Acute neurology Flashcards by Fatima Osman

What are common symptoms before epileptic seizures

Epileptic aura

2. triggers such as flashing lights

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What are common symptoms during epileptic seizures

stiffness
jerking
incontinence
tongue biting
sweating
frothing at the mouth

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What are the characteristics of simple partial seizures

Focal (one hemisphere or lobe) seizures without LOC
awareness unimpaired (can remember what is happening)
No post ictal confusion

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What are common symptoms post-ictal

ache
Todd’s paralysis: unilateral paralysis which is self-limiting
post-ictal drowsiness

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What are characteristics of complex partial seizures

focal seizure with LOC
usually cannot remember what is happening to them
post ictal confusion
Deja-viu, depersonalisaion, altered emotion, epigastric fullness

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A 25-year-old man was hit on the side of the head with the ball, whilst playing cricket. He recovered enough to finish off the game. He then presented to A&E 8 hours later with a severe headache and vomiting. On Examination he pupil are looking down and out, and soon after this he rapidly loses consciousness

Subarachnoid Haemorrhage
Extradural Haemorrhage
Stokes-Adam’s Attack
Postural Hypotension
Hypoglycaemia

Extradural Haemorrhage

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A 52 year old fund manager with a history of previous heart attacks, feels some palpitations and collapses. A witness said that he went very pale as he collapsed but then became flushed and regained consciousness after 30 seconds.

Subarachnoid Haemorrhage
Extradural Haemorrhage
Stokes-Adam’s Attack
Postural Hypotension
Hypoglycaemia

Stokes-Adam’s Attack

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A previously well 14 year old girl collapses after being in a crowd for 2 hours at a pop concert.

Cardiac Arrhythmia
Aortic Stenosis
Vasovagal Syncope
Postural Hypotension
Situational Syncope

Vasovagal Syncope

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A 75-year-old man is found on his bedroom floor by his wife and is now conscious. He got out of bed in the middle of the night to go to the toilet and felt dizzy and fell to the ground. He is on treatment for hypertension and has no other medical problems.

Cardiac Arrhythmia
Aortic Stenosis
Vasovagal Syncope
Postural Hypotension
Situational Syncope

Postural Hypotension

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A 56 year old lady collapses whilst running for the bus. O/E there is a thrusting apex beat and an ejection systolic murmur. This is best heard on expiration and radiates to the carotids.

Cardiac Arrhythmia
Aortic Stenosis
Vasovagal Syncope
Postural Hypotension
Situational Syncope

Aortic Stenosis

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A 20 year old man, who was picked up by the police, is behaving irrationally & is confused & irritable. He is pale & sweaty & smells of alcohol. He keeps asking for biscuits.

Subarachnoid Haemorrhage
Extradural Haemorrhage
Stokes-Adam’s Attack
Postural Hypotension
Hypoglycaemia

Hypoglycaemia

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44 y/o gentleman. On examination he appears drowsy, only opening his eyes in response to speech, he seems confused and disorientated, and when assessing his movements he is able to obey commands. Calculate his GCS

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A 65 year old man with a history of an MI 2 years ago. He lost consciousness and presents to you 36 hours later with reduced power in his left arm and leg.

Stroke
Subdural Haematoma
Encephalitis
SOL
Epilepsy

Stroke

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A 21-year-old man is walking down the street to visit his friends while suddenly he falls to the ground unconscious. His body goes stiff and then he begins to jerk his arms. He becomes incontinent of urine.

Stroke
Subdural Haematoma
Encephalitis
SOL
Epilepsy

Epilepsy

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COL in COLLAPSE

Carotid si

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COL in COLLAPSE

Carotid sinus syncope
Orthostatic (postural) hypotension
refLex - vasovagal syncope

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Loss of consciousness: causes (beat - heart)

Syncope = loss of consciousness due to a drop in blood pressure 
BP = HR X SV X TPR

HR = bradycardia + arrhythmia (i.e. AF, VT, long QT, complete heart block)

SV inc outflow obstruction =
tamponade, cardiomyopthay
Left = HOCM, aortic stenosis
Right = PE

TPR inc neuropathy =
vagal overactivity
peripheral autonomic neuropathy (DM, Parkinson’s)

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What is orthostatic hypotension

LOC when lying to standing

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What is (refLex) vasovagal syncope

reflex bradycardia

+/- vasodilation provoked by emotion, pain, fear, standing too long

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APS in COLLAPSE

Arrhythmia/Stoke’s Adam’s attack
Panic attack
Situational synocpe

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How does a collapse due to arrhythmia/Stoke’s Adam’s attack manifest

Collapse with no warning
recovery in seconds
patient flushes
pulse returns

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What is Stokes Adam attack

a sudden reduction in CO

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What is postural hypotension

When systolic BP >20mmHg or diastolic BP >20 mmHg after standing for 3 minutes vs lying down

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What are the risk factors for postural hypotension

Elderly
Hypovolaemia
Drugs: Nitrates, diuretics, antihypertensives, antipschychotics
peripheral neuropathy
Endocrine (addison’s, hypopituitarism - reduced ACTH)

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How do you confirm postural hypotension

tilt test

What are the main causes of aortic stenosis

1. congenital bicuspid valve | 2. calcification of normal tri-leaflet valves

How does aortic stenosis present

1. Chest pain 2. dyspnoea 3. syncope

What are the clinical signs of aortic stenosis

1. Harsh ejection systolic murmur, heard loudest at the right upper sternal edge at end expiration, which radiates up towards the carotids 2. narrow pulse pressure + slow rising pulse

What are the risk factors for hypoglycaemia

1. mainly diabetic on NEW insulin/oral hypoglycaemic + exercise 2. Alcohol, liver failure = reduced glucose production

What are the symptoms of hypoglycaemia

1. sweating 2. weakness 3. reduced GCS 4. palpitations and anxiety 5. asking for biscuits

What are the first line investigations for blackouts

``` 1. Bedside: cardio, neuro examination, lying and standing BP Bloods: FBC, U+E, glucose, ABG Imaging: - ECG, cardiac monitor, 24hrs ECG - Echocardiogram - EEG, CT/MRI ```

What is a TIA

are acute episodes of focal loss or cerebral function lasting <24 hours due to in adequate blood supply

What is the difference between a stroke and TIA

duration of symptoms TIA <24 hours Stroke >24 hours

Blockage to anterior cerebral artery affects which parts of the brain

frontal lobe, parietal lobe

What are the symptoms of stroke via the anterior cerebral artery

Affects the frontal and parietal lobe 1. personality changes 2. Disturbance of judgement /loss of social behaviour 3. Contralateral hemiparesis (weakness) leg>arm 4.

What are the symptoms of stroke via the anterior cerebral artery

Affects the frontal and parietal lobe 1. personality changes 2. Disturbance of judgement /loss of social behaviour 3. Contralateral hemiparesis (weakness) leg>arm 4. mild sensory deficit

blockage to the middle cerebral artery affects to which part of the brain

``` frontal, parietal, temporal subcortical structures (e.g. basal ganglia) internal capsule ```

What are the symptoms of stroke via the middle cerebral arteries

1. Contralateral hemiplegia (paralysis) arms>legs 2. aphasia 3. hemisensory deficits

Blockage to the posterior cerebral artery affects which parts of the brain

occipital and lower temporal

A 65-year-old hypertensive man has complained of losing vision twice in one eye, which lasted for a few hours and then went back to normal. He says it’s like ‘a black sheet falling over the front of my eye’. ``` Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke ```

Transient Ischaemic Attack

An 80-year-old woman who is a smoker was brought into A&E from a residential home where her carers noticed that she had difficulty swallowing and that she also had difficulty moving her left arm and leg for the past few days. ``` Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke ```

Right-sided Stroke

A 30-year-old woman experienced a strange feeling in her stomach, followed by stiffness & jerking in the left arm. Afterwards, she felt drowsy but remembers everything. ``` Myoclonic Seizure Complex Partial Seizure Simple Partial Seizure Tonic-Clonic Seizure Absence Seizure ```

Complex Partial Seizure

Tonic-Clonic Seizure

What are the investigations for a TIA

1. CT head to exclude a haemorrhagic aetiology esp if pt has - depressed consciousness (GCS<13) - suspected haemorrhage (drugs etc) or raised ICP

What is the treatment for TIA

thrombolysis with tPA within 4.5 hours | Thrombolysis is done with Altplase at 10% bolus, 90% infusion at dose 0.9 mg/kg

What drug is used in thrombolysis in a TIA

Alteplase

How is alteplase administered

10% bolus | 90% infusion at a dose of 0.9 mg/kg

TIA: What if a patient presents after 4.5 hours after the onset of symptoms

manage with aspirin

All people presenting with acute ischaemic stroke should be given ...

aspirin

Name Convulsive (generalised seizures)

1. tonic 2. clonic 3. tonic-clonic 4. myoclonic

Seizures: describe tonic

limb stiffening

Seizures: tonic characteristics

limb stiffening

Seizures: clonic characteristics

limb jerking

Seizures: tonic-clonic characteristics

1. LOC followed by stiff body with flexed elbows and extended legs followed by violent shaking with eyes rolling (grand mal) 2. incontinence 3. post-ictal confusion & drowsiness

Seizures: myoclonic characteristics

sudden isolated jerk of limb, face or trunk

what are the non-convulsive seizures

1. absence | 2. atonic (akinetic)

Seizures: absence characteristics

<10 seconds of vacancy, sometime myoclonic jerks (petit mal), presents in childhood no post ictal

Seizures: atonic (akinetic) characteristics

sudden loss of muscle tone | 'drop attacks' w/out LOC

What is status epilepticus

continuous seizure or serial (>2) discrete seizures between which there is incomplete recovery of consciousness of at least 30 minutes duration MEDICAL EMERGENCY

What do you do when approached with someone with status epilepticus

``` MEDICAL EMERGENCY 1. ABC approach 2. Oxygen 100% 3. Slow IV bolus Lorazopam 2-4mg Lorazepam again in 10 minutes if no response 4. Continuing seizure ```

What do you do when approached with someone with status epilepticus

MEDICAL EMERGENCY 1. ABC approach 2. Oxygen 100% 3. Slow IV bolus Lorazopam 2-4mg Lorazepam again in 10 minutes if no response 4. Continuing seizure IV infusion phenytoin/diazepam

What condition can present with seizures and LOC

1. stroke 2. epilepsy 3. Infection (encephalitis, meningitis) 4. Metabolic

What is encephalitis

inflammation of the brain parenchyma

What are the causes of encephalitis

Viral: 1. HSV (herpes simplex virus) 2. CMV (cytomegalovirus) 3. EBV (epstein barr virus) 4. VZV (varicella zoster virus) Non-viral: 1. any bacterial meningitis 2. TB

What are the symptoms of encephalitis

1. bizarre encephalopathic behaviour

What are the symptoms of encephalitis

1. bizarre encephalopathic behaviour 2. reduced GCS/coma 3. fever 4. focal signs 5. sizures

When would encephalitis be a medical emergency

If the CT scan showed cerebral oedema + compressive symtpoms

What is the most common cause of meningitis

meningococcus pneumococcus

What are the symptoms of meningitis

1. headache 2. meningism 3. reduced GCS/coma 4. focal signs seizures 5. fever 6. rash

What signs are positive in meningitis

1, Kernig's sign | 2. Brudzinski's sign

What is a cause of hyponatraemia

thiazide diuretics (hypo/eu/hypervolaemic)

What are the symptoms of hyponatraemia

1. headaches 2. vomiting 3. drowsiness 4. seizures

What is hyponatraemia

low sodium | <135

What are they symptoms of hypocalcaemia

``` 4CATS Convulsions Arrhythmia tetany spasms ```

What are the clinical signs of hypocalcaemia

positive | chvostek's and trousseu's sign

A 50-year-old man presents with an instantaneous onset of a severe headache, followed by drowsiness & vomiting. Shortly after presentation he loses consciousness ``` Subarachnoid Haemorrhage Extradural Haemorrhage Anaemia Postural Hypotension Hypoglycaemia ```

Subarachnoid Haemorrhage

An 80 year old man fainted with a 2 week history of abdominal pain and coughing up a black coffee-ground like substance. He has been feeling irritable, tired and sleepy. ``` Subarachnoid Haemorrhage Extradural Haemorrhage Anaemia Postural Hypotension Hypoglycaemia ```

Anaemia

A 10-year-old girl is not doing well at school, her teacher says she doesn't concentrate and shows no interest. Her parents also noticed the girl has moments (around 10secs) when she just stares blankly, blinking and then returns to normal. It happens up to several times an hour. ``` Myoclonic Seizure Complex Partial Seziure Simple Partial Seizure Tonic-Clonic Seizure Absence Seizure ```

Absence Seizure

A 87-year-old lady had a seizure at home. Her husband says she has been drowsy for the last couple of days. She is otherwise in good health but she has recently started antihpertensive drugs. On examination, her skin turgor is reduced. ``` Hypercalcaemia Hypocalcaemia Hyperglycaemia Hypoglycaemia Hyponatraemia ```

Hyponatraemia

A 66-year-old was getting increasing confused over the last couple of days. She was admitted after a seizure. She appears distressed and is pyrexial with mild meningism but no rash. A CT head scan shows changes in the left temporal lobe and cerebral oedema. ``` Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke ```

Encephalitis

A 71 year old man with long standing hypertension lives on his own. He is found by his son with marked right upper limb weakness and difficulties with speech. He is now incontinent of urine and has some personality changes. ``` Right-sided Stroke Transient Ischaemic Attack Meningitis Encephalitis Left-side Stroke ```

Left-side Stroke

Acute neurology Flashcards

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