Core Flashcards
Stroke - sudden onset neuro signs:
- What are the main causes of haemorrhage (4) and ischaemic (2) stroke?
- In which ethnicities is stroke more common?
- What is a watershed stroke? Where do they normally occur?
- What features are required for TACS, PACS, POCS and LACS?
- What is locked-in syndrome? Which artery is likely occluded?
- A stroke in which artery can cause lateral medullary syndrome? What are the signs?(4)
- What are the common vessels ruptured in haemorrhagic stroke?(3)
- Haemorrhagic = HTN, amyloidosis, anticoagulation, ruptured aneurysm
Ischaemic = atheroma and emboli - Black and Asian
- Ischaemic stroke due to drop in SBP >40mmhg - can be caused by sepsis. In the area with shared blood supply from MCA and ACA.
- TACS = contralateral hemiplegia/hemiparesis in 2 or more of UL/LL/Face, contralateral homonymous hemianopia, evidence of higher cortical dysfunction (Visio-spatial loss, dysphasia)
PACS = 2/3 of TACS
POCS = isolated contralateral hemianopia, cerebellar or brainstem syndrome
LACS = pure sensory or motor, sensory-motor or ataxic hemiparesis - Vertebral pons infarct - basilar artery
- In the posterior inferior cerebellar artery - Vertigo, trunk ataxia, N+V and nystagmus
- Intraparenchymal, subarachnoid and intracerebral vessel
Stroke Managment:
- What are the immediate steps in stroke management? (5)
- What is the drug Rx for secondary prevention for stroke? (2)
- What are the two main rehabilitation factors which need to be prevented?
- What is a CHA2DS2-VASc score? What do the scores mean?
- What is a HASBLED score?
- What is the drug Mx for someone with ischaemic stroke and AF?
- Resuscitate and call stroke ward
- Monitor BP and BM
- Imaging - urgent CT to rule out haemorrhagic
- Medical: Thrombolysis if CT head not suggestive of haemorrhage and <4.5 hours = alteplase.
Aspirin 300mg once haemorrhage is excluded - Surgical: neurosurgery opinion if there is haemorrhage
- Clopidogrel 75mg/day for life or Warfarin if cardioembolic stroke or AF.
- DVT and pressure sores
- Assess the risk of stroke in a patient with AF to see if anticoagulation is necessary
0 = no anticoagulation necessary
1 = consider anticoagulation if male
2+ = offer anticoagulation - The risk of haemorrhage with anticoagulation
- Aspirin daily, start long term anticoagulation after 2 weeks
Meningitis:
- What is the main causative organism in 6-60y/o?
- What is the main causative organism in >60s?
- What is the main causative organism in <5y/o?
- What is the likely causative organism in a HIV patient?
- What are some viral causes of meningitis? (3)
- What Abx are given for bacterial meningitis >55 and <55?
- What prophylactic Abx should be given to friends and family?
- What should be given in addition to Abx in treating bacterial meningitis?
- What are the CIs to LP? (4)
- What is the most common complication of meningitis?
- What drug is given for viral meningitis?
- Neisseria meningitidis
- Strep pneumoniae
- Haemophilus influenzae B
- TB
- HSV, VSV, enteroviruses
- > 55 = ceftriaxone + amox + dex
<55 = ceftriaxone + dex - Ciprofloxacin
- Dexamethasone
- Thrombocytopenia, raised ICP, unstable, focal neuro signs
- Sensory-hearing loss
- Acyclovir
Subdural and Extradural Haematoma:
- Who is a greatest risk for these bleeds? (2)
- What is the risk of an untreated subdural? (2)
- What does and acute and chronic subdural haematoma look like on CT? What is important to check for?
- What is the likely ruptured vessel in chronic subdural haematoma?
- How do chronic subdurals present? (3)
- What are the 1st and 2nd lines of treatment for subdural?
- Which artery is typically damaged in extradural haemorrhage?
- How do extradural’s present? (3)
- What do extradural’s look like on CT? How are they managed?
- What might you see O/E with an extradural haemorrhage?
- Those on anticoagulation and the elderly
- Tentorial herniation and coning
- Acute = hyper-dense crescentic collection
Chronic = hypo-dense crescentic collection
Ask for ‘bone windows’ setting on CT to assess for skull#
4. Bridging veins between cortex and venous sinuses in subdural space
5. Week to month progressive confusion, reduced consciousness or neurological deficit
6. 1st = Burr hole craniostomy irrigation and evacuation
2nd = craniotomy (organised clot)
7. Middle meningeal artery
8. Fluctuating consciousness, raised ICP, brainstem compression
9. Biconvex and hyper-dense - surgical removal
10. Fixed dilated pupil due to CNIII parasympathetic fibre compression
What signs would be seen in septicaemic pt. vs meningitic?
Septicaemic = increased CRT, hypotension, cold hands + feet Meningitic = neck stiffness + photophobia
Seizures/Epilepsy:
- What are the most common causes of seizure? (4)
- What are the congenital causes of seizure? (3)
- What can cause a provoked/non-epileptic seizure? (4)
- What is the difference between simple and complex focal seizure?
- Describe the Jacksonian march, when is it seen?
- Where do most focal seizures arise form?
- What are generalised seizures? What are the main types? (6)
- What are the signs localising seizure activity to each lobe?
- What are the driving restrictions surrounding epilepsy?
- What are the indications for MRI in suspected epilepsy? (3)
- Which Ix is used to support a diagnosis of epilepsy?
- What is the 1st and 2nd Rx for focal seizures?
- What is the Rx for: tonic-clonic, absence and atonic/myoclonic seizures?
- Idiopathic, congenital, CVA, drugs
- Neurofibromatosis, Tuberous Sclerosis, perinatal anoxia
- Metabolic= glucose, Na+, Ca2+ and urea
Infection = meningitis + encephalitis
Withdrawal = alcohol, benzodiazepines and opiates
Raised ICP - Simple focal = seizure activity (any change in motor, sensory or autonomic function) arising from one hemisphere of the brain with no LOC
Complex focal = same as simple but LOC or impaired awareness
- Seizure activity starting with distal and small muscle twitching which ascends proximally to larger muscles - simple focal seizures
- Temporal lobe
- Seizure activity arising from both hemispheres.
Tonic-clonic - LOC, post-ictal confusion, tongue biting, incontinence
Myoclonic - sudden muscle twitching
Atonic - sudden loss of muscle tone with no LOC
Febrile - children following CNS infection or electrolyte imbalance
Absence - childhood with abrupt onset <10s
West-syndrome/infantile spasms (cluster of head nodding and arm jerks) - Frontal = motor features
Temporal = automatisms, deja vu, emotion, taste/smells
Parietal = paraesthesia
Occipital = visual changes - Advise not to drive after any seizure, if a diagnosis of epilepsy has been made then can’t drive until seizure free for >1 year
- Adult onset, any evidence of focal onset or seizures despite 1st line Rx
- EEG - cannot exclude nor prove only supports clinical suspicion
- 1st = lamotrigine or carbamazepine
2nd = oxycarbazepine - Tonic-clonic = lamotrigine (G) or valproate (B)
Absence = ethosuxamide (G) or valproate (B)
Atonic/myoclonic = leretiracetam (G) or valproate (B)
Dementia:
- What are the two distinctive hallmarks of AD?
- Which three main areas with those with AD find the greatest difficulty in?
- What would make you consider a diagnosis of AD as the cause of dementia?
- Which will MRI of a patient with AD show?
- What is the drug Mx for AD?
- What factors may make you consider a diagnosis of vascular dementia? (Onset, RFs and rate of deterioration)
- What is the likely cause of vascular dementia? What might be seen on MRI? (2)
- What may make you consider a diagnosis of Lewy body dementia in terms of symptoms? (3)
- How do you manage Lewy body dementia?
- What may point to a diagnosis of fronto-temporal dementia in terms of symptoms? (3)
- Before considering a diagnosis of dementia, what are some ameliorable causes of the symptoms? (5)
- Senile plaques and neurofibrillary tangles
- Visio-spatial, memory and executive planning
- Enduring, progressive cognitive decline
- Medial temporal lobe atrophy
- Anti-cholinesterase
- Onset = sudden
RFs = vascular RFs
Rate = step-wise - CVA resulting in multiple infarcts - multiple infarcts or small vessel disease
- Fluctuating cognitive decline, visual hallucinations and Parkinsonism
- Anti-cholinesterase
- Disinhibition, personality changes, progressive aphasia
- Infection, chronic subdural, neoplasia, B12 and folate, normal pressure hydrocephalus
MS:
- Which gene is associated with MS?
- What is the common presentation of MS? (PEAS)
- Describe the main subtypes of MS? (3)
- What are Lhermitte’s and Uhthoff’s phenomena? When are they seen?
- Which Ix is diagnostic?What might you find on LP with MS?
- Which criteria may aid MS diagnosis?
- What drug do you give to manage acute attacks in MS?
- Which drugs do you give to prevent relapses in MS? (2)
- What is the drug Mx for the symptoms of MS? (Fatigue, depression, pain, spasticity, urgency/frequency and tremor)
- HLA-DRB1
- Paraesthesia, eye (optic neuritis), Ataxia, Spastic paraparesis
- Relapsing-remitting (85%) = acute attacks lasting 1-2 months followed by periods of remission
- Primary progressive (10%) = progressive deterioration from onset which is more common in older people
- Secondary progressive = relapsing-remitting patients with neuro signs developed between relapses (mainly gait and bladder disorders are seen). 65% of relapsing-remitting patients develop secondary progressive disease within 15 years.
- Lhermitte’s = flexion of the neck = tingling down neck and back (MS + cervical spondylosis)
Uhthoff’s = worsening of symptoms in heat (MS) - MRI
IgG oligoclonal bands which are absent in serum, shows CNS inflammation - McDonald Criteria
- Methylprednisolone for 5 days
- Biologics + DMARDs
9. Fatigue = modafinil Depression = citalopram Pain = amitriptylline Spasticity = Baclofen Urgency/frequency = oxybutinin Tremor = clonazepam
Cerebral Abscess:
- What are the main causes? (3)
- What are the main causative bacterial (3) and fungal organisms (3)?
- In which type of patients is fungal cerebral abscess more likely to be in? (3)
- What are some of the signs/symptoms of cerebral abscesses? (4)
- Which Ix confirms the diagnosis - what is the hallmark feature?
- What is the medical (2) and surgical management?
- Middle ear or sinus infection, trauma or surgery to scalp, emboli from endocarditis (rare)
- S aureus, listeria, streptococcus
Aspergillus, candida, cryptococcus - Those with broad spectrum Abx, immunosuppressed and steroids
- Fever, signs of raised ICP, altered mental state and focal neurology to the site of the abscess
- Contrast CT - ring enhanced lesion
- Medical = IV ceftriaxone + metronidazole
Surgical = craniotomy to debride the abscess
CN Palsies:
- Down and out eye, ptosis + miosis is associated with which CN? What are the main causes? (3)
- What is trigeminal neuralgia? What are the causes?(2) How does it present?
- What are the red flag signs of trigeminal neuralgia? (3) How is it managed normally? When is urgent referral required?
- Which CN palsy may present with internucelar ophathalmoplegia and conjugate lateral gaze disorder with diplopia?
- Third nerve palsy - DM, vasculitis + PCA aneurysms
- Pain syndrome of the trigeminal nerve, idiopathic and compression of trigeminal nerve roots may occur.
Presents as sudden onset ‘stabbing’ pains in one or more of the divisions of the trigeminal nerve - evoked by light touch and last seconds to minutes
- Red flags = <40 y/o, hearing changes, pain only in ophthalmic division - requires urgent referral
Otherwise Rx via carbamaezpine - failure to respond = urgent referral
- CNXI - there is inability for the affected eye to abduct
MND:
- What are the main diseases regarded under MND? (4)
- What might point to a diagnosis of MND? What signs are seen O/E?
- How would you distinguish MS and MND? (2)
- Which medication is given to control drooling in MND? (2)
- How do you reduce spasticity in MND?
- Which drug class may delay mortality? Which blood test can it affect?
- Which muscles are spared in MND?
- ALS (amyotrophic lateral sclerosis), progressive muscular atrophy, bulbar palsy and primary lateral sclerosis
- Age 40+ with spastic stumbling gait and foot drop, weak grip and weak shoulder abduction - UMN +LMN signs with absence of sensory or cerebellar signs
- No sensory change or sphincter disturbance in MND
- Amitriptyline or propantheline
- Baclofen
- Anti-glutaminergic drugs (riluzole) - can derange LFTs
- Extra-ocular
Bulbar palsy and pseudobulbar palsy:
- What is bulbar palsy? Where are the lesions usually?
- What are the signs of bulbar palsy? (3)
- What are the causes of bulbar palsy? (4)
- How is pseudobulbar palsy different to bulbar palsy? Where are the lesions usually?
- What are the signs of pseudobulbar palsy? (3)
- What are the causes of pseudobulbar palsy? (4)
- Diseases of nuclei CN IX-XII in the medulla
- LMN lesions of tongue (flaccid and fasciculating), speech is quiet and nasal, dysphagia
- MND, GBS, MG, central pontine myelinosis
- Similar symptoms but due to UMN bilateral lesions above the mid pons.
- Spastic tongue, slow tongue movements and brisk jaw jerk
- Stroke, MS, MND, Central pontine myelinosis
CNS tumours:
- What are the most common types of brain tumour? (2)
- How are they diagnosed?
- Which drug is given to manage cerebral oedema?
- Which tumours most commonly metastasise to the brain? (4)
- Why can’t gliomas be managed surgically?
- Glioma or metastatic
- MRI
- Dexamethasone
- Lung (most common), breast, bowel, melanoma
- Have a propensity to invade the brain tissue quickly
How do you differentiate between a syncopal and seizure LOC?
Syncope seizures have rapid recovery and <2min post-ictal period. Seizure post octal periods last at least 15mins.
GBS:
- What is the pathophysiology?
- What is the classic causative organism?
- What is the pattern of weakness?
- What reflex change may be seen?
- What Ix can confirm GBS? (2)
- What is the management?
- What are some complications to be aware of?
- Immune-mediated demeylination of the peripheral nervous system triggered by infection
- Campylobacter jejuni
- Progressive ascending weakness (from legs to arms - proximal muscles to distal)
Sensory changes may also be present
- Reduced or absent
- LP (raised protein) and nerve conduction studies
Isolated raised protein on LP is highly suggestive of GBS
- IV immunoglobulins
- Respiratory depression, bulbar symptoms, autonomic dysfunction