Week 15 - Neurology

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Author:
mewinstanley@googlemail.com
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132005
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Week 15 - Neurology
Updated:
2012-02-01 07:29:15
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Neurology
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Description:
Cranial nerves, stroke, myasthenia gravis, parkinsons
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  1. 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]
  2. What is Horners syndrome?
    • Pancoast tumour invasion of cervical/thoracic sympathetic chain
    • Affects CN 3 & 6
    • signs
    • Ptosis
    • Miosis
    • Anhidrosis
    • Enopthalmus
  3. What are teh features of a 3rd nerve palsy?
    • Eyelid droop [Ptosis]
    • Eye in down & out position
  4. 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
  5. 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
  6. What structures comprise the basal Ganglia?
    • Basal Ganglia
    • Caudate nucleus
    • PutamenGlobus pallidus [interna & Externa]
    • Subthalamic Nucleus
    • Substansia Nigra
    • Venterolateral nucleus of thalamus
  7. What is the function(s) of the basal ganglia?
    • Initiate voluntary movement
    • Maintain posture/ movement
    • Eye movement
    • Executive functions → working memory
  8. What is the Pathology sorrounding Parkinsons Disease?
    Staging?
    • Lewy body → intracytoplasmic inclusion body containing misfolded protein
    • gradually ascend thru stem
    • loss of dopaminergic neurones within substansia nigra [CF >50% loss]

    • Staging
    • 1 → Lewy bodies in lower brain stem
    • 3-4 → midbrain/ substansia nigra ~symptomatic
    • 6 → throughout basal ganglia, severely demented
  9. What are the CF of Parkinsons?
    • CF
    • Bradykinesia → slow to initiate voluntary movement, reduction in sped of following movements
    • Muscular rigidity
    • postural instability
    • asymetrical

    Non motor → dementia, poor sleep [restless legs] ^^ANS [constipation, ED, urinary urgency]
  10. What is the role of Imaging in Parkinsons?
    • CT/ MRI = normal
    • Abn in vascualr/ parkinson plus disorders

    Functional imaging → DAT SPEC → dopaminergic sys
  11. DDx for Parkinsons?
    • Benign tremor disorder
    • dementia w lewy bodies
    • Vascular Parkinsons [Stepwise progression, leg symptoms]
    • Parkinson plus disorders
    • Drug induced parkinsonism → dopamine antagonists
  12. Outline the drug Tx of Parkinsons?
    • 1. Replace DA/ DA agonists
    • Levodopa
    • 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

    • Pramipexole
    • 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
    • Benzotropine
    • MoA → anticholinergic, reduces tremor & rigidity
  13. Outline the CF & complications of Myasthenia Gravis?
    • Myasthenia Gravis
    • Acquired autoimmune disorder

    CF → muscle weakness & ^^fatigueability on exertion

    Complications → respiratory failure, dysphagia, long term steroid use
  14. What is te underlying pathology in myasthenia gravis?
    • Pathology
    • B cell mediated
    • Ab against ACh-R
    • reduced receptors = reduced Na influx
    • smaller end plate potential → no muscle movement
  15. 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]

    • Prednisalone
    • MoA → immunosuppression, decrease circulating Ab
    • A/E → cushings
  16. What is multiple sclerosis?
    • MS
    • Chronic disease of brain & SC
    • CF → changes in sensation, visual problems, weakness, poor coordination & speech, impaired mobility → disability

    • Peak onset ~30yo
    • Unknown cause
  17. 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

    CNS only
  18. What are the differenct types of MS?
    • Relapsing remitting
    • Commonest
    • 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
    • >m:f
    • Progressive spinal damage

    • Progressive relapsing
    • gets steadily worse with occaisional really bad patches
  19. What are the main symptoms of MS?
    Could be anything, most neuro problems

    • Relapsing remitting → clinically isolated syndromes
    • e.g.
    • optic neuritis [PAIN]
    • Brainstem syndrome → opthalmoplegia, dyarthria, ataxic
    • Spinal cord → transverse myelitis
  20. 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
  21. Outline the Mx of MS
    • Prednisalone for first timers
    • Refer to MS specialist nurses
    • PT/ OT
    • Later → Natalizumab → anti-TNF alpha
  22. What are the signs of an upper motor neurone lesion?
    • Pronator Drift [indicates spasticity]
    • ^^tone
    • Brisk Reflexes
    • Extensor Plantar Response

    UMN lesion → lower half of face = paralysed
  23. What are the features of a Lower motor neurone lesion?
    • Flaccid Paralysis
    • Muscle loss → weakness
    • Fasciculations
    • Hypotonic
    • Areflexic

    LMN → complete facial paralysis
  24. Draw and label the circle of willis?
  25. Outline the pathophysiological mechanism of damage in ischaemic stroke
    When BF stops, not instant tissue death

    • Tissue death via;
    • apoptosis
    • inflammation
    • oxidative stress
    • excitotoxicity → breakdown of Na/K pumps [K out, Na in], water in cell swells, stimulate Glu release, ^^Ca, Protease activeation → cell degredation

    • Geography
    • Infarct core = irreversible dam
    • Ischaemic Penumbra = potentially salvageable sorrounding tissue
    • Benign oligaemia
  26. Give 5 RF for Iscaemic Stroke?
    • ^age
    • HBP
    • Heart Disease [AF]
    • Smoking
    • Diabetes
    • Hypercholestrolaemia
    • Previous stroke/ TIA
    • FH
  27. Give 3 RF for haemorrhagic stroke
    • Hypertension
    • Cerebral Amyloid Angiopathy
    • Anti-Coagulants
    • Antiplatelet medication
    • Dementia
    • ^age
    • Male
    • Illegal drugs → cocaine
    • Hypocholestrolaemia
    • Vascular lesions → aneurisms
  28. 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
  29. 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
  30. 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]
  31. Outline the secondary prevention of stroke?
    • Aspirin + dipyramidol/ clopidogrel
    • Antihypertensives
    • Cholesterol lowering therapy
    • Warfarin if in AF
    • Carotid Endartectomy → remove carotid stenosis
  32. Define Seizure?
    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]
  33. Define Epilepsy?
    • A tendency to have recurrant unproveked seizures
    • Imbalance of excitation & inhibition in brain
  34. 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
  35. What are the Hx & O/E features of a raised pressure headache?
    • Hx
    • Worse lying flat
    • Worse in morning
    • Persistant nausea & Vom
    • Worse w exertion

    • O/E
    • Papilloedema
    • CN6 signs
    • CN3 signs
    • Pain on valsalva
  36. What are the Hx features of a low pressure headache?
    • Hx
    • Worse sitting/ standing up
    • Eased by lying flat
    • Due to CSF leakage → traction of meninges → pain
  37. What is the normal ICP?
    What causes ^^ICP?
    • ICP = 7-15mmHg
    • >25 = shit your pants time [Brain herniation]

    • Causes
    • Mass effect → space occupying lesion
    • ^ venous pressure → cerebral sinus thrombosis
    • Idiopathic → obese young women
  38. 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
  39. What is a thunderclap headache?
    • Abrupt onset, reaching maximum severity in <5min
    • Subarachnoid haemorrhage until proven otherwise

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