Neurology

Hand nerves motor functions?

        ·        Median – rock – ape hand - wrist and finger flexion, moves thumb away from palm

        ·        Radial – paper - extension of elbow, wrist, fingers, forearm supination

        ·        Ulnar – scissors – claw hand - finger spreading and power grip

Reflexes?

        ·        Biceps – C5-C6

        ·        Triceps – C7-C8

        ·        Knee – L3-L4

        ·        Ankle – S1-S2

Dermatomes and myotomes?

•  C1 = no dermatome. Head and neck movements.

• C2 = upper part of head.

• C3 = side of face and back of head. (C3,4,5 diaphragm)

• C4 = upwards shoulder movements.

• C5 = deltoids and biceps, forearm rotation

• C6 = elbow flexion, wrist extension

C7 = elbow extension and triceps

• C8 = hands, finger flexion

• L1 = sensation groin + genitals. Hip muscles.

• L2,3,4 = sensation anterior thigh and medial lower leg. Hip and knee movements.

• L5 = outside leg, upper foot, 1^st webspace. Dorsiflexion, inversion, eversion.

• S1 = lateral malleolus sensation. Plantar flexion.

Leg nerves? Sciatic nerve lesion? Common peroneal nerve lesion?

        ·        Femoral nerve = hip flexion, knee extension, patella reflex

        ·        Sciatic nerve lesion = knee flexion. lesion = paralysis of knee flexion and all movements below knee, sensory loss below knee, ankle and plantar reflexes lost, knee jerk intact

        ·        Common peroneal nerve = neck of fibula injury, main sx is foot drop, can have weak dorsiflexion and eversion.

        ·        Tibial nerve = Dorsiflexion, inversion, eversion, plantar flexion.

What nerve is affected in olecranon fracture, humeral neck/proximal humerus fracture and humeral shaft fracture?

        ·        Olecranon fracture = ulnar nerve

        ·        Humeral neck/proximal humerus = axillary nerve → reduced shoulder abduction

        ·        Humeral shaft = radial nerve

Ascending tracts?

-          DCML – vibration, proprioception, fine touch

-          Anterior spinothalamic – crude touch and pressure

-          Lateral spinothalamic – pain and temperature

-          Spinocerebellar – info about muscle stretch

Descending tracts?

-          Pyramidal

Ø  Corticospinal – lateral and anterior

Ø  Corticobulbar – head and neck

-          Extrapyramidal

Ø  Reticulospinal – muscle tone and voluntary movements

Ø  Vestibulospinal – posture and tone adjustments

Ø  Rubrospinal – upper limb flexion = disinhibition / upper limb extension = inhibition

Ø  Tectospinal – superior colliculi = visual stimuli / inferior colliculi = auditory stimuli

Stroke arteries affected? PICA? AICA? Weber’s syndrome?

        ·        ACA – leg

        ·        MCA – arm and leg, hemianopia, dysphasia, facial droop

        ·        PCA – contralateral homonymous hemianopia, headache

        ·        Posterior inferior cerebellar artery / lateral medullary syndrome

-          Ipsilateral face pain and temperature loss and contralateral body pain and temperature loss

-          Ipsilateral Horner’s and contralateral weakness

-          No face motor loss

-          Vertigo, etc.

        ·        Anterior inferior cerebellar artery

-          Similar to above but ipsilateral facial paralysis, deafness, vertigo, vomiting

        ·        Weber’s syndrome = ipsilateral CN3 palsy and contralateral weakness

Medical management of stroke and TIA?

        ·        Aspirin 300mg STAT then 2 weeks and clopidogrel lifelong

        ·        If clopidogrel CI, aspirin and dipyridamole lifelong

        ·        AF – anticoagulated after 14 days

        ·        Start statin 48 hours after

        ·        TIA – aspirin 300mg initial dose then 75mg for 21 days + clopidogrel lifelong

Thrombolysis in stroke timeframe? Contraindications?

Thrombolysis within 4.5 hours,

Contraindications to thrombolysis – Seizure, SAH sx, stroke/head injury last 3 months, major surgery/trauma within 2 weeks, previous intracranial haemorrhage, intracranial neoplasm, LP within past week, current anticoagulation INR >1.7

Thrombectomy in stroke guidelines?

Thrombectomy within 6 hours of symptom onset + thrombolysis (if within 4.5 hours) if confirmed proximal anterior circulation occlusion

Offer thrombectomy ASAP to people who were last known to be well between 6 and 24 hours previously if confirmed proximal anterior circulation occlusion ad potential to salvage brain tissue as seen by imaging

Consider thrombectomy with thrombolysis (if within 4.5 hours) ASAP for people last known to be well up to 24 hours previously with proximal posterior circulation occlusion if there is potential to salvage brain tissue

When is carotid endarterectomy done?

If carotid stenosis >50%

NICE suggest starting anti-epileptics after first seizure if? What are the rules on valproate and topiramate?

Any of following:

-          Pt has neuro deficit

-          Brain imaging shows structural abnormality

-          EEG shows unequivocal epileptic activity

-          Patient/family consider further seizure risk unacceptable

        ·        Valproate must not be started for first time in male or female under 55 unless 2 specialists independently feel there is no other effective or tolerated treatment or there are compelling reasons that reproductive risks do not apply.

        ·        Topiramate should not be used in women/girls of childbearing age unless conditions of Pregnancy Prevention Programme are fulfilled.

Anti-epileptics for gen ton-clon, focal, tonic/atonic, myoclonic and absence seizures?

        ·        Gen ton clon – lamotrigine or levetiracetam

        ·        Focal – lamotrigine or levetiracetam → 2^nd line carbamazepine, oxcarbazepine, zonisamide

        ·        Tonic/atonic – lamotrigine → 2^nd line clobazam, rufinamide, topiramate

        ·        Myoclonic – levetiracetam → lamotrigine

        ·        Absence – ethosuximide → 2^nd line lamotrigine or levetiracetam (carbamazepine may exacerbate)

Management of status epilepticus?

        ·        Status epilepticus = benzo → 5-10 mins later benzo again → IV phenytoin or levetiracetam or valproate. If no response after 45 mins from onset, GA or phenobarbital

Timeframe for CT head in head injury 1 hour vs 8 hours?

CT head within 1 hour of injury

-          GCS <13 on initial assessment

-          GCS <15 at 2 hours post injury

-          Suspected open or depressed skull fracture

-          Any sign of basal skull fracture

-          Post-traumatic seizure

-          Focal neuro deficit

-          More than 1x vomiting

CT head within 8 hours of injury – following risk factors + some LOC or amnesia since injury

-          >65, hx of bleeding/clotting disorders, anticoagulants, dangerous mechanism of injury, more than 30mins retrograde amnesia of events immediately before injury

-          If on warfarin and head injury with no other indications for CT

SAH - when would you do LP?

CT head done within 6 hours and normal – guidelines suggest not doing LP

If CT head after 6 hours and normal – LP

LP should be 12 hours after symptom onset to allow xanthochromia to develop to distinguish SAH from traumatic tap

MND most common presentation? What isn’t affected? Is ALS UMN or LMN? Is PBP UMN or LMN? Medication?

Most common presentation is asymmetric limb weakness

No sensory signs/symptoms, doesn’t affect ocular muscles, no cerebellar signs

Nerve conduction studies – normal

ALS – UMN + LMN

PBP – LMN – CN9,10,11,12

Riluzole – monitor LFTs

MS types? CSF finding? What is Lhermitte’s sign?

Relapsing-remitting – acute attacks followed by periods of remission

Secondary progressive – relapsing-remitting pts who have deteriorated and developed neuro signs and symptoms between relapses

Primary progressive – progressive deterioration from onset

CSF - oligoclonal bands

Lhermitte’s sign = electric shock down spine into limbs when neck flexed

MS management in acute relapse? Fatigue? Spasticity? Bladder dysfunction? Oscillopsia?

-          Acute relapse – high-dose steroids

-          Disease modifying drugs

-          Fatigue – amantadine

-          Spasticity – baclofen, gabapentin

-          Bladder dysfunction – need USS first!! If significant residual volume, intermittent self-catheterisation. If no significant residual volume – anticholinergics.

-          Oscillopsia – gabapentin

Autonomic neuropathy symptoms sympathetic vs parasympathetic?

        ·        Sympathetic – postural hypotension, ejaculation failure, reduced sweating

        ·        Parasympathetic – erectile dysfunction, constipation, urine retention

Degenerative cervical myelopathy symptoms? Sign? Gold standard test?

Pain, loss of motor or sensory function, loss of autonomic function

Hoffman’s sign – gently flick one finger of patient’s hand – positive = reflex twitching of other fingers in same hand

MRI c-spine gold standard

Decompressive surgery

GBS main symptoms and signs? LP findings?

Ascending weakness, flaccid weakness and HYPOreflexia

LP – increased protein, normal WCC, normal RCC and slow EMG

Brighton criteria

Meningitis CSF analysis - bacterial? Viral? TB? Fungal?

Signs in meningitis?

        ·        Kernig’s sign – hips and knees at 90 – extend knee – pain

        ·        Brudzinski’s sign – flexion of neck causes flexion of hips and knees

Meningitis management? Prophylaxis?

If LP cannot be done in 1^st hour, start IV abx after taking blood cultures

3 months – 60 years – ceftriaxone

>60 – ceftriaxone + amoxicillin (covers listeria)

Add IV vanc if recent prolonged/multiple abx use or travel to areas with high resistance to pneumococci

IV dex no later than 12 hours after starting abx. Avoid in septic shock, meningococcal septicaemia, immunocompromised.

Prophylaxis – close contact within 7 days before onset. PO cipro or rifampicin. For pneumococcal no prophylaxis generally needed.

Giant cell arteritis symptoms? Investigations?

Scalp tenderness, jaw claudication, visual changes

Duplex USS – hypoechoic halo sign and stenosis of temporal artery

Temporal artery biopsy– multinucleated giant cells

Subacute combined degeneration of spinal cord - which tracts are involved - symptoms?

Due to vitamin B12 deficiency

Dorsal column involvement

• Distal tingling/burning/ sensory loss – symmetrical and legs > arms

• Impaired proprioception and vibration

Lateral corticospinal tract involvement

• Muscle weakness, hyperreflexia

• UMN signs

Spinocerebellar tract involvement

• Sensory ataxia and Romberg’s sign

Parkinson’s disease management? What is on-off phenomenon? What is weaning off?

Motor sx affecting QoL – levodopa (always combined with decarboxylase inhibitor)

Motor sx not affecting QoL – dopamine agonist, levodopa or MAO-B inhibitor (rasagiline)

On levodopa and ongoing sx or developed dyskinesia – add dopamine agonist or MAO-B inhibitor or COMT inhibitor (entacapone)

Excessive daytime sleepiness – modafinil

Orthostatic hypotension – midodrine

On-off phenomenon – sudden changes in movement control

Weaning off – over time, symptoms a few hours after dose as medication wears off

Huntington’s disease inheritance pattern? Symptoms? What is anticipation?

Autosomal dominant. Chromosome 4 – CAG repeats in huntingtin gene

Personality change, dementia, agitation, rigidity, seizures, parkinsonism

Anticipation – disease presents at earlier age in successive generations.

Myasthenia gravis - what is it? Investigations? Treatment? Treatment for myasthenic crisis? What is Lambert-Eaton syndrome?

Antibodies against acetylcholine receptors and anti-MuSK antibodies

Ix – single fibre electromyography, CT thorax to exclude thymoma, CK normal, antibodies to acetylcholine receptors.

Treat with pyridostigmine

Myasthenic crisis – plasmapheresis, IVIG

Lambert-Eaton syndrome

• LEMS – antibodies against voltage-gated calcium channels

• Affects lower limbs first, hyporeflexia, autonomic sx

• Unlike MG, ophthalmoplegia and ptosis not common features

Neurofibromatosis I and II features? Inheritance pattern? NF1 complications?

Autosomal dominant

NF1 - CRABING

• Café au lait patches

• Relative – FHx

• Axillary/inguinal freckling

• Bone dysplasia

• Iris hamartomas

• Neurofibromas (skin)

• Glioma – optic

Complications - malignant peripheral nerve sheath and GI stromal tumour

NF2 - vestibular schwannomas, multiple intracranial schwannomas, meningiomas, ependymomas

Tuberous sclerosis - inheritance pattern? Features?

Autosomal dominant

Ash leaf spots, shagreen patches, angiofibroma, café au lait spots

Development problems, epilepsy, retinal hamartomas

Migraines management? Prophylaxis 1st line, 2nd line, menstrual migraines?

1^st line – oral triptan + NSAID/paracetamol

12-17 – nasal triptan

2nd line – non-oral metoclopramide or prochlorperazine

Prophylaxis

-          Propranolol, topiramate (teratogenic), amitriptyline

-          If fails – up to 10 sessions acupuncture over 5-8 weeks

-          Menstrual migraines – frovatriptan, zolmitriptan

What is normal pressure hydrocephalus? Triad? What does imaging show? Management?

Reversible cause of dementia due to reduced CSF resorption at arachnoid villi.

Triad – urinary incontinence, dementia, gait abnormality.

Imaging – hydrocephalus with ventriculomegaly in absence of or out of proportion to sulcal enlargement .

Management – VP shunt

CN3 palsy? CN4 palsy? CN6 palsy?

CN3 – oculomotor – palsy results in ptosis, ‘down and out’ eye, dilated, fixed pupil

CN4 – Trochlear – superior oblique – palsy results in defective downward gaze, vertical diplopia

CN6 – abducens – lateral rectus – palsy results in defective abduction

Quadrantanopia lobes inferior and superior? Causes of inferior and superior issues?

Quadrantanopia – PITS

Inferior = craniopharyngioma

Superior = pituitary tumour

What is parasellar syndrome?

CN5 damage – facial pain, paraesthesia

Pontine haemorrhage signs?

Reduced GCS, pinpoint pupils, paralysis

What is Charcot Marie Tooth disease? Motor or sensory? UMN or LMN?

Hereditary, mostly motor peripheral neuropathy, only LMN signs.

What is syringomyelia?

CSF in spinal cord. Spinothalamic sensory loss. Cape-like loss of sensation to temp.

Treatment of infantile spasms / West syndrome?

ACTH and vigabatrin

Gold standard investigation for venous sinus thrombosis?

MR venogram

What is Cushing’s reflex?

Hypertension, bradycardia, irregular breathing pattern

Bell’s palsy management?

Oral pred within 72hrs, can add antiviral if severe. If no improvement in paralysis after 3 weeks urgent ENT referral.

Cluster headaches investigation? Acute management? Prophylaxis?

MRI with gadolinium Ix of choice.

Acute – 100% O2, subcut triptan.

Verapamil for prophylaxis.

DMD inheritance pattern? What muscles are affected? Main sign?

X-linked recessive.

Progressive proximal muscle weakness from 5 years.

Gower’s sign.

30% have intellectual impairment.

Encephalitis main cause? What lobe is usually affected? CSF findings? Treatment?

HSV-1 in 95%.

Usually temporal lobe affected.

CSF – high lymphocytes, high protein, send for viral PCR.

IV acyclovir.

Essential tremor inheritance pattern? What usually helps? 1st line treatment?

Autosomal dominant

Improved by alcohol and rest.

1^st line – propranolol.

Friedreich’s ataxia inheritance pattern? Age? Common features?

Autosomal recessive. Onset 1-15 years.

Common presenting features are gait ataxia and kyphoscoliosis.

Neuro features – absent ankle jerks, cerebellar ataxia, optic atrophy

Other features – HOCM, diabetes, high-arched palate

Myotonic dystrophy - inheritance pattern? Age? General features? DM1 vs DM2?

Inherited myopathy, autosomal dominant.

20-30 years old.

Skeletal, cardiac and smooth muscle.

General features – myotonic facies, frontal balding, bilateral ptosis, cataracts, dysarthria

DM1 – distal weakness more prominent, DM2 – proximal weakness more prominent

Progressive supranuclear palsy symptoms?

Postural instability and falls, impairment of vertical gaze (down gaze worse), parkinsonism, cognitive impairment

IIH management? What meds can worsen IIH?

Weight loss, acetazolamide, topiramate.

Tetracyclines increase IIH risk.

Driving advice for TIA/stroke? Seizures? Withdrawing anti-epileptics? Fainting?

TIA/stroke – 1 month – unless ongoing symptoms

First unprovoked seizure and no structural issues on brain imaging – 6 months

Otherwise or established epilepsy – 12 months seizure free

Withdrawing anti-epilepsy meds – no driving whilst and for 6 months after last dose

Single faint episode – explained and treated – 4 weeks off.

Single unexplained faint – 6 months off. 2+ - 12 months off.

SEs of phenytoin? SEs of lamotrigine?

Phenytoin - peripheral neuropathy (glove and stocking), lymphadenopathy, bleeding gums (gingival hyperplasia)

Lamotrigine - skin rashes, SJS