Neuro Flashcards
(93 cards)
1
Q
Differential of headache
A
Tension headache Migraine Cluster headache Giant cell arteries Raised ICP Trigeminal Neuralgia Subarachnoid Haemorrhage Trauma Sinusitis Glaucoma Iatrogenic
2
Q
Symptoms of raised ICP
A
Worse on... Waking Lying down Bending forwards Coughing
Need to rule out SOL
3
Q
Symptoms of tension headache
A
Frontal
Gradually worsens
Lasts hours to days
Precipitated by stress/fatigue
Recurrent bilateral, often described as tight band
4
Q
Symptoms of migraine
A
Lasts hours
Associated with vomiting/photophobia
May be aura/altered sensation
Female
Strong family history
Usually unilateral and throbbing
In women may be associated with menstruation
5
Q
Symptoms of cluster headache
A
Episodic - 2-10x a day lasting 15mins-2hrs
Peri orbital
Isolated sweating/lacrimation/rhinorrhoea/nasal stuffiness
Alcohol common trigger, typically men and smokers
6
Q
Symptoms of subarachnoid
A
Thunderclap
Occipital headache
Severe
Drop in GCS
Possible trauma
7
Q
Symptoms of giant cell arteritis
A
Sub Acute onset (few weeks)
Elderly patient
Tender temporal arteries
Jaw claudication
Raised ESR
8
Q
Symptoms of trigeminal neuralgia
A
Lasts seconds
Classic - washing or shaving affected area
9
Q
Red flags for headache
A
Suddenly onset and severe
Altered consciousness level
Fever/neck stiffness
New onset focal neurology
Trauma
Position dependent
Red eye/eye pain/ visual loss/ nausea
Tender temporal regions
Pregnancy
10
Q
Manage
Tension headache
A
Simple analgesia
Paracetamol + Ibuprofen
11
Q
Manage
Migraine
A
Acute
- 1st NSAIDs + Aspirin 900mg
- 2nd triptans
Prophylaxis
- 1st propranolol
- 2nd topiramate or amitriptyline
12
Q
Manage
Cluster headache
A
Acute = Triptan/100% oxygen
Prophylaxis = Verapamil or Topiramate
13
Q
Manage
Trigeminal Neuralgia
A
1st Carbemazepine
2nd Lamotrigine
14
Q
Manage
Giant Cell Arteritis
A
Prompt steroids
15
Q
Types of strokes and how common
A
Ischaemic = 85%
Haemorrhagic = 15%
Urgent CT head to differentiate and treat
16
Q
Subtypes of haemorrhagic stroke
A
Intracerebral
- intra parenchymal
- intra ventricular
Subarachnoid (between pia mater and arachnoid)
17
Q
Risk factors for haemorrhagic stroke
A
Elderly
Male
Anticoagulation (warfarin or NOAC)
FH
Chronic liver disease
HTN
18
Q
Managing haemorrhagic stroke
A
Neurosurgery
May opt for burr hole/craniotomy
19
Q
Risk factors for ischaemic stroke
A
HTN
Smoking
Carotid artery stenosis
AF
FH
Previous stroke
20
Q
Management of Ischaemic Stroke
A
- Within 4.5 hours of onset of symptoms – thrombolyse with ALTEPLASE in the absence of contraindications e.g. recent major surgery
- If not suitable for thrombolysis – aspirin 300mg
- Aspirin for 2 weeks then lifelong anti-thrombotic management with clopidogrel 75mg
21
Q
Secondary Prevention of Ischaemic Stroke
A
Statin, anti-hypertensive, anticoagulate if in context of AF, optimize treatment of co-morbidities e.g. DM
22
Q
History for head injury
A
Mechanism? High/low energy? Likely part of polytrauma or isolated?
Pain? Where? Head? Neck?
Loss of consciousness, amnesia, persistent vomiting, progressive headache, altered level of consciousness
Intoxication?
More difficult to assess severity
Anticoagulation?
PMH - previous head trauma, seizures
23
Q
Examination of head injury
A
C-spine, ABCDE GCS 13-15 mild, 9-12 mod, <9 severe Pupils – indicator of ICP Sluggish response to light Asymmetrical Papilloedema ‘down and out’ BOS fracture signs
24
Q
Head Injury DDx
A
BOS fracture CN VII, CN VIII deficit – can complain of facial numbness/vertigo Subdural haematoma Extradural haematoma Intra-cranial haemorrhage Diffuse axonal injury
25
Rules for CT1
GCS 12 or less
GCS 13-15 and:
BOS/depressed skull fracture and/or penetrating injury
Dropping GCS or new focal neurology
Anticoagulated and LOC, amnesia or any neurological feature
Persistent and severe headache
TWO distinct episodes of vomiting
26
Rules for CT2 (within 8 hours)
```
GCS 15 and any of:
Age >65 with LOC or amnesia
Evidence of possible skull fracture but no other features indicative of immediate CT
Retrograde amnesia >30 minutes
Any seizure activity
Significant mechanism of injury
```
27
Signs of base of skull fracture
Battle's sign – bruising of the mastoid process of the temporal bone.
Raccoon eyes – bruising around the eyes, i.e. "black eyes"
CSF rhinorrhea
Cranial nerve palsy
Bleeding (sometimes profuse) from the nose and ears
Hemotympanum
Conductive or perceptive deafness, nystagmus, vomitus
In 1–10% of patients, optic nerve entrapment occurs.The optic nerve is compressed by the broken skull bones, causing irregularities in vision.
28
Subdural Haematoma
Bleed between dura and arachnoid mater
Caused by bleeding between damaged bridging veins between cortex and venous sinuses
29
Subdural Haematoma is associated with...
Anticoagulation
alcohol xs
elderly falling and cerebral atrophy
30
CT of subdural haematoma
CT – crescent shaped, bleeding does not cross midline
31
Management of subdural haematoma
Conservative. Reverse coagulopathy, consider antiepileptics prophylactically
Burr hole if GCS <9/neuro signs
32
Extradural Haematoma
Direct impact injury
Lucid interval, then drop GCS
Often focal neurology
CT - ‘lentiform’ appearance
33
Diffuse Axonal Injury
Rapid acceleration/deceleration e.g. RTC
Rapid deterioration in GCS
CT can appear normal in acute phase
Examination findings out of keeping with CT findings
34
Causes of seizures
```
Idiopathic – approx 2/3
Structural
Cortical scarring secondary to previous HI
Developmental
SOL
AVM
Non-epileptic causes of seizures
Trauma
Stroke
Haemorrhage/raised ICP
Alcohol or BDZ withdrawal
Metabolic e.g. hyponatraemia
Iatrogenic e.g. tricyclics, tramadol
```
35
Classification of seizures
Generalised
Awareness is always impaired
Both hemi-spheres involved
Tonic-clonic
Absence
Myoclonic
atonic
36
Classification of seizures
Focal
Awareness may or may not be impaired
Originates in a single hemisphere
Simple
Complex
Secondary generalisation
37
Describe tonic clonic seizure
```
Loss of consciousness
Urinary incontinence
Tongue biting
Stiffened limbs +/- shaking
Post-ictal state
```
38
Describe absence seizure
Child
Brief pause (under 10s)
Returns to normal
Unaware it's happened
39
Describe a myoclonic seizure
Sudden jerk
| Thrown to the ground or throw object out of hand involuntarily
40
Describe an atonic seizure
Sudden loss of tone
41
Localising features of focal lesions
Temporal Lobe - most common
Automatisms e.g. ‘lip smacking’, fiddling fingers
Dysphasia
Memory phenomena i.e. déjà vu/jamais vu
Hippocampal – emotional disturbance
Hallucinations (auditory, gustatory, olfactory)
Epigastric rising, emotional
42
Localising features of focal lesions
Frontal Lobe
Motor features e.g. posturing, peddling of legs, pelvic thrust
Head/leg movements, post-ictal weakness
43
Localising features of focal lesions
Parietal Lobe
Sensory disturbance eg tingling, numbness or pain
44
Localising features of focal lesions
Occipital
Visual phenomena such as spots, lines and flashes
45
Investigations of seizure
Rule out precipitating cause
EEG
NOT diagnostic
Used once clinical diagnosis is made after two seizures
Can help differentiate type of seizures and guide prognosis
Normal EEG does not exclude epilepsy
46
Status Epilepticus - Definition
5 or more minutes of continuous seizure activity or repetitive seizures with no intervening period of recovery
47
Status Epilepticus - Treatment
IV Lorazepam 4mg
2nd line = Phenytoin
48
Management of Generalised Tonic Clonic Seizure
1st Line = Valproate/ Lamotrigine
49
Management of Absence Seizure
1st line = Ethosuximide
50
Management of Tonic/Atonic Seizure
1st line = Valproate
51
Management of Myoclonic Seizure
1st line = Levetiracetam
52
Management of Focal Seizure
1st line = Carbemazepine or lamotrigine
| Carbemazepine can make generalised epilepsy worse!
53
Side effects of Sodium Valproate
Teratogenic
Weight Gain
Hair loss
Fatigue
54
Side effects of Phenytoin
Mechanism of action : binds to sodium channels increasing their refractory period
Monitor due to toxicity
Acute - initially dizzy, diplopia, nystagmus, slurred speech, ataxia
Later - confusion, seizures
Chronic - common - gingival hyperplasia, hirsutism, coarsening of facial features drowsiness
- megaloblastic anaemia (altered folate metabolism), peripheral neuropathy, lymphadenopathy, dyskinesia, osteomalacia (enhanced Vit D metabolism)
Idiosyncratic - fever, rashes (including toxic epidermal necrolysis), hepatitis, dupytrens, aplastic anaemia, drug induced lupus
Teratogenic - cleft palate and congenital heart disease
55
Driving and epilepsy
1st seizure – car = 6 months, 5 years for HGV/PCV
| Epilepsy – car = 1 year or 3years during sleep, 10 years off medication for HGV/PCV
56
Cerebellar Symptoms
DANISH
```
Dysdiadokokinesis, Dysmetria
Ataxia
Nystagmus (horizontal)
Intention Tremor
Slurring speech, scanning dysarthria
Hypotonia
```
57
Causes of cerebellar syndrome
Unilateral cerebellar lesions cause ipsilateral signs
```
Friedrichs ataxia, ataxic telangiactasia
Neoplastic: cerebellar haemangioma
Stroke
Alcohol
MS
Hypothyroidism
Drugs - phenytoin, lead poisoning
Paraneoplastic eg. Secondary to lung cancer
```
58
Symptoms of medication overuse headache
Present for 15 days or more per month
Developed or worsened while taking regular symptomatic medication
Patients using opioids and triptans most at risk
May be psychiatric comorbidity
59
Carbamazepine - side effects, mechanism of action, common uses
Common uses - partial seizures, neuropathic pain, bipolar disorder
Mechanism - binds to sodium channels and increases their refractory period
Adverse effects - P450 enzyme inducer, dizziness and ataxia, drowsiness, headache, visual disturbances (especially diplopia), SJS, leukopenia and agranulocytosis, SIADH
60
Neuroleptic malignant syndrome
| 4 features
Hyperthermia
Muscle rigidity
Autonomic instability
Altered mental status
61
Painful third nerve palsy
Posterior communicating artery aneurysm
62
Amyotrophic lateral sclerosis associated with...
Mixed UMN and LMN signs (usually no sensory deficits)
63
Subdural Haemorrhage - what is happening?
Damage to bridging veins between cortex and venous sinuses
64
Essential tremor
Autosomal Dominant
Worse when arms outstretched
Better with alcohol and propranolol
65
Triptans - what are they, prescribing points, adverse affects and contraindications
5HT1 agonists used in acute treatment of migraine
Should be taken after onset of headache, not aura.
Adverse effects - triptans sensations - tingling, heat, tightness in throats and chest, heaviness, pressure
Contraindicated - in patients with a history of, or significant risk factors for, ischaemic heart disease of cerebrovascular disease
66
Most common complication following meningitis
Sensorineural hearing loss
67
Features of Wernicke's Encephalopathy
CAN OPEN
```
Confusion
Ataxia
Nystagmus
Opthalmoplegia
PEripheral
Neuropathy
```
Caused by B1 - thiamine - deficiency
68
Ptosis + Dilated Pupil
Third nerve palsy
69
Ptosis + Constricted Pupil
Horner's syndrome
70
Pseudoseizures..
Tend to have a gradual onset
71
Management of restless leg syndrome
Dopamine agonists such as ropinirole
72
Sinusitis + focal neurology and fever
? Brain Abscess
73
What is pituitary apoplexy?
Sudden enlargement of pituitary tumour secondary to haemorrhage or infection
74
Features of pituitary apoplexy
Sudden onset headache
Vomiting
Neck stiffness
Visual field defects - classically bitemporal superior quadrantic defect
Extraocular nerve palsied
Features of pituitary insufficiency eg hypotension secondary to hypoadrenalism
75
Management of pituitary apoplexy
Urgent steroids
76
Management of mysathenic crisis
IV immunoglobulin
Plasma electrophoresis
77
Stroke by anatomy
Anterior cerebral artery
Contralateral hemiparesis and sensory loss, lower extremity>upper
78
Stroke by anatomy
Middle Cerebral Artery
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
79
Stroke by anatomy
Posterior cerebral artery
Contralateral homonymous hemianopia with macular sparing
| Visual agnosia
80
Stroke by anatomy
Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain)
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
81
Stroke by anatomy
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)
Ipsilateral: facial pain and temp loss
Contralateral: limb/torso pain and temp loss
Ataxia, nystagmus
82
Stroke by anatomy
Anterior inferior cerebellar artery (lateral pontine syndrome)
Similar to Wallenbergs but
Ipsilateral: facial paralysis and deafness
83
Stroke by anatomy
Retinal/ophthalmic artery
Amaurosis fugaxy
84
Stroke by anatomy
Basilar artery
Locked in syndrome
85
Features of syringimyelia
Spinothalamic sensory loss (pain and temp)
Loss of reflexes, bilateral upgoing plantars
Motor wasting and weakness of arms
Slow progression - years
May be asymmetrical initially
Development of cavity in spinal cord (if extends into medulla then syringobulbia)
86
Describe subacute combined degeneration of spinal cord and explain why it happens
Happens due to vitamin B12 deficiency
Dorsal and lateral columns affected
Joint position and vibration sense lost first then distal paraesthesia
UMN signs typically develop in legs - classically extensor planters, brisk knee reflexes, absent ankle jerks
If untreated stiffness and weakness persist
87
Multiple system atrophy
Suspect if unilateral Parkinsonism and severe autonomic disturbance
Shy Drager syndrome is a type -
Parkinsonism
Autonomic disturbance (atomic bladder, postural hypotension)
Cerebellar signs
88
When a young person (under 55) with no obvious cause of stroke has a stroke what is the blood test work up?
Thrombophilia
Autoimmune screening
ANA antinuclear antibodies, APL antiphospholipid antibodies, ACL anticardiolipin, LA lupus anticoagulant, coagulation factors, ESR, homocysteine and syphilis serology
89
TIA immediate antithrombotic therapy
Give aspirin 300mg immediately
Unless
- patient has a bleeding disorder or takes anticoagulant
- patient is taking low dose aspirin regularly
- aspirin is contraindicated
90
Antithrombotic therapy for TIA
Clopidogrel
91
Types of dysphasia
Wernickes (receptive)
Superior temporal gyrus
Fluent speech
Abnormal comprehension
Repetition good
92
Types of dysphasia
Conductive (associative)
Actuate fasciculus
Fluent speech
Abnormal comprehension
Poor repetition
93
Types of dysphasia
Broca's (expressive)
Inferior frontal gyrus
Non fluent speech
Normal comprehension
Repetition good
