Neurological Flashcards
1
Q
What is the definition of a stroke?
A
An acute focal (or global in a coma) neurological deficit/disturbance, of an arterial origin, which lasts more than 24 hours, or >24 hours with positive neuro imaging.
2
Q
What is a TIA?
A
It is a transient ischaemic attack which lasts less than 24 hours, and will have no positive neurological imaging.
3
Q
What are the two main types of stroke and which of the two occurs more commonly?
A
- Ischaemic stroke - 85%
2. Haemorrhagic stroke - 15%
4
Q
What are the other two, rarer causes of stroke?
A
- Cerebral venous thrombosis
2. Carotid artery dissection
5
Q
What are the two main types of haemorrhagic stroke?
A
- Intracerebral haemorrhagic stroke
2. Subarachnoid haemorrhagic stroke
6
Q
What is an intracerebral haemorrhagic stroke?
A
A focal collection of blood from a ruptured blood vessel within the brain parenchyma or ventricular system
7
Q
What is a subarachnoid haemorrhagic stroke?
A
A focal collection of blood between the surface of the brain and the arachnoid tissues covering the brain.
8
Q
What are the two common causes of ischaemic stroke?
A
- Thrombus (often as a complication of atherosclerosis)
- Embolus of fatty material from an atherosclerotic plaque or a clot in a larger artery of the heart (often as a complication of AF).
9
Q
What is the main cause of intracerebral haemorrhagic stroke?
A
High blood pressure
10
Q
What are the main causes of subarachnoid haemorrhagic stroke? (3)
A
- Bleeding from a cerebral blood vessel
- Aneurysm
- Vascular malformation.
11
Q
What are the lifestyle risk factors associated with CVD which raise the risk of stroke and TIAs? (4)
A
- Smoking
- Alcohol/drug misuse
- Physical inactivity
- Poor diet
12
Q
What established CVDs are risk factors for strokes/TIAs? (7)
A
- Hypertension
- AF
- Infective endocarditis
- Valvular disease
- Carotid artery disease
- Congestive heart failure
- Congenital or structural heart disease, including patent foramen ovale
13
Q
Other than CVDs what are the other risk factors associated with strokes/TIAs? (8)
A
- Age
- Gender (more common in males)
- Hyperlipidaemia
- Diabetes
- Sickle cell disease
- CKD
- Obstructive sleep apnoea
- Antiphospholipid syndrome
14
Q
In the UK, approximately how many people per 100,000 experience a stroke for the first time each year?
A
230/100,000
15
Q
In the UK, approximately how many people per 100,000 experience their first TIA each year?
A
50/100,000
16
Q
What are the complications in the early period following a stroke? (6)
A
- Haemorrhagic transformation of ischaemic stroke (important to remember!)
- Cerebral oedema
- Seizures
- VTE - PE has been associated with 13-25% of deaths in the early period following stroke
- Cardiac complications - e.g. MI/AF/arrhythmias
- Infection - increased risk of aspiration pneumonia, UTI and cellulitis
17
Q
What mobility problems can frequently occur after suffering a stroke? (4)
A
- Hemiparesis/hemiplegia - affects 80%
- Ataxia
- Falls
- Spasticity and contractures
18
Q
In terms of muscle movement, what is the difference between neglect and inattention?
A
Neglect is when there is a definite loss of power in the limb/affected region, so for example squeezing their first is not possible.
Inattention is when the patient for example is asked to clench both their fists at the same time, the affected side won’t do anything, but if asked just to clench the affected side, they will be able to.
19
Q
What are long-term complications are people who have suffered a stroke going to experience? (12)
A
- Sensory problems (80% experience some loss of touch/temperature/pain)
- Continence problems
- Pain
- Fatigue
- Problems with swallowing, hydration and nutrition
- Sexual dysfunction
- Skin problems (increased risk of pressure sores)
- Visual problems (altered acuity, hemianopia, diplopia etc)
- Cognitive problems
- Difficulties with activities of daily living (ADL)
- Emotional and psychological problems- depression & anxiety are common
- Communication problems - dysphasia & dysarthria
20
Q
What % of all deaths in the UK are attributed to stroke?
A
7%
21
Q
The mortality rates in haemorrhagic stroke are what % higher than for ischaemic strokes?
A
35-40% higher
22
Q
What comorbidity increases the risk of mortality in someone suffering an acute ischaemic stroke?
A
AF
23
Q
What are the clinical signs of focal neurological deficits which tend to resolve within a couple of hours and may indicate a TIA? (7)
A
- Unilateral weakness or sensory loss.
- Dysphasia.
- Ataxia, vertigo, or incoordination.
- Syncope.
- Sudden transient loss of vision in one eye (amaurosis fugax).
- Homonymous hemianopia.
- Cranial nerve defects.
24
Q
What are the clinical signs of focal (or global if severe) neurological deficits which last longer than 24 hours may indicate a stroke? (11)
A
- Confusion, altered level of consciousness and coma.
- Headache – sudden, severe and unusual headache which may be associated with neck stiffness. Sentinel headache(s) may occur in the preceding weeks.
- Weakness − sudden loss of strength in the face or limbs.
- Sensory loss – paraesthesia or numbness.
- Speech problems such as dysarthria.
- Visual problems – visual loss or diplopia.
- Dizziness, vertigo or loss of balance — isolated dizziness is not usually a symptom of TIA.
- Nausea and/or vomiting.
- Specific cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis).
- Difficulty with fine motor co-ordination and gait.
- Neck or facial pain (associated with arterial dissection).
25
What are the differential diagnosis when it comes to stroke/TIA? (7)
1. Migraine
2. Giant cell arteritis
3. Hypoglycaemia
4. Seizures
5. Trauma
6. Meningitis/Encephalitis
7. Tumour (or space occupying lesions)
26
What drug should immediately be given to someone who has had a transient ischaemic attack (TIA)?
Aspirin
27
What drug is recommended for treatment of an acute ischaemic stroke, if it can be administered within the 4.5 hours from onset of symptoms?
Alteplase
28
What type of drug is Alteplase?
Thrombolytic/fibrinolytic
29
Which drug should be initiated 24 hours after thrombolysis with alteplase (or streptokinase)?
Aspirin
30
If a patient has aspirin sensitivity, which drug is an alternative?
Clopidogrel
31
What drug is recommended for the long-term treatment following a stroke or TIA?
Clopidogrel
32
If clopidogrel is not tolerated or contraindicated for the patient, what other drug can be used?
Modified release dipyridamole, in combination with aspirin.
33
Anti-coagulants are not recommended for use in long-term prevention of stroke, except in patients with which condition?
AF
34
What drug should be initiated 48 hours post-stroke, regardless of patients serum-cholesterol concentration?
A statin
35
In people experiencing a TIA, what is the target BP they should aim to achieve? (through medication and lifestyle changes)
<130/80mmHg
36
Which drug should not be used to aid lowering hypertension in patients who have experienced a stroke/TIA?
Beta-blockers
37
What is the initial management of someone experiencing a haemorrhagic stroke?
Surgical intervention
38
What is the recommendation regarding treatment for people who have suffered a haemorrhagic stroke, yet have atrial fibrillation?
Unless the patient is at a very high risk of ischaemic stroke, they should not be given anti-coagulants or aspirin. Statins may be used with caution when the risk of vascular event outweighs the risk of further haemorrhage. (This rule applies to the anticoagulants/aspirin too).
39
What does TACS stand for?
Total anterior circulation stroke
40
What are the three distinct symptoms used to identify a total anterior circulation stroke?
1. Higher dysfunction (aphasia, visuospatial disturbance, decreased consciousness level)
2. Homonymous hemianopia
3. Hemiparesis (2 of face, arm and leg)
41
What does PACS stand for?
Partial anterior circulation stroke
42
How is a PACS identified?
It is 2 out of the 3 clinical features of a TACS.
1. Higher dysfunction (aphasia, visuospatial disturbance, decreased consciousness level)
2. Homonymous hemianopia
3. Hemiparesis (2 of face, arm and leg)
43
What is important to remember when diagnosing/identifying a PACS/TACS?
The symptoms must all be on the same side! If it is a right TACS/PACS then there will be left-sided symptoms and vice versa.
44
What does LACS stand for?
Lacunar stroke
45
What commonly occurs in a LACS?
Either:
Purely motor loss
Purely sensory loss
Ataxic hemiparesis
46
What does POCS stand for?
Posterior circulation stroke
47
What is generally affected in a POCS?
Cerebellar function;
48
Which examination needs to be carried out in a suspected POCS, and what is the useful acronym to remember?
VANISH'D:
1. Vertigo
2. Ataxia
3. Nystagmus
4. Intention tremor
5. Slurred speech (this occurs in TACS/PACS too)
6. Heel-shin test
7. Dysdiaodochokinesis
49
In the event of a stroke, once it haemorrhagic stroke has been ruled out, what is the course of action?
1. If less than 4.5 hours post initial symptoms, then initiate thrombolysis - i.e. alteplase
2. Give aspirin ASAP
3. Clopidogrel is the preferred anti-platelet to be given long-term
4. If clopidogrel is not tolerated, then dipyridamole is indicated
50
What is a subarachnoid haemorrhage, and what causes it?
It is a spontaneous arterial bleed into the subarachnoid space. It can be caused by:
1. Saccular (berry) aneurysms - 70% of cases
2. Congenital arteriovenous malformations - 10%
3. Head trauma
51
What are the risk factors associated with subarachnoid haemorrhage? (5)
1. Smoking
2. Alcohol
3. Hypertension
4. CVD
5. Marfan syndrome
52
How does a SAH present? (3)
1. Thunderclap headache
2. Nausea and vomiting
3. Sometimes a loss of consciousness
Most intracranial aneurysms remain asymptomatic until they rupture and cause an SAH. Typical presentation of a SAH is sudden onset, severe 'thunderclap' headache, often occipital region, that reaches its maximum intensity immediately or within minutes.
53
What are the signs of a SAH on examination? (2)
1. Meningeal irritation - neck stiffness and a positive kernings sign
2. Possible papilloedema
54
What investigations are performed when symptoms suggest a SAH?
1. Immediate CT scan - 95% of cases will show bleeding (lumbar puncture if CT scan appears normal but symptoms strongly suggestive)
2. MR angiography to establish source of bleeding
55
What is the treatment for SAH? (3)
1. A calcium channel blocker - Nimodipine - to reduce cerebral artery spasm
2. Surgical clipping or insertion of fine wire coil to prevent further bleeding
3. Cautious control of hypertension and bed rest
56
What is the prognosis for a SAH?
1/3 die
1/3 survive with disability
1/3 survive with good recovery
57
What conditions may present similarly to SAH?
1. Other types of strokes
2. Hypoglycaemia
3. Migraine
4. Hepatic encephalopathy
58
How many people in the UK have epilepsy or take anti-epilepsy medication?
9.7 per 1000, so approximately 600,000 people take anti epileptic medication
59
What is an epileptic seizure?
An epileptic seizure is the transient occurrence of signs or symptoms due to abnormal electrical activity in the brain. This manifests itself as a disturbance of consciousness, behaviour, emotion, motor function, or sensation
60
How does the International League Against Epilepsy define epilepsy?
A disease of the brain characterised by one any the following:
1. At least two unprovoked seizures occurring more than 24 hours apart.
2. One unprovoked seizure and a probability of further seizures similar to the general recurrence risk after two unprovoked seizures, occurring over the next 10 years.
3. Diagnosis of an epilepsy syndrome — there are at least 30 different epilepsy syndromes distinguished by their seizure type, age of onset, family history, neurological findings, cerebral imaging (such as CT or MRI scan), electroencephalogram (EEG) pattern, and underlying cause.
61
Who does epilepsy tend to affect? When does it tend to occur?
1. Most commonly starts in children or in older people >60 years of age - bimodal incidence
2. More common in people with learning disabilities
62
What is status epilepticus?
A continuous seizure for 30 minutes or longer, or recurrent seizures without regaining consciousness lasting 30 minutes or longer
63
What are the causes of epilepsy?
1. About 2/3 of people in the UK with epilepsy do not have an identifiable cause - idiopathic epilepsy. There is thought to be a genetic component, as 30% of people with idiopathic epilepsy have a first-degree relative with the condition
2. About 1/3 of people in the UK have symptomatic epilepsy - meaning there is an identifiable cause. The most common causes are:
- cerebrovascular disease
- cerebral tumour
- post-traumatic epilepsy.
Less commonly they can be:
- fetal hypoxia or trauma
- cerebral abscess
-surgery to the brain.
64
What are the types of generalised epileptic seizures?
1. Tonic
2. Clonic
3. Typical absence seizures which begin in childhood
4. Myoclonic
5. Atonic
65
What are the types of focal epileptic seizures?
1. Focal motor
| 2. Focal sensory
66
How does a tonic seizure present?
Tonic : impairment of consciousness and stiffening (trunk straight or flexed at waist)
67
How does a clonic seizure present?
Clonic : jerking and impairment of consciousness
68
How do typical absence seizures present?
Begin in childhood: sharp onset and offset with no residual symptoms. Normal activity is interrupted and the child stares for a few seconds The eyelids may twitch and some very small jerking movements of the hands may occur. Lasts 5-10 seconds and usually less than 30. Can occur hundreds of times a day in children.
69
How does a myoclonic seizure present?
Myoclonic : brief, shock-like contraction of the limbs, without the apparent impairment in consciousness
70
How does a atonic seizure present?
Atonic : sudden brief attacks of loss of tone, associate with falls and loss of consciousness (LOC)
71
How does a focal motor seizure present?
Focal motor : jerking movement, typically beginning in the face or one hand, and spreading to involve the limbs. May also present with apparent purposeful movements such as turning the head, eye movements, lip smacking and mouth movements, drooling or rhythmic muscle contractions. Limb weakness may occur for several hours after the seizure.
72
How does a focal sensory seizure present?
Focal sensory : includes temporal lobe seizures that may cause sensory, autonomic, emotional, cognitive, or other changes. Consciousness may be fully retained (simple partial seizures) or impaired (complex partial seizures) during an attack.
73
What are the risk factors associated with epilepsy? (5)
1. Family history
2. Genetic condition that is associated with epilepsy
3. Previous febrile seizures
4. Previous intracranial infections/brain trauma/surgery
5. Comorbid conditions such as cerebrovascular disease or cerebral tumours
74
Auras (simple partial seizure with no LOC) can develop before generalised/focal seizures, which may indicate epilepsy, what are the features of these auras? (4)
1. Unexpected tastes
2. Unexpected smells
3. Paraesthesia
4. A rising abdominal sensation
75
What are the differential diagnoses with epilepsy? (5)
1. Syncope
2. Cardiac arrhythmias
3. Panic attacks with hyperventilation
4. Non-epileptic attack disorders
5. In children between 6 months - 5 years: night terrors/breathing holding attacks
76
If signs and symptoms indicate a person may have epilepsy, what are the appropriate steps to take? (3)
1. Urgent referral to a neurologist
2. Explain to patient and family/carers how to identify and manage a seizure
3. Advise not to drive (if applicable) and avoid swimming/take caution when bathing
77
What is the advise for managing someone experiencing a tonic-clonic seizure that lasts less than 5 minutes or having other types of seizures (for example focal, tonic, atonic, and myoclonic seizures)? (5)
1. Protect them from injury (cushion their head, removal harmful objects)
2. Do not restrain them or put anything in their mouth
3. When seizure stops - check airway and place in recovery position
4. Examine for and manage any injuries
5. Arrange emergency admission if it is their first seizure
78
For people having a tonic-clonic seizure lasting more than 5 minutes or who have had three seizures in an hour, what are the appropriate steps to take?
1. All the steps mentioned for tonic-clonic under 5 minutes, in addition to this:
2. Treat with buccal midazolam (or rectal diazepam or IV lorazepam)
3. Call an ambulance if no response to treatment OR it was status epilepticus, high risk of recurrence etc.
79
What is the current advise regarding anti-epileptic medication?
The objective of the drug is to prevent seizures from occurring. It may require more than one anti-epileptic drug, and careful dose adjustment. The type of seizure should determine the choice of drug, in addition to age, co-morbidities and gender.
80
Which anti-epileptic drugs belong to category one? (4)
1. Phenytoin
2. Carbamazepine
3. Phenobarbital
4. Primidone
81
What are the indications for use of phenytoin? (4)
1. Tonic-clonic seizures
2. Focal seizures
3. Prevention/treatment of seizures during neurosurgery
4. Status epilepticus
82
What are the indications for use of carbamazepine? (6)
1. Tonic-clonic seizures
2. Focal seizures
3. Trigeminal neuralgia
4. Prophylaxis of bipolar disorder if lithium is ineffective
5. Adjunct in acute alcohol withdrawal
6. Diabetic neuropathy
83
Name some category 2 anti-epileptic drugs? (at least 2)
1. Valproate (sodium valproate and valproic acid)
2. Lamotrigine
3. Clobazam
4. Perampanel
84
What are the indications for use of valproate? (4)
1. First choice treatment for control of generalised or absence seizures
2. Treatment option for focal seizures
(basically all forms of epilepsy)
3. Bipolar disorder - acute treatment and prophylaxis
4. Migraine prophylaxis
85
When should use of valproate be avoided? ...and if necessary, folic acid must be prescribed alongside..
In women of child-bearing age, particularly around time of conception and in the first trimester. It is the anti-epileptic drug associated with highest risk of fetal abnormalities including neural tube defects.
86
What are the indications for use of lamotrigine? (4)
1. Monotherapy for all seizures
2. Monotherapy for seizures associated with Lennox-Gastaut syndrome
3. Adjunct therapy when valproate is primary medication
4. Monotherapy and adjunct therapy for bipolar disorder
87
Name some anti-epileptic drugs found in category 3? (4)
1. Levetiracetam
2. Pregabalin
3. Gabapentin
4. Tiagabine
88
What are the indications for use of levetiracetam? (2)
1. Monotherapy and adjunct therapy for focal seizures
| 2. Adjunct therapy for myoclonic and tonic-clonic seizures
89
What are the indications for use of pregabalin? (3)
1. Adjunct therapy for focal seizures
2. Neuropathic pain
3. Generalised anxiety disorder
90
What are the indications for use of gabapentin?
1. Adjunctive/monotherapy treatment for focal seizures with/without secondary generalisation
2. Peripheral neuropathic pain
3. Migraine prophylaxis
4. Menopausal symptoms - particularly hot flushes in women with breast cancer
91
What are the potential complications of epilepsy? (5)
1. Death - Sudden unexpected death in epilepsy (SUDEP), accidents and status epilepticus
2. Depression and anxiety disorders
3. School performance - seizures affect concentration, behaviour and attendance at school
4. Behavioural difficulties
5. Injuries - head injuries, lacerations, burns, fractures (all from seizures)
92
What is SUDEP?
The person with epilepsy dies suddenly without an identifiable cause. It accounts for half of all epilepsy related deaths. The risk of SUDEP correlates with frequency and intensity of seizures.
93
What is meningitis?
It is a condition caused by inflammation of the meninges , the outer membrane of the brain and spinal cord. It is different from encephalitis which is inflammation of the brain tissue itself.
94
What are the three types of bacteria that most commonly cause bacterial meningitis in children aged 3 months and older, and in adults?
1. Neisseria meningitidis
2. Streptococcus pneumoniae
3. Haemophilus influenzae type b (Hib)
95
In neonates, what are the most common causative agents of meningitis? (4)
1. Streptococcus agalactiae
2. Escherichia coli
3. S. pneumoniae
4. Listeria monocytogenes
96
What does the term, meningococcal disease refer to?
It is a term referring to meningococcal meningitis, meningococcal septicaemia, or a combination of both.
It is meningitis resulting from infection with N. meningitidis
97
How are bacterial meningitis and meningococcal diseases transmitted?
Through close contact via droplets or secretions from the upper respiratory tract. Transmission usually requires either frequent or prolonged close contact.
98
What is the annual incidence of acute bacterial meningitis in developed countries?
The annual incidence of acute bacterial meningitis in developed countries is estimated to be 2–5 per 100,000 population
99
Of the 2357 cases of bacterial meningitis in the UK in 2011/12, what % were meningococcal and what % were pneumococcal? (don't equate to 100%)
```
58% = meningococcal
15% = pneumococcal
```
100
What are the risk factors associated with meningitis? (7)
1. Young age (most significant risk factor)
2. Winter season
3. Absent or poorly functioning spleen
4. Organ dysfunction (lung, heart, liver, kidney disease)
5. Smoking (including passive smoking)
6. Living in overcrowded households or military barracks
7. Older age >65
101
What are the specific risk factors associated with pneumococcal disease? (5)
1. Basal skull fractures with leakage of cerebrospinal fluid
2. Cochlear implants
3. Otitis media
4. Sinusitis
5. Sickle cell disease
102
What are the complications associated with bacterial meningitis? (7)
It is one of the top 10 causes of infection-related death worldwide
1. Hearing loss (33.6%)
2. Seizures (12.6%)
3. Motor deficit (11.6%)
4. Cognitive impairment (9.1%)
5. Hydrocephalus (7.1%)
6. Visual disturbance (6.3%)
103
Which type of meningitis - meningococcal or pneumococcal is associated with poorer outcomes in terms of prognosis?
Pneumococcal
104
What are the common non-specific signs/symptoms to look out for in suspected bacterial meningitis? (9)
1. Fever
2. Vomiting/nausea
3. Lethargy
4. Irritability/unsettled behaviour
5. Ill appearance
6. Refusing food/drink
7. Headache
8. Muscle ache/joint pain
9. Respiratory symptoms/sign of breathing difficulties
105
What are the less common signs/symptoms that can present with bacterial meningitis? (3)
1. Chills/shivering
2. Diarrhoea/abdominal pain/distension
3. Ear, nose and throat symptoms
106
What are the specific signs and symptoms associated with bacterial meningitis? (16)
1. Non-blanching rash
2. Stiff neck
3. Capillary refill time of more than 2 seconds
4. Cold hands and feet
5. Unusual skin colour
6. Shock and hypotension
7. Leg pain
8. Back rigidity
9. Bulging fontanelle
10. Photophobia
11. Kernig's sign (person unable to fully extend at the knee when hip is flexed)
12. Brudzinski's sign (person’s knees and hips flex when neck is flexed)
13. Unconsciousness or toxic/moribund state
14. Paresis
15. Seizures
16. Focal neurological deficit including cranial nerve involvement and abnormal pupils
107
What type of rash may develop with bacterial meningitis?
Non-blanching rash:
1. Scanty petechial rash (red or purple non-blanching macules smaller than 2 mm in diameter).
2. Purpuric (haemorrhagic) rash (spots larger than 2 mm in diameter) — this may be absent in the early phase of the illness and may initially be blanching or macular in nature.
108
In a child with petechiae, when is the risk of meningococcal disease particularly high? (5)
1. The petechiae start to spread.
2. The rash becomes purpuric.
3. There are signs of bacterial meningitis.
4. There are signs of meningococcal septicaemia.
5. The child or young person appears unwell.
109
What vital signs need to be checked in someone with suspected bacterial meningitis? (7)
1. Conscious level e.g. AVPU
2. Heart rate
3. Blood pressure
4. Respiratory rate
5. Oxygen saturation (if a pulse oximeter is available)
6. Temperature
7. Capillary refill time
110
What are the differential diagnoses with bacterial meningitis? (6)
1. Viral meningitis (enteroviruses and herpes simplex virus) - normally self-limiting with good prognosis
2. Viral encephalitis
3. Brain/CNS malignancy
4. Brain/CNS abscess
5. Parameningeal infection e.g. cranial oesteomyelitis
6. Non-infective causes of meningitis e.g. lupus or Bahcet's syndrome
111
Other than bacterial meningitis, what are the causes of petechiae? (4)
1. Epstein barr virus
2. Adenoviruses
3. Enterovirus
4. Clotting factor/platelet deficiencies
112
If bacterial meningitis is suspected and the person presents to primary care, what is the course of action?
```
Call 999
Administer benzylpenicillin (aka penicillin G) IV, though IM is ok if vein not available
(obviously if history of penicillin allergy, do not administer)
```
113
What are the types of primary headaches? (4)
1. Migraines (10%)
2. Tension-type headache (40%)
3. Cluster headaches (a form of trigeminal autonomic cephalgias) (1%)
4. Others include primary cough headache and cold-stimulus headache
114
What are the secondary causes of headaches? (8)
1. Trauma or injury to the head and/or neck.
2. Cranial or cervical vascular disorders such as intracerebral haemorrhage, central venous thrombosis or giant cell arteritis.
3. Non-vascular intracranial disorders such as idiopathic intracranial hypertension or malignancy.
4. Withdrawal from a substance such as carbon monoxide, cocaine, opioids, ergotamines, triptans, simple analgesics, or alcohol.
5. Infection including bacterial or viral meningitis.
6. Disorders of homeostasis such as hypoxia or hypertension.
7. Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial and cranial structures such as acute glaucoma, temporomandibular disorder or sinusitis.
8. Psychiatric disorders such as somatization disorder.
115
Each year, what % of adults consult their GP for headaches?
4%
116
What % of headaches are primary?
90%
117
What are the features of a tension-type headache? (3)
1. Generalised (or less often unilateral) headache typically described as a pressure or tightness around the head which often spreads into or arises from the neck.
2. Mild to moderate intensity headache which can last minutes to days and is not aggravated by routine physical activity such as walking.
3. Pericranial tenderness which may be elicited on manual palpation.
118
What are the three classifications of a tension-type headache?
1. Infrequent episodic tension-type headache
2. Frequent episodic tension-type headache
3. Chronic tension-type headache
119
What are the causes of tension-type headaches? (3)
The exact mechanism is unknown however it is thought the following contribute:
1. Peri-cranial pain sensitivity
2. Exacerbating environmental factors such as psychological stress, caffeine, or disturbed sleep may lead to central nervous system excitation.
3. Genetic factors.
120
What is the most common complication of frequent tension-type headaches?
Reduced quality of life and disability
121
How does tension-type headaches commonly present? (3)
1. Attacks of headache (usually bilateral) which are pressing or tightening (non-pulsating) in quality and of mild to moderate intensity lasting minutes to days.
2. The pain is not aggravated by routine activities of daily living and is not associated with nausea or autonomic symptoms — photophobia or phonophobia may occur in some cases.
3. Neurological examination should be normal.
122
If the tension-type headache is episodic, what is the recommended course of action/management? (3-ish)
1. Offer analgesia including paracetamol/NSAIDs/aspirin (taking into consideration co-morbidities)
2. Do NOT offer opioids
3. Identify lifestyle causes and manage appropriately - stress, mood disorders, sleep disorders etc.
123
If tension-type headache is chronic, what is the recommended course of action/management? (2)
1. Acupuncture is recommended but may not be easily accessible through primary care
2. Pharmacological prophylaxis - amitriptyline
124
What is the definition of a migraine?
A migraine is a primary episodic headache disorder. It is characterized by episodic severe headaches (commonly, but not always unilateral, and often described as throbbing or pulsating), with associated symptoms such as photophobia, phonophobia, and nausea and vomiting. It can be accompanied with an aura = visual symptoms include zigzag or flickering lights, spots, lines, or loss of vision, and/or sensory symptoms include pins and needles, or numbness.
125
What is the cause of a migraine?
Migraines are a complex condition and the pathophysiology remains unclear. There is a definite genetic component as about 1/2 of people with migraines have a first-degree relative with the condition too.
126
Are migraines more common in men or women? and what is their prevalence?
In women = 18%
In men = 6%
....hence it is 3 times more common in women
127
What are the complications associated with migraines? (4)
1. Reduced quality of life and reduced productivity at work
2. Higher risk of ischaemic and haemorrhagic stroke
3. Status migrainosus - debilitating migraine lasting more than 72 hours
4. Persistent auras lasting up to a week
128
What are the symptoms of a migraine without aura?
Recurrent episodes of headache, lasting between 4 hours and 72 hours, associated with either nausea or vomiting, or photophobia and phonophobia, or both and with at least two of the following characteristics:
1. Unilateral (more commonly bilateral in children).
2. Pulsating in character.
3. Moderate or severe in intensity.
4. Aggravated by routine physical activity.
129
What are the symptoms/signs of a migraine with aura?
When symptoms of migraine are preceded by the onset of an aura consisting of visual or sensory symptoms or dysphasia. Symptoms develop gradually and each individual symptom is fully reversed within 1 hour.
Visual symptoms include zigzag or flickering lights, spots, lines, or loss of vision.
Sensory symptoms include pins and needles, or numbness.
130
In addition to migraine with and without aura, what are the other forms of migraines? (4)
1. Episodic migraine
2. Chronic migraine
3. Menstrually-related migraine
4. Pure menstrual migraine
131
In women who have migraines with aura, what medication is contraindicated?
Combined hormonal contraceptive pill
132
What are the risk factors that can predispose someone to a migraine? (5)
1. Stress
2. Menstruation
3. Menopause
4. Head and/or neck injury
5. Depression or anxiety
133
What are the 'internal triggers' that can cause a migraine? (4)
1. Menstural cycle in women
2. Altered sleep pattern
3. Stress
4. Relaxation after stress - 'weekend migraine'
134
What are the 'external triggers' that can cause a migraine? (6)
1. Specific foods (within 6 hours of consumption) - i.e. chocolate, cheese, caffeine, alcohol
2. Strong smells
3. Bright lights
4. Dehydration and missed meals
5. Jet lag
6. Strenuous exercise; in those not accustomed to it
135
How do migraines in children tend to present and which area of the head/brain is normally affected?
They may last between 1 and 72 hours, usually bilateral and frontotemporal in region. They may present with cyclical vomiting, abdominal migraine and benign paroxysmal vertigo of childhood.
136
What drug is used to treat both migraines and cluster headaches?
Sumatriptan (brand name = Imigran®)
137
What is sumatriptan often prescribed alongside in the treatment of migraines and cluster headaches?
NSAIDs - normally ibuprofen or naproxen
| or paracetamol instead
138
If the patient suffers from nausea and vomiting when getting a migraine, what other medication can be added?
An anti-emetic, e.g. metoclopramide or domperidone
139
Anti-emetics prescribed for people with nausea and vomiting in addition to migraines should be used for what maximum number of days?
Metoclopramide - 5 days
| Domperidone - 7 days
140
In the treatment of migraines, combination analgesics are given with anti-emetics to be taken as an oral solution. What is the name of the common brands? (2)
1. MigraMax® - lysine acetylsalicylate and metoclopramide
| 2. Paramax® - paracetamol and metoclopramide
141
Why are opioids not indicated for use in migraines and cluster headaches?
They may initiate nausea and vomiting and may increase the risk of medication overuse headache
142
If people are experiencing medication overuse headaches due to the amount of triptan/analgesia they require (due to the frequency of their migraines/cluster headaches) what preventative medicine is available? (2 first-line treatment options)
1. Topiramate
| 2. Propanolol
143
Topiramate has 3 indications for use in the BNF, what are they?
1. Monotherapy of generalised tonic-clonic seizures or focal seizures with or without secondary generalisation
2. Adjunctive treatment of generalised tonic-clonic seizures, seizures associated with Lennox-Gastaut syndrome or focal seizures with or without secondary generalisation
3. Migraine prophylaxis
144
What important side effect regarding the eyes has been identified with topiramate use?
Occurrence of acute myopia with secondary angle-closure glaucoma
145
What needs to be offered alongside topiramate in women of child bearing age?
Contraceptive advice and appropriate contraception; as topiramate can cause fetal malformations and impair the effectiveness of hormonal contraceptions
146
If propranolol is prescribed as migraine prophylaxis, what conditions must the patient NOT have? (4 - although 1 is most important)
1. Asthma
2. COPD
3. Peripheral vascular disease
4. Uncontrolled heart failure
147
Which vitamin is known to be effective in reducing the frequency of migraine attacks/intensity of the migraines?
Riboflavin B2 - 400mg
148
In people under the age of 17 with migraines, what medication is indicated for use/which are not? (5)
1. Simple analgesia - NSAIDs or paracetamol
2. Combination of analgesia with NASAL sumatriptan
3. Oral triptans are NOT indicated for use under 18yrs
4. Monotherapy (nasal sumatriptan or NSAID or aspirin) can be considered, but do not give aspirin to children under the age of 16
5. Anti-emetic e.g. metoclopramide, in children over 12yrs
149
Migraine in pregnancy is quite unusual, but if it does occur, what can it increase the risk of? (2)
1. Pregnancy induced hypertension
| 2. Pre-eclampsia
150
What is the definition of a cluster headache/how does it present? (3)
A rare but severe headache disorder characterized by:
1. Unilateral periorbital pain.
2. Ipsilateral autonomic symptoms such as conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhoea, eyelid oedema, forehead and facial sweating or flushing.
3. Brief attacks of less than 3 hours duration
151
What are the 2 categories cluster headaches can be separated in to?
1. Episodic cluster headache — attacks occur in periods lasting from 7 days to 1 year and are separated by pain-free periods lasting at least 1 month.
2. Chronic cluster headache — attacks occur for more than 1 year without remission, or with remission periods lasting less than 1 month.
152
At what time of day do cluster headaches often occur?
Often in the early morning waking the person from sleep, and often occur at the same time of day for the duration of the cluster period
153
What are the risk factors for cluster headaches?
1. May be inherited as an autosomal dominant condition in 5% of people
2. Previous head trauma
3. Cigarette smoking
4. Alcohol intake
154
In which gender are cluster headaches more common?
Males, the male:female ratio is 15:1 for chronic cluster headaches and 3.8:1 for episodic cluster headaches.
155
What is the typical age of onset for cluster headaches?
20-40 years of age
156
What is the main complication of cluster headaches?
80% report restriction of daily activities during attacks
157
How do cluster headaches typically present?
1. Unilateral peri-orbital pain associated with ipsilateral cranial autonomic symptoms (such as conjunctival injection, lacrimation and eyelid oedema).
2. Severe pain, most often described as sharp, but can be pulsating, boring, burning or pressure-like
3. During the attack the person is restless or agitated and often paces the room
158
What can trigger attacks of cluster headaches?
1. Alcohol
2. Histamine
3. Physical exertion
4. Sleep
5. The smell of volatile substances such as perfume or petrol.
159
What are the differential diagnoses for cluster headaches? (5)
1. Migraine
2. Tension-type headache
3. Paroxysmal hemicranias
4. Secondary headaches
5. Painful cranial neuropathies and other facial pains
160
If a person presents with clinical features which indicate cluster headaches, what is the recommended guideline?
To refer to a neurologist or GP with special interest in headaches (confirmation of diagnosis by a specialist is required)
161
What is the recommended treatment for someone experiencing cluster headaches? (2)
1. Sumatriptan - subcutaneous injection 6mg (max. 12mg per day) OR intranasal sumatriptan/zolmitriptan (10-20mg)
2. Short-burst oxygen therapy
162
What drugs should not be used in the treatment of cluster headaches? (though are often used to treat migraines/tension headaches)
NSAIDs, paracetamol, opioids, ergots, oral triptans
163
What is Parkinson' s disease?
Parkinson's disease is a chronic, progressive neurodegenerative condition resulting from the loss of the dopamine-containing cells of the substantia nigra
164
Approximately what % of dopaminergic cell activity has been lost by the time symptoms appear?
50%
165
What are the symptoms/signs that build up the Parkinsonism syndrome?
Parkinsonism is an umbrella term for the clinical syndrome involving bradykinesia plus at least one of:
- Tremor
- Rigidity
- and/or Postural instability.
Parkinson's disease is the most common form of Parkinsonism.
166
In addition to Parkinson's disease, what are the other causes of Parkinsonism syndrome?
1. Drug-induced Parkinsonism
2. Cerebrovascular disease
3. Lewy-body dementia
4. Multiple system atrophy
5. Progressive supranuclear palsy.
167
Is Parkinson's disease more common in males or females?
Males (1.5 times more common)
168
The risk of dementia is how many times more likely in people with Parkinson's disease compared to healthy people the same age?
2-6 times higher
169
What are the motor complications associated with Parkinson's disease (some of which are related to the use of anti-Parkinsonian medication)? (6 - some are vague)
1. Deteriorating function
2. Loss of drug effect
3. Motor fluctuations (end-of-dose fading and on-off phenomenon
4. Dyskinesia
5. Freezing of gait
6. Falls
170
What are the non-motor complications associated with Parkinson's disease?
1. Depression and anxiety
2. Dementia
3. Impulse control disorders and psychosis
4. Constipation
5. Postural hypotension
6. Dysphagia and weight loss
7. Excessive salivation and sweating
8. Bladder and sexual problems
9. Nausea and vomiting
10. Pain
11. Sleep disturbance
12. Aspiration pneumonia
13. Pressure sores
171
What are the motor-related signs and symptoms that may present with Parkinson's disease? (5)
1. Bradykinesia
2. Hypokinesia
3. Stiffness/rigidity
4. Resting tremor
5. Postural instability
172
What does bradykinesia mean?
A slowness in initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions, such as finger or foot tapping
173
What does hypokinesia mean? (3)
1. Reduced facial expression, arm swing, or blinking.
2. Difficulty with fine movements such as buttoning clothes and opening jars, or small, cramped handwriting (micrographia).
3. Slow, shuffling, festinating gait, or difficulty turning in bed.
174
What are the two types of rigidity to look for on examination, and what are they?
1. Cogwheel rigidity; regular intermittent relaxation of tension felt when a limb is passively flexed in the presence of tremor and increased tone OR
2. Lead-pipe rigidity; constant resistance felt when a limb is passively flexed in the presence of increased tone without tremor
175
When does a resting tremor tend to improve? (3)
1. Upon moving
2. With mental concentration
3. During sleep.
176
What is the pin-rolling sign?
The resting tremor is commonly found in the thumb and index finger, and gives the appearance of someone rolling a pill in between these two digits.
177
In addition to the hands, which other parts of the body may be affected by a resting tremor, and which areas are rarely affected?
Affected: wrists, legs, lips, chin and jaw
Unaffected: head, neck, (and voice)
178
How can postural instability be demonstrated?
'Pull test' - the examiner sharply pulls the patient backwards, and the patient will fall (if positive test) as they cannot reactive quickly enough to take a step backwards and stop themselves.
179
Are the symptoms of Parkinson's disease unilateral or bilateral at early stages of the disease?
Unilateral
180
What are the non-motor signs and symptoms that someone with Parkinson's disease may present with? (6)
1. Depression and anxiety
2. Fatigue
3. Reduced sense of smell
4. Cognitive impairment
5. Sleep disturbance
6. Constipation
181
As a differential diagnosis for Parkinson's disease, is drug-induced parkinsonism, what are the drugs that can cause this? (11)
```
First two groups most common:
1. Antipsychotics e.g. haloperidol, chlorpromazine (first generation antipsychotics are more likely than second generation)
2. Anti-emetics e.g. Prochlorperazine, metoclopramide
Less commonly:
3. Anti-depressants
4. Calcium-channel blockers
5. Cinnarizine
6. Amiodarone
7. Lithium
8. Cholinesterase inhibitors, such as donepezil or memantine.
9. Sodium valproate
10. Methyldopa
11. Pethidine
```
182
What is the treatment available for Parkinson's disease? (9)
1. Co-beneldopa or Co-careldopa : levodopa combined with dopa decarboxylase inhibitor
2. Oral catechol-O-methyl transferase (COMT) inhibitors
3. Oral monoamine oxidase-B inhibitors (selegiline or rasagiline)
4. Oral dopamine agonists, such as pramipexole or ropinirole; or transdermal dopamine agonist, such as rotigotine
5. Oral amantadine
6. Subcutaneous apomorphine (dopamine agonist
7. Intraduodenal levodopa gel continuous infusion via a jejunostomy
8. Deep brain stimulation (DBS) of the sub thalamic nucleus
9. Referral to specialists such as SALT, physiotherapists, adult social care, urologists and psychologists.
183
When should it be suspected that a person has end-stage Parkinson's disease? (9)
1. Severe, progressive worsening motor symptoms and complications, such as increasing 'off' periods, dyskinesia, mobility problems, and falls.
2. Severe, progressive worsening non-motor symptoms and complications, including worsening cognitive function.
3. Symptoms which show a decreasing response to anti-parkinsonian medication; an increasingly complex regime of anti-parkinsonian medication.
4. Declining physical functioning and an increasing need for support; limited self-care; in bed or chair over 50% of the day.
5. Repeated unplanned or crisis hospital admissions.
6. A low body mass index (BMI) or significant weight loss, for example more than 10% weight loss in the past 6 months.
7. Dysphagia leading to recurrent aspiration pneumonia, sepsis, breathlessness, or respiratory failure.
8. Speech problems causing progressive difficulty communicating and/or progressive dysphagia.
9. Significant comorbidities.
184
What is multiple sclerosis (MS)?
An acquired, chronic, immune-mediated, inflammatory condition of the central nervous system that can affect the brain stem and spinal cord
185
What does the inflammatory process of the central nervous system cause? (3)
1. Demyelination (damage to white matter)
2. Gliosis (subsequent scarring)
3. Secondary neuronal damage (cell loss)
186
What are the three main patterns/types of MS disease?
1. Relapsing-remitting MS (RRMS)
2. Secondary progressive MS (SPMS)
3. Primary progressive MS (PPMS)
187
What does relapsing-remitting MS consist of?
Episodes or exacerbations of symptoms followed by remissions and periods of stability. In the early stages of RRMS, symptoms may go completely during remissions, however after several relapses, there will be residual damage to parts of the CNS, which results in only a partial recovery during remissions.
188
At onset of the disease; MS, what % of people have RRMS?
85%
189
What is secondary progressive MS?
At some point in the disease course, a change occurs from RRMS to SPMS in which neurological function gradually worsens, with or without continued relapses.
190
Within 6 years of onset of RRMS, what % of people with have developed SPMS?
25%
191
What is PPMS?
There is a steady progression or worsening of pre-existing symptoms from onset, without remissions.
192
What causes MS?
MS is thought to be an autoimmune disease with cells of the immune system, mainly T-cells, attacking oligodendrocytes. This results in focal or diffuse areas of inflammation which is thought to cause secondary damage, primarily to axons.
193
What does damage to axons lead to?
Irreversible loss of function of the affected nerves
194
What are the risk factors for developing MS? (5)
1. There is a genetic factor as monozygotic twins have about an 18-30% concordance rate, compared to dizygotic twins who have 5%.
2. Epstein-Barr virus
3. Low levels of vitamin D and in addition to this latitude from the equator
4. Smoking (roughy doubles the risk)
5. Obesity during adolescence
195
Approximately how many people in the UK are diagnosed each year with MS?
6000
196
Which gender does MS tend to affect more?
Women
197
What is the mean age of onset of MS?
30 years of age
198
In people who develop MS over the age of 40 years, which type of MS are they more likely to develop?
PPMS
199
Why are the complications of MS variable?
As lesions can develop almost anywhere in the brain or spinal cord of a person with MS, so there is a large range of complications that may develop
200
What are the most common complications caused by MS? (9)
1. Fatigue (76-92% people with MS report fatigue)
2. Spasticity - stiffness and muscle spasm
3. Ataxia and tremor (usually occur if lesions develop in cerebellum or basal ganglia)
4. Visual problems - optic neuritis, diplopia, oscillopsia
5. Reduced mobility - due to muscle weakness, spasticity, disordered balance, poor coordination, visual problems
6. Pain
7. Bladder problems
8. Sexual dysfunction
9. Mental health problems
201
What scale is used to document disease/disability progression in someone with MS?
The Expanded Disability Status Scale, with the score ranging from 0 to 10. 0 indicates no signs or symptoms and 10 indicates death from MS
202
What are the 4 most common initial presentations of MS?
1. Optic neuritis - inflammation of the optic nerve with typical symptoms including partial or total unilateral visual loss developing over days
2. Transverse myelitis - paraesthesia, weakness, tight band sensation around the trunk at the level of inflammation, shock like sensation radiating down the spine induced by neck flexion (Lhermitte's phenomena)
3. Cerebellar related symptoms - ataxia, vertigo, clumsiness, dysmetria
4. Brainstem syndromes - ataxia, eye movement abnormalities, dysphagia
203
What criteria is used to help diagnose MS?
MacDonald criteria (2010 revised)
204
What are the differential diagnosis for MS? (loads... name at least 7)
1. Neuromyelitis optica
2. Acute disseminated encephalomyelitis
3. Metabolic disorders e.g. vitamin B12 deficiency, copper/zinc deficiency
4. Infections e.g. lyme disease, HIV
5. Primary CNS vasculitis
6. Systemic inflammatory disorders e.g. SLE, Behcet's syndrome, sarcoidosis
7. Neoplasia e.g. metastatic neoplastic brain lesions
205
What is the management of MS?
1. Encourage regular exercise
2. Smoking cessation
3. Disease modifying therapy DMTs e.g. interferon beta-1a or beta-1b - Avonex, Betaferon, ... huge number of them.
206
What is proximal myopathy?
A symmetrical weakness of proximal upper and or lower limbs.
207
What can cause proximal myopathy?
1. Drugs
2. Alcohol
3. Thyroid disease
4. Osteomalacia
5. Idiopathic inflammatory myopathies
6. Hereditary myopathies
7. Malignancy
8. Sarcoidosis
