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Neurology

Finals Revision
by

Aishwarya Desai

on 22 February 2016

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Transcript of Neurology

Neurology
DR AISHWARYA DESAI
PARKINSONISM
Motor Problems:
Rigidity
Resting tremor
Bradykinesia - reduced arm swinging, decreasing amplitude of repeats movements
Shuffling + festinant gait
Non Motor Problems
:
Anosmia
Dementia
Depression
Hallucinations
Insomnia
Parkinsons Disease
Degeneration of dopaminergic neurones in the substantia nigra of basal ganglia + deposition of Lewy bodies
EXAM
: Give differentials for a tremor. What is the inheritance of Huntingdons disease? List 3 symptoms of HD.
MANAGEMENT
Motor problems
Levodopa + carbidopa = Co-careldopa = Sinemet
Treatment failure - dyskinesia, freezing, motor fluctuation, on off features
Bromocriptine - dopamine receptor agonist
Entacapone - COMT inhibitor
Selegiline - MOAB inhibitor
Amantadine

- Adjuncts for non motor problems - anti cholinergics for tremor, SSRIs for depression
- Deep brain stimulation
Myasthenia Gravis
Autoimmune condition - antibodies directed against nicotinic ACh receptors on post synaptic membrane of NMJ
FATIGUEABILITY

with normal sensation
Extraocular muscles
Bulbar
Face, neck
Limbs, trunk
Worsened by infection, pregnancy, b blockers

A/W other AI disorders
Long term management
- Anticholinesterase inhibitor -
Pyridostigmine
before meals

Acute flare
- IV immunoglobulins +/- plasmapharesis +/- pred, azathioprine
- Regular FVC measurement
- ITU involvement
Complications
Aspiration pneumonia, DVT
Respiratory failure - Type 2

EXAM
: How does Eaton Lambert Syndrome vary from myasthenia gravis?
Idiopathic Intracranial Hypertension
investigations + Management
Antibodies
:
ACh receptor
MuSK
Tensilon test
Short acting AChesterase inhibitor
?increased power
Beware: bradycardia and increased vagal tone
EMG
CT Thorax
motor neurone disease
Spinal CORD
(Rubrospinal, vestibulospinal, etc. 2a-2d)
Initiation and maintenance
MULTIPLE SCLEROSIS
Polyneuropathy
FACIAL NERVE PALSY
EPILEPSY
neurofibromatosis
CEREBELLAR LESIONS
Dermatomes and myotomes
Multiple peripheral or cranial nerves affected. Present as:
- Acute symmetrical (Guillian Barre)
- Chronic symmetrical (CIDP, CMT)
- Multiple mononeuropathies

Guillain Barre Syndrome
An acute sensory and motor demyelinating polyneuropathy
Usually starts in lower extremities and has an ascending pattern
Can lead to respiratory failure
Can be proximally and is generally symmetrical
Related to infection
Campylobacter jejuni, CMV, EBV
1-3 weeks after onset of infection
Lower motor neurone symptoms

Investigations:
Bloods
- LFTs, U&E, FBC, CRP, ESR, Clotting
Lumbar puncture
- raised protein in CSF
Spirometry
- regular FVC monitoring
EMG

MRI

Management
ITU
- 1/3 of patients
Immunotherapis
IV immunoglobulins
Plasma pharesis
DVT prophylaxis
Hospital acquired infections
Physiotherapy
Presents with the symptoms of
raised ICP
- Headache worse in the morning
- Worse with coughing / sneezing
- Nausea / vomiting

Signs:
Bilateral
papilloedema
+/- CN VI palsy
Severe
Optic nerve compression
Blindness 10%


EXAM
: What would you see on LP? List some triggers for migraines. What prophylaxis / medication can be used in migraines? List features of a cluster headache
Management
1. Rule out other causes of raised ICP - imaging required

Drugs:
Acetazolamide - carbonic anhydrase inhibitor
Loop diuretics
Weight loss

Practical:
Therapeutic lumbar puncture
Measure opening and closing pressure

Surgical:
Optic nerve sheath fenestrating, shunting
D
ysdiadokinesia
A
taxia
N
ystagmus
I
ntention tremor
S
lurred speech
H
ypotonia
EXAM
: Perform a focused examination to test for a cerebellar lesion
Abnormal intermittent electrical activity that manifests as a seizure
Causes
:
Idiopatic
Structural -
SOL, stroke, SAH
Autoimmune diseases
Alcohol
Metabolic
Na, Ca2+, glucose
Meningitis
Prodrome > Aura > Seizure > Post ictal
- 1st fit clinic
- Commence therapy after 2nd seizure
- Unless structural abnormality

Tonic clonic: Valproate
Absence: Valproate, ethosuximide
Partial: Carbamazepine

Side effects:
Valproate (teratogenic, pancreatitis, ataxia)
Lamotrigine (rash, diplopia, fever)
Carbamazepine (rash, diplopia, leucopenia, SIADH)

Counseling
:
Inform DVLA, avoid swimming / diving / baths
EXAM
: What is Uthoff's phenomenon and Lehmitte's sign?
T cell mediated central demyelination.
Onset 30yrs M:F, 1:3
Presentation: McDonald criteria
Optic neuritis
Internuclear opthalmoplegia
Sensory loss
Investigations:
MRI head - white plaques
LP - oligoclonal bands of IgG
Serum IgG
HLA DRB1
Management:
Exacerbation - methyl pred; Remission - interferon B + monoclonal antibodies
Autosomal dominant inheritance (spontaneous mutations)
Neurofibromas
= firm demarcated nodule arising from nerve
Cafe-au-lait spots
= flat, coffee coloured patches
Lisch nodule
= hamartoma on iris
Axillary freckles
Optic nerve glioma
First degree relative
TYPE I - mainly cutaneous
TYPE II - a/w other H&N tumours
Brainstem > Pons > Int acoustic meatus > Facial canal > stylomastoid
foramen
Facial weakness, difficulty in closing eye, watery / dry eye, loss of taste, unable to tolerate loud noises
UMN = CAN wrinkle forehead - bilateral cortical representation
SOL, MS, Cerebrovascular disease, HIV
LMN = CANNOT wrinkle forehead
Otitis media, DM, Parotid gland
disease, Bells Palsy, HSV
EXAM
: What is Ramsay Hunt Syndrome? What are the branches of the facial nerve?
Eye care, prednisolone <72hrs, aciclovir, role for surgery
85% improve spontaneously
Degeneration of neurones in the motor cortex - causes a PYRAMIDAL WEAKNESS - mixed UMN and LMN lesions

Clinical diagnosis
Only motor symptoms
Amyotrophic lateral sclerosis
Bulbar palsy

Investigations are done to rule out alternative causes

Management:
Riluzole = antiglutamate drug
Nocturnal NIV
Symptomatic control with antispasmodics, pain relief, excess saliva, end of life care
Corticospinal tracts (1a, 1b)
- Fine, specific movements

Causes
: Posterior circulation strokes, malignancies, congential malformations, Freidreich's ataxia, MS, thiamine def.
Dorsal Columns:

Fine touch
Vibration
Proprioception (positional)
Motor = descending
Sensory = ascending
Spinothalamic (5a + 5b):
Pain
Temperature
Spinocerebellar (4a + 4b):
Proprioception (unconscious)
pYRAMIDAL V EXTRAPYRAMIDAL
Begin in the motor cortex

Pass through the medullary pyramids

Corticospinal tracts

Responsible for fine movements
Lesions
spasticity
clasp knife
weakness
Lesions
tremor
rigidity
bradykinesia
cogwheeling
Begin in the brain stem (basal ganglia etc)

Do not pass through the medulla

Rubrospinal
Reticulospinal
Vestibulospinal
Tectospinal

Responsible for initiation and maintenance
Contributes to coordination, precision and accuracy
Syndrome which is characterised by rigidity, tremor, bradykinesia and postural instability
Causes:
Parkinsons disease
Drugs (dopamine antagonists)
Vascular
Parkinson Plus Syndromes (MSA, PSP)
Wilson's disease
Mononeuritis multiplex

W
egners granulomatosis
A
IDS/amyloidosis
R
heumatoid arthritis
D
iabetes
S
arcoidosis
P
olyarteritis nodosum
L
eprosy
C
arcinomatosis
EXAM
: What is Miller Fisher Syndrome?
MIGRAINES
Headache
SPINAL CORD syndromes
headache
RED FLAGS:
- Sudden
- Worse in the morning
- Vomiting
- Focal neurology
- Progressive
CAUSES:
Migraine
Tension headache
Cluster headaches
SAH
Temporal arteritis
Medication overuse
Meningitis
SOL
Benign intracranial HTN
NERVE PALSIES
CN III
Down and out
Ptosis
Dilated pupil
CN IV (Superior oblique)
Worse on downward gaze

CN VI (Lateral rectus)
Loss of abduction
ptosis
Drooping of the eyelid
Normal pupil

Cataract surgery
Myasthenia
Trauma
Dilated pupil = mydriasis

CN III palsy
Constricted pupil = miosis

Horners Syndrome
Brown-Sequard Syndrome
Partial cord lesion
IPSILATERAL paralysis
IPSILATERAL loss off proprioception + vibration
CONTRALATERAL loss of pain and temp

Syringomyelia
Lesion of central spinal cord
'Cape' distribution
Loss of pain and temp - burns on hands
Arnold Chiari malformation

Subacute degeneration of the spinal cord
Dorsal + lateral regions affected most
B12 deficiency, HIV
Associated with pernicious anaemia
STATUS EPILEPTICUS
Medical emergency
Continuous seizuring can lead to brain damage

Management
- A + B : NPA + high flow
- C: ABG, IV access, bloods (electrolytes, drug levels)
- DRUGS:
1st line: benzodiazepine (diazepam, lorazepam)
2nd line: phenytoin infusion
3rd line: ITU to commence RSI
MANAGEMENT
Todd's palsy
- Focal weakness after a seizure
-Resolves in 48 hours
- Beware differentials
Full transcript