1
Q
Which kind of head injury produces a biconvex shape on imaging?
A
Extradural haemorrhage appears as a biconvex on imaging.
On imaging, an extradural haematoma appears as a biconvex (or lentiform), hyperdense collection around the surface of the brain. They are limited by the suture lines of the skull.
2
Q
Lucid interval is typically seen in which kind of head injury?
A
The lucid interval is typical of extradural haemorrhage.
The classical presentation is of a patient who initially loses, briefly regains and then loses again consciousness after a low-impact head injury. The brief regain in consciousness is termed the ‘lucid interval’ and is lost eventually due to the expanding haematoma and brain herniation. As the haematoma expands the uncus of the temporal lobe herniates around the tentorium cerebelli and the patient develops a fixed and dilated pupil due to the compression of the parasympathetic fibers of the third cranial nerve.
3
Q
Bleeding in extradural haemorrhage is typically from which artery?
A
Middle meningeal artery.
An extradural (or ‘epidural’) haematoma is a collection of blood that is between the skull and the dura. It is almost always caused by trauma and most typically by ‘low-impact’ trauma (e.g. a blow to the head or a fall). The collection is often in the temporal region since the thin skull at the pterion overlies the middle meningeal artery and is therefore vulnerable to injury.
In patients who have no neurological deficit, cautious clinical and radiological observation is appropriate. The definitive treatment is craniotomy and evacuation of the haematoma.
4
Q
What are the first-line options for ACUTE management of migraine?
A
- First-line: Offer combination therapy with an Oral Triptan and an NSAID, OR an Oral Triptan and Paracetamol.
- If the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan
- caution should be exercised with young patients as acute dystonic reactions may develop
5
Q
What are the drug choices for prophylactic management of migraine?
A
- Prophylaxis should be given if patients are experiencing 2 or more attacks per month.
- NICE advise either TOPIRAMATE or PROPANOLOL ‘according to the person’s preference, comorbidities and risk of adverse events’. Propranolol should be used in preference to topiramate in women of CHILD-BEARING age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives.
- if these measures fail NICE recommend ‘a course of up to 10 sessions of acupuncture over 5-8 weeks’
- NICE recommend: ‘Advise people with migraine that Riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people’
- For women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’
6
Q
What is the cause of Myasthenia gravis?
A
Myasthenia gravis is an autoimmune disease which results from antibodies that block or destroy nicotinic Acetylcholine Receptors at the neuromuscular junction. This prevents nerve impulses from triggering muscle contractions
7
Q
What are the symptoms of Myasthenia Gravis?
A
The key feature is muscle fatigability - muscles become progressively weaker during periods of activity and slowly improve after periods of rest:
- Extraocular muscle weakness: Diplopia (double vision)
- Proximal muscle weakness: face, neck, limb girdle
- Ptosis
- Dysphagia
Associations:
- Autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE
- Those affected often have a large thymus (thymic hyperplasia) or develop a thymoma.
8
Q
What investigations are performed in suspected Myasthenia gravis cases?
A
- Single fibre electromyography: High sensitivity (92-100%)
- CT thorax to exclude thymoma
- CK NORMAL
- Autoantibodies: around 85-90% of patients have antibodies to acetylcholine receptors. In the remaining patients, about about 40% are positive for anti-muscle-specific tyrosine kinase antibodies
- Tensilon test: IV edrophonium reduces muscle weakness temporarily - not commonly used anymore due to the risk of life threatening bradycardia.
9
Q
What is the first line drug used in myasthenia gravis?
A
- Long-acting acetylcholinesterase inhibitors:
Pyridostigmine is first-line - Immunosuppression may be used:
- prednisolone initially
- azathioprine, cyclosporine, mycophenolate mofetil may also be used
- Thymectomy
10
Q
What anti-emetic can precipitate extra-pyramidal side effects?
A
Metoclopramide.
11
Q
What is the first-line imaging method for carotid artery stenosis?
A
- First-line imaging method for carotid artery stenosis is duplex ultrasound.
12
Q
What is the pharmacological management of TIA?
A
Immediate antithrombotic therapy:
Give ASPIRIN 300 mg immediately, unless
- the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
- the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
- Aspirin is contraindicated: discuss management urgently with the specialist team
13
Q
What are the features of cluster headache? How long do episodes last?
A
Cluster headaches are known to be one of the most painful conditions that patients can have the misfortune to suffer. They typically occur in clusters lasting several weeks, with the clusters themselves typically once a year.
Cluster headaches are more common in men (3:1) and smokers. Alcohol may trigger an attack and there also appears to be a relation to nocturnal sleep (attack while sleeping).
Features:
- Pain typically occurs once or twice a day, each episode lasting 15 mins - 2 hours
- Clusters typically last 4-12 weeks
- Intense sharp, stabbing PAIN AROUND ONE EYE (recurrent attacks ‘always’ affect same side)
- Patient is restless and agitated during an attack
- Accompanied by REDNESS, LACRIMATION, LID SWELLING
- Nasal stuffiness (or can be runny nose)
- Miosis and ptosis in a minority
14
Q
What is the management for cluster headaches?
A
Management:
- Acute: 100% oxygen (80% response rate within 15 minutes), Subcutaneous Triptan (75% response rate within 15 minutes)
- Prophylaxis: Verapamil is the drug of choice. There is also some evidence to support a tapering dose of prednisolone
15
Q
What is a suitable anti-emetic for a parkinson’s disease patient?
A
Domperidone.
Domperidone does not cross the blood-brain barrier and therefore does not cause extra-pyramidal side-effects.
Cyclizine is an antihistamine which, like prochlorperazine, may exacerbate Parkinson’s disease.
16
Q
What is the triad seen in Wenicke’s encephalopathy?
A
A classic triad of Ophthalmoplegia/Nystagmus, Ataxia and Confusion may occur.
Features:
- nystagmus (the most common ocular sign)
- ophthalmoplegia
- ataxia
- confusion, altered GCS
- peripheral sensory neuropathy
17
Q
What is the cause of wernicke’s encephalopathy?
A
Wernicke’s encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics. Rarer causes include: persistent vomiting, stomach cancer, dietary deficiency.
- Treatment is with urgent replacement of thiamine
18
Q
What are the features of trigeminal neuralgia?
A
Trigeminal neuralgia is a pain syndrome characterised by severe unilateral pain. The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems may occur.
The International Headache Society defines trigeminal neuralgia as:
- A UNILATERAL disorder characterised by brief electric SHOCK-like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve
- The pain is commonly evoked by light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors), and frequently occurs spontaneously
- Small areas in the nasolabial fold or chin may be particularly susceptible to the precipitation of pain (trigger areas)
- The pains usually remit for variable periods
19
Q
What is the drug of choice for trigeminal neuralgia?
A
Management:
- Carbamazepine is first-line.
- Failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology
20
Q
What are the first line pharmacological options for neuropathic pain?
A
Neuropathic pain examples:
- diabetic neuropathy
- post-herpetic neuralgia
- trigeminal neuralgia
- prolapsed intervertebral disc
first-line treatment: Amitriptyline, Duloxetine, Gabapentin or Pregabalin
- if the first-line drug treatment does not work try one of the other 3 drugs
- tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
- topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
21
Q
What are the classic triad of parkinson’s disease symptoms?
A
Parkinson’s disease is a progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra. Around twice as common in men, mean age of diagnosis is 65 years.
This results in a classic triad of features:
- Bradykinesia
- Tremor
- Rigidity
The symptoms of Parkinson’s disease are characteristically asymmetrical.
22
Q
What are some of the features seen in Parkinson’s disease?
A
Bradykinesia
- Poverty of movement also seen, sometimes referred to as hypokinesia
- Short, shuffling steps with reduced arm swinging
- Difficulty in initiating movement
Tremor
- Most marked at rest (resting tremor), 3-5 Hz
- Worse when stressed or tired, improves with voluntary movement
- Typically ‘pill-rolling’, i.e. in the thumb and index finger
- Unilateral tremor is seen initially in Parkinson’s prior to it becoming bilateral.
Rigidity
- Lead pipe
- Cogwheel: due to superimposed tremor
Other characteristic features:
- mask-like facies
- flexed posture
- micrographia
- drooling of saliva
- psychiatric features: depression is the most common feature (affects about 40%); dementia, psychosis and sleep disturbances may also occur
- impaired olfaction
- REM sleep behaviour disorder
- fatigue
- autonomic dysfunction:
- postural hypotension
23
Q
Why is the COCP an absolute contraindication in those with migraines?
A
Migraine and the combined oral contraceptive (COC) pill: If patients have migraine with aura then the COC is absolutely contraindicated due to an increased risk of ischaemic stroke
24
Q
Absence seizures in children are usually provoked by…?
A
Absence seizures (petit mal) are a form of generalised epilepsy that is mostly seen in children. The typical age of onset of 3-10 years old and girls are affected twice as commonly as boys
- Absences last a few seconds and are associated with a quick recovery
- Seizures may be provoked by hyperventilation or stress
- The child is usually unaware of the seizure
- They may occur many times a day
EEG: bilateral, symmetrical 3Hz spike and wave pattern
Management
- Sodium valproate and ethosuximide are first-line treatment
- Good prognosis - 90-95% become seizure free in adolescence
25
What biological marker can be used to differentiate between a true seizure and a pseudoseizure?
Elevated serum prolactin 10 to 20 minutes after an episode can be used to differentiate a general tonic-clonic/partial seizure from a non-epileptic pseudo seizure.
26
What is the management option for Bell's palsy?
Bell's palsy may be defined as an acute, unilateral, idiopathic, FACIAL NERVE PARALYSIS. The aetiology is unknown although the role of the herpes simplex virus has been investigated previously. The peak incidence is 20-40 years and the condition is more common in pregnant women.
Features:
- Lower motor neuron facial nerve palsy - forehead affected.
- Patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis (increased sensitivity to sound).
Management:
- It is now recommended that prednisolone 1mg/kg for 10 days should be prescribed for patients within 72 hours of onset of Bell's palsy. Adding in aciclovir gives no additional benefit.
- Eye care is important - prescription of artificial tears and eye lubricants should be considered!
Prognosis:
- If untreated around 15% of patients have permanent moderate to severe weakness
27
What is the first-line radiological investigation for suspected stroke?
Non-contrast CT head scan is the first line radiological investigation for suspected stroke.
Using a contrast medium with CT head scans in the acute phase of stroke has not generally been useful. Contrast CT head scans are more useful for detecting cerebral metastases and abscesses.
28
Infection with which organism is strongly associated with the development of Guillain-Barre syndrome?
Campylobacter jejuni is strongly associated with the development of Guillain-Barre syndrome.
Guillain-Barre syndrome describes an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni).
29
First line treatment in patients with status epilepticus?
IV Lorazepam (IV access available)
Management:
1. ABC
- Airway adjunct
- Oxygen
- Check blood glucose
2. First-line drugs are benzodiazepines such as diazepam or lorazepam.
- In the prehospital setting DIAZEPAM may be given rectally
- In hospital IV LORAZEPAM is generally used. This may be repeated once after 10-20 minutes
- If ongoing (or 'established') status it is appropriate to start a second-line agent such as phenytoin or phenobarbital infusion
If no response ('refractory status') within 45 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia.
30
What is the CHA2DS2VASC score used for?
CHA2DS2VASC is a scoring tool used to assess the risk of stroke in patients with atrial fibrillation.
31
What is the ROSIER score used for?
ROSIER is an acronym for 'Recognition Of Stroke In the Emergency Room'. It is the tool recommended by NICE to assess stroke symptoms in an acute setting.
32
What are the additional symptoms seen in wernicke-korsakoff syndrome?
If wernicke's encephalopathy is not treated Korsakoff's syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- and retrograde amnesia and confabulation.
33
Pabrinex is used for prevention/treatment of wernicke's encephalopathy. What does it contain?
Pabrinex, a yellow coloured fluid contains vitamins B and C.
Vitamin B1, also called thiamine, is essential for glial cells of the nervous system, as well as other bodily systems. Deficiency can cause Wernicke's encephalopathy and if left untreated can lead to irreversible Korsakoff's syndrome.
34
Acute management of seizures? (at home)
Acute management of seizures:
Most seizures terminate spontaneously. When seizures don't terminate after 5-10 minutes then it is often appropriate to administer medication to terminate the seizure. Patients are often prescribed these so family members may administer them in this eventuality, often termed 'rescue medication'. Benzodiazepines such as DIAZEPAM are typically used are may be administered rectally or intranasally/under the tongue.
If a patient continues to fit despite such measures then they are termed to have status epilepticus. This is a medical emergency requiring hospital treatment. Management options include further benzodiazepine medication, infusions of antiepileptics or even the use of general anaesthetic agents.
35
What are the types of generalised seizures?
Specific types include:
```
→ tonic-clonic (grand mal)
→ tonic
→ clonic
→ typical absence (petit mal)
→ myoclonic: brief, rapid muscle jerks
→ atonic
```
36
What is the difference between a generalised seizure and a focal seizure?
Generalised:
- These engage or involve networks on both sides of the brain at the onset
- Consciousness lost immediately. The level of awareness in the classification is therefore not needed, as all patients lose consciousness.
- Generalised seizures can be further subdivided into motor (e.g. tonic-clonic) and non-motor (e.g. absence)
Focal seizures:
- previously termed partial seizures
- These start in a specific area, on ONE SIDE of the brain
- The level of awareness can VARY in focal seizures. The terms focal aware (previously termed 'simple partial'), focal impaired awareness (previously termed 'complex partial') and awareness unknown are used to further describe focal seizures
- further to this, focal seizures can be classified as being motor (e.g. Jacksonian march), non-motor (e.g. déjà vu, jamais vu; ) or having other features such as aura
37
What is a focal to bilateral seizure?
Focal to bilateral seizure:
- Starts on one side of the brain in a specific area before spreading to both lobes
- Previously termed secondary generalized seizures
38
What is the first-line drug used in patients with generalised seizures?
Sodium valproate is used first-line for patients with generalised seizures.
39
What is the first-line drug used in patients with focal/partial seizures?
Carbamazepine is used first-line for patients with partial seizures
40
Patients with epilepsy have to be fit-free for how long before being allowed to drive?
What are some of the considerations to counsel patients on before starting them on antiepileptics?
Most neurologists now start antiepileptics following a second epileptic seizure.
Antiepileptics are one of the few drugs where it is recommended that we prescribe by BRAND, rather than generically, due to the risk of slightly different bioavailability resulting in a lowered seizure threshold.
It is useful when thinking about the management of epilepsy to consider certain groups of patients:
1. Patients who drive: generally patients cannot drive for 6 months following a seizure. For patients with established epilepsy they must be fit free for 12 months before being able to drive.
2. Patients taking other medications: antiepileptics can induce/inhibit the P450 system resulting in varied metabolism of other medications, for example warfarin.
3. Women wishing to get pregnant: antiepileptics are generally teratogenic, particularly sodium valproate. It is important that women take advice from a neurologist prior to becoming pregnant, to ensure they are on the most suitable antiepileptic medication. Breastfeeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates.
4. Women taking contraception: both the effect of the contraceptive on the effectiveness of the anti-epileptic medication and the effect of the anti-epileptic on the effectiveness of the contraceptive need to be considered
41
Name 4 commonly used antiepileptics?
1. Sodium valproate: First-line for generalised seizures
2. Carbamazepine: First-line for partial seizures
3. Lamotrigine: Used second-line for a variety of generalised and partial seizures
4. Phenytoin: No longer used first-line due to side-effect profile
42
What are some of the side effects of Sodium valproate?
- Increased appetite and weight gain
- Alopecia: regrowth may be curly
- P450 enzyme inhibitor
- Ataxia
- Tremor
- Hepatitis
- Pancreatitis
- Thrombocytopaenia
- Teratogenic (neural tube defects)
43
What is the pharmacological therapy for a patient presenting with a transient ischaemic attack?
ASPIRIN 300mg
A patient who presents to their GP within 7 days of a clinically suspected TIA should have 300mg aspirin immediately (and be referred for specialist review within 24h). NICE recommend also giving gastric protection (e.g. PPI) if clinically indicated.
Immediate antithrombotic therapy:
Give aspirin 300 mg immediately, unless
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team
44
What is the further management in anti thrombotic therapy for those who had a TIA?
Further management:
Antithrombotic therapy:
1. Clopidogrel is recommended first-line (as for patients who've had a stroke)
2. Aspirin + Dipyridamole should be given to patients who cannot tolerate clopidogrel
45
What are some of the symptoms of migraine?
Migraine is a common type of primary headache. It is characterised typically by:
- A severe, unilateral, throbbing headache
- Associated with nausea, photophobia and phonophobia
- Attacks may last up to 72 hours
- Patients characteristically go to a darkened, quiet room during an attack
- 'Classic' migraine attacks are precipitated by an aura. These occur in around one-third of migraine patients.
- Typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma.
46
What are some common triggers for migraine attacks?
Common triggers for a migraine attack:
- Tiredness, stress
- Alcohol
- Combined oral contraceptive pill
- Lack of food or dehydration
- Cheese, chocolate, red wines, citrus fruits
- Menstruation
- Bright lights
47
Is Bell's palsy an upper or lower motor lesion? Is the forehead affected?
Bell's palsy is a lower motor neurone facial nerve palsy- the movement of the forehead/ eyebrow-raising is therefore affected.
48
Which nerve root controls biceps reflex?
C5 - C6
Ankle: S1-S2
Knee: L3-L4
Biceps: C5-C6
Triceps: C7-C8
49
What is the triad of symptoms for normal pressure hydrocephalus?
Urinary incontinence + Gait abnormality + Dementia = Normal pressure hydrocephalus
Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi. These changes may be secondary to head injury, subarachnoid haemorrhage or meningitis.
A classical triad of features is seen:
- urinary incontinence
- dementia and bradyphrenia
- gait abnormality (may be similar to Parkinson's disease)
It is thought around 60% of patients will have all 3 features at the time of diagnosis. Symptoms typically develop over a few months.
Management:
- Ventriculoperitoneal shunting
- around 10% of patients who have shunts experience significant complications such as seizures, infection and intracerebral haemorrhages
50
What causes the symptoms seen in multiple sclerosis?
Multiple sclerosis is chronic cell-mediated autoimmune disorder characterised by demyelination (insulating covers of nerve cells) in the central nervous system.
Epidemiology:
- 3 times more common in women
- Most commonly diagnosed in people aged 20-40 years
- Much more common at higher latitudes (5 times more common than in tropics)
A variety of subtypes have been identified:
Relapsing-remitting disease
- most common form, accounts for around 85% of patients
- acute attacks (e.g. last 1-2 months) followed by periods of remission
Secondary progressive disease
- describes relapsing-remitting patients who have deteriorated and have developed neurological signs and symptoms between relapses
- around 65% of patients with relapsing-remitting disease go on to develop secondary progressive disease within 15 years of diagnosis
- gait and bladder disorders are generally seen
Primary progressive disease
- accounts for 10% of patients
- progressive deterioration from onset, more common in older people
51
What are 3 features of a third cranial nerve palsy?
- Eye is deviated 'down and out'
- Ptosis
- Pupil may be dilated (sometimes called a 'surgical' third nerve palsy)
52
When is thrombolysis given in an acute stroke?
Thrombolysis with Alteplase should only be given if:
- it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
- Haemorrhage has been definitively excluded (i.e. Imaging has been performed)
53
What are the absoulte and relative contraindications to thrombolysis for acute stroke?
ABSOLUTE:
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
RELATIVE:
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
54
Essential tremor is imporved by what?
Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs.
Features:
- postural tremor: worse if arms outstretched
- improved by alcohol and rest
- most common cause of titubation (head tremor)
Management:
- Propranolol is first-line
- Primidone is sometimes used
55
What is the recommended antiplatelet regimens following an acute ischaemic stroke?
Once an ischaemic stroke is confirmed the patient should be given:
- Aspirin 300 mg daily for 2 weeks then Clopidogrel 75 mg daily long-term.
- A statin should also be offered if the patient is not already on statin therapy.
56
What is the recommended antiplatelet regimens following an acute ischaemic stroke?
Once an ischaemic stroke is confirmed the patient should be given:
- Aspirin 300 mg daily for 2 WEEKS then Clopidogrel 75 mg daily long-term.
- A statin should also be offered if the patient is not already on statin therapy.
57
Which class of Parkinson's drugs is most linked with impulse control disorders?
Dopamine receptor agonists.
58
Briefly state the acute and prophylactic treatment for migraine.
Migraine:
Acute: triptan + NSAID or triptan + paracetamol
Prophylaxis: topiramate or propranolol
59
Briefly state the acute and prophylactic treatment for migraine.
Migraine:
Acute: triptan + NSAID or triptan + paracetamol
Prophylaxis: topiramate or propranolol (avoid in asthmatics)
60
When can anti-epileptic drugs (AED) be stopped?
Can be considered if seizure free for MORE THAN 2 YEARS with AEDs being stopped over 2 - 3 months.
61
List the aspects of the GCS.
MOTOR response
6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
VERBAL response
5. Orientated
4. Confused
3. Words
2. Sounds
1. None
EYE opening
4. Spontaneous
3. To speech
2. To pain
1. None
62
What are the characteristic features of Gullian barre syndrome?
Guillain-Barre syndrome describes an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni).
The characteristic features of Guillain-Barre syndrome is progressive weakness of all four limbs.
- The weakness is classically ascending i.e. the lower extremities are affected first, however it tends to affect proximal muscles earlier than the distal ones
- Reflexes are reduced or absent
- Sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs
- Around 65% of patients experience back/leg pain in the initial stages of the illness
63
What is a common presenting feature of multiple sclerosis?
Visual:
- Optic neuritis: common presenting feature
- optic atrophy
- Uhthoff's phenomenon: worsening of vision following rise in body temperature
- internuclear ophthalmoplegia
Sensory:
- pins/needles
- numbness
- trigeminal neuralgia
- Lhermitte's syndrome: paraesthesiae in limbs on neck flexion
Motor
- spastic weakness: most commonly seen in the legs
Cerebellar
- ataxia: more often seen during an acute relapse than as a presenting symptom
- tremor
Others
- urinary incontinence
- sexual dysfunction
- intellectual deterioration
64
What is the most common presenting feature of multiple sclerosis?
Visual:
- Optic neuritis: common presenting feature
- optic atrophy
- Uhthoff's phenomenon: worsening of vision following rise in body temperature
- internuclear ophthalmoplegia
Sensory:
- pins/needles
- numbness
- trigeminal neuralgia
- Lhermitte's syndrome: paraesthesiae in limbs on neck flexion
Motor
- spastic weakness: most commonly seen in the legs
Cerebellar
- ataxia: more often seen during an acute relapse than as a presenting symptom
- tremor
Others
- urinary incontinence
- sexual dysfunction
- intellectual deterioration
65
What are some side effects of levodopa?
Usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of L-dopa to dopamine. Reduced effectiveness with time (usually by 2 years)
no use in neuroleptic induced parkinsonism
Adverse effects:
- dyskinesia
- 'on-off' effect
- postural hypotension
- cardiac arrhythmias
- nausea & vomiting
- psychosis
- reddish discolouration of urine upon standing
66
What are the classical symptoms seen in acoustic neuroma?
The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex.
67
Patients with epilepsy must be seizure free for how long before being allowed to drive?
The person with epilepsy may qualify for a driving licence if they have been free from any seizure for ONE YEAR.
68
Which drug is used to treat cerebral oedema in patients with brain tumours?
Dexamethasone.
Dexamethasone is a potent steroid with predominantly glucocorticoid effects. It is used to treat vasogenic oedema that occurs due to the break down of the blood-brain barrier. A common use within neurosurgery is to treat oedema caused by brain tumours.
69
State the name, function and clinical relevance of cranial nerves 1 - 3.
CN I: Olfactory
- Smell
CN II: Optic
- Sight
CN III: Oculomotor
- Eye movement muscles (MR, IO, SR, IR)
- Pupil constriction
- Accomodation
- Eyelid opening
Palsy results in:
- 'Down and out' eye
- Dilated, fixed pupil
- Ptosis
70
State the name, function and clinical relevance of cranial nerves 4 - 6.
CN IV: Trochlear
- Eye movement (SO)
- Palsy results in defective downward gaze → vertical diplopia
CN V: Trigeminal
- Facial sensation including cornea
- Muscles of mastication
Lesions may cause:
- Trigeminal neuralgia
- Loss of corneal reflex (afferent)
- Loss of facial sensation
- Paralysis of mastication muscles
- Deviation of jaw to weak side
CN VI: Abducens
- Eye movement (LR)
- Palsy results in defective abduction → horizontal diplopia
71
State the name, function and clinical relevance of cranial nerves 7 - 9.
CN VII: Facial
- Facial movement
- Taste (anterior 2/3rds of tongue)
- Lacrimation
- Salivation
Lesions may result in:
- Flaccid paralysis of upper + lower face
- Loss of corneal reflex (efferent)
- Loss of taste
- Hyperacusis
CN VIII: Vestibulocochlear
- Hearing, balance
- Hearing loss
- Vertigo, nystagmus
- Acoustic neuromas are Schwann cell tumours of the cochlear nerve
CN IX: Glossopharyngeal
- Taste (posterior 1/3rd of tongue)
- Salivation
- Swallowing
- Mediates input from carotid body & sinus
Lesions may result in;
- Hypersensitive carotid sinus reflex
- Loss of gag reflex (afferent)
72
State the name, function and clinical relevance of cranial nerves 10 - 12.
CN X: Vagus
- Phonation
- Swallowing
- Innervates viscera
Lesions may result in;
- Uvula deviates away from site of lesion
- Loss of gag reflex (efferent)
CN XI: Accessory
- Head and shoulder movement
Lesions may result in;
- Weakness turning head to contralateral side
CN XII: Hypoglossal
- Tongue movement
Lesion: Tongue deviates towards side of lesion
73
What features are commonly seen in haemorrhagic stroke compared to ischaemic stroke?
Whilst symptoms alone cannot be used to differentiate haemorrhagic from ischaemic strokes, patients who've suffered haemorrhages are more likely to have:
- Decrease in the level of consciousness: seen in up to 50% of patients with a haemorrhagic stroke
- Headache is also much more common in haemorrhagic stroke
- Nausea and vomiting is also common
- Seizures occur in up to 25% of patients
74
Features of levodopa?
Levodopa:
- Usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of levodopa to dopamine.
- Reduced effectiveness with time (usually by 2 years)
- Unwanted effects: dyskinesia (involuntary writhing movements), 'on-off' effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness
- No use in neuroleptic induced parkinsonism
- It is important not to acutely stop levodopa, for example if a patient is admitted to hospital. If a patient with Parkinson's disease cannot take levodopa orally, they can be given a dopamine agonist patch as rescue medication to prevent acute dystonia
75
Features of levodopa?
Levodopa:
- Usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of levodopa to dopamine.
- Reduced effectiveness with time (usually by 2 years)
- Unwanted effects: dyskinesia (involuntary writhing movements), 'on-off' effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness
- No use in neuroleptic induced parkinsonism
- It is important not to acutely stop levodopa, for example if a patient is admitted to hospital. If a patient with Parkinson's disease cannot take levodopa orally, they can be given a dopamine agonist patch as rescue medication to prevent acute dystonia
76
Features of dopamine agonist?
Dopamine receptor agonists:
- e.g. bromocriptine, ropinirole, cabergoline, apomorphine
- Ergot-derived dopamine receptor agonists (bromocriptine, cabergoline) have been associated with pulmonary, retroperitoneal and cardiac fibrosis. The Committee on Safety of Medicines advice that an echocardiogram, ESR, creatinine and chest x-ray should be obtained prior to treatment and patients should be closely monitored
- Patients should be warned about the potential for dopamine receptor agonists to cause impulse control disorders and excessive daytime somnolence
- More likely than levodopa to cause hallucinations in older patients. Nasal congestion and postural hypotension are also seen in some patients
77
Management for Parkinson's Disease?
For first-line treatment:
- If the motor symptoms are affecting the patient's quality of life: levodopa
- If the motor symptoms are not affecting the patient's quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
If a patient continues to have symptoms despite optimal levodopa treatment or has developed dyskinesia then NICE recommend the addition of a dopamine agonist, MAO‑B inhibitor or catechol‑O‑methyl transferase (COMT) inhibitor as an adjunct.
78
Treatment for generalised tonic-clonic seizures?
Sodium valproate is considered the first line treatment for patients with generalised seizures with carbamazepine used for focal seizures.
Generalised tonic-clonic seizures:
1. Sodium valproate
- Second line: lamotrigine, carbamazepine
Medicine
flashcards
Decks in class (21)
# Cards
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ENT3
-
Ethics and Legal issues14
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Opthalmology16
-
Metabolic Medicine18
-
Obstetrics18
-
Psychiatry21
-
Contraception23
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Oncology + Immunology + Geri25
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Orthopaedics29
-
Pharmacology31
-
Haematology36
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DERMATOLOGY38
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Nephrology38
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Rheumatology41
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Respiratory52
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Surgery61
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Endocrinology64
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Gynaecology71
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Gastroenterology77
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Neurology78
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Cardiology83
