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Phase 1c > Neuro > Flashcards

Neuro Flashcards

1
Q

tension headache presentation

A

generalised, bilateral
non-pulsatile
tight band, pressure like
can radiate to neck and shoulders
episodic, chronic

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2
Q

tension headache ix

A

none specific to tension headaches
normal neuro exam
pericranial or neck muscle tenderness possible on examination

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3
Q

is a recent fall a red flag

A

yes for subdural haemorrhage

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4
Q

what do you need to be aware of when prescribing analgesia for headaches

A

medication overuse headaches (aka rebound headaches)

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5
Q

cluster headache presentation

A

unilateral
episodic
sudden onset
excruciating pain
lacrimation, rhinorrhea, partial Horner’s

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6
Q

cluster headache ix

A

no ix specific for cluster headaches.
MRI- exclude anything more sinister
ESR - exclude giant cell arteritis
pituitary function tests - exclude pituitary adenoma

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7
Q

cluster headache mx

A

acute
-subcutaneous sumatriptan
-high dose, high flow O2

prophylaxis
-verapamil (CCB)

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8
Q

migraine presentation

A

unilateral
comes on gradually
pulsating, throbbing
4-72 hrs
exacerbating: activity, stress, phonophobia, photophobia
relieving: quiet, dark room

associated symptoms:
aura. n+v, visual changes, tingling, numbness, migraine interferes with current activities

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9
Q

migraine ix

A

mostly ix of exclusion
- MRI - exclude smth more sinister
- ESR - exclude giant cell arteritis
- LP - haemorrhage, meningitis

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10
Q

migraine mx

A

conservative:
- headache diary
- avoid triggers
- relaxation techniques (CBT, mindfulness)

acute:
- simple analgesia
- triptans
- consider anti-emetic

prophylaxis:
- propanolol
- topimarate
- amitryptiline

DO NOT GIVE OPIATES

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11
Q

trigeminal neuralgia presentation

A

unilateral pain along trigeminal distribution
paroxysmal, lasting seconds, recurrent episodes
stabbing, shooting pain, like electric shock
exacerbated by moving jaw

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12
Q

risk factors for trigeminal neuralgia

A

increased age
female
multiple sclerosis

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13
Q

management of trigeminal neuralgia

A

1st
acute - anticonvulsants (eg carbamazepine)

long term - microvascular decompression or ablation surgery

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14
Q

raised ICP headache presentation

A

bilateral, gradual, throbbing
vomiting
confusion
worse in mornings
severe pain
papilloedema

Cushings triad - increased systolic BP, irregular breathing, bradycardia

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15
Q

raised ICP Ix

A

urgent CT head

never do lumbar puncture, can cause brainstem herniation

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16
Q

raised ICP mx

A

management of risk factors
analgesia
treat underlying cause

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17
Q

what layers of brain does meningitis affect

A

arachnoid and pia

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18
Q

causes of meningitis

A

bacteria - e.coli, h.influenzae, strep pneumoniae, neisseria meningitidis, listeria monocytogenes

virus - enteroviruses, HSV, VZV, HIV

tuberculosis

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19
Q

meningitis signs and symptoms

A

meningism: neck stiffness, photophobia, headache
fever
n+v
seizures
malaise
hypotension
tachycardia

Kernig’s sign
Brudzinski’s sign
petechial non-blanching rash

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20
Q

meningitis Ix

A

obs
VBG

lumbar puncture (most important)
2 sets of blood cultures

CT head before LP

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21
Q

CSF analysis in bacterial meningitis

A

appearance - cloudy
cells - increased neutrophils (polymorphs)
glucose - reduced
protein - increased

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22
Q

CSF analysis in viral meningitis

A

appearance - clear
cells - increased lymphocytes (mononuclear)
glucose - normal
protein - normal/increased

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23
Q

CSF analysis in TB meningitis

A

appearance - fibrin web
cells - increased lymphocytes (mononuclear)
glucose - reduced
protein - increased

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24
Q

meningitis mx

A

at GP: benzylpenicillin IM & urgent referral to hospital

at A&E: broad spec ABs (ceftriaxone IV, benzylpenicillin IM) acyclovir if viral

targeted ABs
consider dexamethasone
manage close contacts

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25
Q

complications of meningitis

A

hearing loss
sepsis
impaired mental status

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26
Q

encephalitis causes

A

viral: HSV 1-2, CMV, EBV, HIV, measles
non-viral: bacterial meningitis, TB, malaria, listeria, lyme disease, legionella

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27
Q

encephalitis presentation

A

viral prodrome
can have signs of meningism
headache
altered mental state

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28
Q

encephalitis Ix

A

EEG
LP
Blood (FBC, LFT, culture)
CT/MRI

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29
Q

encephalitis Mx

A

give acyclovir to all pts with suspected encephalitis
then give appropriate antiviral or antibiotic according to underlying aetiology

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30
Q

stroke definition

A

sudden onset focal neurological deficit of presumed vascular origin lasting more than 24 hrs

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31
Q

types of stoke

A

haemorrhagic
ischaemic

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32
Q

stroke symptoms

A

acute onset
limb weakness/numbness
facial droop
dizziness
loss of coordination and balance
speech difficulties
visual changes

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33
Q

ACA stroke associated signs

A

contralateral hemiparesis (legs > arms)
behaviour changes

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34
Q

MCA stroke associated signs

A

contralateral hemiparesis (arms > legs)
contralateral hemisensory loss
apraxia
aphasia
quadranotopias

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35
Q

PCA stroke associated symptoms

A

contralateral homonymous hemianopia
visual agnosia

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36
Q

cerebellar dysfunction signs

A

DANISH

Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/heel-shin test

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37
Q

stroke Ix

A

urgent within 1hr:
- non contrast CT head to rule out haemorrhage

ROSIER score - risk of stroke in emergency room

serum glucose - hypoglycaemia may mimic stroke

u&e - exclude hyponatraemia

cardiac enzymes to exclude MI

FBCs - anaemia or thrombocytopenia prior to initiation of thrombolysis or anticoagulants

ECG - monitor vital signs

CT angiogram
carotid doppler

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38
Q

stroke mx

A

once haemorrhage excluded, initial treatment depends of time from symptom onset

<4.5 hrs - thrombolysis (IV alteplase)
then give aspirin 300mg oral

> 4.5 hrs or thrombolysis contraindicated- aspirin 300mg oral

all pts should be referred to stroke unit MDT
swallowing assessment - aspiration pneumonia, choking

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39
Q

secondary prevention of stroke

A

300mg PO of aspirin for 2 weeks
then
AF pts: DOAC/warfarin prophylaxis
non-AF pts: (1st line) clopidogrel lifelong (2nd) aspirin + dipyrimadole + antihypertensive/glucose control/atorvastatin

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40
Q

score used to estimate stroke risk in TIA pts

A

ABCD2 score

score 4+ refer to stroke specialist

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41
Q

transient ischaemic stroke mx

A

300mg aspirin

if within 7 days of episode: specialist review within 24 hrs

if after 7 days of episode:
specialist review within 7 days

secondary prevention
clopidogrel 75mg o.d
+ high intensity statin (atorvastatin)
+ BP control with antihypertensive if necessary

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42
Q

vessels affected in extradural haematoma

A

middle meningeal artery underneath pterion

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43
Q

extradural haematoma signs and symptoms

A

head trauma > loss of consciousness > lucid interval > headache, decreased GCS, symptoms of raised ICP

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44
Q

extradural haematoma ix

A

urgent non-contrast CT head - lemon shape
maybe MRI

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45
Q

extradural haematoma mx

A

surgical emergency
refer to neurosurgery for burr hole or craniotomy

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46
Q

blood vessels affected in subdural haematoma

A

bridging veins

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47
Q

RF for subdural haematoma

A

head trauma and falls
elderly
alcoholics
anticoagulation

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48
Q

classification of subdural haematoma

A

acute - within 72 hrs (younger pts, trauma)

subacute - 3-20 days (worsening headache, elderly)

chronic - after 3 weeks (headache, confusion)

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49
Q

subdural haematoma signs and symptoms

A

gradual continuous headache
fluctuating consciousness
confusion
personality changes
symptoms of raised ICP

50
Q

subdural haematoma ix

A

urgent non-contrast CT head
- banana shape

51
Q

subdural haematoma mx

A

depends on size and presenting symptoms

A to E approach and neurosurgery referral

small (<10mm) + no significant neurological dysfunction - observe

large (>10mm) or significant neurological dysfunction - Burr hole or craniotomy

52
Q

subarachnoid haemorrhage risk factors

A

polycystic kidney disease
alcohol
smoking
hypertension

53
Q

signs and symptoms of subarachnoid haemorrhage

A

pain in back of head
thunderclap headache
meningism signs

54
Q

subarachnoid haemorrhage ix

A

urgent non contrast CT head
- look for hyper-attenuation around circle of Willis

if CT head normal, lumbar puncture
- xanthochromia and oxyhaemoglobin

55
Q

subarachnoid haemorrhage mx

A

same as haemorrhagic stroke

refer for neurosurgical evaluation
nimodipine to prevent delayed cerebral ischaemia
review anticoagulant medication

56
Q

epilepsy triggers

A

there may be no triggers

lack of sleep
alcohol
flashing lights
stress

57
Q

epilepsy signs and symptoms

A

before
- strange feeling in stomach
- strange smells or taste
- visual disturbances

during
- tongue biting
- incontinence
- jerking movements

after
- slow recovery
- post-ictal headache
- post-ictal confusion and drowsiness
- post-ictal myalgia

58
Q

frontal lobe epilepsy presentation

A

motor symptoms
jacksonian march
post-ictal flaccid weakness
involuntary actions

59
Q

temporal lobe epilepsy presentation

A

aura (epigastric discomfort)
automatisms
hallucinations

60
Q

parietal lobe epilepsy presentation

A

sensory disturbances (pain, tingling, numbness)

61
Q

occipital lobe epilepsy presentation

A

visual phenomena

62
Q

tonic-clonic seizures phases

A

tonic phase - muscles stiff
clonic phase - quick rhythmical jerking of limbs

63
Q

absence seizures presentation

A

brief staring episodes lasting 5-10 seconds
LOC but posture may be maintained
common in children
may be mistaken for not paying attention

64
Q

epilepsy Ix

A

EEG
bloods to identify cause
glucose - hypoglycaemia
fbc - infection
u+e - electrolyte disturbances
serum prolactin - post-ictal transient elevation
CT,MRI to identify potential lesion

clinical diagnosis made after 2+ unprovoked seizures occurring >24 hrs apart

65
Q

epilepsy mx

A

focal
- carbamazepine
- lamotrigine

generalised
1st - sodium valproate
2nd - carbamazepine

avoid sodium valproate in women of childbearing age
lamotrigine preferred

66
Q

side effects of antiepileptics

A

psychiatric disturbances
weight gain

carbamazepine - neutropenia and osteoporosis
lamotrigine - Stevens-Johnson syndrome

67
Q

what are dissociative seizures

A

resemble epileptic seizures but no biological correlate

suspect if prolonged duration and history of abuse, psychological precipitants

mx often involves psychotherapy

68
Q

status epilepticus definition

A

seizure lasting > 5 mins or repeated seizures without recovery or regain of consciousness in between

medical emergency

69
Q

status epilepticus triggers

A

non adherence to medication
alcohol abuse
overdose and drug toxicity

70
Q

status epilepticus mx

A

secure airway
- high flow o2

iv access and monitoring

IV lorazepam or PR diazepam
- repeat after 10 mins if seizure doesn’t stop

IV phenytoin

refer to ICU

71
Q

epilepsy complications

A

sudden unexpected death in epilepsy (SUDEP)
behavioural problems
fractures from seizures
complications from drugs

72
Q

Guillain-Barre syndrome aetiology

A

autoimmune process attacking myelin surrounding peripheral nerves

30% cases after gastroenteritis infection caused by Campylobacter jejuni

73
Q

Guillain-Barre syndrome signs and symptoms

A

gastroenteritis
URTI
peripheral neuropathy
-ascending paraesthesia and pain
-symmetrical limb weakness
-hypotonia
- flaccid paralysis
-altered sensation/numbness
-fasciculations

can cause respiratory paralysis

Miller-Fischer syndrome (25% of cases)
- opthalmoplegia
- areflexia
- ataxia

74
Q

Guillain-Barre syndrome Ix

A

definitive diagnosis
- nerve conduction studies

spirometry

lumbar puncture
- increased protein
- normal glucose and WCC

bloods
- anti-ganglioside antibody in Miller-Fisher variant

75
Q

Guillain-Barre syndrome mx

A

IV immunoglobulin (IVIG)

76
Q

cord compression signs and symptoms

A

motor
- limb weakness
-UMN symptoms below level of lesion
-LMN symptoms at level of lesion

sensory
-sensory loss below a specific level
-back pain

autonomic
- constipation
- urinary retention
- erectile dysfunction

77
Q

cord compression Ix

A

definitive diagnosis - MRI
may use CT

bloods- FBCs, u&e, calcium, ESR, immunoglobulin electrophoresis (multiple myeloma)

urine- Bence Jones proteins (multiple myeloma)

78
Q

radiculopathy cause

A

compression of nerve at or near the nerve root as it exits the spinal cord

79
Q

signs and symptoms of radiculopathy

A

LMN symptoms for muscles innervated by this spinal root
dermatomal pattern of pain, numbness

eg sciatica

80
Q

management of radiculopathy

A

physiotherapy and NSAIDs

81
Q

Lasegue’s sign

A

pain in the distribution of the sciatic nerve is reproduced on passive flexion of the straight leg at the hip between 30-70 degrees

82
Q

types of hydrocephalus

A

obstructive
- stenosis of cerebral aqueduct or intraventricular foramina
- posterior fossa lesions compressing 4th ventricle

communicating
- decreased CSF absorption
- increased CSF production

normal pressure
- idiopathic chronic ventricular enlargement without significantly elevated CSF pressure
- triad: urinary incontinence, cognitive impairment, gait apraxia (wet, wacky and wobbly)

hydrocephalus ex vacuo
- ventricular expansion secondary to brain atrophy such as in Alzheinmer’s

83
Q

signs and symptoms of hydrocephalus

A

acute onset
- features of raised ICP
- n+v
- headache
- papilloedema

chronic onset
- cognitive impairment
- unsteady gait
- double vision
- CN palsies

in children
- sunset eyes
- skull enlargement

84
Q

hydrocephalus Ix

A

1st line - CT/MRI head

CSF analysis from ventricular drain

85
Q

management of hydrocephalus

A

ventriculoperitoneal shunting to drain CSF

86
Q

multiple sclerosis types

A

relapsing remitting (RR) ms
or primary progressive MS

both turn into secondary progressive MS

87
Q

multiple sclerosis signs and symptoms

A

optic neuritis
motor weakness
sensory disturbance
fatigue
hemiparesis/hemisensory loss
Lhermitte’s sign

88
Q

multiple sclerosis diagnosis

A
  1. absence of alternative diagnosis
  2. dissemination in time (DIT)
  3. dissemination in space (DIS)

methods:
clinical history and examination
MRI
CSF
electrophysiology (VEPs)

89
Q

antibodies associated with myasthenia gravis

A

autoantibodies against AChR at NMJ
some pts may have anti-MuSK antibodies

90
Q

gland associated with myasthenia gravis

A

thymus gland !

thymic hyperplasia (70%)
thymoma (10%)

91
Q

myasthenia gravis symptoms

A

muscles fatigue with use:

ptosis
diplopia
dysarthria
dysphagia
+/- SOB
fatigable muscles
normal reflexes

92
Q

mysathenia gravis ix

A

bloods
- anti-AChR and anti-MuSK autoantibodies
- some patients are seronegative

EMG
CT/MRI to check for thymomas

93
Q

Lambert Eaton Myasthenic Syndrome pathophysiology

A

autoantibodies against presynaptic VGCC at NMJ

94
Q

Lambert Eaton Myasthenic Syndrome symptoms

A

muscle weakness improves with use
- difficulty walking
- weakness in upper arms and shoulder
- similar symptoms to MG
- autonomic: dry mouth, constipation, incontinence
- hyporeflexia

95
Q

Lambert Eaton Myasthenic Syndrome associations

A

small cell lung cancer - paraneoplastic
autoimmune

96
Q

Lambert Eaton Myasthenic Syndrome Ix

A

CT/MRI of chest for cancer detection should be performed

bloods for autoantibodies
EMG
CT/MRI to check for thymomas

97
Q

motor neurone disease pathophysiology

A

build up of ubiquitinated proteins in the cytoplasm
death of corticospinal tracts

98
Q

MND symptoms and signs

A

progressive muscle weakness
dysphagia
shortness of breath
sparing of oculomotor, sensory and autonomic function
wasting of thenar muscles
wasting of tongue base

upper neurone symptoms
- spasticity
- hyper-reflexia
- clonus
-positive Babinski’s sign

lower neurone symptoms
- hyporeflexia
- hypotonia
- muscle atrophy
- fasciculations and fibrillations

99
Q

Parkinson’s pathophysiology

A

loss of dopaminergic neurones in substantia nigra
misfolded alpha synuclein builds up
Lewy bodies and Lewy neurites

100
Q

drugs that cause parkinsonism

A

drugs that lower dopamine like antipsychotics and antiemetics

101
Q

parkinsonian triad

A

resting tremor
rigidity
bradykinesia

102
Q

6 Ms of Parkinsons

A

Monotonous hypotonic speech
Micrographia
Marche a petit pas
Misery
Memory loss
hypomiMesis

103
Q

diagnosis of parkinsons

A

clinical diagnosis

104
Q

Atypical Parkisonisms

A

Multiple system atrophy
- early autonomic and cerebellar features
- Papp-Lantos bodies

Progressive supranuclear palsy
- early postural instability and vertical gaze palsy

Corticobasal degeneration
- alien limb phenomenon

Vascular Parkinsons
- legs particularly affected
- gait worse than tremor

Lewy Body Dementia
- early dementia + visual hallucinations

105
Q

Huntington’s disease pathophysiology

A

autosomal dominant inheritance
mutation of huntingtin gene (HTT)
expansion of CAG trinucleotide
atrophy of the striatum (caudate and putamen)

106
Q

Huntington’s signs and symptoms

A

motor
- chorea
- athetosis
- dysphagia
- ataxia

cognitive
- depression
- personality changes
- lack of concentration
- dementia

107
Q

Huntington’s Ix

A

CAG repeat testing
MRI

108
Q

Huntington’s CAG repeat testing analysis

A

< 29 repeats: normal range
29-34: pt will not develop disease but next generation is at risk
35-39: some pt may develop disease, next gen at risk
40+: pt will develop disease

109
Q

types of dementia

A

Alzheimer’s
Frontotemporal
Vascular
Lewy body

110
Q

dementia pathophysiology

A

buildup of abnormal amyloid precursor protein (APP)
normally this breaks down into alpha and gamma secretase but in dementia breaks down into beta and gamma secretase which is resistant to degradation

this causes:
- extracellular amyloid plaques
- phosphorylation of tau
- intracellular neurofibrillary tangles
- leads to build up of abnormal APP
- degeneration of ACh neurones

111
Q

5 As of Alzheimers

A

Amnesia
Anomia
Apraxia
Agnosia
Aphasia

(+/- depression and paranoid delusions)

112
Q

Alzheimer’s ix

A

clinical diagnosis
- CSF: high tau, low beta amyloid
- CT, MRI, PET, SPECT
- brain tissue required for definitive diagnosis

MMSE
Addenbrooke’s cognitive assessment
MOCA

113
Q

frontotemporal dementia (Pick’s disease) pathophysiology

A

tauopathy
involves tau. not amyloid beta.
frontal and temporal lobes affected
pick bodies - hyperphosphorylated tau protein
death within 5-10 yrs

114
Q

frontotemporal dementia signs and symptoms

A

onset 40-60yrs

personality change
disinhibition
overeating- prefer sweet foods
emotional blunting
relative preservation of memory

115
Q

Vascular dementia pathophysiology

A

CVS risk factors, female
sx similar to Alzheimer’s
location-specific deficits
affects small and medium vessels
step-wise progression

116
Q

Wernicke’s encephalopathy pathophysiology

A

thiamine deficiency

117
Q

Wernicke’s encephalopathy risk factors

A

alcoholism
malnourishment
bariatric surgery
dialysis

118
Q

Wernicke’s Encephalopathy Ix

A

bloods (serum albumin, vit B1, LFTs)
ECG
CT
neuropsychology

118
Q

Wernicke’s Encephalopathy signs and symptoms

A

triad: ataxia, eye signs, confusion

alcoholism
malnourishment

119
Q

Wernicke’s Mx

A

medical emergency
likely give Pabrinex (B1)

120
Q

Wernicke’s vs Korsakoff’s

A

Wernickes’s:
- acute
- confusion
- cerebellar and eye signs
- reversible

Korsakoff’s:
- chronic
- alert
- amnesia and confabulation
- irreversible?

Phase 1c (13 decks)

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