronal inclusino
2. fluctating attention, visual hallucinations, parkinsonism
3. Spect scan. MIBG scintography
4. rivastigmine
74
Fronto-temporal dementia
1. pathology
2. assos
3. pres
4. ix
5. mx
1. frontal+temporal lobe atrophy, Tau inclusions in cells
2. PSP, CBD, MND
3. disinhibition, loss of vocab, progressive aphasia, parkinsonism
4. MRI
5. dementia mx
75
Parkinsonism
1. pres (triad)
2. other sx
3. causes
1. tremor, rigidity, bradykinesia
2. mask-like face, shuffling gait, anosmia, depression
3. idiopathic, DLB, PSP, MSA, CBD, drugs [antipsychotic, metoclopramide]
76
IPD
1. pres
2. pathology
3. RF
4. dx
1. insidious, u/l onset, parkinsonism, depression, dementia
2. reduced dopamine in SN
3. age, male,
4. bradykinesia, rigidity, tremor (resting, 4-5Hz), post instab
77
DDx of Parkinson's
- Benign essential tremor (worse on movement, less at rest)
- Drug induced
- HD, WD, vascular
- Parkinson's plus
78
Parkinson's plus conditions + feature
```
VIVID
Visual hallucinations (LBD)
Incontinence (MSA)
Vertical gaze palsy (PSP)
Interference (CBD)
DM
```
79
Parkinson's ix
- trial dopaminergic agent
| - transcranial sonography
80
Parkinsons mx
- MDT
- Pharma [carbidopa, ropinirole, selegiline]
- surgery / DBS
81
1. Comps of PD
| 2. comps of L-dopa
1. infections, aspiration pneumonia, pressure sores, falls, depression, dementia
2. wearing off, on-off, dyskinesias
82
Normal Pressure Hydrocephalus
1. triad
2. ix
3. mx
1. urinary incontinence, gait abnorm (magnetic), dementia (reversible!!)
2. MRI/CT, CSF tap test
3. Pharma [acetazolamide], Surgery [VP shunt]
83
Huntington's
1. pathology
2. age of onset
3. pres
4. ix
5. mx
1. Autosomal dominant, chromosome 4, CAG rpts
2. 30-50yo
3. Early [personality change, apathy, clumsiness, depression]
later [chorea, parkinsonism, dementia, dysarthria/phagia]
4. r/o SLE, WD, TFT. MRI/CT, genetic testing
5. chorea--> benzo
84
Initial stroke management
- ABCDE
- Neuro imaging
- Haemorrhagic --> control BP, nimodipine, consider surgery
- Ischaemic --> aspirin 300mg (2w), thrombolysis in 4.5h, thrombectomy in 6h
85
Topiramate consideration
teratogenic --> contraception/alternate if of child bearing age
86
Epilepsy ix
EEG (+video=gold standard), MRI, ECG
87
Epilepsy 1st line mx
1. focal seizures
2. GTC seizures
3. absence seizures
4. myocloinc seizures
5. tonic
6. other mx points1
1. carbamazepine/lamotrigine
2. sodium valproate
3. ethosuximide
4. sodium valproate
5. sodium valproate
6. ketogenic diet, surgery
88
considerations for sodium valproate
teratogenic
89
CI in absence seizures
carbamazepine
90
Status Epilepticus
1. 1st line
2. 2nd line
3. if in hospital
1. buccal midazolam
2. rectal diazepam
3. IV lorazepam
91
Dorsal column
1. function
2. decussation
2. deficit -->
1. Sensory [vibration, proprioception, light touch, 2-point discrim]
2.
3. . tingling, clumsiness, numbness, electric shock like, position and vibration sense lost
92
Lateral spinothalamic tract
1. function
2. decussation
3. deficit -->
1. Sensory [crude touch, pain, temp]
2. synapse with dorsal horn in cord, cross within cord
3. contralat loss of pain + temp
93
Corticospinal tract
1. function
2. decussation
3. deficit -->
4. aka
1. Motor
2. cerebral cortex to IC, cross in medulla to anterior horn cell
3. ipsilateral spastic paresis below the lesion
4. pyramidal / UMN
94
UMN lesion signs
- pronator drift
- weakness
- hypertonia
- hyperreflexia
- +ve babinski
95
LMN lesion signs
-muscle wasting
-fasciculation
-
96
Guillain-Barre
1. what
2. pres
3. ix
4. mx
1. acute inflam demyelinating polyradiculopathy (AI to peripheral nerves)
2. symmetrical ascending muscles weakness (3w post infection)
3. NCS, LP (raised protein), spirometry if resp involvement [?ITU]
4. O2, IVIg, SC heparin
97
Myasthenia Gravis
1. what
2. pres
3. signs
4. ix
5. mx
1. Anti-AChR antibodies [+/- Anti-MuSK], thymic hyperplasia in 70%
2. weakness and fatiguability of muscles [ocular, bulbar, proximal], no pain
3. ptosis, diplopia, snarl, peek sign
4. NCS, Anti-AChR, Anti-MuSK, CT thorax
5. Pyridostigmine +/- thymectomy
98
Trigeminal neuralgia
1. what
2. ix
3. mx
1. knife-like pain in distribution of trigem nerve
2. MRI to r/o 2dary cause
3. carbamazepine +/- surg decomp
99
GCA
1. what
2. pres
3. ix
4. mx
1. vasculitis (m,l)
2. headache, scalp tenderness, jaw claud
3. ESR, CRP, temporal artery biopsy
4. prednisolone high dose
100
Cerebellum
1. function
2. cause of dysfunction
3. mx
1. coordinator for all movements (IPSILATERALLY)
2. infarct, MS, alcohol, compression
3. treat cause + involve: SALT, physio, OT
101
Jacksonian seizure
Partial seizure in motor cortex
102
Pseudo seizure features
- hip thrusting
- tiring + restarting
- awareness
103
Driving in epilepsy
- must be seizure free for 1y
| - for HGV - seizure free + off meds for 10y
104
4 types of MND
1. ALS [UMN + LMN]
2. Prog bulbar palsy [CN VII - XII]
3. prog muscular atrophy [pure LMN]
4. Primary lateral sclerosis [pure UMN]
105
1. Bulbar palsy features
| 2. psuedobulbar palsy
1. muscles of speech, chewing, swallowing --> flaccid, fasciculating tongue
2. tongue paralysed, no fasciculations
106
Rare forms of MND
1. PMA
2. PLS
1. progressive muscular atrophy [wasting, often small muscles of hand; starts u/l --> quick progress to b/l]
2. primary lateral sclerosis [weakness, spasticity]
107
MND
1. ix
2. mx
3. mx for drooling
4. mx for spasticity
1. evidence of mixed UMN/LMN, NCS
2. Conservative [resp support, OT/SALT, ?PEG]
Pharma [antidepressants, riluzole (slows progress)]
3. hyoscine
4. baclofen
108
4As of Alzheimers
- apraxia
- amnesia
- agnosia
- aphasia
Finals
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