Neurology - Revision Boxes (Ultimate Revision)

Headache: classic presentation

• Tension headache
• Stress, tight band around head
• Subarachoid haemorrhage
• Sudden onset, 'kicked in back of head'; associated with vomiting
• Migraine
• Unilateral 'throbbing', aura, vomiting, photophobia
• Giant-cell arteritis
• Tender pulseless temporal arteries; jaw claudication
• Mass lesion
• Pain worse on coughing/sneezing
• Confusion
• Seizures
• Localising focal neurology
• Signs of intracranial pressure, e.g. papilloedema
• Benign intracranial hypertension
• Usually obese young woman; increased CSF (cerebrospinal fluid) pressure but no mass lesion
• Meningitis
• Fever, neck stiffness, photophobia, rash
• Subdural haemorrhage
• Head injury, chronic course, fluctuating consciousness

Distinguishing UMN and LMN lesions

UMN

• Involves corticospinal tract
• Weakness in upper limb extensors, lower limb flexors (pyramidal distribution)
• Increased tone
• Hyperreflexia, clonus
• Pronator drift
• Loss of abdominal reflexes
• Extensor plantar response

LMN

• Lesion at level of anterior horn cell or distal to it
• Fasciculation and wasting
• Loss of reflexes
• Hypotonia

Neurological disease

• Motor neuron disease
• Mixed UMN and LMN signs
• NO sensory loss
• Multiple sclerosis
• Optic neuritis is a common finding in EMQs
• Non-specific signs, e.g. leg weakness, ataxia
• May mention heat worsens symptoms (increases CSF protein, oligoclonal IgG bands on electrophoresis)
• Delayed visual/somatosensory evoked potential
• Parkinson's disease
• TRAP - Tremor, Rigidity, Akinesia, Postural hypotension
• Lead-pipe rigidity, cog-wheel rigidity (if tremor)
• Pill rolling tremor
• Festinant gait with poor arm swing
• Myasthenia gravis
• Young woman presents with weakness of muscles
• On examination: bilateral ptosis, proximal muscle weakness
• Electromyography (EMG): decreased muscle action potential after continuous simulation
• Serum acetylcholine receptor antibodies
• Huntington's disease
• Onset of chorea in middle age, dementia later
• Positive family history (autosomal dominant)
• Normal pressure hydrocephalus
• Triad of gait apraxia, confusion and incontinence

Features of eponymous syndromes

• Cauda equina syndrome
• Saddle anaesthesia
• Bowel/bladder disturbance
• Bilateral pain legs
• Brown-Sequard syndrome
• Ipsilateral pyramidal signs
• Contralateral loss of pain and temperature
• Guillain-Barre syndrome
• Ascending symmetrical flaccid muscle weakness preceding recently respiratory/gastrointestinal infection
• Shy-Drager syndrome
• Combination of parkinsonism plus primary autonomic failure, e.g. postural hypotension
• Wernicke's encephalopathy
• Triad of
• Nystagmus
• Ophthalmoplegia
• Ataxia
• Caused by thiamine (vitamin B1) deficiency
• Reversible but if untreated develops to Korsakoff's syndrom
• Korsakoff's syndrome
• Signs of gross defect in memory of recent events
• Confabulation may be present
• Condition is irreversible

Gait and different conditions

• Parkinson's disease
• Shuffling, festinant gait
• Sensory ataxia, e.g. peripheral neuropathy
• High-stepping/stamping gait
• Spastic paraplegia
• Scissor gait
• Cerebellar lesion
• Wide-based gait
• Cerebrovascular disease (marche a la petit pas)
• Shuffling small steps

Symptoms/signs of nerve root innervation

Reflex

• C5-C6 supinator
• C5-C6 biceps
• C7 triceps
• L3-L4 knee
• S1 ankle

OR

• S1,S2 ankle
• L3,L4 knee
• C5,C6 biceps
• C7,C8 triceps
• 1,2,3,4,5,6,7,8 :)

Movements

• C5 shoulder abduction
• C5,C6 elbow flexion
• C7 elbow extension
• T1 finger abduction
• L1, L2 hip flexion
• L3, L4 knee extension
• L4, L5 dorsiflex ankle
• L5-S1 hip extension
• S1 knee flexion, plantar flexion and eversion ankle

The pupil in neurological problems

• Bilateral dilated pupils
• Plus no vestibulo-ocular reflexes = Brain stem death
• Plus euphoric = Amphetamines, cocaine
• Plus anticholinergic signs, e.g. increased pulse, decreased BP, urinary retention = Tricyclic antidepressant overdose
• Bilateral, pinpoint pupils
• With respiratory depression = Opiate overdose
• Dilated pupil:
• Ptosis, eye deviated laterally and downwards = Nerve III lesion
• Irregular, reacts poorly to light and accommodation = Myotonic pupil
• Usually young woman may have reduced tendon reflexes = Holmes Adie pupil
• Constricted pupil:
• Irregular pupils, reacts to accommodation but not light (known as Argyll Robertson pupil) = Neurosyphilis
• Unilateral ptosis, loss of sweating on same side of face (anhidrosis) = Horner's syndrome

Limited movements and visual field defects

Limited movements

• Defective elevation, depression, adduction = Nerve III lesion
• Defective depression in adduction, vertical diplopia worse in downgaze = Nerve IV lesion
• Failure to abduct, horizontal diplopia worse on abduction = Nerve VI lesion

Visual field defects

• Bitemporal hemianopia
• Chiasma lesion (e.g. pituitary tumour)
• Superior quadrantanopia
• Temporal lobe lesion
• Inferior quadrantanopia
• Parietal lobe lesion
• Homonymous hemianopia
• Optic radiation, visual cortex injury
• Central scotoma
• Macula (e.g. degeneration/oedema)

Nerve injury

• Median nerve C6-T1
• Wasting thenar eminence
• Loss of sensation on lateral palmar surface of three and a half digits
• Test for weakness in abductor pollicis brevis
• Frequently affected in carpal tunnel syndrome
• LOAF
• Lateral 2 lumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis
• Ulnar nerve C8-T1
• Wasting of hypothenar eminence
• Sensory loss over medial one and a half fingers
• Test for weakness of abductor digiti minimi
• 'Claw hand' deformity
• MAFIA
• Medial 2 lumbricals
• Adductor pollicis
• First dorsal interossei
• Interossei
• Abductor digiti minimi
• Radial nerve C5-T1
• Weakness of wrist extension, leading to 'wrist drop'
• Anaesthesia over first dorsal interosseous muscle
• BESTS
• Brachioradialis
• Extensors of the wrist
• Supinator
• Triceps
• Sensation over anatomical snuffbox
• Common peroneal nerve L4-S1
• Weakness in dorsiflexion and eversion of foot
• Sensory loss over dorsum of foot
• Tibial nerve L4-S3
• Inability to invert foot or stand on tip-toe
• Sensory loss over sole of foot
• Klumpke's palsy C8-T1
• paralysis of intrinsic muscles of the hand
• Loss of sensation in ulnar distribution
• Horner's syndrome sometimes present
• Erb's palsy C5-C6
• Loss of shoulder abduction and elbow flexion
• Arm held internally rotated
• 'Waiter's tip' sign if arm adducted behind back

Stroke: Signs and symptoms

• Anterior circulation stroke
• Unilateral weakness/sensory deficit
• Homonymous hemianopia
• High cerebral dysfunction, e.g. dysphasia, neglect
• Posterior circulation stroke
• Cranial nerve palsies/cerebellar signs, e.g. vertigo, dysarthria, ataxia, choking
• Isolated homonymous hemianopia
• Site: dominant frontal lobe (Broca's area). Broca's (expressive) dysphasia
• Patient can understand you but replies in non-fluent speech
• Site: dominant temporoparietal lobe. Wernicke's (receptive) dysphasia. Site: PICA thrombosis. Lateral medullary syndrome
• Patient has impaired comprehension
• Speech fluent but jargon
• Patient has symptoms of
• Vertigo
• Vomiting
• Dysphagia
• Ipsilateral signs can include
• Ataxia
• Horner's syndrome
• Nerve V, VI palsy
• Contralateral signs include loss of pain, temperature and sensation in face