Neuro Flashcards
(40 cards)
TIA
Path RFs Symps DDx Ix Mx
transient ischaemia (emboli/thrombosis) resolved in 24hrs
Same as stroke
-Transient global amnesia
90% - anterior circulation (one-sided carotid territory)
-hemiparesis, amaurosis fugax, dysphasia, hemisensory disturbance
10% - posterior (vertebro-basilar)
-LOC, bilateral motor+sensory probs
Stroke, hypoglycaemia, focal epilepsy
Todd’s paralysis - focal weakness one sided after seizure
Bloods
ECG - AF/myocardial ischaemia
Carotid doppler
Echo
ABCD2 score - assess stroke risk (high risk >4 = specialist assessment in24hrs, low risk 1week)
-AF, >1 TIA in week, TIA on anticoag = high risk
Control CV risk - weight loss, diet, smoking etc…
No driving 4 weeks
2 weeks 300mg Aspirin
Long term anticoag - clopidogrel
Statin
Carotid endarterectomy - 70% stenosis
Stroke territory types / arteries affected / symps?
Anterior Circulation (MCA/ACA)
- Unilateral weakness (+/- sensory deficit) - face, arm, leg
- Homonymous hemianopia
- High cerebral dysfunction (dysphasia, visuospatial disorder)
Partial anterior circ - 2outof3 symps ^^
Posterior circulation (POCS) - ONE OF:
- Cerebellar / brainstem syndromes
- LOC
- Isolated homonymous hemianopia
Lacunar syndrome (subcortical/midbrain/internal capsule)
- Unilateral weakness (+/-sensory loss) - face/arm/leg
- Ataxic hemiparesis (cerebellar + motor symps)
- Pure sensory loss
Stroke Mx?
ABCDE - hydration, O2, nil by mouth
URGENT CT HEAD - before tx = could be haemorrhagic
if onset time known:
Alteplase (WITHIN 4.5HOURS) –> 24 hours –> 75mg clopidogrel
if time not know:
300mg Aspirin –> 2weeks –> Clopidogrel life long
SAH
Path RFs Symps Ix Mx Comps
berry aneurysm
HTN, aneurysm, FH, predisposition to aneurysms (PCOS, Ehler-danlos, coarctation)
Thunderclap headache, vomiting Neck stiffness -kernig's sign Altered consciousness - collapse, seizure, drowzy, coma Papilloedema CNS def - cranial nerves, hemiplegia
CT - Star-shaped lesion
LP - IF NO ^ICP (done if -ve CT)
-blood –> few hours –> yellow (xanchromic - due to bilirubin from Hb breakdown)
Nipodipine - stop vasospasm + ischaemia
Maintain cerebral perfusion - fluids, DEXAMETHOSE (lower cerebral oedema)
Surgery - clip/coil aneurysm
Comps
hyponatraemia - SIADH
hydrocephalus
Subdural Haematoma
Path RFs Symps - acute/chronic DDx Ix - SHAPE?? Mx Comps
Rupture of bridging veins = deceleration injury
^ICP - shifting of midline
Trauma, ^age - bridging veins more vulnerable, Alcoholism, coagulation
Interval between injury–>symps = days-months
ACUTE:
-^ICP - headache, nausea, vom, HTN
-Focal neuro
-altered consciousness - seizures, confused…
CHRONIC:
-cognitive decline, personality change, headache
-ELDERLY –> symptoms evelove SLOW –> personality+decreased GCS…
EDH, SAH, ICH (contusion), Stroke, Dementia, encephalitis
CT - CRESCENT SHAPE - crosses suture lines
–>N.B. as clot ages density changes
Bloods
ABCDE- prioritise CT
Surgery - craniotomy
Manniotol - if ^ICP
Comps:
Death - due to herniation
^ICP, cerebral oedema
Extra dural haematoma
Path RFs Symps - Main COMP - BAD!!! DDx Ix - SHAPE!!!! Mx
Laceration middle meningeal artery - trauma to temple
Rapid (mins-hours) blood accumulation between bone + dura
Young adults, temporal/parietal bone fracture, RUGBY PLAYERS!!
Brief post-trauma LOC –> LUCID PERIOD (hours-days) –> altered consciousness
^ICP - Headache, nausea, vomiting, seizures, confusion
Neuro def - seizures, contralateral hemiparesis
IMPORTANT - may be RAPID ^ICP
–> ipsilateral pupil dilatation, signs of brainstem compression, DEATH!!
SDH, SAH, ICH (contusion), encephalitis
CT - BICONVEX
X-ray - skull fracture
ABCDE
Mannitol
Surgery - craniotomy
Tension Headache
Path - episodic vs chronic RFs Symps DDx Ix Mx
Episodic <15days/month
Chronic >15days/month for 3 months
Triggers - stress, anxiety, fumes, concentrated visual effort, noise
‘Tight band’ - bilateral ,non-pulsatile, chronic daily
[NOT - aura, nausea, vom, sensitivity to movement]
Migraine, cluster, drug-induced, GCA
CLINICAL
Headache diaries useful
Analgesia - NSAIDs, aspirin, paracetamol - NOT OPIOIDS
Stress relief - massage, acupuncture
lifestyle - reassurance, avoid triggers, diet, exercise
(maybe amytryptilline / other anti-depressants)
Migraine
Path RFs Symps DDx Ix Mx
Throbbing headache preceded by aura
F>M, strong genetics
Triggers - caffeine, chocolate, cheese, alcohol, menstruation, oral contraceptives, exercise , anxiety
+/- Aura - 5-60mins (headache following within 1hour)
- Visual (jagged lines, flashing, hemianopia)
- Sensory (paraesthesia, numbness)
- motor, vestibular
Lasts 4-72hours - mod-severe THROBBING, PULSATILE, UNILATERAL, AGRRAVATED BY MOVEMENT Nausea/vomiting Photophobia Phonophobia - FEAR of loud sounds
tension headache, cluster headache, GCA
CLINICAL DIAGNOSIS - test to rule out co-morbs
CRP, ESR
Imaging / LP indications - worse/severe headache, changing symptoms, posterior headaches, abnormal neuro
Sumatriptan + NSAID/paracetamol + antiemetic
Prophylaxis (2+ per moth / acute mx >2/week)
-Propanolol / topiramate
Cluster Headache
Path RFs Symps DDx Ix Mx
Unilateral, rapid onset, around one eye
In ‘clusters’ of 1-2x/day –> over 5-12weeks –> pain free for months-years
**can be chronic
Smoking, M>F 5:1
Rapid, excruciating pain around one eye - rises to crescendo in minutes - lasts 15-160mins - often wakes from sleep Watery/bloodshot eye - lacrimation, lid swelling, facial flushing. miosis/ptosis \+/-vomiting
Migraine
CLINICAL
Abortive: O2, SUMATRIPTAN Preventative: - Verapamil - 1st line - Avoid alcohol - during headaches - Prednisolone (may help)
Trigeminal neuralgia
Path RFs - main one? Symps - triggers? DDx Ix Mx
Paroxysms of intense, debilitating pain - in CN V distribution (mainly maxillary+mandibular branches)
N.B. CN V = motor + sensory
Compression of trigeminal nerve - from blood vessels/local pathology = demyelination + excitation –> erratic pain signalling
F>M, 50 peak age
HTN - MAIN RF
Sudden, unilateral, knife-like electric shock pain
- starts in mandibular + spreads up
- seconds-mins –> many through day, rarely in sleep
Atypical –> burning sensation
TRIGGERS - shaving, eating, talking, cold wind exposure, dental prostheses, vibration –> i.e. using nerve
MS, GCA - RULE IT OUT!!
MRI - exclude secondary causes /other path
typical analgesia + opioids DO NOT WORK
Carbemazepine (others: Gabapentin, lamotrigene)
Surgical - neurovascular decompression
Radiation - stereotactic radiosurgery
GCA aka Temporal arteritis
Path RFs Symps DDx Ix Mx Additional diagnosis?
Inflammatory granulomatous vasculitis of large cerebral arteries
EXCLUDE IN ALL >50YEAR OLDS WITH NEW HEADACHE THAT HAS LASTED FEW WEEKS
Male, >50years
Takyasu’s - if <50 + esp. Japanese
TEMPORAL PULSATING HEADACHE
SCALP TENDERNESS
JAW CLAUDICATION
AMAUROSIS FUGAX
Tender, thick, pulseless temporal artery
morning stiffness, fatigue, breathless, fever
RISK - ANTERIOR ISCHAEMIC OPTIC NEURITIS
CRP/ESR^ - vasculitis
FBC - normochromic anaemia
Teporal artery biopsy
Doppler USS
Prednisolone
PPIs, bisphosphonates
PMR = presents in 50%!!! - morning stiffness!!
Encephalitis
Path RFs - bugs? Symps DDx Ix Mx Comps
Infection + inflammation of brain PARENCHYMA
-Mainly affecting frontal+temporal lobes
VIRAL - HSV1+2 most common (CMV, EBV, varicella)
non-viral - post meningitis
Extremes of age, immunocompromised
viral infection - headache, fever, fatigue, nausea
Progression:
- DECREASED CONSCIOUSNESS / CONFUSION!!!
- focal neuro def
- seizures
- coma
(may have signs of meningitis)
Meningitis, stroke, brain tumour, space occup. lesion
LP + CSF studies (cultures + PCR)
- +proteins, lecuocytes +/- glucose
FBC+blood film - lecuocytosis
Bloods
Viral PCR + Blood cultures (and others..throat, stool)
CT/MRI - rule out space occupying lesions + identify ^ICP (LP=CI!!!!!)
EEG - diffuse abnormal slow wave changes
Acyclovir
meningitis? - IV BenPen
Supportive +/- anti-seizure meds
Permanent brain damage - if Mx delayed
Meningitis. Define meningococcal septicaemia
Path RFs - bugs? spread? Symps DDx Ix - what is seen?? - for each of bacteria/virus Mx - when do you start Abx? Comps
Inflammation of meninges
Meningococcal septicaemia = when it invades the blood
N. meningitides - droplet spread S. pneumoniae, H.influenza (less common) Preg - listeria monocytogenes Neonates - GBS, E.coli immunosuppressed - TB, CMV Fever **Headache - worst ever **Meningism - Neck stiffness, Photophobia - Kernig's + Brudzinski's NON BLANCHING RASH sezures \+/-altered mental state (cerebral oedema)
SAH (headache more sudden)
Encephalitis (altered mental state = dominant symp)
FBC, Blood culture, Swabs, PCR
LP - microscopy, culture, glucose, PCR (ONLY IF NO ^ICP)
- Bacteria: cloudy, ^protein, low glucose, neutrophils
- Virus: clear, ^protein, normal/low glucose, lymphocytes
NOTIFIABLE DISEASE **Start before tests!! IV Cefotaxime community - IM BenPen Dexamethasone - cerebral oedema Prophylaxis - ciprofloxacin / rifampicin
hearing loss, seizures, dev problems
Guillain-Barre syndrome
Path RFs - bugs? Symps DDx Ix Mx
Acute inflammatory, demyelinating, ascending polyneuropathy - following URTI / GI infection
infection –> antibodies/inflammation –> demyelination
40% - no obvious infectious cause
*Campylobacter jejuni, *CMV, Mycoplasma, zoster, EBV
1-3 weeks post infection:
symmetrical, ascending muscle weakness +/- numbness
GLOVE + STOCKING - distal muscles + progresses
Loss of reflexes, neuropathic pain
Autonomic dysfunction (tachycardia, sweating, arrhythmias)
20% - resp muscles involved - ITU!!
acute paralysis: stroke, TIA, encephalitis, cord compression
peripheral: vasculitis
Nerve conduction studies - slow conduction
LP - ^protein, normal WCC
Spirometry - resp muscle involvement? ITU?
SELF-LIMITING
IV immunoglobulin (decreases severity + duration of paralysis
Monitor ventilation
Epilepsy
Path RFs Symps DDx Ix Mx Who must be informed?
Recurrent spontaneous, intermittent, abnormal, electrical activity - in form of seizures
Seizure = clinical feature of desynchronus neuronal discharge
40%-Primary generalised - bilateral symmetrical synchronus –> no focal abnormality
57%-Partial - One hemisphere (focal/structural abnormality until proven otherwise)
Mostly idiopathic
Cerebrovascular disease, tumour, CNS infection, Trauma
Symps - SEE TYPES OF SEIZURE CARD + LOBE CARD
POST - ICTAL (esp tonic-clonic)
- confusion/drowzy/coma - up to hours
SYNCOPE!!
arrhythmia, TIA, Migraine, hypoglycaemia, panic attack, non-epileptic seizure
CLINICAL - 2 unprovoked seizures, 24hours apart
EEG - only supports diagnosis
Bloods - DEFG!
MRI>CT - ?structural
Primary generalised - Valproate / Lamotrigene
Absence - Valproate / ethosuxamide
Partial - Carbemazepine / Lamotrigene
MUST INFORM DVLA:
- FORMAL EPILEPSY DX = 1year w/o seizure
- 1 seizure = wait 6months
Types of seizures:
1) Primary
2) Partial - simple, complex?
PRIMARY
Generalised tonic clonic - stiff then jerking. BITE TONGUE
Clonic seizures - repeated myoclonic 2-3 per second
Tonic seizures - sudden increased tone - characteristic guttural cry/grunt
Absence
Myoclonic seizures
Atonic seizure –> sudden loos of tone
PARTIAL - i.e. focal seizures Simple - 90secs - No LOC, sudden jerking, sensory phenomena, aware of surroundings - NO post-ictal
Complex
- 1-2mins
- automatisms (lip-smacking, chewing), AURA, unaware of environment, LOC
- Post-ictal symps
Partial w/ secondary generalisation - partial –> generalised
Epilepsy symps for each lobe - i.e. partial seizures?
Temporal:
- Aura - deja-vu, audito hallucinations, funny smells, fear
Frontal
- Motor features. Jacksonian march
Parietal
- Sensory disturbance - tingling/numbness
Occipital
- visual phenomena
SUDEP? What?
Sudden unexpected death in epilepsy
-non-drowning death
DEFINE + Management of prolonged seizure / status epilepticus!!!
Seizure lasting >30mins / recurrent seizures w/o full recovery between
ABCDE --> DEFG!! oxygen buccal midaz / rectal diaz / IV loraz repeat IV loraz IV Phenytoin / Valproate Anaesthetist
Parkinson’s
Path RFs Symps - TRIAD??? DDx Ix Mx - Problem with 1st line?
LOSS OF DOPAMINE AND MELANIN IN STRIATUM
degeneration of dopaminergic neurons in substantia nigra
Lewy bodies develop - eosinophillic inclusions of ubiquitin + alpha-synuclein
peak onset 55-65yrs - ^prevalence with age
insidious - commonly impaired dexterity + unilateral foot drop TRIAD - RESTING TREMOR, BRADYKINESIA, RIGIDITY - tremor = pill-rolling Others: - Difficulty with fine movements - Cogwheeling - Parkinsonian gait - postural instability - falls - Micrographia - brisk reflexes - monotonous scattato speech - depression, anosmia, visual hallucinations, constipation, urinary incontinence/freq.
Lewy Body dementia, Parkinsons plus, drug-induced (EPSE), Wilson’s
CLINICAL DIAGNOSIS
response to Levodopa - to confirm
MRI - later show substantia nigra atrophy
MDT - progressive + incurable
GOLD - LEVODOPA + CARBIDOPA (decarboxylase inhibitor –> prevents L-DOPA peripheral conversion)
- N.B. L-DOPA ONLY SYMPTOM RELIEF
Other treatments - due to L-DOPA limitations (don’t start until absolutely necessary)
- Dopmaine agonists - ropinirole
- MOABs - rasagiline
- COMT inhibitors - tolcapone
Limitations of L-DOPA. Reason why it’s not started until absolutely necessary
other treatments offered first?
Reduced efficacy over time - even with ^dose
Induced dyskinesia
on-off effect –> fluctuations in motor performance
- Dopmaine agonists - ropinirole
- MOABs - rasagiline
- COMT inhibitors - tolcapone
Parkinson plus syndromes?? 4 of them!
Progressive supranuclear palsy
- Postural instability - falls
- vertical gaze palsy
Multiple system atrophy
- autonomic features - postural hypotension, urinary dysfuction)
- cerebellar signs - DANISH
Corticobasal Degeneration
Lewy Body dementia - if motor symptoms + dementia TOGETHER
- if dementia >1year after motor = feature of parkinsons!
HUNTINGTON’S
Path RFs Symps DDx Ix Mx
AUTOSOMAL DOMINANT CAG repeats Decreased GABA + ACh synthesis (normal dopamine) Progressive cerebral atrophy in caudate nucleus and putamen - in basal ganglia
30-50years = onset
Chorea - jerky, repetitive, explosive, figidity movements
Personality change (e.g. irritability, apathy, depression) + intellectual impairment (dementia)
Dystonia
Saccadic eye movements
Syndenham’s chorea, Wilson’s Disease
CLINICAL
CT/MRI - caudate nucleus atrophy
Genetic testing - CAG repeats
No Mx to prevent progression Counselling Chorea - tetrabenazine, benzos, valproic acid Antidepressants Antipsychotics
MOTOR NEURONE DISEASE
Path RFs Symps - 4 TYPES!! What is spared?? DDx Ix Mx
Progressive degenration of motor nerves in:
- Spinal cord - anterior horn
- CN motor nuclei
- Brain cortex
Genetic
Mainly sporadic - unknown trigger
Mixtures of UMN/LMN signs depending: Amyotrophic Laterelising Sclerosis (ALS): - UMN + LMN - Frontotemproal dementia link - regardless what body part first affected = spreads to other parts of body Primary Lateralising Sclerosis (PLS) - UMN Progressive muscular atrophy (PMS) - LMN Progressive Bulbar palsy (PBP) - UMN + LMN of lower CN - early bulbar symps - dysphagia + dysarthria
3 PATTERN OF ONSET:
- Limb
- Bulbar (20%)
- Resp onset (least common)
SPARED:
- RECTAL/BLADDER SPHINCTERS
- OCULOMOTOR MUSCLES
CLINICAL
EMG/nerve conduction
Genetics - research only
RILUZOLE!!! - not a cure extends life by 3months MDT Symptomatic - e.g.: - baclofen - spasms - PEG tube for feeding - Non-invasive ventilation
