Week 15 - Neurology
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Name to 12 Cranial nerves and breifly sate their function
- 1 → Olfactory → smell
- 2 → Optic → Vision
- 3 → Occulomotor → 4/6, levaetor pelpebrae sup, pupil constrictors
- 4 → Trochlear → motor to superior oblique, long course
- 5 → Trigeminal → sensation face [3 segments] muscles of mastication [messeter, pterygoid & temporalis]
- 6 → Abducens → lateral rectus [abduct eye]
- 7 → Facial → sensory ant 2/3 tongue [taste], motor = facial muscles
- 8 → Vestibulocochlear → sensory, balance & hearing
- 9 → Glossopharyngeal → sensory post 1/3 tongue, motor soft palate, salivary glands
- 10 → Vagus → longest, chemoceptors in carotid bodies, HR, SV etc
- 11 → Spinal Accessory → motor to sternocleidomastoid & trapezius
- 12 → Hypoglossal → motor to tongue [deviate to affected side]
What is Horners syndrome?
- Pancoast tumour invasion of cervical/thoracic sympathetic chain
- Affects CN 3 & 6
What are teh features of a 3rd nerve palsy?
- Eyelid droop [Ptosis]
- Eye in down & out position
What are the features of a 4th nerve palsy?
Longest intracranial course → susceptible to tumour/ ^^ICP
- Head tilt away from lesion
- Hypertropia [one eye higher than other]
- when looking down towards nose, other eye moves upwards
What are the components of the brainstem?
Why is it important?
Brainstem = Midbrain, pons & medulla
- Origin of all cranial nerves
- all spinal tracts pass thru here
What structures comprise the basal Ganglia?
- Basal Ganglia
- Caudate nucleus
- PutamenGlobus pallidus [interna & Externa]
- Subthalamic Nucleus
- Substansia Nigra
- Venterolateral nucleus of thalamus
What is the function(s) of the basal ganglia?
- Initiate voluntary movement
- Maintain posture/ movement
- Eye movement
- Executive functions → working memory
What is the Pathology sorrounding Parkinsons Disease?
- Lewy body → intracytoplasmic inclusion body containing misfolded protein
- gradually ascend thru stem
- loss of dopaminergic neurones within substansia nigra [CF >50% loss]
- 1 → Lewy bodies in lower brain stem
- 3-4 → midbrain/ substansia nigra ~symptomatic
- 6 → throughout basal ganglia, severely demented
What are the CF of Parkinsons?
- Bradykinesia → slow to initiate voluntary movement, reduction in sped of following movements
- Muscular rigidity
- postural instability
Non motor → dementia, poor sleep [restless legs] ^^ANS [constipation, ED, urinary urgency]
What is the role of Imaging in Parkinsons?
- CT/ MRI = normal
- Abn in vascualr/ parkinson plus disorders
Functional imaging → DAT SPEC → dopaminergic sys
DDx for Parkinsons?
- Benign tremor disorder
- dementia w lewy bodies
- Vascular Parkinsons [Stepwise progression, leg symptoms]
- Parkinson plus disorders
- Drug induced parkinsonism → dopamine antagonists
Outline the drug Tx of Parkinsons?
- 1. Replace DA/ DA agonists
- MoA → DA precursor, crosses BBB, converted to DA in brain
- A/E → abn voluntary movement, confusion & hallucinations
- PK/PD → give with decarboxylase inhibitor or will convert in tissues → lethal
- MoA → DA-r agonist [D2]
- A/E → nausea, headache & vom
- 2. Prevent DA synapse degredation
- Entacapone/ Selegiline
- MoA → MAO-B inhibitors, prevent DA degredation, ^^acting DA
- 3. Reduce Action of ACh
- MoA → anticholinergic, reduces tremor & rigidity
Outline the CF & complications of Myasthenia Gravis?
- Myasthenia Gravis
- Acquired autoimmune disorder
→ muscle weakness & ^^fatigueability on exertion
→ respiratory failure, dysphagia, long term steroid use
What is te underlying pathology in myasthenia gravis?
- B cell mediated
- Ab against ACh-R
- reduced receptors = reduced Na influx
- smaller end plate potential → no muscle movement
Outline the drug Tx of Myasthenia Gravis?
- Neostigmine/ Endrophonium
- MoA → acetyl cholinesterase inhibitors, ^ACh at junction, muscle movement
- A/E → Cholinergic crisis [sweating, salivation, miosis]
- MoA → immunosuppression, decrease circulating Ab
- A/E → cushings
What is multiple sclerosis?
- Chronic disease of brain & SC
- CF → changes in sensation, visual problems, weakness, poor coordination & speech, impaired mobility → disability
- Peak onset ~30yo
- Unknown cause
Outline the pathology underlying MS?
- CD4 T cells activate B cells → anti-myelin Ab
- Macrophages & Cytotoxic T → demyelination
- Failure of conducton & loss of function
- Eventual remyelination but never same function
What are the differenct types of MS?
- Relapsing remitting
- decent recovery from initial attacks, variable freq
- 70% → secondary progressive MS
- Secondary Progressive MS
- gets steadily worse, after initial relapsing remitting course of disease
- Primary Progressive
- Worst prognosis
- Progressive spinal damage
- Progressive relapsing
- gets steadily worse with occaisional really bad patches
What are the main symptoms of MS?
Could be anything, most neuro problems
- Relapsing remitting → clinically isolated syndromes
- optic neuritis [PAIN]
- Brainstem syndrome → opthalmoplegia, dyarthria, ataxic
- Spinal cord → transverse myelitis
How is MS diagnosed?
2 clinical attacks, >1m apart & O/E evidence of 2 separate lesions
- MR brain & Spine → T2 & FLAIR weighted
- lesions → paraventricular, corpus callosum, BS/Cerebellum
- CSF → Lumbar puncture
- Oligoclonal bands → IgG heavy chains
Outline the Mx of MS
- Prednisalone for first timers
- Refer to MS specialist nurses
- PT/ OT
- Later → Natalizumab → anti-TNF alpha
What are the signs of an upper motor neurone lesion?
- Pronator Drift [indicates spasticity]
- Brisk Reflexes
- Extensor Plantar Response
UMN lesion → lower half of face = paralysed
What are the features of a Lower motor neurone lesion?
- Flaccid Paralysis
- Muscle loss → weakness
LMN → complete facial paralysis
Draw and label the circle of willis?
Outline the pathophysiological mechanism of damage in ischaemic stroke
When BF stops, not instant tissue death
- Tissue death via;
- oxidative stress
- excitotoxicity → breakdown of Na/K pumps [K out, Na in], water in cell swells, stimulate Glu release, ^^Ca, Protease activeation → cell degredation
- Infarct core = irreversible dam
- Ischaemic Penumbra = potentially salvageable sorrounding tissue
- Benign oligaemia
Give 5 RF for Iscaemic Stroke?
- Heart Disease [AF]
- Previous stroke/ TIA
Give 3 RF for haemorrhagic stroke
- Cerebral Amyloid Angiopathy
- Antiplatelet medication
- Illegal drugs → cocaine
- Vascular lesions → aneurisms
What is the Oxford Community Stroke classification?
- TACS → Total Anterior Circulation Syndrome
- All 3 of; Contra-lateral hemiparesis, contra-lateral hemianopia, higher dysfunction [dysphasia, visuospatial]
- MCA/ICA occlusion
- PACS → Partial Anterior Circulation Syndrome
- 2 of above or higher function dysfunction alone
- MCA branch
- LACS → Lacunar Stroke
- small lacunae of blood [stroke]
- Pure motor or pure sensory or sensorimotor [Ataxic hemiparesis, dyarthria]
- Perforating arteries/ small artery disease
- POCS → Posterior Circulation syndrome
- Isolated Hemianopia/ brainstem syndrome
- Perforating arteries, PCA or cerebella arteries
Give 3 investigations for stroke & why you would use them?
- ECG → look for AF
- FBC → low PLTs cant give rTPA
- BM → hypoglycaemia can mimic stroke
- CT/ MRI → distinguish between ischaemic & haemorrhagic
Outline the Acute management of Ischaemic Stroke
- Admit Pt to stroke unit
- Thrombolysis <4.5hrs → Alteplase [rTPA]
- Exclude heamorrhagic on non contrast CT
- Antiplatelets after 24hr scan
- >4.5hr → antiplatelet therapy [300mg aspirin]
Outline the secondary prevention of stroke?
- Aspirin + dipyramidol/ clopidogrel
- Cholesterol lowering therapy
- Warfarin if in AF
- Carotid Endartectomy → remove carotid stenosis
What is status epilepticus?
Sustained synchronised electrical discharge in brain causing symptoms/signs
- Status Epilepticus
- Seizure >30min
- Series of seizures w/o regaining consciousness [benzos/ anticonvulsants]
- A tendency to have recurrant unproveked seizures
- Imbalance of excitation & inhibition in brain
How are seizures classified?
- Generalised Tonic-clonic
- Tonic phase → stiff, rigid muscles
- Clonic → dysrhythmic shaking **better define
- Partial Seizures w
- Loss of awareness
- Motor phenomena
- Sensory phenomena
- Psych phenomena
- Cognitive phenomena
What are the Hx & O/E features of a raised pressure headache?
- Worse lying flat
- Worse in morning
- Persistant nausea & Vom
- Worse w exertion
- CN6 signs
- CN3 signs
- Pain on valsalva
What are the Hx features of a low pressure headache?
- Worse sitting/ standing up
- Eased by lying flat
- Due to CSF leakage → traction of meninges → pain
What is the normal ICP?
What causes ^^ICP?
- ICP = 7-15mmHg
- >25 = shit your pants time [Brain herniation]
- Mass effect → space occupying lesion
- ^ venous pressure → cerebral sinus thrombosis
- Idiopathic → obese young women
What are the red flag features of a headache?
- Oh PANTS!
- Older age onset
- Previous headaches = different/ absent
- Acute onset <5min → thunderclap
- Neurological signs/ Symptoms
- Triggered headache → valsalva/ postural
- Systemic symptoms
What is a thunderclap headache?
- Abrupt onset, reaching maximum severity in <5min
- Subarachnoid haemorrhage until proven otherwise
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