neuro to work on Flashcards
Name 2 types of secondary headache
Underlying cause
- Meningitis
- Subarachnoid haemorrhage
- Giant cell arteritis
- Idiopathic intracranial hypertension
- Medication overuse headache
Briefly describe the pathophysiology of migraines
- Cerebrovascular constriction –> aura, dilation –> headache
- Spreading of cortical depression
- Activation of CN V nerve terminals in meninges and cerebral vessels
what are the differential diagnoses for a migraine?
- Other headache type
- Hypertension
- TIA
- Meningitis
- Subarachnoid haemorrhage
How does triptan work?
Selectively stimulates 5-hydroxytryptamine (serotonin) receptors in the brain
Give 3 causes of trigeminal neuralgia
- Compression of trigeminal nerve by a loop of vein or artery
- Aneurysms
- Meningeal inflammation
- Tumours
What is the treatment for trigeminal neuralgia?
Carbamazepine - suppresses attacks
Less effective options = phenytoin, gabapentin and lamotrigine
Surgery = microvascular decompression, gamma knife surgery
What does a small response on an nerve conduction study suggest?
There is axon loss
What does a slow response on an nerve conduction study suggest?
There is myelin loss
Name 2 organisms that can cause meningitis in immunocompromised patients
- CMV
- Cryptococcus
- TB
- HIV
- herpes simplex
what are the signs of meningitis
Kernig’s sign = unable to straighten leg more than 135 degrees without pain when hip is flexed to 90 degrees
Brudzinski’s sign = severe neck stiffness cause hip and knees to flex when neck is flexed
What investigations might you do in someone you suspect has meningitis?
- Blood cultures (pre LP)
- Bloods - FBC, U+E, CRP, ESR, serum glucose, lactate
- Lumbar puncture (contraindicated with raised ICP)
- CT head - exclude lesions
- Throat swabs - bacterial and viral
What is the treatment of bacterial meningitis?
- ABCDE + support
- Empirical therapy = IV Benzylpenicillin
Assess GCS - First line = Ceftriaxone / Cefotaxime
- Add IV Benzylpenicillin for rash
- Penicillin allergy = Chloramphenicol
- Immunocompromised ( Risk of Listeria) = Amoxicillin / Ampicillin
oral dexamethasone to reduce cerebral oedema
What is the treatment of viral meningitis?
Watch and wait
acyclovir
What is the treatment for meningococcal septicaemia?
IV BENZYLPENICILLIN (in community)
IV CEFOTAXIME (in hospital)
Give 4 reasons why a lumbar puncture might be contraindicated
- Thrombocytopenia
- Delay in Abx admin
- Signs of raised ICP
- Unstable cardio or resp systems
- Coagulation disorder
- Infections at LP site
- Focal neurological signs
what are the non-viral causes of encephalitis
- Bacterial meningitis
- TB
- Malaria
- Lyme’s disease
What investigations might you do on someone with encephalitis?
- MRI - shows areas of inflammation, may be midline shifting
- EEG - periodic sharp and slow wave complexes
- lumbar puncture
- blood and CSF serology
what are the causes/risk factors of MS?
Unknown Environment and genetic components - exposure to EBV in childhood - low levels of sunlight and vitamin D - female - white - living far from equator
what are the symptoms of MS?
TEAM
- Tingling
- Eye = optic neuritis
- Ataxia
- Motor - spastic paraparesis, pyramidal weakness (UL = extensors, LL = flexors)
- swallowing disorders
- bladder incontinence
- dizziness, falls
- constipation
- fatigue
- cognitive impairment, depression
what are the signs of MS?
- Lhermitte sign - electric jolt felt down the spine when flexing neck
- Uhthoff phenomenon - symptoms worse with heat, e.g. hot bath/exercise
Name 3 differential diagnosis’s of MS
- SLE
- Sjogren’s
- AIDS
- Syphilis
Describe the pharmacological treatment for MS
acute relapse
- steroids = IV METHYLPREDNISOLONE
chronic/frequent relapse
- biological - SC BETA INTERFERON (contraindicated in pregnancy)
- DMARDs - IV alentuzumab, IV natalizumab
What symptomatic treatments can you give to those with MS?
Spasticity
- BACLOFEN (GABA analogue, reduces Ca2+ influx)
- TIZANIDINE (alpha-2 agonist)
- BOTOX INJECTION (reduces ACh in neuromuscular junction)
urinary incontinence = catheterisation
incontinence
- DOXAZOSIN (anti-cholinergic alpha blocker drugs
Define epilepsy
Recurrent, spontaneous, intermittent abnormal electrical activity in part of the brain, manifesting seizures
Define epileptic seizure
Paroxysmal event in which changes of behaviour, sensation or cognitive processes are caused by excess, hypersynchronous neuronal discharge in the brain
Give 5 causes of epilepsy
- Idiopathic (2/3)
- cortical scarring
- tumour
- stroke
- alzheimers dementia
- alcohol withdrawal
What is the treatment for focal epileptic seizures?
Lamotrigine = 1st line Carbamazepine = 2nd line
How do lamotrigine and Carbamazepine work?
Inhibit pre-synaptic Na+ channels so prevent axonal firing
What is the treatment for generalised epileptic seizures?
Sodium valproate = 1st line
Lamotrigine = 2nd line
How does sodium valproate work?
Inhibits voltage gated Na+ channels and increases GABA production
Give 4 potential side effects of anti-epileptic drugs (AED’s)
- Cognitive disturbances
- Heart disease
- Drug interactions
- Teratogenic
Give 4 differential diagnosis’s of epilepsy
- Syncope
- Non-epileptic seizure
- Migraine
- Hyperventilation
- TIA
Define non-epileptic seizure
Mental processes associated with psychological distress causes paroxysmal changes in behaviour, sensation and cognitive processes
1-20 minute duration
Closed eyes and mouth
Name 3 intra-cranial haemorrhages
- Sub-arachnoid haemorrhage
- Sub-dural haemorrhage
- Extra-dural haemorrhage
What can cause a subarachnoid haemorrhage?
- Traumatic injury
- Berry aneurysm rupture
(70-80%) - at common points round Circle of Willis - Arteriovenous malformations (15%) - abnormal tangle of blood vessels connecting arteries and veins
- Idiopathic (15-20%)
Give 3 risk factors for a subarachnoid haemorrhage
Hypertension
Known aneurysm
Previous aneurysmal SAH
Smoking
Alcohol
Family history
Bleeding disorders
- associated with berry aneurysms:
- Polycystic Kidney Disease
- Coarctation of aorta
- Ehlers-Danlos syndrome & Marfan syndrome
Briefly describe the pathophysiology of a subarachnoid haemorrhage
- tissue ischaemia - less blood, O2 and nutrients can reach the tissue due to bleeding loss -> cell death
- raised ICP - fast flowing arterial blood is pumped into the cranial space
- space occupying lesion - puts pressure on the brain
- brain irritates meninges - these inflame causing meningism symptoms. This can obstruct CSF outflow -> hydrocephalus
- vasospasm - bleeding irritates other vessels -> ischaemic injury
Describe the treatment for a subarachnoid haemorrhage
- NIMODIPINE for 3 weeks -> CCB which prevents vasospasm so reduces cerebral ischaemia
- surgery = endovascular coiling
- IV fluids - maintain cerebral perfusion
- ventricular drainage for hydrocephalus
Give 3 possible complications of a subarachnoid haemorrhage
- Rebleeding (common = death)
- Cerebral ischaemia
- Hydrocephalus
- Hyponatraemia
Give 3 risk factors of a subdural haematoma?
- Elderly - brain atrophy, dementia
- Frequent falls - epileptics, alcoholics
- Anticoagulants
- babies - traumatic injury (“shaking baby syndrome”)
Name 3 differential diagnosis’s of a subdural haematoma
- Stroke
- Dementia
- CNS masses (tumour vs abscess)
What is the treatment for a subdural haematoma?
SURGERY
- 1* = irrigation via burr-hole craniostomy
- 2* = craniotomy
IV MANNITOL - to reduce ICP
address cause of trauma
Give 3 things that modulate LMN action potential transmission to effectors
- Cerebellum
- Basal ganglia
- Sensory feedback
Give 3 disease that are associated with motor neurone damage
- Motor neurone disease
- Spinal atrophy
- Poliomyelitis
- Spinal cord compression
Give 3 pathologies that are associated with ventral spinal root damage
- Prolapsed intervertebral disc
- Tumours
- Cervical or lumbar spondylosis
Describe the pyramidal pattern of weakness in the upper limbs
Flexors are stronger than extensors
Describe the pyramidal pattern of weakness in the lower limbs
Extensors are stronger than flexors
Give 3 causes of UMN weakness
- MS
- Brain tumour
- Stroke
- MND
Give 4 sites of UMN damage
- Motor cortex lesions
- Internal capsule
- Brainstem
- Spinal cord
Define motor neurone disease (MND)
A group of neuro degenerative disorders that selectively affect the motor neurons
Most in the anterior horn, cells of the spinal cord and the motor cranial nuclei
There are no sensory problems
What is the clinical presentation of MND?
- results in mixed UMN and LMN presentation (LMN symptoms predominate)
- wrist drop/foot drop
- change in appearance of hands - wasting
- gait disorders/tendencies to trip
- excessive fatigue
What investigations might you do in someone you suspect to have MND?
Head/spine MRI Blood tests = muscle enzymes, autoantibodies Nerve conduction studies EMG Lumbar Puncture
What is the diagnostic criteria for MND?
LMN + UMN signs in 3 regions
El Escorial criteria
- Presences of LMN and UMN degeneration and progressive history
- Absence of other disease processes
What is the treatment for MND?
- MDT care
- anti-glutaminergic drugs - ORAL RILUZOLE - Na+ channel blocker, inhibits glutamate release
- Drooling - ORAL PROPANTHELINE or ORAL AMITRIPTYLINE
- Dysphagia: NG tube
- Spasms: ORAL BACLOFEN
- Non-invasive ventilation
- Analgesia e.g. NSAIDs - DICLOFENAC
Give 3 limb onset symptoms of MND
- Weakness
- Clumsiness
- Wasting of muscles
- Foot drop
- Tripping
Give 3 respiratory onset symptoms of MND
- Dyspnoea
- Orthopnoea
- Poor sleep
What are the 4 cardinal presenting symptoms of brain tumours?
- Raised ICP –> headache, decrease GCS, n+v, papilloedema
- Progressive neurological deficit –> deficit of all major functions (motor, sensory, auditory, visual) + personality change
- Epilepsy
- lethargy/tiredness - caused by pressure on brainstem
Name 2 differential diagnosis’s for a brain tumour
- Aneurysm
- Abscess
- Cyst
- Haemorrhage
- Idiopathic intracranial hypertension
Where might secondary brain tumours arise from?
- non-small cell lung cancer
- small cell lung cancer
- breast
- melanoma
- renal cell carcinoma
- GI
Give 3 causes of dementia
- Alzheimer’s disease (50%)
- Vascular dementia (25%)
- Lewy body dementia (15%)
- Fronto-temporal (Pick’s)
- Huntington’s
- Liver failure
- Vitamin deficiency - B12 or folate
Give 3 risk factors of dementia
- Family history
- Age
- Down’s syndrome
- Alcohol use, obesity, HTN, hyperlipidaemia, DM
- Depression
- ? Head injury
what is the clinical presentation of Alzheimer’s Disease
● Memory - episodic and semantic ● Language - difficulty understanding or finding words ● Attention and concentration issues ● Psychiatric changes, e.g. withdrawal, delusions ● Disorientation, e.g. time and surroundings
What does vascular dementia often present with?
● Characterised by stepwise progression - Periods of stable symptoms, followed by a sudden increase in severity
● Presentation varies massively but can include:
- Visual disturbances,
- UMN signs (e.g. muscle weakness, overactive reflexes, clonus),
- attention deficit,
- depression,
- incontinence,
- emotional disturbances
○ If infarct was subcortical, then expect to see dysarthria and parkinsonisms
Describe the pathophysiology of Lewy body dementia
● Characterised by eosinophilic intracytoplasmic neuronal inclusion bodies (Lewy bodies) in the brainstem and neocortex
● Also see substantia nigra depigmentation and amyloid deposits
what are the clinical features of Lewy body dementia
● Dementia is often presented initially
○ Memory loss, spatial awareness difficulties,
loss of cognitive function
● Parkinsonisms, e.g. tremor, rigidity, change in gait
● Visual hallucinations
● Sleep disorders, restless leg syndrome
Give 3 symptoms of Fronto-temporal dementia
● Onset tends to be insidious and progressive
● Present with 3 main symptoms:
○ Behavioural issues, e.g. loss of inhibition/empathy, compulsive behaviours, difficulty planning
○ Progressive aphasia, e.g. slow, difficult speech, grammatical errors
○ Semantic dementia, e.g. loss of vocabulary, problems understanding
What is functional memory dysfunction?
Acquired dysfunction of memory that significantly affects a person’s professional/private life in absence of an organic cause
What investigations can you do in primary care to determine whether someone might have dementia?
- Good history of symptoms
- 6 item cognitive impairment test (6CIT)
- Blood tests - FBC, liver biochemistry, TFTs, vitamin B12 and folate
- Mini mental state examination = screening
What questions are asked in 6CIT?
- What year is it?
- What month is it?
- Give an address with 5 parts
- Count backwards from 20
- Say the months of the year in reverse
- Repeat the address
Name the staging system that classifies the degree of pathology in AD
Braak staging
Stage 5/6 = high likelihood of AD
Stage 3/4 = intermediate likelihood
Stage 1/2 = low likelihood
Give 3 ways in which dementia can be prevented
- Smoking cessation
- Healthy diet
- Regular exercise
- Low alcohol
- Engaging in leisure activités
What support should be offered to patients with dementia?
Social suport
Cognitive support
Specialist memory service
What medications might you use in someone with dementia?
Acetylcholinesterase inhibitors - increase ACh = donepezil, rivastigmine Control BP (ACEi) to reduce further vascular damage
what are the causes/risk factors for myasthenia gravis?
If <50 = associated with other AI conditions (pernicious anaemia, SLE, RA) and more common in women
If >50 = associated with thymic atrophy, thymic tumour, SLE and RA and more common in men
what are the clinical features of myasthenia gravis?
- Muscle weakness
- Increasing muscular fatigue
- Ptosis
- Diplopia
- Myasthenic snarl
- Tendon reflexes normal but fatigable
● Weakness is more marked in proximal muscles ● Weakness might be seen in: ○ Small muscle of the hands ○ Deltoid and triceps muscles ○ Bulbar muscles ○ Muscles involved in chewing ● No muscle wasting, sensation is unimpaired ● Seizures can occur
What muscle groups are affected in myasthenia gravis?
muscle groups affected in order:
- extra-ocular
- bulbar - chewing and swallowing
- face
- neck
- trunk
What can weakness due to myasthenia gravis be worsened by?
Pregnancy Hypokalaemia Infection Emotion Exercise Drugs (opiates, BB, gentamicin, tetracycline)
What investigations might you do to see if someone has myasthenia gravis?
- mostly clinical examination
- positive tensilon test
- anti-AChR antibodies
- TFTs
- EMG
- CT of thymus
- crushed ice test - ice is applies to ptosis for 3 mins, if it improves it is likely to be myasthenia gravis
Give 3 possible differential diagnosis’s for myasthenia gravis
- MS
- Hyperthyroidism
- Acute Guillain-Barre syndrome
- Lamert-Eaton myasthenia syndrome
What is treatment for myasthenia gravis?
Anti-cholinesterase = pyridostigmine
Immunosuppression = prednisolone (with alendronate - bisphosphonate)
Steroids can be combined with azathioprine or methotrexate
Thymectomy
Give a complication of myasthenia gravis
Myasthenic crisis
Weakness of respiratory muscle during relapse
Treatment = plasmapheresis and IV immunoglobulin
Describe the pathophysiology of Parkinson’s disease
destruction of dopaminergic neurones (in substantia nigra) –> reduced dopamine supply –> thalamus inhibits –> decrease in movement + symptoms
Lewy body formation in basal ganglia
What is the 3 cardinal symptoms for Parkinsonism?
resting tremor
rigidity
bradykinesia
postural instability
what are the clinical features of Parkinson’s disease
● Often an insidious onset
- impaired dexterity,
- fixed facial expressions,
- foot drag
● Common associated symptoms:
- dementia,
- depression,
- urinary frequency,
- constipation,
- sleep disturbances
You ask a patient who you suspect to have Parkinson’s disease to walk up and down the corridor to assess their gait, what features would be suggestive of PD?
Stooped posture
Asymmetrical arm swing
Small steps
Shuffling
What investigations might you do in someone you suspect to have PD?
DaTscan
Functional neuroimaging - PET
Can confirm by reaction to levodopa
Describe the pharmacological treatment for Parkinson’s disease
young onset + fit
- Dopamine agonist (ropinirole)
- MAO-B inhibitor (rasagiline)
- L-DOPA (co-careldopa)
frail + co-morbidities
- L-DOPA (co-careldopa)
- MAO-B inhibitor (rasagiline)
How do dopamine agonists work in the treatment of PD and give an example of one?
Reduced risk of dyskinesia
First line in patient <60
Ropinirole, pramipexole
How do MAO-B inhibitors work in the treatment of PD and give an example of one?
Inhibit MAO-B enzymes which breakdown dopamine -> increases amount of dopamine available
Rasagiline, selegiline
How do COMT inhibitors work in the treatment of PD and give an example of one?
Inhibit COMT enzymes which breakdown dopamine
Entacapone, tolcapone
What surgical treatment methods are there for Parkinson’s disease?
Deep brain stimulation of the sub-thalamic nucleus
Surgical ablation of overactive basal ganglia circuits
Define Huntington’s disease
Neurodegenerative disorder characterised by the lack of inhibitory neurotransmitter GABA - too much dopamine
autosomal dominant - 100% penetrance
Briefly describe the pathophysiology of Huntington’s disease
Less GABA causes less regulation of dopamine to striatum causing increased dopamine levels resulting in excessive thalamic stimulation and subsequently increased movement (chorea)
Name the cardinal features of Huntington’s disease
● Main sign is hyperkinesia
● Characterised by:
○ Chorea, dystonia, and incoordination
● Psychiatric issues
● Depression
● Cognitive impairment, behavioural difficulties
● Irritability, agitation, anxiety
Name 3 signs of Huntington’s disease
- Abnormal eye movements
- Dysarthria
- Dysphagia
- Rigidity
- Ataxia
What investigations might you do in someone you suspect to have Huntington’s disease?
● MRI/CT - loss of striatal volume
● Genetic testing
Describe the treatment of Huntington’s disease
poor prognosis - no treatment
● Benzodiazepines/valproic acid - chorea
● SSRIs = depression
● Haloperidol = psychosis
what are the causes/risk factors of carpal tunnel syndrome
- Pregnancy
- Obesity
- RA
- DM
- Hypothyroidism
- Acromegaly
What investigations might you do in someone who you suspect to have carpal tunnel syndrome?
clinical diagnoses based on symptom presentation
EMG = slowing conduction velocity in median sensory nerves
Phalen’s test = 1 min maximal wrist flexion –> symptoms
Tinel’s test = tapping over nerve at wrist –> tingling
USS or MRI if other damage is suspected
What can cause Guillain-Barre syndrome?
Bacteria
- Camplylobacter jejuni
- Mycoplasma
Viruses
- CMV
- EBV
- HIV
- Herpes zoster
Describe the pathophysiology of Guillain-Barre syndrome
Same antigens on infectious organisms as Schwann cells (PNS) –> autoantibody mediated nerve cell damage -> via molecular mimicry
Schwann cell damage consists of demyelination, which results in a reduction in peripheral nerve conduction –> causes acute polyneuropathy
spreads from proximal to distal
what are the clinical features of Guillain-Barre syndrome
Breathing problems Back pain Sensory disturbance Sweating Urinary retention
- Ascending symmetrical muscle weakness 1-3 weeks post-infection (proximal muscles most affected - trunk, respiratory, CN) TOES TO NOSE WEAKNESS
- Pain in legs, back is rare
- sensory loss in lower extremities
- Reflexes lost early on (LMN sign)
- Autonomic features =
- reduced sweating
- reduced heat tolerance
- paralytic ileus - intestinal obstruction w/o blockage
- urinary hesitancy
What investigations might you do in someone you suspect has Guillain-Barre syndrome?
- Nerve Conduction Studies (NCS) = diagnostic -> shows slowing of conduction
- Lumbar Puncture at L4 = raised protein and normal WCC (cyto-protein dissociation)
- bloods - FBC, U&E, LFT, TFT
- Spirometry = respiratory involvement
- ECG
Describe the treatment for Guillain-Barre syndrome
- If FVC <1.5L/80% = ventilate and ITU monitoring
- IV immunoglobulin (IvIg) for 5 days = decrease duration and severity of paralysis
- Plasma exchange
- Low molecular weight heparin (LMWH) - SC ENOXAPARIN
- Analgesia
What are the causes of an ischaemic stroke?
- small vessel occlusion by thrombus
- atherothromboembolism (e.g. from carotid artery)
- cardioembolism (post MI, valve disease, IE)
- hyper viscosity
- hypoperfusion
- vasculitis
- fat emboli from a long bone fracture
- venous sinus thrombosis
What are the causes of an haemorrhagic stroke
Bleeding from the brain vasculature
- Hypertension - stiff and brittle vessels, prone to rupture
- Secondary to ischaemic stroke - bleeding after reperfusion
- Head trauma
- Arteriovenous malformations
- Vasculitis
- Vascular tumours
- Carotid artery dissection
what are the risk factors for ischaemic stroke?
- Age
- Male
- Hypertension
- Smoking
- Diabetes
- Recent/past TIA
- Heart disease - IHD, AF, valve disease
- Combined oral contraceptive
Give 3 signs of an ACA stroke
- Leg weakness - contralateral
- Sensory disturbance in legs
- Gait apraxia
- Incontinence
- Drowsiness
- Akinetic mutism - decrease in spontaneous speech (in a stupor)
- truncal ataxia - can’t sit or stand unsupported
Give 3 signs of a MCA stroke
- Contralateral arm and leg weakness and sensory loss
- Hemianopia
- Aphasia
- Dysphasia
- Facial droop
Give 3 signs of a PCA stroke
visual issues
- Contralateral homonymous hemianopia
- Cortical blindness
- Visual agonisa
- Prosopagnoisa
- Dyslexia
- Unilateral headache