General Neurology Questions

Front 1

What is Amaurosis Fugax?

Back 1

Temporary occlusion of the RETINAL artery

"feels like curtain descending"

Front 2

3 most common causes of TIA?

Back 2

Atherothromboembolism from Carotid

Cardioembolism = Mural thrombus post MI / AF/ Valve Disease/ Prosthetic Valve

Hyperviscosity = Polycythaemia / Sickle Cell / Myeloma

Front 3

3 most common differential diagnosis for a TIA?

Back 3

Hypoglycaemia

Migraine Aura

Focal seizure

Front 4

Investigations for a TIA?

Back 4

Blood glucose

FBC

ECG

Carotid Doppler + MRI/Angiography

Front 5

What is the risk of stroke after TIA criteria called?

Back 5

ABCD2

Age > 60

Blood pressure (Systolic >140 or Diastolic >90)

Clinical Features

Duration (10-59 or 60>)

Diabetes

Greater than 4 points = referral in 24 hours

Front 6

Management of TIA

Back 6

1) Control CV risk factors (BP/Cholesterol/Smoking/DM)

2) Anti-Platelets = Aspirin / Dipyridamole (ONLY FOR TIA/ POST MI)

3) Warfarin = IF cardiac embolic - AF/mitral stenosis/ septal MI)

4) Carotid Endarterectomy

Front 7

What is the different types of stroke classification?

Back 7

Bamford Classification / Oxford Stroke Classiciation

Front 8

What are the four types of strokes

Back 8

TACS

PACS

POCS

LACS

Front 9

What is TACS

Back 9

Total Anterior Circulation Stroke

All 3

1) Unilateral Weakness of Face + Arm+ Leg (+/- sensory deficit)

2) Homonymous Hemianopia

3) Higher cerebral dysfunction

(Dysphasia/Visualspatial disorder)

Front 10

What is PACS

Back 10

Partial Anterior Circulation Stroke

2/3 of

1) Unilateral Weakness of Face + Arm + Leg (+/- sensory deficit)

2) Homonymous Hemianopia

3) Higher cerebral dysfunction (Dysphasia/Visuosparial disorder)

Front 11

What is POCS?

Back 11

Posterior Circulation Syndrome

1/3 of

1) Cerebellar of Brainstem Syndrome

2) Loss of consciousness

3) Isolated Homonymous Hemianopia

Front 12

What is LACS

Back 12

Lacunar Syndrome (Basal Ganglia/ Internal Capsule/ Thalamus/ Pons)

CS-PAP

1) Clumsy hand dysarthria

2) Sensorimotor stroke

3) Pure Motor stroke

4) Ataxic hemiparesis

5) Pure sensory stroke

Front 13

4 Most common causes of a stroke?

Back 13

1) Small Vessel Occlusion / Cerebral Microangiopathy

2) Cardiac Emboli

3) Atherothromboembolism

4) CNS bleeds (Increased BP/Trauma/Aneurysm Rupture/Anti-Coagulants)

Front 14

Other rarer causes of stroke

Back 14

Watershed stroke (BP drop by >40 mmHg)

Carotid Artery Dissection

Vasculitis

Subarachnoid Haemorrhage

Venous Sinus Thrombosis

Antiphospholipid Syndrome

Paradoxial Emboli (ASD/VSD)

Front 15

What stroke symptoms would make you think of a haemorrhagic stroke?

Back 15

Meningism

Severe headache coma

Front 16

3 types of stroke

Back 16

Cerebral Infarct

Brain stem infarct

Lacunar Infarct

Front 17

What happens in a cerebral infarct

Back 17

Contralateral sensory loss OR hemiplegia - initially FLACCID (about 1 hour) before SPASTIC (UMN lesion)

Dysphasia/Homonymous hemianopia/ Visuo-spatial deficit

Front 18

What happens in a brain stem infarct

Back 18

QUADRIPLEGIA / Disturbance of gaze and vision / Locked-In Syndrome

Pseudo-bulbar palsy = CN9-12 affected due to stroke

Front 19

What happens in a lacunar infarct?

Back 19

Affects the: Pons/Basal Ganglia/ Thalamus/ Internal Capsule

CS-PAP

1) Clumsy Hand Dysarthria

2) Sensorimotor Stroke

3) Pure motor stroke

4) Ataxic Hemiplegia

5) Pure sensory stroke

Front 20

4 differential diagnosis for a stroke?

Back 20

Head injury

Hypoglycaemia

Subdural haemorrhage

Hemiplegic Migraine

Front 21

What is the first hour management plan for stroke?

Back 21

Protect Airway

Blood Glucose

Urgent CT Head

IV Alteplase (once haemorrhagic is ruled out) within 4.5 hours of a stroke

Nil by mouth

Aspirin (After haemorrhagic ruled out)

Front 22

Contraindications of IV Alteplase

Back 22

Previous CNS bleed

AVM

Aneurysm

Varices

Portal hypertension

Front 23

If a patient has prosthetic valves, what must you give them as primary prevention for a stroke?

Back 23

Warfarin

Front 24

What is the name of the scoring system used to predict whether AF will cause a stroke?

Back 24

CHA2DS2-VASc Score

Front 25

If the CHA2DS2-VASc score is 0 or >1 what do you give as prophylaxis?

Back 25

0 = Aspirin/ Nothing

>1 = Warfarin

Front 26

7 cardiac causes of a stroke?

Back 26

1) Non valvular AF

2) Prosthetic Valve

3) Post MI

4) External cardioversion

5) Cardiac Surgery - e.g. bypass graft

6) Paradoxical systemic emboli

7) Valve vegetation from Subacute Bacterial Endocarditis/IE

Front 27

What is the secondary prevention for a stroke? (After adjusting modifiable risk factors)

Back 27

1) Copidogrel ONLY (P2Y12 inhibitor)

2) Warfarin (if indicated - e.g. prosthetic valve / CHA2D2-VASc >1)

Front 28

Investigations for causes of a stroke?

Back 28

1) Hypertension? - retinopathy/nephropathy/CXR

2) Cardiac source? - 24 hour ECG/ECHO

3) Carotid Artery Stenosis? Carotid Doppler USS + CT/MRI Angiography

4) Hypo/hyperglycaemia - Dyslipidaemia - Hyperhomocyteinaemia

5) Vasculitis? ESR/ANA

6) Prothrombic state? Thrombophilia / Antiphospholipid syndrome

7) Hyperviscosity = Polycythaemia / Sickle Cell Disease

8) Genetic Tests = CADASIL/Fabry's Disease

Front 29

4 complications of a stroke

Back 29

Aspiration Pneumonia

Pressure sores

Constipation

Depression

Front 30

How do you manage a patient non-medically after a stroke?

Back 30

BARTHEL'S index of activities of daily living

- Enablement Approach = Agree to tasks/ plan steps - agree to goals/ review goals

- Make physio fun - swimming/music/videogames

Front 31

2 most common causes of Sub-Arachnoid Haemorrhage?

Back 31

1) Rupture of a Saccular Aneurysm (80%)

2) Arterio-venous malformations

Front 32

5 risk factors of an SAH

Back 32

Hypertension

Smoking

Alcohol misuse

Bleeding disorders

Microcytic Aneurysm

Front 33

3 most common sites for a saccular aneurysm

Back 33

JUNCTION of ANTERIOR communicating artery and ANTERIOR cerebral artery

JUNCTION of POSTERIOR communicating artery and internal carotid

BIFURCATION of the MIDDLE cerebral artery

Front 34

3 causes of saccular aneurysms ?

Back 34

ADPKD

Ehlers- Danlos

Coarctation of the aorta

Front 35

Symptoms of SAH?

Back 35

Sudden occipital headache (thunderclap - hit in the back of the head)

Vomiting

Collapse

Seizures

Coma/Drowsiness

Neck stiffness

Kernig's Sign

Front 36

What is TERSON'S Syndrome?

Back 36

Retinal/Subhyaloid/Vitreous bleeds

Front 37

What may a person with an SAH feel before the headache

Back 37

Sentinel headache = warning headache a few days before

Front 38

Investigations for an SAH

Back 38

1) CT scan within 48 hours

2) Lumbar puncture = IF CT is negative and NO contraindications AFTER 12 hours

x 3 times = should see XANTHOCHROMIA (yellow due to bilirubin)

Front 39

Management of SAH?

Back 39

If proven = Immediate Neurosurgery

Re-examine CNS / Keep Hydrated

NIMODIPINE (Ca2+ antagonists - reduced vasospasm in coronary arteries)

CT Angiography --> Endovascular coiling / Surgical clipping / Intracranial stents

Front 40

4 complications of SAH

Back 40

Rebleed

Hyponatraemia

Hydrocephalus

Cerebral ischaemia

Front 41

Subdural Haemorrhage - what blood vessels/ what shape on CT/ where?

Back 41

Bridging veins between cortex and venous sinuses

Sickle/Crescent Shape (S=S)

Haematoma between DURA and ARACHNOID

Front 42

What happens in a subdural haemorrhage?

Back 42

Gradual rise in ICP

Shifts mid-line structures AWAY from the side of the clot = eventual tentorial herniation & coning

Front 43

Risk Factors for a SUB-DURAL haemorrhage?

Back 43

Elderly (brain atrophy makes bridging veins more vulnerable)

Falls (Alcoholics/ Epileptics)

Anticoagulation

Front 44

Symptoms of Subdural haemorrhage

Back 44

Fluctuating levels of consciousness

Physical or intellectual slowing

Sleepiness

Headache

Personality Change

Raised ICP

Seizures

Front 45

Investigations for a subdural haemorrage?

Back 45

CT scan = Clot (Sickle/Crescent shaped) + midline shift

Front 46

Management of Subdural Haemorrhage?

Back 46

Irrigation via Burr Twist Drill & Burr Hole Craniostomy

Front 47

Where does an extra-dural haemorrhage occur? What blood vessel?

Back 47

Between the dura and skull

Middle meningeal artery AND vein

Front 48

Most common cause of an extra-dural haemorrhage

Back 48

Fractured Temporal or Parietal Bone - typically after trauma

Front 49

Clinical Features of an ExtraDural Haemorrhage

Back 49

After head injury - conscious level falls

LUCID INTERVAL - may last up to days before a decrease in the GCS due to a raised ICP

Severe headache / vomiting / confusion / fits

Hemiparesis with brisk reflexes + upgoing plantar

Front 50

What are the complications of an extra-dural haemorrhage if the bleeding continues?

Back 50

Ipsilateral pupil dilatation

Coma

Bilateral limb weakness

Death

Front 51

Investigations for an extra-dural haemorrhage

Back 51

CT = Biconvex/Lens-shaped haematome

Front 52

Management of Extra-Dural Haemorrhage

Back 52

Clot Evacuation + Ligation of Bleeding Vessel

Mannitol (Do decrease raised ICP)

Front 53

Define a seizure?

Back 53

Recurrent tendency to spontaneous/intermittent/abnormal electrical activities in parts of the brain = SEIZURES

Front 54

What are the 3 elements of a seizure?

Back 54

1) Prodrome

2) Aura = part of the seizure when the patient is aware (Deja-Vu/Jamais-Vu/Strange smells/Flashing lights) - implies a FOCAL seizure

3) Post-Ictally

Headache/confusion/myalgia/sore tongue

Temporary weakness after a focal seizure in the motor cortex (Todd's Palsy)

Dysphasia following focal seizure in temporal lobe

Front 55

What are the three types of partial seizures?

Back 55

Partial Seizure = Focal onset with features referable to part of one section

1) Simple Partial Seizure

2) Complex Partial Seizure

3) Partial Seizures with secondary generalisation

Front 56

What happens in a simple partial seizure?

Back 56

UNIMPAIRED awareness

Focal/motor/sensory/autonomic/psychic disturbance

NO post-ictal seizures

Front 57

What happens in a complex partial seizure?

Back 57

IMPAIRED awareness

Most common from the temporal lobe = Post Ictal Confusion

Rapid recovery after seizures = Frontal Lobe

Front 58

What happens in partial seizures with secondary generalisation?

Back 58

Electrical disturbance = focal --> wide = secondary generalised

Front 59

What are the classical symptoms of a TEMPORAL LOBE partial seizure?

Back 59

1) Automatisms (Lip-smacking / singing / kissing)

2) Abdominal rising sensation / pain

3) Dysphasia

4) Deja-vu/Jamais vu

5) Hippocampal involvement = Emotional disturbances (terror/panic/anger)

6) Uncal involvement = Auditory/Smell/Taste hallucinations

Front 60

What are the classical symptoms of a FRONTAL LOBE partial seizure?

Back 60

1) Motor Features = Peddling legs / posturing

2) Jacksonian March --> Todd's Paralysis

3) Motor Arrest

4) Subtle behaviour disturbances

5) Dysphasia or speech arrest

Front 61

What are the classical symptoms of a PARIETAL LOBE partial seizure?

Back 61

1) Sensory disturbances = tingling / numbness

2) Motor symptoms = due to spread to pre-central gyrus

Front 62

What are the classical symptoms of an OCCIPITAL LOBE partial seizure?

Back 62

Visual phenomena / Spots - Lines - Flashes

Front 63

5 types of primary generalised seizures?

Back 63

1) Absence (usually children)

2) Tonic-Clonic Seizures

3) Myoclonic Seizures

5) Atonic (akinetic) seizures

5) Infantile Spasms (Associated with tuberous sclerosis)

Front 64

What are absence seizures (Petit mal)?

Back 64

Usually last for under 10 seconds - usually children

Child suddenly PAUSE - stops mid-sentence - then carries on

Front 65

What are Tonic-Clonic Seizures (Grand-mal)?

Back 65

Loss of awareness

Limbs stiffen (TONIC) --> Jerk (CLONIC)

May have one without the other

Post-ictal confusion and drowsiness

Front 66

What are MYOCLONIC seizures

Back 66

Sudden JERK of a limb/face or trunk

Either patient suddenly is thrown onto the ground or has a VIOLENTLY DISOBEDIENT limb

Front 67

What is an Atonic (akinetic) seizure?

Back 67

Sudden loss of muscle tone = FALL (no lose of consciousness)

Front 68

If you're diagnosed with epilepsy - what do you have to tell the DVLA?

Back 68

Cannot drive until seizure free for >1 year

Front 69

Causes of Epilepsy?

Back 69

Idiopathic

Cortical scarring

Space-occupying lesions

Stroke

Vascular malformations

Tuberous sclerosis

SLE

Sarcoidosis

Front 70

Non-epileptic causes of seizures?

Back 70

Alcohol

Trauma

Stroke

Haemorrhage

Raised ICP

Front 71

Metabolic disturbance causes of seizures?

Back 71

Hypoxia

Liver Disease

Infection (Meningitis / Encephalitis/ Syphilis / HIV)

Fever

Drugs (Cocaine / Tramadol)

Front 72

Management of primary generalised seizures?

Back 72

1) Generalised Tonic-Clonic Seizures =

Sodium Valporate - Lamotrigine - Toprimate

2) Absence Seizures =

Sodium Valporate - Lamotrigine - Ethosuximide

3) Tonic/Atonic/Myoclonic

Sodium Valporate - Lamotrigine - Toprimate

Front 73

Management of partial seizures?

Back 73

CARBAMAZEPINE

Sodium Valporate/ Lamotrigine / Topiramate

Front 74

Side effects of Sodium Valporate

Back 74

Nausea + VALPORATE

Appetite increase - weight gain

Liver failure

Pancreatitis

Oedema

Reversible hair loss

Ataxia

Teratogenic (Neural Tube Defects) / Tremor

Encephalopathy

Front 75

Side effects of LAMOTRIGINE

Back 75

Maculopapular rash (STEVENS-JOHNSON syndrome)

Hypersensitivity (Fever/DIC)

Vomiting

Diplopia

Blurred Vision

Photosensitivity

Tremor

Front 76

Side effects of CARBAMAZEPINE?

Back 76

Leucopenia

Diplopia

Blurred Vision

Impaired balance

Drowsiness

Front 77

Side effects of Phenytoin?

Back 77

Nystagmus

Diplopia

Depression

Decreased intellect

Acne

Gum hypertrophy

Front 78

What is non-epileptic attack disorder?

Back 78

Uncontrollable symptoms

No learning disabilities

CT/MRI/EEG = All normal

Front 79

How do you investigate Seizures?

Back 79

Bloods/LP

EEG (Normal between attacks)

CT + Enhancement

MEG

PET

Ictal SPECT

Front 80

How do you manage epilepsy if an epileptogenic focus can be identified? (e.g. hippocampal sclerosis or small low grade tumour?)

Back 80

Neurosurgical resection

Vagal nerve stimulation

Front 81

What is Status Epilepticus?

Back 81

Seizure lasting >30 minutes OR repeated seizures without intervening consciousness

Front 82

Name 2 percipitating factors for status epilepticus?

Back 82

Alcohol

Stopping medication

Pre-Eclampsia (If pregnant)

Front 83

How do you treat Status epilepticus?

Back 83

100% Oxygen

IV Lorazepam x 2

Rectal Diazepam

Buccal Midazolam

Phenytoin/Diazepam infusion

Dexamethason

Front 84

3 Cardinal Symptoms of PARKINSONISM

Back 84

(RAT)

Rigidity/ Tone = "Cog-Wheel" / "Lead-Pipe" Rigidity - Increase in tone in limbs + trunk

Limb resists THROUGHOUT movement

Bradykinesia / Hypokinesia = Slow to initiate movement / Stoop / Micrographia/ Lessened Arm swing/ FESTINANCE (shuffling steps) / Freezing at obstacles/ HYPOMIMIA

Tremor = 4-7Hz RESTING - "pill-rolling" thumb & fingers - IMPROVED by voluntary movement/ worse by anxiety

Front 85

5 Causes of Parkinsonism

Back 85

1) Idiopathic Parkinson's Disease (Mutation in Fbx07) (Fbitches x 07)

2) Drugs (Neuroleptics / Metoclopramide)

3) Wilson's

4) HIV

5) Trauma

Front 86

Non motor features of Parkinson's Disease?

Back 86

REM sleep disorders

Prosody

Constipation

Frequency

Dementia

Decreased sense of smell

Visual Hallucinations

Depression

Front 87

Pathology behind IPD?

Back 87

Mitochondrial DNA dysfunction causes a degeneration of the dopaminergic neurones in the substantia nigra pars compacta (associated with Lewy Bodies) = Lowered striatal dopamine levels

Front 88

Management of IPD?

Back 88

MDT Meeting Involvement =

GP

Neurologist

PD Nurse

Social Worker

Carers

Physiotherapist

Occupational therapist

Front 89

Management of IPD?

Back 89

1) LevoDopa + Benserazide (Dopa-decarboxylase inhibitor) = CO-BENELDOPA
SE = Nausea and Vomiting (Give Domperidone)
Efficacy reduced with time/psychosis/visual hallucinations/painful dystonias

Carbedopa + LevoDopa

2) Dopamine Agonists (ROPINOROLE)
SE = Pathological gambling / compulsive shopping

3) MAO-B Inhibitors (SELEGILINE)
SE = Postural Hypotension

4) COMT Inhibitors (TOLCAPONE)
SE = Severe hepatic complications

Front 90

Other management ideas for PD?

Back 90

1) Anticholinergics - for tremor = BENZHEXOL

2) APOMORPHINE (DA agonist - rescue pen)

3) Depression? SSRI

4) Disease Psychosis? OLANZAPINE

5) Respite Care

6) Deep brain stimulation

7) Surgical ablation of overactive subthalamic nuclei

Front 91

Mneumonic for remembering 5 key symptoms of IPD?

Back 91

SMART

Shuffling Gate

Mask-like facies

Akinesia

Rigidity

Tremor

Front 92

5 Parkinson's Plus Syndrome

Back 92

Parkinsonism + Evidence of separate pathology

PMLVC (Parkinson's Makes Life Very Crap)

Progressive Supranuclear Palsy

Multiple System Atrophy (Shy-Drager)

Lewey Body Dementia

Vascular Parkinsonism

Cortico-Basal Degeneration

Front 93

5 Parkinson's Plus Syndrome plus VIVID signs

Back 93

VIVID

Progressive supranuclear palsy = Vertical gaze palsy

Multiple System Atrophy = Impotence / Incontinence

Lewey Body Dementia = Visual Hallucinations

Cortico-Basal Degeneration = Autonomous Interfering Activity

Vascular Dementia = In Diabetics

Front 94

Define Huntington's Disease?

Back 94

Autosomal DOMINANT condition affecting the corpus striatum and cortex = incurable/progressive/neurodegenerative disorder

Front 95

Pathology behind Huntington's Disease

Back 95

Atrophy and Neuronal Loss of CORPUS STRIATUM AND CORTEX

Expansion of CAG repeats on Ch4

= Depletion of GABA and Acetylcholine

BUT SPARES DOPAMINE

Front 96

Clinical Features of Huntington's?

Back 96

Irritability/Depression/Incoordination --> Chorea --> Dementia + Fits ---> Death

Front 97

What is Chorea?

Back 97

Continuous flow of jerky, quasi-purposive movement

Fleeting from one part of the body to the other

Front 98

Investigation and Management for Huntingtons?

Back 98

MRI = Ventricularmegaly

NO CURE - only symptomatic

Chorea = Neuroleptics

Depression = Seroxate

Aggression = Haloperidol

Front 99

7 Classical Features of DEMENTIA

Back 99

MAHAWAM

MEMORY LOSS

Agitation

Hallucinations

Aggression

Wandering

Apathy

Mood Disturbances

Front 100

2 Diagnostic Tests for Dementia?

Back 100

AMT

Addenbrooke's Cognitive Examination

Front 101

4 Main Types of Dementia?

Back 101

A VERY LOVELY FRIEND

Alzheimer's

Vascular Dementia

Lewey Body Dementia

Fronto-Temporal Dementia

Front 102

Describe Vascular Dementia

Back 102

Cumulative effects of MANY small strokes

Thus - SUDDEN ONSET and STEP-WISE deterioration is characteristic

Look for evidence of vascular pathology = HTN/Past strokes/ Focal CNS signs

Front 103

Describe Lewy Body Dementia

Back 103

Typically FLUCTUATING cognitive impairment

Detailed Visual Hallucinations - Small Animals / Children

Histologically = Lewy Bodies in BRAINSTEM & Neocortex

Front 104

Decribe Fronto-Temporal Dementia

Back 104

Contains PICK inclusion bodies

Executive impairment

Behavioural/Personality Change

Disinhibition

Hypeorality

Emotional Unconcern

Front 105

5 other causes of dementia?

Back 105

HIV

HD

IPD

Whipple's

Repeated Head Trauma

Front 106

Clinical Features of Alzheimer's

Back 106

MAVEV ---> BIMAL

Memory loss

Anosognosia

Verbal Abilities

Executive Function

Visuo-spatial skills

Behavioural Change (aggression/wandering)

Irritability

Mood disturbance (depression)

Agnosia

Hallucinations/Dellusions (Psychosis)

Front 107

Pathogenesis behind Alzheimer's disease?

Back 107

Accumulation of B-amyloid peptide --> Progressive Neuronal Damage

NEUROFIBRILLARY TRIANGLES

B-AMYLOID PLAQUES

TAU PROTEINS

Decreased Acetylcholine

Neuronal Loss is Selective = Hippocampus/Amygdala/Temporal neocortex

Front 108

RISK Factors of Alzheimer's

Back 108

Down's Syndrome

1st Degree Relative

Depression

Loneliness

Front 109

Management of Alzheimers Disease

Back 109

1) Referral to memory service
2) Acetylcholinesterase inhibitors = RIVASTIGMINE
SE = D&V/Cramps/Headache/Insomnia

3) NMDA inhibitor=
MEMANTINE
SE = Hallucinations / Confusion / Hypertonia

4) Sensation stimulation/ CBT/Cognitive stimulation programmes/ Massage/ Dance therapies

Front 110

8 Issues in managing someone with dementia?

Back 110

1) Care Coordinator? Laundry/DayCare/Priority Parking

2) Capacity to make decisions?

3) MUST develop a routine

4) PLAN AHEAD - DO NOT MOVE HOUSE

5) Day Care

6) Care for the carers?

7) Challenging Behaviour? Lorazepam

8) Depression? Citalopram

Front 111

What is the difference between common and classic migraines?

Back 111

Common = Migraine WITHOUT aura

Classic = Migraine WITH aura

Front 112

Define migraine

Back 112

Episodic severe headaches with/without aura

Often prementrual

Usually Unilateral with NAUSEA/VOMITING +/- Photo/phonophobia

Front 113

What 4 auras can occur in migraine?

Back 113

Visual = Chaotic cascading / Distorting / Dots / Zigzags / Scotomata hemianopia

Somatosensory = Paraesthesiae = fingers -->face

Motor = Dysarthria / Ataxia/ Opthalmoplegia / Hemiparesis

Speech = Dysphasia / Paraphasia

Front 114

Pathophysiology of Migraine?

Back 114

Cortical spreading depression

Altered modulation of normal sensory stimuli + trigeminal nerve dysfunction

Front 115

What is the diagnostic criteria for a NON-migraine aura?

Back 115

>5 Headaches (Lasting 4-72 hours + N&V (or Photo/phonophobia)

AND

2 of : Unilateral - Pulsating - Worsened by routine activity

Front 116

Triggers of a migraine?

Back 116

CHOCOLATE

Caffeine

Hangovers

Orgasms

Cheese

Oral contraception

Lie-In

Alcohol

Tireness

Exercise/Emotions

Front 117

Management of a migraine?

Back 117

1) NSAIDS (Ketoprofen)

2) Oral 5HT Agonists (Sumatriptan)

CI = IHD/Coronary Spasm

3) Ergotamine

SE = Gangrene

4) 12-weekly Botulinim Toxin Type A

5) Warm/Cold Packs

Front 118

Prophylaxis for Migraine?

Back 118

Avoid Triggers

IF over 2x per month AND not responding to treatment =

1) Propanolol

2) Amitriptyline

3) Topiramate

4) Valporate

Front 119

What facial pain has post-nasal drip/ dull constant ache over the face / worse pain on bending over?

Back 119

SINUSITIS

Front 120

What happens in acute glaucoma?

Back 120

Occurs in the elderly/long-sighted

Constant aching pain - develops around one eye - radiates to forehead

CF = Cloudy cornea/decreased acuity/red eye/N&V/ haloes

Percipitating Factors = Dilating Eye drops/ emotional upset/ sitting in the dark

Rx = IV ACETAZOLAMIDE

Front 121

Describe a tension headache?

Back 121

Tight band around the head

BILATERAL

Non-pulsatile headache + scalp muscle tenderness

Rx = Explanation/Reassurance/ Withdraw analgesics / Massage/ AMITRIPTYLINE

Front 122

4 things that make raised intracranial pressure headaches worse?

Back 122

Walking

Lying

Bending forward

Coughing

Front 123

4 symptoms associated with raised intracranial pressure?

Back 123

Vomitting

Papilloedema

Seizures

Odd behaviour

Alleviated by standing

Front 124

Investigations for suspected raised intracranial pressure?

Back 124

CT Head = EXCLUDE space occupying lesion

Consider idiopathic intracranial hypertension

NO NO NO LUMBAR PUNCTURE

Front 125

Management for raised ICP

Back 125

Lose Weight

Mannitol

Front 126

Tell me a bit about medication overuse (analgesic rebound) headache?

Back 126

Causes by mixed analgesics usually (paracetamol + codeine / opiates)

Also Ergotamine/ triptans

Front 127

Management of medication overuse headache?

Back 127

Withdraw analgesia + aspirin

After = Valporate/Gabapentin

Inform them - no more than 6 painkillers a month

Front 128

Causes of Cluster Headache?

Back 128

Superficial temporal artery smooth muscle hyper-reactivity to 5HT

ALSO hypothalamic grey matter abnormalities

Front 129

Clinical Features of Cluster Headaches?

Back 129

Rapid-onset of EXCRUCIATING pain around one eye

Watery & Bloodshot / Lid swelling/ Lacrimation/ Facial Flushing/ Rhinorrhoea / Miosis + Ptosis

STRICTLY unilateral

Front 130

Management of Cluster Headaches?

Back 130

100% OXYGEN

SC Sumatriptan / ZOLMITRIPTAN nasal spray

Front 131

2 preventative treatments for cluster headache?

Back 131

Sub-occipital steroid injections

Verapamil

Lithium

Front 132

What is Trigeminal Neuralgia? Where do you most often get it?

Back 132

Paroxysms of intense STABBING pain - lasting seconds in trigeminal nerve distribution

MOSTLY Mandibular & Maxillary

- Face screws up with pain (Tic Doloureux)

Front 133

5 Triggers for Trigeminal Neuralgia

Back 133

WASTED

WAshing

Shaving

Talking

Eating

Dental prostheses

Front 134

Causes of Trigerminal Neuralgia

Back 134

1) Compression of nerve root = Anomalous or Aneurysmal intracranial vessels/tumour

2) Chronic meningeal inflammation

3) MS

4) Skull base malformation

Front 135

Management of Trigerminal Neuralgia?

Back 135

CARBAMAZEPINE

Lamotrigine

Surgical = Microvascular Decompression / Thermocoagulation of trigeminal ganglion

Front 136

What age group does GCA normally affect?

Back 136

OVER 60

If under 55 - think Takayasu's Arteritis

d

Front 137

Define Giant Cell Arteritis

Back 137

Granulomatous arteritis of unknown aetiology - associated with Polymyalgia Rheumatica

Front 138

Clinical Features of GCA

Back 138

Headache

Temporal artery & scalp tenderness (when combing hair)

Jaw Claudication

Amaurosis Fugax OR sudden blindness (central retinal artery)

Front 139

Extracranial symptoms of GCA?

Back 139

Dyspnoea

Morning Stiffness

Unequal or weak pulses

Weight loss

Malaise

Fever

Front 140

What do you see on examination of the superficial temporal artery in GCA?

Back 140

Tender

Firm

Pulseless

Front 141

Investigations for GCA

Back 141

ESR&CRP UP UP UP UP

Raised Platelets and Alk Phos

TEMPORAL ARTERY BIOPSY within 7 days of steroids

Front 142

Management of GCA

Back 142

PREDNISOLONE RIGHT AWAY

Also:

PPI's

Bisphosphonates

Front 143

What is Polymyalgia Rheumatica?

Back 143

>50 years old

Subacute onset (<2 weeks)

Bilateral aching tenderness

Morning stiffness in SHOULDERS and PROXIMAL LIMB MUSCLES (Pelvic Girdle?)

Also:

Mild polyarthritis / Tensosynovitis / Carpal Tunnel Syndrome

Fatigue / Fever/ Weight loss/ Anorexia

Front 144

Investigations for PMR

Back 144

Raised ESR/CRP/ALP

Front 145

Management of PMR?

Back 145

PREDNISOLONE

= Dramatic response within 1 week

Front 146

Where is the lesion if there is paraplegia?

Hemiplegia?

Back 146

Paraplegia = Cord compression

Hemiplegia = Brain lesion

Front 147

Clinical Features of Spinal Cord Compression?

Back 147

Spinal/Nerve root dull ache pain

Leg weakness/sensory loss

Arm weakness (suggests cervical cord lesion)

Bladder and anal sphincter involvement = LATE symptom

Front 148

What are typical LMN signs?

Back 148

Decreased tone

Decreased reflexes

Wasting

Fasciculations

Front 149

What are typical UMN signs?

Back 149

Increased tone

Brisk reflexes

Weakness in EXTENSORS (bent arm post stroke)

Front 150

Cord compression will produce UMN or LMN?

Back 150

LMN at the level of the lesion

UMN signs below

Front 151

7 Causes of Spinal Cord compression

Back 151

1) SECONDARY MALIGNANCY (BBTKP)

2) Infection (Epidural Abscess)

3) Cervical Disc prolapse

4) Haematoma (warfarin?)

5) Intrinsic cord tumour

6) Myeloma

7) Spinal TB (Pott's Disease)

Front 152

Differential Diagnosis for spinal cord compression?

Back 152

Transverse myelitis

MS

Cord vasculitis

Trauma

Dissecting Aneurysm

Front 153

Investigations for spinal cord compresssion?

Back 153

IMMEDIATE MRI

Front 154

Management of Spinal Cord Compression?

Back 154

If secondary to a malignancy?
IV DEXAMETHASONE + Chemo/Radio

Epidural abscess? Decompression + Antibiotics

Decompressive Laminectomy

Front 155

Causes of Unilateral Food Drop

Back 155

DM

Common Peroneal Nerve Palsy

Stroke

Prolapsed Disc

MS

Front 156

Causes of weak legs with NO sensory loss

Back 156

MND

Polio

Front 157

Causes of chronic spastic paraparesis

Back 157

MS

Cord tumour (astrocytoma)

Cord metastases

MND

Front 158

Causes of chronic flaccid paraparesis?

Back 158

Peripheral Neuropathy

Myopathy

Front 159

Cauda Equina Syndrome - 4 CLASSIC symptoms

Back 159

1) Bowel/Bladder Dysfunction

2) Decreased sensation in SADDLE area (Perineal)

3) Sexual Dysfunction

4) Neurological deficit in the lower limb = Motor/sensory loss/ reflex change

Front 160

Causes of Cauda Equina?

Back 160

L4/L5 --> L5/S1= LUMBAR DISC HERNIATION

Tumours

Epidural Abscess

Congenital (Spina bifida)

Sponylolisthesis

Late stage AS

Front 161

Other symptoms of cauda equina syndrome?

Back 161

Lower back / leg pain / motor or sensory deficits

Urinary retention

Saddle & Perineal Anaesthesia

Bowel/Bladder Dysfunction

Asymmetrical weakness with loss of reflexes

Sexual dysfunction

Front 162

Investigations for Cauda Equina?

Back 162

MRI MRI MRI MRI MRI

Front 163

What is the difference between cauda equina and conus medullaris syndrome?

Back 163

Conus medullaris is located at T12-L2

Associated with urinary retention and constipation

LESS PAINFUL

Front 164

Management of cauda equina syndrome?

Back 164

URGENT SURGICAL DECOMPRESSION

Front 165

Define Multiple Sclerosis?

Back 165

Discrete PLAQUES of demyelination at multiple CNS sites from T-cell mediated immune response

RELAPSING AND REMITTING

DISSEMINATED IN TIME AND SPACE

Front 166

What happens after prolonged demyelination?

Back 166

Axonal Loss

Clinically progressive symptoms

Front 167

Eye Signs in Multiple Sclerosis

Back 167

Unilateral Optic neuritis (Pain on eye movement + rapid decreased in central vision)

Diplopia / Hemianopia

BILATERAL INTERNUCLEAR OPTHALMOPLEGIA

Charles Bonnet Syndrome = Decreased Visual Acuity + Hallucinations

Uhthoff's Phenomenon = Decreased vision on exercise/hot meals/ hot bath. Phosphenes (flashed) on eye movement

Pulrich Effect = Unequal Eye Latencies

Argyle Robertson Type Pupil

Front 168

Sensory Signs in MS?

Back 168

Lhermitte's Sign = Neck Flexion causes "electric shock in trunk and limbs

Numbness/tingling in limbs

Decreased vibration sense

Trigeminal neuralgia

Front 169

Motor Signs in MS?

Back 169

Spastic Weakness (Les?)

Transverse Myelitis = Loss of motor/sensory/autonomic/reflex and sphincter function BELOW the level of the lesion

Devic's Syndrome = Neuromyelitis Optics = Transverse myelitis + Optic atrophy + NMO-IgG antibodies

Front 170

GI Signs in MS?

Back 170

Swallowing Disorders

Constipation

Front 171

Cerebellum Signs in MS?

Back 171

Trunk and limb ataxia

Intention tremor

Scanning speech

Falls

Front 172

Sexual/GU signs in MS?

Back 172

Erectile Dysfunction

Urinary retention

Incontinence

Front 173

Cognitive / Visuospatial Signs in MS?

Back 173

Amnesia

Decreased executive functioning

Change in mood

Front 174

5 signs of POOR prognosis in MS?

Back 174

Increased AGE

Motor signs at onset

Many relapses early

Axonal loss

Increased MRI lesions

Front 175

Diagnosis of MS?

Back 175

Clinical = Lesions Disseminated in TIME&SPACE - with no other viable causes

MRI of brain and spinal cord

CSF = Oligoclonal bands of IgG on electrophoresis NOT present in the serum

Evoked potentials = Delayed visual/auditory/somatosensory

Front 176

What is the criteria required to diagnose MS?

Back 176

McDONALD CRITERIA

Attacks must be >1 hour - with 30 days in between

Front 177

MRI abnormalities seen in MS?

Back 177

3/4 needed

Gadolinum enhancing

OR

>9 T2 hyperintense lesions

>1 infratentorial lsions

>1 juxtacortical leions

>3 periventricualr lesions

Front 178

3 antibodies in MS?

Back 178

NMO-IgG (Devic's Syndrome)

MOG

MBP

Front 179

Management of MS

Back 179

MINGA - White Trash 30 year old

Methylprednisolone

Interferon 1-B & Interferon-IA

x = Abortion/ Depression

Natalizumab (Acts against VLA-4 Receptors)

Glatiramer Acetate (Doxorubicin Analogue)

Azathioprine

Front 180

Palliative Treatment?

Back 180

Spasticity? Diazepam

Tremor? Botulinum Toxin Type A

Urgency/Frequency? Intermittend Self-Catheterisation

Front 181

What is Myasthenia Gravis?

Back 181

Autoimmune disease mediated by ANTIBODIES to nicotinic AchR - interfering with neuromuscular transmission VIA a depletion of post-synaptic receptor sites

MAY BE ASSOCIATED WITH THYMOMA

Front 182

Pathophysiology in MG?

Back 182

Antibodies BLOCK the postsynaptic ACh receptors = prevent end plate potential from triggering muscle contraction = MUSCLE WEAKNESS

Acetylcholinesterase then BREAKS down ACh = takes it away

Front 183

Clinical Features of MG

Back 183

Increasing muscular fatigue

- Extra-ocular (Ptosis / Diplopia / Peek sign)

- Bulbar

- Face (Myasthenic snarl / Dysphonia / Chewing or Talking difficulties)

- Neck

- Limb girdle

IMPROVES AFTER REST

Front 184

6 things that worsens weakness in MG?

Back 184

1) Pregnancy

2) Hypokalaemia

3) Gentamicin

4) Opiates

5) Emotion

6) Exercise

7) Infection

8) Over treatment

Front 185

Aetiology of MG?

Back 185

<50 years old = Female/Other AI Diseases/ THYMIC HYPERPLASIA

>50 years old = Male / Thymic Atrophy or Tumour I

Front 186

Investigations for MG?

Back 186

Anti-AChR antibody OR MUSK Antibody

Neurophysiology (Evoked Potentials)

CT of Thymus

ICE PACK TEST -ptosis improves by >2mm after Ice pack for >2 minutes

Tensilon Test

Front 187

Management of MG?

Back 187

Acetylcholinesterase Inhibitor = PYRIDOSTIGMINE

SE = Lacrimation / Sweats / Vomiting / Diarrhoea

Immunosuppression = PREDNISOLONE + AZATHIOPRINE

THYMECTOMY

- Consider if <50 OR not controlled by Pyridostigmine

Front 188

What happens during a Myasthenic Crisis?

Back 188

WEAKNESS OF THE RESPIRATORY MUSCLES

during a relapse - can be life threatening

Must must monitor FVC + Give Ventilatory Support

Front 189

Management of Myasthenic Crisis?

Back 189

Plasmapheresis

IV Immunoglobulin

Front 190

Causes of Lambert-Eaton Myasthenic Syndreom

Back 190

Paraneoplastic (Small Cell Lung Ca)

Autoimmune

Front 191

3 clinical signs of LEMS

Back 191

Gait difficulty FIRST - before eye signs

Autonomic involvement = Dry mouth / constipation / Impotence

Hyporeflexia & Weakness = Improves AFTER exercise

Front 192

Management of LEMS

Back 192

IV Immunoglobulin

Front 193

MND affects which neurones?

Back 193

MOTOR CORTEX

CRANIAL NERVE NUCLEI

ANTERIOR HORN CELLS

Front 194

What does MND spare?

Back 194

Affects BOTH LMN and UMN BUT

1) No Sensory loss or sphincter disturbance (Distinguishes from MS/Polyneuropathies)

2) NEVER affects eye movements

(Distinguishes from MG)

Front 195

Genetics behind MND?

Back 195

ALS-FTD locus at Ch9

Or

Autosomal Dominant D90A SOD1 Mutation

Front 196

4 Clinical Patterns of MND

Back 196

All Bald Men Shine (ABML)

ALS (Amyotrophic Lateral Sclerosis)

Progressive Bulbar Palsy

Progressive Muscular Atrophy

Primary Lateral Sclerosis

Front 197

What happens in ALS (Amyotrophic Lateral Sclerosis)

Back 197

Loss of motor neurones in the MOTOR CORTEX and in the ANTERIOR HORN

Weakness

UMN Signs (Increase Tone/Increased Reflexes/ Upgoing Plantars)

LMN Signs (Wasting / Fasciculation)

Worse prognosis if: Older/Decreased FVC/Bulbar onset

Front 198

What happens in Progressive Bulbar Palsy?

Back 198

Only affects CN9-12

See LATERP

Front 199

What happens in Progressive Muscular Atrophy

Back 199

ANTERIOR HORN CELL ONLY = No UMN signs

Affects DISTAL muscle groups before proximal

Weakness/Wasting/Fasciulations

Front 200

What happens in Primary Lateral Sclerosis?

Back 200

Loss of BETZ cells in motor cortex

UMN signs + Marked Spastic Weakness + Pseudobulbar Palsy

Front 201

When to think of MND?

Back 201

>40

Stumbling/Spastic gait

Foot drop + Proximal Myopathy

Weak grip & shoulder abduction

Aspiration pneumonia

Front 202

How do you diagnose MND?

Back 202

EL ESCORIAL CRITERIA

Front 203

Most likely cause of death in MND?

Back 203

Respiratory Failure due to bulbar palsy + pneumonia

Front 204

MDT involvement in MND?

Back 204

Neurologist

Palliative Nurse

Hospice

Physiotherapy

OT

Speech and Language Therapist

Dietician

Social Services

Front 205

Management for MND

Back 205

1) Antiglutamateric Drugs (Sodium Channel Blocker)

= RILUZOLE

2) Drooling? =

PROPANTHELINE + AMITRIPTYLINE

3) Dysphagia?

Blended food/ Ng tube

4) Non-invasive ventilation / NSAIDs/ Opiods

Front 206

What is Bulbar Palsy?

Back 206

Disease of the NUCLEI of CN9-12 in the medulla

Front 207

Signs of Bulbar Palsy?

Back 207

LMN lesions of the tongue and muscles of talking/swallowing

= Flaccid / Fasciculating tongue/ Jaw Jerk Decreased/ Dysphonia / Drooling

Front 208

Causes of Bulbar Palsy

Back 208

MND

GBS

Polio

MG

Front 209

What is Psudobulbar palsy (Corticubulbar palsy)?

Back 209

More common than Bulbar

UMN lesions of the muscles of swallowing & talking due to BILATERAL lesions above the mid-pons

e.g. Corticobulbar tracts

(MS/MND/STROKE)

Front 210

Signs of Corticobulbar palsy?

Back 210

Slow tongue movements with slow deliberate speech

Increased Jaw Jerk

Increased Pharyngeal & Palatal Reflexes

Emotional incontinence = uncontrolled weeping/giggling

Palatal movements absent

Persistent dribbling

Front 211

Define a TIA

Back 211

Sudden onset of a focal neurological deficit lasting for less than 24 hours due to an occlusion of part of the cerebral circulation

Front 212

Define Gullian-Barre Syndrome

Back 212

Acute inflammatory demyelinating polyneuropathy = symmetrical ascending muscle weakness starts

Front 213

4 things that can trigger GBS?

Back 213

Campylobacter Jejuni

CMV

HIV

EBV

= Leads to autoantibody mediated nerve cell damage

Front 214

Clinical Features of GBS

Back 214

Progressive onset of LIMB weakness = 4 WEEKS -----> Recovery

- Proximal muscles affected more (e.g. Trunk/Respiratory/Cranial Nerves CN7)

- Pain in back/limbs

DIAGNOSTIC =

PROGRESSIVE WEAKNESS OF ALL 4 LIMBS

AREFLEXIA

Supporting symptoms = Progression over days / symmetrical / CN involvement

Front 215

What is the main DD for GBS?

Back 215

MG

Botulism

Poliomyelitis

Chronic Inflammatory Demyelinating Radiculopathy = Slower onset & recovery

Front 216

What is Miller Fisher Syndrome?

Back 216

Associated with Anti- GQ1b antibodies in serum

1) Opthalmoplegia

2) Ataxia

3) Areflexia

Front 217

Investigations for GBS?

Back 217

1) Nerve Conduction Studies = Slow motor conduction

2) CSF = Increased protein

3) Respiratory Involvement = FVC check every 4 hours

4) Spine MRI

Front 218

Management of GBS

Back 218

IV Immunoglobulin ///

CI = in IgA deficiency

Plasma Exchange

Supportive Treatment (Heparin / Physiotherapy / NG Tube)

Front 219

Causes of Mononeuropathies

Back 219

Trauma

Entrapment (e.g. tumour)

Acute compression (e.g. common peroneal nerve)

Front 220

Define Mononeuritis Multiplex

Back 220

When 2 or more peripheral nerves affects --> tends to be systemic

Front 221

Causes of Mononeuritis Multiplex

Back 221

WARDS PLC

Wegener's

Aids

Rheumatoid

DM

Sarcoidosis

PAN

Leprosy

Carcinomatosis

Front 222

Median Nerve (C6-T1) - Which muscles does it innervate?

Back 222

LOAF

Lumbricals

Opponens Pollicis

Abducter Pollicis Brevis

Flexor Pollicis Brevis

Front 223

Hand Examination = Thumb abduction and opposition = which nerve?

Back 223

Median Nerve

Front 224

Ulnar Nerve C6-T1 - Most common cause of damage?

Back 224

Elbow Trauma (Cubital Tunnel / Epicondylar Groove)

Front 225

5 Signs of Ulnar Nerve Damage

Back 225

Weakness/wasting of :

1) Medial wrist flexors (ulnar side)

2) Interossi (Cannot cross fingers)

3) Medial two lumbricals (claw hand)

4) Hypothenar eminence

5) Also sensory loss in ulnar distribution

Front 226

4 ways to treat ulnar nerve damage?

Back 226

Rest/Avoid pressure

Night time soft elbow splint

Decompression in situ

Medial epicondylectomies

Front 227

Where does damage to the radial nerve (C5-T1) happen?

Back 227

Compression against the humerus

Front 228

Signs of Radial Nerve Damage

Back 228

SATURDAY NIGHT PALSY

Wrist/Finger drop

Sensory loss at snuff box

Front 229

What 4 muscles are innervated by the radial nerve?

Back 229

BEST

Brachoradialis

Extensors

Supinator

Triceps

Front 230

Clinical features of brachial plexus damage?

Back 230

Pain/paraesthesiase and weakness in affected arm

Front 231

Causes of Brachial Plexus damage?

Back 231

Trauma

Radiotherapy (e.g. for Breast Ca)

Pancoasts Tumour

Cervical Rub

Front 232

What two clinical features will present with phrenic nerve palsy

Back 232

C3,4,5 keeps the diaphragm alive

Orthropnoea

Raised hemidiaphragm on CXR

Front 233

Causes of Phrenic Nerve palsy

Back 233

Lung carcinoma

Myeloma

Thymoma

Cervical spondylosis

HIV

Lyme disease

TB

Front 234

What symptoms do you get from damage to the LATERAL cutaneous nerve of the thigh (L2-L3)

Back 234

Meralgia Paraesthesia

Burning pain on the anterolateral part of the thigh due to entrapment of the nerve under the inguinal ligament

Front 235

Sciatic Nerve (L4-S3) - Damage from where?

Back 235

Pelvic tumours or fractures to the pelvis/femur

Lesions affect the hamstrings and all muscles below the kneed (e.g. foot drop)

Loss of sensation below the knee (laterally)

Front 236

Common Peroneal Nerve Damage (L4-S1) - What happens?

Back 236

Originates from the SCIATIC nerve just above the knee

Damage is from the FIBULAR head (trauma/sitting cross legged)

FOOT DROP FOOT DROP FOOT DROP

Weak ankle dorsiflexion/eversion

Sensory loss over the dorsum of the foot

Front 237

What happens in Tibial Nerve Damage

Back 237

Loss of plantar flexion of the foot (tip toe)

Loss of inversion/flex toes

Sensory loss over the sole

Front 238

Carpal Tunnel Syndrome affects WHAT nerve?

Back 238

MEDIAN NERVE - WAKE AND SHAKE WAKE AND SHAKE

Front 239

Clinical Features of Carpal Tunnel Syndrome?

Back 239

Aching pain (typically at night)

Paraesthesiae in the thumb / index / middle fingers (relieved by hand shake)

Sensory loss and weakness of Abducter Pollicis ?brevis

Loss of light touch / 2-point discrimination / sweating

Front 240

Causes of Carpal Tunnel Syndrome

Back 240

MEDIAN TRAPS

Myxoedema (Hypothyroid)

Enforced flexion

Diabetic neuropathy

Idiopathic

Acromegaly

Neoplasm (Myeloma)

Tumour - Benign (Lipoma)

RA

Amyloidosis

Pregnancy

Sarcoidosis

Front 241

Investigations for Carpal Tunnel Syndrome?

Back 241

Neurophysiology

Tinnel's test

Phalen's test

Front 242

Management of Carpal Tunnel Syndrome?

Back 242

Splinting

Local Steroid Injection

Decompression Surgery

Front 243

Classical features of polyneuropathy?

Back 243

Symmetrical & widespread distribution - distal weakness and sensory loss (glove&stocking)

Front 244

3 ways to classify polyneuropathy?

Back 244

Course (acute or chonic - e.g. GBS?)

Function (Sensory/Motor/Autonomic)

Pathology (Demyelination / Axonal degeneration/ Both)

Front 245

3 causes of MOTOR polyneuropathies

Back 245

GBS

Charcot-Marie Tooth (Distal wasting below the knees - inverted champagne bottles)

Lead Poisoning

Front 246

3 causes of SENSORY polyneuropathies

Back 246

DM

Renal Failure

Leprosy

Front 247

Causes of Polyneuropathies in general

Back 247

Metabolic = DM/Renal Failure/ Hypo/Hyper Thyroidism / Hypoglycaemia

Vasculitides: PAN/RA/Wegner's

Malignancy: Polycythaemia Rubra Vera

Inflammatory: GBS/Sarcoidosis

Infections: Syphillis / HIV

Nutritional: Deficiency in Vitamin B1 & B12

Too much OR Too little Vit B6

Drugs: Alcohol/ Isoniazid / Phenytoin

Front 248

Symptoms of Peripheral Neuropathy?

Back 248

Sensory = Numbness/ Pins&Needles - glove and stocking/ Trauma or Burns

Motor = Progression/ Weak or clumsy hands / Difficulty in walking/ Breathing difficulty

= LMN lesion symptoms / Decreased FVC

Front 249

Autonomic Neuropathy Symptoms?

Back 249

SEE NEXT FEW CARDS

Front 250

Investigations for polyneuropathy

Back 250

Nerve Conduction Studies (Demyelinating v axonal causes)

BLOODS - CXR - URINALYSIS - LP + specific genetic tests (PMP22 for charcot)

Front 251

Management of polyneuropathy

Back 251

Treat the cause

Involve physiotherapy / OT

Foot care / shoes

Neuropathic Pain? Amitriptyline / Gabapentin

Front 252

6 causes of autonomic neuropathy

Back 252

GDL is ASS

GBS

DM

Leprosy

Amyloidosis

Sjogren's

SLE

Front 253

Clinical features of SYMPATHETIC autonomic neuropathy?

Back 253

Postural Hypotension

Decreased sweating

Constipation

Horner's

Front 254

Clinical Features of PARASYMPATHETIC autonomic neuropathy?

Back 254

Constipation

Nocturnal Diarrhoea

Urine retention

Holmes- Adie pupil

Front 255

Penis and autonomic neuropathy?

Back 255

POINT & SHOOT

Parasympathetic = Erectile Dysfunction

Sympathetic = Ejaculatory Failure

Front 256

Investigations for autonomic neuropathy

Back 256

BP standing and lying - DROP of >20/10 is abnormal

ECG

Cystometry

Pupils

Paraneoplastic antibodies (Anti-Hu/Anti-Yo/Anti-Ri)

Front 257

What does Vitamin B1 (THIAMINE) deficiency cause

Back 257

WERNICKE'S ENCEPHALOPATHY

Classical Triad:

1) Confusion

2) Ataxia

3) Opthalmoplegia (Nystagmus/Lateral Rectus palsy)

Front 258

Pathology of B1 deficiency

Back 258

Periaqueductal punctate haemorrhages & focal damage

Front 259

Causes of Vitamin B1 deficiency?

Back 259

Chronic Alcoholism

Eating Disorders

Malnutrition

Front 260

Management of Vitamin B1 deficiency

Back 260

Can lead Korsakoff's syndrome

IV/IM THIAMINE

Front 261

What is Vitamin B6?

Back 261

PYRIDOXINE

Front 262

What causes Vitamin B6 deficiency? What symptoms can this cause?

Back 262

Mainly isoniazid therapy for TB - SENSORY NEUROPATHY MOSTLY

Management=

PYRIDOXINE

Front 263

What can Vitamin B12 deficiency cause?

Back 263

Subacute combined degeneration of the spinal cord = Insidious onset with peripheral neuropathy

Front 264

Vitamin B12 deficiency clinical symptoms?

Back 264

Symmetrical Dorsal Column Loss = Touch/ Propioception/ Vibration & LMN signs

Symmetrical Corticospinal tract loss = Motor & UMN signs

Joint position/Vibration --> Ataxia --> Stiffness --> Weakness

Front 265

Triad of symptoms in Vitamin B12 deficiency

Back 265

1) Extensor Plantars (UMN)

2) Absence Knee Jerks (LMN)

3) Absent Ankle Jerks (LMN)

Pain and Temperature IN TACT

Front 266

Management of Vitamin B12 deficiency?

Back 266

IM HYDROXOCOBALAMIN

Front 267

What happens in Brown-Sequard Syndrome?

Back 267

Hemisection or unilateral cord lesion

Front 268

Clinical Features of Brown-Sequard?

Back 268

1) IPSILATERAL UMN weakness below the lesion

** Severed corticospinal tract**

= Spastic paraparesis

= Brisk reflexes

= Extensor plantars

2) IPSILATERAL loss of propioception and vibration

**Severed dorsal column**

3) CONTRALATERAL loss of pain and temperature

**Severed spinothalamic tract that has crossed**

Front 269

Causes of Brown-Sequard?

Back 269

Bullet

Tumour

Disc Hernia

Cervical Spondylosis

MS

Myelitis

Septic Emboli

MRI MRI MRI MRI MRI MRI MRI MRI MRI MRI

Front 270

What is a pontine lesion? What does it cause?

Back 270

Pons lies above the decussation of the posterior columns

Pontine lesion causes LOSS of ALL forms of sensation on the OPPOSITE side of the lesion

Front 271

Causes of Cranial Neve Lesions?

Back 271

DM

Stroke

MS

Tumours

Sarcoidosis

Vasculitis = PAN/SLE

Syphillis

Front 272

Loss of sense of smell?

Back 272

CN1 - OLFACTORY NERVE

Causes = Trauma / Respiratory Tract Infection / Meningitis

Front 273

Loss of Vision?

Back 273

CN2 - OPTIC NERVE

1) Monocular Blindness = MS/GCA

2) Bilateral Blindness = DM/MS/Neurosyphillis

3) Bitemporal Hemianopia = Optic chiasm compression (Pituitary adenoma/craniopharyngioma/internal carotid aneurysm)

4) Homonymous hemianopia = Stroke/Abscess/Tumour

5) Optic neuritis = Pain on moving eye / loss of central vision / relative afferent pupillary defect/ Disc swelling

6) Papilloedema

Bilateral swollen discs = RAISED ICP / Retro-orbital lesion (e.g. cavernous sinus thrombosis)

7) Optic Atrophy = Pale optic disc/Reduced Acuity = MS/Frontal Tumours

8) Ischaemic Papillopathy = Swelling of disc due to stenosis of posterior ciliary artery = GCA

Front 274

Causes of raised ICP

Back 274

Tumour

Abscess

Encephalitis

Hydrocephalus

Idiopathic intracranial hypertension

Front 275

Optic Nerve Tract Lesions?

Back 275

Front 276

Cranial Nerve 3 (Occulomotor Lesion) causes?

Back 276

PCA aneurysm

Raised ICP

GCA

DM

HTN

Front 277

What muscles does the occulomotor nerve supply?

Back 277

Superior Rectus

Inferior Rectus

Medial Rectus

Inferior Oblique

Sphincter Pupillae

Levator Palpebrae Superioris

Front 278

What do you see in a patient with CN3 palsy?

Back 278

Eye is DOWN and OUT

DILATED PUPILS

Ptosis

Front 279

Most common symptoms of a brainstem infarct?

Back 279

Lateral Medullary Syndrome

= Occlusions of one vertebral artery / posterior inferior cerebellar artery

= Vertigo / Vomiting/ Dysphagia / Nystagmus / Ipsilateral ataxia / Ipsilateral Horner's Syndrome

Front 280

What muscle does CN4 supply?

Back 280

TROCHLEAR NERVE

SO4? = Superior Oblique

Front 281

Clinical Features of CN4 palsy?

Back 281

Diplopia on looking down and in

Head tilting compensation (OCULAR TORTICOLLIS)

Front 282

CN6 (Abducens) Which Muscle?

Back 282

Lateral Recturs

Eye cannot be abducted beyond the midline

Horizontal diplopia on looking outwards

Front 283

CN 5 - What Nerve? What lost first? What does it supply?

Back 283

Trigeminal Nerve

3 Branches = Opthalmic/Maxillary/Mandibular

Supplies sensation to these three areas

CORNEAL reflex is lost first

Motor = Travels with Mandibular - supplies muscles of mastication = JAW deviates TOWARDS the side of the lesion

Front 284

Causes of CN5 palsy

Back 284

Sensory? = Trigeminal Neuralgia / Herpes

Motor? (Rare) = Nasopharyngeal Carcinoma / Acoustic Neuroma

Front 285

What is CN7?

Back 285

Facial Nerve

Supplies muscles of expression in the face

Two major branches

1) Chorda tympani

2) Stapedius

Front 286

What causes a CN7 lesion?

Back 286

Fracture affecting the PETROUS bone

Front 287

What happens in an LMN CN7 lesion

Back 287

Ipsilateral weakness of the facial expression muscles

commonest = BELLS PALSY

Front 288

What is Bell's Palsy

Back 288

Sudden onset unilateral facial weakness

Ipsilateral numbness/pain around the ear

Hypersensitive to sounds

Drooling

Frontalis weakness

Eyes can't close

Front 289

Investigation's of Bell's Palsy

Back 289

ESR

Glucose

Increase in Borrelia Antibodies in Lyme Disease

MRI

Front 290

Complications of Bell's Palsy

Back 290

Synkinesis

Crocodile Tears

Front 291

Management of Bell's Palsy?

Back 291

Prednisolone

Protect Eyes

= Dark glasses / Lateral Tarsorrhaphy / Artificial Tears

Front 292

Causes of Bell's Palsy

Back 292

HSV

HIV

EBV

CMV

Sarcoidosis

Lyme Disease

Front 293

Other causes of LMN lesions?

Back 293

Polio

Otitis Media

Acoustic Neuroma

Malignant parotid tumours

Herpes Zoster = RAMSAY HUNT SYNDROME

Front 294

What is Ramsay Hunt Syndrome?

Back 294

LATENT VARICELLA ZOSTER VIRUS reactivates in the geniculate ganglion

= Painful vesicular rash on auditory canal

= Loss of taste in anterior 2/3rd of tongue

Rx = ACICLOVIR / PREDNISOLONE

Front 295

UMN Lesion of the facial nerve?

Back 295

Weakness in the lower part of the face

Upper facial muscles are SPARED (Can still lift eyebrows)

Cause = Stroke / Tumour

Front 296

CN8 palsy- clinical features?

Back 296

Vestibulocochlear nerve

Vetibular = Equilibrium

Cochlear = Hearing

Sensorineural Deafness and tinnitus

Vertigo (Illusion of movement)

Vomiting

Nysatgmus (Pendular = poor visual fixation - Jerk Horizontal = Middle Ear - Jerk Vertical = Brain stem/Cerebellum)

Ataxia C

Front 297

Causes of CN8 Palsy

Back 297

ACOUSTIC NEUROMA

Paget's

Gentamicin

Meniere's disease

Front 298

CN9-12?

Back 298

Glossopharyngeal

Vagus

Accessory

Hypoglossal

All usually affected together (Bulbar palsy)

Front 299

CN9-11 lesion causes?

Back 299

Trauma / Jugular Foramen Lesion

Front 300

Groups of CN's affected?

Back 300

CN8 ---> 5/6/9/10 = Cerebellopontine angle tumours (Acoustic Neuroma)

CN3/4/6 = Stroke/MS

CN3/4/5(a)/6 = Cavernous Sinus thrombosis

CN9/10/11 = Jugular Foramen Lesion

Front 301

5 clinical features of a space occupying lesion?

Back 301

1) RAISED ICP

- Worse on walking/lying/bending forward/coughing

- Vomiting / Papilloedema

- As tumour grows = downward displacement of brain + pressure on stem = drowsiness/respiratory depression/coma

2) SEIZURES

3) EVOLVING FOCAL NEUROLOGY

6th nerve / 3rd nerve palsy

4) SUBTLE PERSONALITY CHANGE

Irritable/Apathy/Socially inappropriate behaviourC

Front 302

Causes of a space occupying lesion?

Back 302

Tumour

Abscess

Aneurysms

Chronic subdural haematoma

Tuberculos

Front 303

5 primary brain tumours

Back 303

Astrocytoma

Glioblastoma Multiforme

Oligodenroglioma

Ependymoma

Meningioma

Front 304

Investigations for an SOL?

Back 304

CT/MRI

NO NO NO LP = Cerebellar tonsils will hermiate through the foramen magnum = death

Front 305

What is the management for an SOL?

Back 305

1) Excision + Carmustine wafers

2) Hydrocephalus? Ventriculo-peritoneal shunt

3) Glioblastoma? TEMOZOLOMIDE

4) Cerebral Oedema? Dexamethasone / Mannitol

Front 306

Clinical Features of a frontal lobe SOL?

Back 306

Hemiparesis

Personality Change

Grasp Reflex

Brocca's Dysphasia

Unilateral anosmia

Front 307

Clinical Features of a PARIETAL lobe SOL?

Back 307

Hemisensory loss

Decreases 2 point discrimination

Astereognosis

Sensory inattention

Dysphasia

Front 308

Clinical Features of a TEMPORAL lobe SOL?

Back 308

Dysphasia

Contralateral homonymous hemianopia

Amnesia

Front 309

Clinical Features of an OCCIPITAL lobe defect?

Back 309

Contralateral visual field defects

Palinopsia

Polyopia

Front 310

Symptoms of a Cerebellopontine angle lesion?

Back 310

Acoustic Neruoma / Vestibular Schwannoma

Ipsilateral deafness

Nystagmus

Decreased corneal reflex

Facial weakness

IPSILATERAL cerebellar signs

Papilloedema

6th nerve palsy

Front 311

What is the classic symptom of a mid-brain infarction (pineal tumour)

Back 311

Failure of up or down gaze

Front 312

3 ways in which micro-organisms can reach the meninges?

Back 312

Ears

Nasopharynx

Bloodstream

Front 313

5 causes of meningitis

Back 313

NHS

Neisseria Meningitides

Haemophilus Influenzae

Streptococcus Pneumoniae

Listeria monocytogenes

Cryptococcus

TB (If immunocompromised)

Front 314

Clinical Features of Meningitis

Back 314

Initially = Headache/ Leg Pains/ Cold Hands & Feet

Later=

MENINGISM = Neck stiffness / Photophobia / Kernig's Sign

Decreased conscious level / coma / seizures/ focal CNS signs

Front 315

What would you suspect if you saw a petechial rash that is NON-BLANCHING on a patient with meningitis?

Back 315

MENINGOCOCCAL SEPTICAEMIA

Front 316

Complications of Meningitis

Back 316

Venous Sinus Thrombosis

Severe cerebral oedema

Cerebral abscess

Front 317

Causes of VIRAL Meningitis

Back 317

Coxsackie A

Coxsacke B

Echovirus

HSV2

Rx = Aciclovir - usually self limiting

Front 318

Management of Meningitis?

Back 318

At GP before hospital = BEN PEN

At hospital

<55 years old = IV CEFOTAXIME

>55 years old = IV CEFOTAXIME + AMPICILLIN (for Listeria)

Front 319

Prophylaxis for meningitis?

Back 319

Rifampicin

Front 320

Investigations for Meningitis?

Back 320

HEAD CT SCAN

U&E/FBC/LFT/ Blood Culture

Front 321

If the patient is immunocompromised with meningitis, what stains do you use?

Back 321

Auramine stain = TB

India ink stain = Cryptococcus

Front 322

What would you see in the CSF of a patient with meningitis?

Back 322

1) Bacterial? Low glucose/ Neutrophilia

2) TB = Low glucose / Lymphocytosis

3) Viral = High protein/ Lymphocytosis

4) SAH = High RBC

Front 323

What is encephalitis?

Back 323

Inflammation of the brain parenchyma

Front 324

Symptoms of encephalitis?

Back 324

Odd behaviour

Headache/Fever

Reduced consciousness

Focal neurological deficit / Seizure

Coma

Front 325

What is the difference between encephalopathy and encephalitis?

Back 325

Encephalopathy = NO PRODROME

Encephalitis = Prodome (Fever/Rash/Lymphadenopathy)

Front 326

Causes of Encephalopathy

Back 326

Hypoglycaemia

Hepatic encephalopathy

DKA

SLE

Front 327

Viral (most common) causes of encephalitis

Back 327

HSV1

HSV2

CMV

EBV

HIV

Varicella-Zoster Virus

ALSO = Japanese B Encephalitis / West Nile VirusN

Front 328

Non viral causes of encephalitis

Back 328

Any bacterial meningitis

TB

Malaria

Listeria

Lyme disease

Schistosomiasis

Legionella I

Front 329

Investigations for Encephalitis?

Back 329

1) Bloods - Blood Culture / Serum for viral PCR /Malaria FIlm

2) Contrast enhanced CT

3) LP

4) EEG

Front 330

Management for Encephalitis?

Back 330

IV ACICLOVIR

Front 331

What causes shingles?

Back 331

After an infection with varicella zoster (chicken pox) - the virus remains dormant in:

1) DORSAL ROOT GANGLION

2) CRANIAL NERVE GANGLIA

Reactivation of the infection = Shingles

Front 332

Clinical Features of Shingles

Back 332

Pain + Tingling in dermatomal distribution

RASH

= Lower thoracic region / Opthalmic division of the trigeminal

Fever

Malaise M

Front 333

Management of shingles?

Back 333

IV ACICLOVIR

Front 334

Compleciation of Shingles and Management?

Back 334

Post-Herpetic Neuralgia

Amitriptyline + Carbamazepine

(or topical lidocaine patches / gabapentine)

Last resort = Ganglion ablation