3a Neurology Flashcards
(184 cards)
1
Q
Define stroke
A
Rapid onset of focal / global neurological dysfunction where Sx last ≥ 24hrs / lead to death
2
Q
Causes of a stroke…
A
Cardiac:
AFib
Infective endocarditis
Paradoxical emboli - (Embolus from DVT enters left circulation through heart defect)
Vascular:
Vasculitis
Aortic dissection
Haematological:
Atherosclerosis
Polycythaemia
Sickle cell
3
Q
Risk factors for stroke…
A
Increased age
FHx
HTN
Smoking
Diabetes
Hypercholesteronaemia
Similar to Atherosclerosis R.F
Carotid artery stenosis
4
Q
Arteries inc. in anterior circulation of the brain
A
Anterior cerebral artery (ACA)
Middle cerebral artery (MCA)
5
Q
Arteries inc. in posterior circulation of brain
A
Posterior cerebral artery (PCA)
Basilar arteries
Vertebral arteries
6
Q
What part of the body is affected if ACA is affected
A
Lower extremities > upper extremities
7
Q
What part of the body is affected if MCA is affected
A
Upper extremities > lower extremities
8
Q
How can you tell what part of the body is affected when there is a disruption to the ACA/MCA?
A
Think motor Homunculus.
Each area of brain controls different region of body.
More medial… controls lower extremities
&
More lateral… controls upper extremities
ACA —> Medial part of brain —> controls lower extremities!
MCA —> Lateral part of brain —> controls upper extremities!
9
Q
Describe stroke signs when ACA is affected
A
Contralateral hemiparesis +/ hemisensory loss in
Lower extremities > upper
10
Q
Describe stroke signs when MCA is affected
A
Contralateral Hemiparesis +/ hemisensory loss in
Upper extremities > lower
Contralateral homonymous hemianopia
Aphasia (if dominant hemisphere affected)
Hemispatial neglect (if non-dominant hemisphere affected)
11
Q
Why is contralateral homonymous hemianopia a stroke sign in MCA infarct?
A
MCA supplies region where optic tracts lie.
Left hemisphere processes the right visual field
Right hemisphere processes the left visual field
12
Q
Why is Aphasia a stroke sign in MCA infarct?
A
Broca’s area and Wernicke’s area are both supplied by the MCA.
These areas (particularly Broca’s) are found in the dominant hemisphere
I.E. Right-handed = left hemisphere dominant
So
Px could present with aphasia if in a right handed patient, they have a left hemispheric infarct…
Left-handed is a bit more complex - allow it!
13
Q
What is hemispatial neglect
A
When person can see but can not process a side of their vision.
So they neglect that side…
Can see when Px is asked to draw a clock… they write all the numbers 12-11 on one side and leave the other half (which they cannot process) as empty but they can see that side they just cannot acknowledge it
14
Q
Why is hemispatial neglect a stroke sign for MCA infarcts?
A
The area is supplied by MCA but found in the non-dominant hemisphere.
So, if in a…
Right-handed Px —> Right hemisphere is affected —> contralateral hemispatial neglect (left side is ignored)
15
Q
Give an associated effect in a stroke when there’s a PCA infarct
A
Contralateral homonymous hemianopia with macular sparing
Contralateral loss of pain +/ temperature
(due to thalamic infarction; thalamus is supplied by PCA and spinothalamic tract runs through thalamus hence Sx of pain + temp loss…)
16
Q
Why is Contralateral homonymous hemianopia with macular sparing a stroke sign of PCA infarct
A
Macular sparing = they still have central vision
Area of brain responsible for macular = occipital pole; found right at the back of brain.
It has 2 blood supplies; PCA + MCA, therefore, if PCA supply is disrupted, the macular still has blood supply from MCA
17
Q
Give 3 associated signs of a stroke when vertebrobasilar arteries are affected
A
Cerebellar signs; D.A.N.I.S.H
Quadriplegia or Hemiplegia
Dysdiadokinesia / dysmetria.
Ataxia.
Nystagmus.
Intention tremor.
Slurred speech
Hypotonia.
18
Q
If basilar artery supply to the pons is interrupted, what condition could you get
A
Locked-in syndrome
19
Q
Describe what locked-in syndrome is…
A
Px is completely conscious (cortex is intact)
But…
Complete paralysis with only eye movement (motor tracts in pons disrupted)
20
Q
What artery supplies the pons
A
Mainly pontine arteries which are branches of the basilar arteries
21
Q
What is a ROSIER score and what’s it used for
A
Recognition Of Stroke In the Emergency Room
Score > 0 = suspected stroke
Do CT head
Features ( /score)
Loss of consciousness/syncope (-1pt)
Seizure activity (-1pt)
new, acute onset…
Asymmetrical Facial weakness (+1pt)
Asymmetrical Arm weakness (+1pt)
Asymmetrical Leg weakness (+1pt)
Speech disturbance (+1pt)
Visual field defect (+1pt)
22
Q
What tool is used to identify stroke in the community
A
Face
Arms
Speech
Time (act fast, call 999)
23
Q
What tool is used to identify stroke in the emergency department
A
ROSIER
24
Q
What are the types of stroke
A
Ischaemic (most common type)
Reduced blood supply —> reduced O2 + glucose —> abnormal cellular ion homeostasis
Haemorrhagic
Rupture blood vessel —> blood accumulation in brain tissue + subarachnoid space —> increased intracranial pressure + compression on tissue etc
25
Stroke classification system
Oxford’s stroke classification
AKA
Bamford’s classification.
*Classifies strokes according to area affected*
26
What does oxford’s stroke classification state?
_Categorises strokes based on their initial Sx_
Remember as… **Triple H**
**H**emiparesis +/ Hemisensory loss *of face, arms, legs*
**H**homonymous hemianopia
**H**igher cognitive dysfunction (*dysphasia*)
_**Total Anterior Circulation Infarcts** (TACI);_
All 3 of above criteria is present
_**Partial Anterior Circulation Infarcts** (PACI);_
2 of above criteria are present
_**Lacunar Infarcts** (LACI)_;
One-of the following criteria
**Pure sensory stroke (thalamus).**
**Unilateral pure motor stroke**
**Sensori-motor stroke.**
**Ataxic hemiparesis.** *- Ataxia*
_**Posterior Circulation Infarcts** (POCI)_;
*Involves vertebrobasilar arteries and presents with one of the following…*
**cerebellar or brainstem syndromes** *- D.A.N.I.S.H*
**loss of consciousness**
**Isolated homonymous hemianopia**
27
State 4 Sx you more likely to see in haemorrhagic > Ischaemic
Reduced levels of consciousness
Headaches
N & V
Seizures
28
Vessels affected in lacunar stroke
Perforating arteries
*surrounding thalamus, basal ganglia, internal capsule.*
29
Lesion to what part of brain causes locked-in syndrome
Basilar artery infarct
30
Lesion to what part of the brain causes amaurosis fugax
Retinal ophthalmic artery
*Transient darkening… and it is used by doctors to describe a temporary loss of vision through one eye, which returns to normal afterwards.*
31
Lesion to what part of the brain can lead to Wellenberg’s syndrome
Posterior inferiorly cerebellar artery
32
Define wellenberg’s syndrome
*_Essentially a stroke in the brain stem…_*
*Posterior inferiorly cerebellar artery affected*
Spinal trigeminal Nucleus; **_Ipsilateral: facial pain + temperature loss_**
Spinothalamic Tract; **_Contralateral: limb/ torso pain + temperature loss_**
Cerebellum; **_Ataxia, nystagmus_**
33
Define Weber’s syndrome
*_Essentially stroke of the midbrain_*
**_Ipsilateral_ CNIII Palsy**
*Out and Down,
Ptosis (**droopy eyelid**)
Pupil mydriasis (**pupil dilation**)*
+
**_Contralateral_ Hemiparesis**
34
Lesion to which part of the brain causes lateral pontine syndrome
**Anterior** inferior cerebellar artery = lateral pontine syndrome
_____________________________________________________________________
*Remember; _Posterior_ inferior cerebellar artery infarct = _Wellenberg’s_ syndrome*
35
Define lateral pontine syndrome
_Similar presentation to Wellenberg’s syndrome -
***P**osterior **I**nferior **C**erbellar **A**rtery stroke*_
Plus…
***_Ipsilateral_ CNIII Palsy***
*Out and Down,
Ptosis (droopy eyelid)
Pupil mydriasis (pupil dilation)*
+
***_Contralateral_ Hemiparesis***
36
Lesion in what part of the brain can cause Amaurosis fugax
**Retinal ophthalmic artery**
_______________________________________________________________________
*”transient darkening” - temporary vision loss through one eye!*
37
Describe symptoms of cerebellar syndrome
**_Remember D.A.N.I.S.H_**
D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear 'Drunk'
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremor
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
38
What investigations are done for suspected stroke?
1st line: **Non-contrast CT head** - *to differentiate haemorrhagic from Ischaemic stroke*
**Urgently > 1hr**
_______________________________________________________________________
**_Bedside:_**
Blood **glucose** - *rule out hypoglycaemia; can cause neurological deficit*
**ECG** - *not needed immediately; helps with management if _aFib detected_*
**_Bloods:_**
U&Es - *rule out hyponatraemia*
**_Imaging:_**
_1st line: **Non-contrast CT head**_ - *to differentiate haemorrhagic from Ischaemic stroke* - **Urgently > 1hr**
**CT Angiogram** - *can be used for thrombectomy*
______________________________
MRI
CXR - *if swallowing compromised*
Echocardiogram
Carotid Doppler - *carotid artery stenosis*
39
What is 1st line investigation for stroke
Non-contract CT head
*Imaging be done **within 1hr** of hospital admission*
40
What presents in non-contrast CT head for **ischaemic** stroke
**hypo**density in affected region with **hyper**dense vessels
41
What presents on non-contrast CT head in **haemorrhagic** stroke
Typically **hyper**density (*blood*) surrounded by **hypodensity** (oedema)
42
Px comes in with a stroke… how are you managing it?
**_Absolutely rule out intracranial haemorrhage before starting_**
_If Px presents **≤ 4.5 hrs**_ of Sx onset:
٠ Start **_thrombolysis (with IV tPA)_** - *Alteplase*
٠ Give **_Aspirin 300mg_ daily** for **2 weeks** starting from **_following day_**
٠ Aim for **BP < 180/110**
٠ Can OFFER thrombectomy via CT angiogram - *if Sx onset < 6hrs*
٠ Can CONSIDER Thrombectomy via CT angiogram - *if Sx onset < 24hrs*
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_If Px presents **> 4.5hrs**_ of Sx onset:
٠ Start **_Aspirin 300mg immediately_**, and daily for **next 2 weeks**
٠ CONSIDER **_Thrombectomy_** via CT angiogram - *if Sx onset < 24hrs*
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All Px start anticoagulation (**Aspirin 300mg**) for 2 weeks *as directed above* & _**Clopidergrol 75mg** lifelong_ after the 2 weeks of Aspirin!!
**Px with aFib** - give anticoagulation such as **Rivaroxaban**
43
What is the long-term management of an ischaemic stroke
Clopidogrel 75mg lifelong
44
MoA for thrombolysis + its risk/ contraindication
**_MoA_**:
**plasminogen —> plasmin**
*Promotes the breakdown of fibrin clots*
**_Risk_**
Haemorrhage
**_Contraindication_**
Haemorrhagic stroke,
Active internal bleeding,
Recent surgeries,
Active cancer
45
Give 2 examples of a thrombolytic agent
Alteplase
Streptokinase
46
Stroke Px is allergic to 1st line long-term management… what is given alternatively?
**_1st line longterm:_**
Clopidogrel 75mg
**_Alternative:_**
Aspirin + Dipyramidol (*given together, not individually*)
47
Tx for haemorrhagic stroke
Immediate neurosurgical referral…
**Surgical decompression** - *Endovascular clipping / coiling*
Aggressive **BP control** - *130-140mmHg systolic*
**Stop anticoagulants** + warfarin reversal if required (*Vit K + beriplex*)
**IV _Hyper_tonic saline** - *if evidence of raised ICP*
48
2º prevention for stroke
**Clopidogrel 75mg** once daily (*or Aspirin + Dipyramidole*)
**Atorvastatin 80mg** - *delay giving for at least 48hrs*
**Address modifiable risk factors** - *smoking, obesity, diabetes, HTN*
49
What key risk factors need further investigation for stroke
_Carotid artery stenosis_
*Carotid imaging (carotid ultrasound, or CT/MRI angiogram)*
_AFib_
*ECG*
50
Px has a stroke most likely due to their AFib… how are you going to manage it?
Start Dx & Tx for stroke…
Plus…
Anticoagulation for AFib - **Rivaroxaban**
51
What surgical interventions are there for carotids artery stenosis *{stroke risk factor}*
Carotid endarterectomy
Angioplasty and stenting
52
What advice do you give to a stroke Px regarding driving
**No driving for 1 month**
HGV drivers cannot drive for 1year
53
Summarise TIA info into 5 points…
**Transient episode of neurological dysfunction 2º to the focal brain/spinal cord/ retinal ischaemia** with **no** sign of infarction
٠ 1st line: **_Aspirin 300mg_**
٠ _Prophylaxis: Lifelong **Clopidogrel 75mg_ // _Atorvastatin 80mg_**
٠ Review Px in TIA clinic within **24hrs if… Sx < 1 week**
OR… **Sx > 1 week**, review within **7 days**
٠ **No** need for CT imaging, routinely —> but need to check if its a stroke due to infarction
٠ ABCD 2 is **NO** longer used to assess the risk of a TIA patient having a stroke in the next 48 hours
54
Tool used to assess risk of Px with aFib developing a stroke
CHA2DS2 Vasc
**C**ongestive H.F____________________________[+1]
**H**ypertension _____________________________[+1]
**A**ge ≥ 75yrs _______________________________[+2]
**D**iabetes __________________________________[+1]
*Previous* **S**troke/TIA ____________________[+2]
**V**ascular disease __________________________[+1]
**A**ge ≥ 65 __________________________________[+1]
**S**ex **c**ategory *(Female)*______________[+]
55
What is the immediate management of TIA
Aspirin 300mg
If Px already taking low dose aspirin regular;y, advise them to continue - do not off them Aspirin 300mg.
56
What is the management of a TIA in a suspected TIA after aspirin has been given..?
For people who have had a suspected TIA less than 7 days ago:
- Specialist assessment within 24 hours
For people who have had a suspected TIA more than 7 days ago:
- Specialist assessment as soon as possible within 7 days.
57
Define Multiple Sclerosis
Chronic, autoimmune **demylination** of the CNS.
*Immune system attacks the myelin sheath of the myelinated neurones*
58
What type of hypersensitivity reaction occurs in multiple sclerosis
**Type 4 Hypersensitivity**
59
Epidaemiology of multiple sclerosis
F > M
20-40yr olds
60
Risk factors of multiple sclerosis
Female
20-40yrs old
**Other autoimmune conditions**
**Vitamin D deficiency**
EBV
61
Aetiology of multiple sclerosis
Environmental
Idiopathic
Genetic predisposition
62
Pathophysiology of multiple sclerosis
Genetic + environmental triggers —> T cell activation —> B cell and macrophages activation —> **Inflammation** of myelin sheath and damage causes **demyelination** and **Loss of axons**
*In early disease, re-myelination can happen, but much thinner myelin… resolving Sx.*
*In the later stages, re-myelination is incomplete. Sx become more permanent - inefficient nerve conduction*
63
Where would demyelinating plaques/lesions be seen in multiple sclerosis
Periventricular
*Perpendicular to ventricles*
64
Give three main features of a multiple sclerosis plaque
Inflammation
Demyelination
Loss of axons
65
What cells are affected in multiple sclerosis
Oligodendrocytes
*Myelin is provided by cells that wrap themselves around the axons:*
***٠Oligodendrocytes in the central nervous system***
*٠ Schwann cells in the peripheral nervous system*
66
What types of patterns in multiple sclerosis are there?
_Relapsing-remitting_
Episodic flare-ups *(lasting days/weeks/months)* with periods of no Sx in-between (*periods of remission*)
_2º progressive_
Starts off as relapsing-remitting… but…
Sx get progressively worse with no periods of remission
_1º progressive_
Sx get progressively worse **from disease onset** with no periods of remission
67
Signs and Sx of multiple sclerosis
_Remember as **D.E.M.Y.E.L.I.N.A.T.I.O.N_**
**D**isturbance to the…
**E**yes (***Optic neuritis // Interocular ophthalmoplegia // Conjugate lateral gaze disorder***)
**M**otor weakness; ***Pyramidal pattern*** - *Upper; weaker extensors > flexors // Lower; weaker flexors > extensors*
N**y**stagmus
**E**levated temperature makes Sx worse (***Uhtoff’s phenomenon***)
**L**hermittes phenomenon - *electric pain on neck flexion*
**I**ntention tremor
**N**europathic pain
**A**taxia
**T**alking slurred (***Dysarthria***)
**I**mpotence (*sexual dysfunction*)
**O**veractive bladder
**N**umbness (***Sensory disturbance***)
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**Optic neuritis** - *pale optic disk; can’t see red —> 1st presenting Sx
**Interocular opthalmoplegia** - *demyelination of medial longitudinal fasciculus (affected eye CANNOT move **medially**.*
**Conjugate lateral gaze disorder** - *Affected eye CANNOT move **laterally**.*
68
What is the **first episode of demyelination with neurological signs** also known as?
**Clinically isolated** multiple sclerosis
*NOT diagnostic as Px with clinically isolated syndrome may never have another episode OR may go on to develop MS*
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***Radiologically isolated*** *syndrome;
The presence of MRI activity in the absence of clinical activity*
69
What the management of multiple sclerosis
_Managing **Relapse**_
PO **Methylprednisolone** - *500mg OD for 5 days*
IV **Methylprednisolone** - *1g OD … if oral fails/not tolerated*
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_Maintaining **Remission**: Disease-Modifying Therapies_
***Monoclonal antibodies*** - **Natlizumab** // **Ofatumimab**
***Immunomodulators;*** - **Siponimod** // **Beta Interferon** // **Glatiramer Acetate**
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_Controlling **Sx**_
***Fatigue*** - Amantadine
***Spasticity*** - Baclofen // Gabapentin
***Oscillopia*** - Gabapentin
***Neuropathic pain*** - Amitryptiline // Gabapentin
***Urge Incontinence*** - Anticholinergics; *Oxybutynin*
70
How do you manage a relapse in multiple sclerosis
PO **Methylprednisolone** 500mg OD
IV if oral fails/not tolerated
71
How do you maintain remission in multiple sclerosis
_Monoclonal antibodies_
Natalizumab // Ofatumimab
_Immunomodulators_
Siponimod // beta-interferon // Glatiramer acetate
72
Tx of fatigue in multiple sclerosis
Amantadine
73
Tx of neuropathic pain in multiple sclerosis
Amitryptaline
Gabapentin
74
Tx of spasticity in multiple sclerosis
Beclofen
Gabapentin
75
Tx of oscillopia in multiple sclerosis
Gabapentin
76
What type of investigations can be done in multiple sclerosis
**MRI brain and spine**
٠ Periventricular demyelinating plaques
٠ High signal T2 lesions
**Lumbar puncture**
٠ Oligoclonal bands (**+ve** in CSF **-ve** in serum —> i.e. **Unmatched**)
٠ Increased IgG
77
What is the diagnostic criteria for multiple sclerosis
_McDonalds criteria_
**≥ 2 relapses**
& either…
Clinical evidence of **≥ 2 lesions** OR **1 lesion + Hx of previous relapse**
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*Clinical evidence = abnormal neuro exam / MRI / L.P, for example.*
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*Relapse = Sx ≥ 24hrs experience with ≥ 1 month apart*
78
How are the lesions in multiple sclerosis described
Lesions are disseminated in space (clinically or on MRI) and time (>1 month apart).
79
What is the most common presentation of multiple sclerosis
**Optic neuritis**
*Demyelination of optic nerve —> unilateral reduced vision*
80
How does optic neuritis present
**Impaired colour vision** - *Struggle to see red*
**Pain** - *with eye movement*
**Central scotoma** - *enlarged **central blind spot***
**R**elative **A**fferent **P**upillary **D**efect (**RAPD**) - *Affected eye; reduced direct light response, normal consensual pupillary reflex*
81
Define RAPD
**Affected eye; reduced direct light response, normal consensual pupillary reflex**
*Where the pupil in the **affected eye constricts** when shining a light in the **contralateral eye**
BUT NOT when shining it in the affected eye.*
82
Tx for optic neuritis
High dose **Methylprednisolone**
83
Aim of steroid therapy in an acute relapse of MS is what…
Aim is to shorten length of recovery NOT degree of recovery
84
Aim of DMT in maintaining remission for MS is what…
To slow progression of MS and reduce rate of relapses
85
Does DVLA need to be notified about MS
Yes
Legal obligation to notify DVLA
86
Mention 4 complications of multiple sclerosis
UTI
Osteoporosis
Depression
Visual impairment
87
Give 4 differential Dx for multiple sclerosis…
Fibromyalgia
Vit B12 deficiency
Peripheral neuropathy
Ischaemic stroke
88
What types of headaches are there…
1º headaches
*Non-specific cause as typically no underlying pathology*
2º headaches
*cayuse is more specific because of ***Underlying pathology***
89
Give examples of a 1º headache
Migraine
Tension
Cluster
*Trigeminal Neuralgia*
90
Give examples of 2º headaches
Giant cell arthritis
SAH
Meningitis
CO poisoning
91
Give red flags for headaches
Rapid new onset occipital headaches *subarachnoid haem*
Fever + neck stiffness *meningitis*
Dizziness *stroke*
Worsening on cough / strain *raised ICP*
Confusion / altered state of consciousness
Postural *raised ICP*
Visual disturbance *G.C arteritis / glaucoma*
Papilloedema *raised ICP;brain tumour, HTN, bleed*
92
Describe pain of a migraine
**Unilateral…
Throbbing
Moderate —> Severe
Worsened on exercise**
+/-
Photophobia/Phonophobia
N&V
93
Types of migraines
**Episodic**
*With Aura (1/3)
Without Aura (2/3)*
**Chronic**
**Silent**
*Px have aura but **without** headaches*
**Hemiplegic**
*Mimics a stroke; Px has Sx of migraine **+** unilateral weakness in limbs*
94
Describe migraine auras..?
Visual phenomena / disturbance…
**ZIGZAG lines**
Blurry / loss of different visual fields
Sparks / lines in vision
*Can last up to 60mins*
95
What can trigger migraines
**_CHOCOLATE_**
**Ch**ocolate
**O**ral cpontraceptive
**C**heese
Alcoh**OL**
**A**nxiety
***T*ravel
**E**xercise
96
How long do migraines last?
Have different stages…
**Prodrome** - *stages before the headache (mood ∆)*
**+/- Aura** - *Part of the attack; _minutes_ before headache*
**Throbbing headache** - **4 - 72hrs**
97
Women comes omplaining of migraines and is on oral contraceptive… what would you do as her dr?
Stop Oral contraceptive;
Offer alternatives; *as it acts as a trigger, increases stroke risk, decreases Triptan efficacy*
98
What is the criteria for a migraine…
Criteria is with / without aura dependant… but… general Dx criteria is…
**_Atleast 2 of…_**
*Unilateral pain
Throbbing in nature
Moderate—>severe
Motion sensitivity*
**_Plus, atleast 1 of…_**
*N+/V
Photophobia+/Phonophobia*
99
Tx for migraine
**_Acute_**
***Analgesia***; *Aspirin 900mg // NSAIDs [**Ibuprofen/Naproxen**] // Paracetamol*
***Triptans***; Sumotriptan 50mg
± ***Anti-emetics***; *Metoclopramide // Prochlorperazine* for N&V
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**_Chronic_**
***Headache diary***
ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ
**_Prophylaxis [Pharmacological]_**
***Beta-Blocker***; *Propanolol - If Asthmatic give…
**Anti-convulsant***; *Topiramate*
***Anti-depressant***; *Amitriptyline*
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**_Prophylaxis [Non-pharmacological]_**
***Acupuncture***
***Vitamin B supplements***; *Riboflavin*
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Avoid Opiates
100
What drug class are triptans
5-HT receptor agonist
101
MoA of triptans
They cause **Vasoconstriction** of cerebral blood vessels - *Alleviates pain as vessels are painfully dilated in migraines*
The act on **peripheral pain receptors** to inhibit activation of the pain receptors - *Alleviating pain*
**ٍReduce neuronal activity** in CNS
102
When are triptans ContraIndicated
**HTN**
IHD
TIA
Previous Stroke
103
When is topiramate contraindicated and its side effect
*Can be given as a prophylaxis in migraines*
C.I in **Preganancy** because it is **teratogenic**
+
Reduces contraceptive efficacy
**Side-effect; Cleft lip/palate**
104
What is defined by a chronic migraine
Headaches **> 15 days /month**…
**8** of which have **migraine features**
105
Most common type of 1º headache is…
Tension headache
106
Describe pain/features of a tension headache
Bilateral
Generalised pain; Pressing/tight
Mild —> Moderate
Not-exercise induced
*Pain in **Frontalis, temporalis and occipitalis muscles**
Rubber band, tight around head*
107
Duration of a tension headache
30 mins —> 7 days
108
Excluding the generalised pain in tension headaches, are there any other sx…
**No**
No motion sickness
No aura
No photophobia / phonophobia
109
Which muscles are involved in tension headaches
Frontalis
Temporalis
Occipitalis
110
Treatment of tension headache
**Basic Analgesia**
Paracetamol // Aspirin
Hot towel across head
Relaxation techniques
111
Describe the pain of a cluster headache
Unilateral
Sharp stabbing pain around eye // temporal region
Severe —> very severe
Headache is accompanied by _cranial autonomic features_
*٠ AKA “Suicide Headache; due to severity”*
112
What is a cluster headache a type of?
Type of **T**rigeminal **A**utonomic **C**ephalgia
[**TAC**]
*Hypersensitivity of the trigeminal autonomic reflex arc (vascular dilation + nerve simulation + increased histamine release from mast cells) —> all adding to the symptoms of a cluster headache*
113
How long do cluster headaches last for
15mins —> 3hrs
114
What type of 1º headache is the most debilitating
Cluster headaches
115
Risk factor for cluster headaches
Male
Smoking
Genetics
116
Signs and Sx of a cluster headache
**Crescendo unilateral periorbital pain** - *a sharp stabbing pain around an eye // temporal region
Severe —> very severe*
With **Ipsilateral autonomic features**;
*Ptosis (_droopy_ eye)
Miosis (_constricted_ unilateral pupil)
Lacrimation (_watery_ blood shot eyes)
Rhinorrhoea (_runny_ nose)*
117
Tx for cluster headaches
**_Acute_**
***High flow 02*** - *for 15-20mins*
***Triptans*** - *Sumotriptan subcutaneously*
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**_Prophylaxis_**
**1st line: Verapamil *[CCB]***
*Lithium* //
*Prednisolone… taper off*
118
Alongside cluster headaches… what other types of **T**rigeminal **A**utonomic **C**ephalgia
[**TAC**] are there?
Remember they are… *A collection of 1º headache disorders characterised by unilateral pain with ipsilateral cranial autonomic features*
**Cluster headaches**
**Paroxysmal hemicrania**
**Unilateral neuralgiform headache**
**Hemicrania continua**
119
What is the most common type of **T**rigeminal **A**utonomic **C**ephalgia [**TAC**]
Cluster headaches
120
Investigations and Dx of cluster headaches
Clinical Dx; ≥ 5 similar attacks confirms Dx
*But remember these headaches come in clusters and so they may experience Sx for like a week — month but then not experience them for years before the next cluster.*
Rule out differentials like ESR; for giant cell arteritis!
121
What syndrome can present 2º to cluster headaches
_Horner’s syndrome;_
***Pain and inflammation from headache —> compression/damage of post-ganglion nerves —> Horner’s syndrome … **
Sympathetic nerves running alongside the internal carotid artery!*
*Triad of Sx: **Ptosis, miosis, anhidrosis***
122
Give differential Dx for cluster headaches
Migraines
Other TACs; *Paroxysmal hemicrania, unilateral neurologiform headache, hemicrania continua*
Giant cell arteritis
SAH
Idiopathic intracranial hypertension
123
Define a subarachnoid haemorrhage
Bleeding into the subarachnoid space
124
What can cause a subarachnoid haemorrhage
Trauma
**Ruptured berry [*/ saccular*] aneurysms** - *M.C cause… usually arise at bifurcation points in circle of Willis*
Arteriovenous malformation
125
Where are berry aneurysms commonly located
junction between the **anterior communicating** and **anterior cerebral arteries**
126
What are the Sx of subarachnoid haemorrhage
_Occipital **Thunderclap** headache_; *”Worse headache ever experienced”*
**_Meningism_ *(photophobia + neck stiffness)***
*Kernig sign* - when hip and knee are flexed, hard to extend knee again
*Brudzinski sign* - automatic knee flexion when neck is flexed - Severe neck stiffness causes Px hips and knees to flex when the neck is flexed
**N&V // Confusion // Photophobia**; *non-specific signs of raised ICP*
**Seizures**
127
What type of headache precedes a berry aneurysm rupture
Sentinel headache
*throbbing occipital pain*
128
What are the 2 signs of meningism
_Kernig’s sign_
*When hip and knee are flexed 90º, inability to then further straighten at the knee* - causes pain and irritation
_Brudzinski’s sign_
*Flexing the Px neck causes flexion of the knee and hip* - due to severe neck stiffness
129
What investigations are done for suspected Subarachnoid haemorrhage
_1st line/diagnostic:_
**Non-contrast CT head** - *star-shaped*
_If +ve_:
**CT angiogram** - *extent of rupture*
_If -ve_:
**Lumbar puncture** - *≥12 hrs post Sx onset is when test is most sensitive.
~ **Xanthochromia;** yellowish CSF —> RBC haemolysis; for SAH*
130
What is the management/Tx of SAH
**_1st line:_**
Neurosurgery referral *endovascular coiling*
+
**Nifedipine** - *CCB; decrease vasospasms + BP*
131
What is the management of raised ICP
*For raised ICP; **IV mannitol***
132
Give 4 risk factors for subarachnoid haemorrhage
**HTN**
**Autosomal dominant Polycystic kidney disease** (**ADPKD**)
Smoking
FHx
Increased age
Marfans/EDS
133
Give 3 differential Dx for SAH
Migraine
Cluster headache
Meningitis
134
Give 5 complications of SAH
Re-bleeding
Vasospasms
Hydrocephalus
Seizures
Hyponatraemia 2º to SIADH
135
Give 1 predictive factor in SAH and how it can be monitored
Conscious level on admission
Monitored using GCS
136
What is GCS referring to…
**Best Motor Response**
6. Obeys commands
5. Localises to pain
4. Flexes to pain
3. Abnormal flexion
2. Extends to pain
1. None
**Best Verbal Response**
5. Orientated in time, place, and person
4. Confused
3. Inappropriate words
2. Incomprehensible sounds
1. None
**Best Eye Opening Response**
4. Eyes open spontaneously
3. Eyes open to speech
2. Eyes open to pain
1. None
**15: best response… ≤ 8: comatose… ≤ 3: totally unresponsive **
137
Define sub subdural haemorrhages
Blood accumulates between the dura mata and the arachnoid mata.
[subdural space]
*Bridging veins found in this space… can rupture due to ‘shearing injury’ - pressure separating the 2 layers*
138
Risk factors for subdural haemorrhage
**Shaken baby syndrome** - child abuse
Trauma
Increased age -*cortical atrophy e.g. in dementia*
139
Signs and Sx of subdural haemorrhages
_Acute *- within 3 days of incident*_
**Cushings triad/reflex** - *Widened pulse pressure, Bradycardia, Reduced resp rate* *_SIGNS OF RAISED ICP_*
+
Papilloedema // Reduced consciousness // headaches & vomiting
_Chronic_
Focal neurological deficits *-CNIII Palsy*
140
Investigations and Dx of a subdural haemorrhage
**Non-contast CT head**
*- banana/crescent shaped haematoma; not confined to suture lines; midline shift*
_Acute_
Hyperdense *-bright*
_Subacute_
Isodense
_Chronic_
Hypodense *- darker than brain image*
141
Tx for subdural haemorrhage
Refer to neurosurgery; *burr hole + craniotomy*
To reduce ICP: IV mannitol
142
Give 2 complications of subdural haemorrhage
Brain stem herniation
Respiratory distress
143
Define extradural haemorrhage
Accumulation of blood within the duration of mata space and the skull
144
What is the main cause of extradural haemorrhages
Trauma
Mainly **_Middle meningeal artery_ bleed.**
In the temporoparietal region (*pterion; thinnest part of skull*)
145
Give risk factors for developing an extradural haemorrhage
M.C seen in 20-30y/o
*Increased age actually has decreased likelihood of EDH*
M>F
Anticoagulation use
146
Signs and symptoms of extradural haemorrhage
_Acute_
**Lucid intervals**
*Initial* loss of consciousness; Intervals of feeling okay // rapid deterioration because of ICP
**cushing’s triad**
*Bradycardia, Widened pulse pressure, irregular resp rate*
**Reduced GCS**
+ papilloedema
147
What causes the rapid deterioration in in extradural haemorrhages
**Increased ICP**
*Blood clots become haemolysed and take up water (i.e. they’re osmotically active) so they increase in volume, increasing the pressure.*
148
Complication of extradural haemorrhage
Death by respiratory arrest;
Due to unTx raised ICP…
*herniation + coning of the brain —> compressed respiratory centres*
149
Investigation and Dx of extradural haemorrhage
**Non-contrast CT head**
*Lentiform-shaped hyperdense bleed
Confined by suture line
Midline shift*
150
Which investigation is contraindicated in extradural haemorrhage
Lumbar puncture;
*The sudden drop in pressure of the CSF in the spinal column —> herniation // brain stem compression + respiratory arrest*
151
What is the management of extradural haemorrhage
Urgent surgical intervention; Craniotomy // Burr holes
*IV mannitol to decreased ICP*
152
Define trigeminal neuralgia
Facial pain syndrome caused by compression of the trigeminal nerve ≥1 division
153
What are the branches of the trigeminal nerve
Ophthalmic (VI)
Maxillary (V2)
Mandibular (V3)
154
Are trigeminal neuralgia cases unilateral / bilateral
90% of cases; Unilateral
155
Which branch of the trigeminal nerve is most affected in trigeminal neuralgia
Mandibular
156
Give 4 possible aetiologies for trigeminal neuralgia
_1º:_ Idiopathic
_2º:_ MS // Tumour // Sarcoidosis
157
What key disease is trigeminal neuralgia associated with
Multiple sclerosis
158
Give triggers for trigeminal neuralgia
Cold weather
Shaving
Brushing teeth
Eating (*spicy foods / citrus fruits*)
Talking
Dental prostheses
159
Signs and Sx of trigeminal neuralgia
Unilateral **electric shock pain** across the face
Very severe
160
Duration of trigeminal neuralgic pain
A few seconds
*Secs —> 2 Mins*
161
Give 3 risk factors for trigeminal neuralgia
**Multiple sclerosis**
Increased age
F>M
162
Investigation & Dx for trigeminal neuralgia
Clinical Dx:
≥ 3 attacks of Sx
*Can do MRI/CT to rule out 2º causes*
163
Tx for trigeminal neuralgia
**Carbamazepine**
(*Anti-convulsant*)
Surgery if persistent
164
Give 2 complications of trigeminal neuralgia
Jaw weakness
Diplopia
165
Define hydrocephalus
Excessive build up of CSF within the ventricular system lead by an imbalance in production and absorption
166
What is CSF produced by
Choroid plexus
*network of blood vessels in each ventricle of the brain*
167
What absorbs CSF
Arachnoid granulations
*projections of the arachnoid membrane (villi) into the dural sinuses that allow CSF to pass into the venous system*
168
What is the flow of CSF
lateral ventricles ———> foramen of Munro ———> 3rd ventricle ———> cerebral aqueduct ———> 4th ventricle ———> subarachnoid space *(Medially by foramen of Magendie, Lateral by Luschka)* ———> dural sinus via arachnoid granulations.
169
Give 3 functions of CSF
Protects brain and spinal cord by providing cushioning
Provides nutrients to the brain
Removal of waste products *from cerebral metabolism*
170
What aetiologies are there for hydrocephalus
**Obstructive** - *structural pathology blocks the flow of CSF*
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**Non-obstructive** - *mismatch in production:absorption of the CSF*
***_Subtype_***; Normal pressure hydrocephalus (*enlarged ventricles with increased CSF but normal pressure*)
171
What can cause obstructive hydrocephalus
Malignancy (tumour)
Haemorrhage
Congenital defect
172
What can cause non-obstructive hydrocephalus
Meningitis - *reduced absorption*
Choroid plexus tumour - *increased production*
173
Signs and Sx of hydrocephalus
*_Signs of raised ICP_*
**Headache** - *worse on waking up / lying down*
N&V
Papilloedema
Blurred vision
174
Investigation and Dx for hydrocephalus
1st line: CT head
Lumbar puncture; diagnostic and therapeutic *allows sampling, measuring opening pressure and can drain CSF to reduce pressure*
***Contraindicated in obstructive hydrocephalus - ∆ in cranial:spinal CSF pressure —> herniation***
175
Tx of hydrocephalus
**Ventriculoperitoneal shunt**; *surgical implantation that help remove CSF via GI system*
*Complication; infection // blockage // intraventricular haemorrhage during surgery*
176
Define normal pressure hydrocephalus and how it presents
Increased CSF and enlarged ventricles without increased pressure
**_Triad of Sx_**
**dementia**
**urinary incontinence**
**abnormal gait**
*To remember the Sx think… very very old person*
177
Define syncope
Transient loss of consciousness
178
Aetiology of syncope
_1º syncope_
Dehydration
Missed meals
Vasovagal response; *vagus nerve —> parasympathetic nervous system —> vasodilation —> reduced blood pressure in cerebral circulation —> hypoperfusion of brain tissue —> leads to survival mechanism to preserve brain by losing consciousness*
Prolonged standing in a warm environment
_2º causes_
Anaemia
Hypoglycaemia
Cardiac; Arrythmias // hypertrophic obstructive cardiomyopathy // valvular heart disease
179
Types of Sx experienced in prodromal phase of syncope
Headaches
Vertigo
Blurry vision
Light headedness
Sweating
Hot / clammy
180
Give 5 signs that a transient loss of conciousness is due to syncope
Situational
5-30s in duration
Sweating
Nausea
Pallor
Dehydration
181
Give 5 causes of transient loss of conciousness
Syncope
Epileptic seizures
Non-epileptic seizures
Intoxication; alcohol
Hypoglycaemia//Ketoacidosis
182
Define epilepsy
Neurological disorder characterised by **recurrent seizures**
183
Define a seizure
Paroxysmal alteration of neurological function leading to **hypersynchronous discharge of electrical activity at neurons**
*(I.E. sudden uncontrollable burst of electrical activity)*
184
What are the types of seizures
Generally, _in adults…_
**_Generalised tonic-clonic_** - *typical epileptic seizure; **tonic**-stiffening of the arms/legs/trunk… **clonic**-jerking of arms/legs on one/both sides of the body*
**_Partial // focal_**
**
Myoclonic
Tonic
Atonic
Generally, _in children…_
Absence
Infantile spasm
Febrile convulsions
