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3B > Neurology 1 > Flashcards

Neurology 1 Flashcards

1
Q

Definitions

Seizure
Epilepsy
Syncope

A

Seizure - Clinical manifestation of abnormal and excessive neuronal discharge

Epilepsy - A tendency to have seizures
(2 or more seizures > 24 hours apart)

Syncope - Transient global cerebral hypoperfusion

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2
Q

Epilepsy - Associated conditions

A 
Cerebral palsy
Tuberous sclerosis
Downs
Mitochondrial disease
SLE 
Cerebral vascular disease
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3
Q

Focal seizures

A

Focal aware

  • No LOC
  • No memory loss
  • No post-ictal symptoms

Focal impaired awareness

  • LOC
  • Memory loss
  • Post-ictal confusion

Jacksonian - Spreads distal to proximal
Todd’s - Paralysis after a seizure

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4
Q

Temporal seizures

A

Hallucinations
Deja vu
Post-ictal dysphasia

Automatisms

  • Lip smacking
  • Grabbing
  • Pulling
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5
Q

Frontal seizures
Parietal seizures
Occipital seizures

A

Frontal seizures

  • Movements
  • Post-ictal weakness
  • Jacksonian march

Parietal seizures - Paraesthesia

Occipital seizures

  • Floaters
  • Flashes
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6
Q

General seizures

A

Both hemispheres
Always LOC

Incontinence
Tongue biting

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7
Q

Pre-ictal symptoms

A

Prodrome - Change in mood or behaviour

Aura

  • Strange feeling in gut
  • Deja vu
  • Flashing lights
  • Olfactory changes
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8
Q

Post-ictal symptoms

A 
Headache
Confusion
Myalgia
Sore tongue
Temporary weakness - Frontal lobe
Dysphasia - Temporal lobe
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9
Q

Organic causes of seizures

A

VITAMIN D

Vascular - Stroke, SAH, haematoma
Infection - Meningitis, abscess
Trauma
Autoimmune - SLE 
Metabolic - See separate card!
Iatrogenic - See separate card! 
Neoplasm - Primary and secondary metastases 
Degenerative
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10
Q

Metabolic causes of seizures

Iatrogenic causes of seizures

A

Metabolic

  • Hypoglycaemia
  • Hypoxia
  • Alcohol withdrawal
  • Hyponatraemia
  • Hypocalcaemia
  • Hypokalaemia
  • Hypernatraemia
  • Hypercalcaemia
  • Uraemia

Iatrogenic

  • Tricyclics
  • Benzos
  • Tramadol
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11
Q

Epilepsy investigations and management

A

EEG / MRI

Start management after second epileptic seizure

Start after first seizure if…

  • FND
  • Brain imaging shows structural abnormality
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12
Q

Focal seizure management

A

Carbamazepine
Lamotrigine
Valproate
Levetiracetam

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13
Q

Generalised seizure management

A

Absence - Valproate + Ethosuximide

Tonic-clonic - Valproate + Lamotrigine + Carbamazepine

Myoclonic - Valproate + Lamotrigine + Clonazepam

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14
Q

Valproate side effects

A 
Vomiting
Anorexia / ataxia
Liver toxicity
Pancreatitis
Retention of weight
Oedema
Alopecia
Teratogenic - Neural tube defects
Enzyme inhibitor - CP450
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15
Q

Epilepsy driving rules

A

Cannot drive for 6 months after first unprovoked seizure
(If no structural defect on imaging + No epilepsy on EEG)

If epilepsy - Must be seizure free for 12 months

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16
Q

Status epilepticus

A

Seizure > 5 minutes

> 2 seizures in 5 minutes

Causes

  • Stopping anti-epileptic drugs
  • Alcohol withdrawal
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17
Q

Status epilepticus management

A 
ABCDE
Buccal midazolam
Rectal diazepam
IV lorazepam
Phenytoin / Phenobarbitol
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18
Q

Status epilepticus complications

A 
AKI from rhabdomyolysis
Lactic acidosis
Hypercapnia
Vomiting
Hypoxia
Pneumonia
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19
Q

Headache red flags

A

Raised ICP - SOL
Jaw claudication - GCA

Paraesthesia and FND - Stroke / migraine

Visual disturbance - TN / SAH / meningitis

Thunderclap headache - SAH

Neck stiffness - Meningitis / SAH

Personality changes - Stroke / tumour / frontal lobe pathology

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20
Q

Migraine criteria

A

ABCDE

At least 5 incidents, fulfilling the criteria…

B - Headache lasting 4-72 hours

Characteristics - 2 of…

  • Unilateral
  • Pulsating
  • Moderate/severe pain
  • Aggravated by / or avoidance of physical activity

During - 1 of…

  • N/V
  • Photophobia

Examination/history does not suggest secondary headache

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21
Q

Migraine investigations

A

Ophthalmoscopy
BP
Full neuro assessment

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22
Q

Migraine management

A

Acute

  1. Combination therapy - Sumatriptan + NSAIDs
  2. Metoclopramide
  3. Prochlorperazine

Prophylaxis > 2 attacks per month

  • Topiramate - CI in pregnancy
  • Propranolol - CI in asthma
  • Acupuncture
  • Riboflavin
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23
Q

Tension headache management

A

Avoid triggers (LADS)

  • Sleep hygiene
  • Meditation

Acute

  • Aspirin
  • Paracetamol
  • NSAIDs

Prophylaxis - Acupuncture

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24
Q

Cluster headache

A

More common in men

Severe unilateral orbital stabbing pain
“ Worst pain of all time”
Relieved by movement
Worse at night

Once a year
15-180 minutes
Clusters of 6-12 weeks

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25
Q

Cluster headache triggers

A 
Alcohol
Smoking
Exercise 
Heat 
Histamine
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26
Q

Cluster headache management

A

Avoid triggers

Acute

  • Sumatriptan
  • O2

Prophylaxis

  • Verapamil
  • Topiramate
  • Prednisolone
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27
Q

Trigeminal neuralgia aetiology and triggers

A

Associated with MS

Triggers - Light skin contact

  • Washing
  • Shaving
  • Talking
  • Brushing teeth

+ Smoking!

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28
Q

Trigeminal neuralgia presentation

A

Shock-like sensations in trigeminal nerve
Most commonly the maxillary branch

Severe unilateral pain
Worse on touching face

Up to 100 attacks per day
1-180 seconds

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29
Q

Trigeminal neuralgia investigations

A

CT/MRI - Rule out SOL

Referral if red flags…

  • Sensory deficit
  • Optic neuritis
  • Family history MS
  • Onset < 40
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30
Q

Trigeminal neuralgia management

A

Carbamazepine

Alternatives…

  • Lamotrigine
  • Phenytoin
  • Gabapentin
  • Surgery
  • Radiotherapy
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31
Q

GCA aetiology

A

Associated with PMR
(Proximal muscle and joint pain)

Cause - Vasculitis

More common in females

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32
Q

GCA presentation

A

Women and older men

Severe pain

  • Jaw claudication
  • Scalp pain - Worse with chewing, talking, brushing hair

Amaurosis fugax
Muscle and joint pain

B symptoms

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33
Q

GCA investigations

A

Bloods

  • ESR ^
  • Platelets ^
  • ALP ^
  • Hb - LOW

Colour duplex USS + Temporal artery biopsy

  • Granulomatous inflammation
  • May be negative due to skip lesions!
34
Q

GCA management

A

Prednisolone (+Bisphosphonate)
Asprin (+Omeprazole)

Urgent ophthalmology review if visual symptoms

35
Q

GCA complications

A

Irreversible bilateral visual loss
Aneurysms
CVA
Seizures

36
Q

SAH causes

A

Aneurysm - HTN, PKD, AVM

Common places…

  • ACA and anterior communicating
  • MCA bifurcation
  • Posterior communicating and internal carotid
37
Q

SAH presentation

A

Sudden onset
Severe “thunderclap” headache

Meningism
Focal neurological deficit
CN3 palsy - Posterior communicating
Seizures
Reduced GCS
Vomiting

Similar to meningitis - Are they systemically unwell?

38
Q

SAH investigations

A

CT - Star shaped lesion in basal cistern

LP

  • Xanthochromia - RBD breakdown product
  • Protein ^

ECG

  • Long QT
  • ST elevation

Ophthalmoscopy

  • Loss of light reflex
  • Intraocular haemorrhage
39
Q

SAH management

A

Neurosurgery - Endovascular coiling
Nimodipine - Reduces spasm
Shunt if ICP ^

40
Q

SAH complications

A

Rebleed
Vasospasm - Stroke
Hyponatraemia
Hydrocephalus

Loss of sympathetic reflex - HTN ^^^

41
Q

SDH aetiology

A

Tear in bridging veins

Alcoholics
Elderly - Anticoagulants?
Shaken babies

42
Q

SDH presentation

A

Head trauma followed by…

LOC
FND
Headache
Personality changes
Reduced GCS
43
Q

SDH investigations

A

CT - Concave lesion - Not limited by suture lines

Dark lesion = Old bleed
Bright lesion = New bleed

Midline shift?

44
Q

SDH management

A

Burr holes
Craniotomy

Old lesion = Conservative management

45
Q

EDH aetiology

A

Low-impact head trauma

Pterion - Joining of parietal, frontal, temporal, sphenoid bones

Middle meningeal artery - 90%
Dural venous sinus - 10%

46
Q

EDH presentation

A

Trauma followed by lucid interval

Sudden drop in GCS
Headache
^ ICP symptoms

Brisk reflexes
Upward plantars

Symptoms of skull fracture

  • Asymmetrical face
  • CSF rhinorrhoea
47
Q

EDH investigations and management

A

CT - Convex lesion - Limited by suture lines

XR - Skull fracture

LP is contraindicated!

Management

  • Mannitol to treat raised ICP
  • Burr holes
48
Q

Parkinson’s aetiology

A

Degenerative
Loss of dopaminergic neurons in SN

More common in men
Mean age of diagnosis is 65
(Associated with ^ age)

Repeated head trauma - Boxing?

Iatrogenic

  • Metoclopramide
  • Neuroleptics
49
Q

Alternative causes of tremor

A

Other causes of tremor…

  • SSRIs
  • Amphetamines
  • Salbutamol
  • Lithium
  • Alcohol
  • Thyroid disease
Wilson's disease
Cerebellar trauma
EPSE
NPH
LBD
50
Q

Parkinson’s presentation

A
  1. Bradykinesia
  2. Resting tremor - Pill rolling
  3. Rigidity - Cog wheel

Shuffling gait
Reduced arm swing

REM sleep disorders
Anosmia
Monotone voice
Micrographia
Loss of facial expression
Dementia
Depression
Urinary incontinence - NPH?
Sexual dysfunction
51
Q

Parkinson’s investigations

A

Clinical diagnosis - Bradykinesia + 1 other

Histology

  • Lewy bodies
  • Eosinophilic cytoplasmic inclusions consisting of alpha synuclein

Exclude differentials

  • Medications?
  • Cerebellar disorder - Imaging?
  • Wilson’s - Bloods?

Screen for depression

52
Q

Parkinson’s pharmacological management

A

Increase dopamine - Levodopa
Dopamine agonist - Ropinirole

Decrease dopamine breakdown

  • Rasagiline
  • Entacapone

Tremor

  • Amantidine
  • Anticholinergics

Depression - SSRI?

53
Q

Parkinson’s non-pharmacological management

A 
PT
SALT
OT
DBS
Surgery - Interruption of overactive BG circuits
54
Q

Parkinson’s meds S/E

A

Ropinirole

  • Drowsiness
  • Impulsivity
  • Inhibition disorder
  • N/V
  • Dizziness
  • Visual hallucinations

Anti-ACh - Falls

Levodopa

  • Reduced efficacy with time
  • On/off effect - Fluctuations
  • Freezing
  • N/V
  • Dry mouth
  • Hypotension
  • Dyskinesia
  • Arrhythmias
55
Q

Parkinson’s PLUS

A

VIVID

Vertical gaze palsy - Supranuclear gaze palsy
Impotence / incontinence - Multiple system atrophy
Visual hallucinations - LBD
Interfering limb - Cortico-basal degeneration
Diabetes / HTN - Vascular Parkinson’s

56
Q

Tremor causes

A

Cerebellar disease - DANISH

Parkinson’s

Essential tremor

  • Vocal cords
  • Worse with arms outstretched
  • Improved by alcohol and rest
  • BBs

Orthostatic - Legs

Multiple system atrophy - Autonomic symptoms

Iatrogenic - See separate card

57
Q

Drugs causing tremor

A

CALVSS

Caffeine
Amphetamines
Lithium 
Valproate
Salbutamol 
SSRIs
58
Q

NPH aetiology

A

Reduced CSF resorption at arachnoid villi

Idiopathic
Meningitis
Head injury
CNS tumour
SAH
59
Q

NPH presentation / investigations / management

A

Wet Whacky Wobbly

  • Urinary incontinence
  • Dementia
  • Falls

Investigations

  • CT - Enlarged 4th ventricle
  • LP - Normal opening CSF pressure

Management

  • VP shunt
  • Acetazolamide
60
Q

Hydrocephalus aetiology

A

Obstructive

  • Tumour
  • Haemorrhage

Non-obstructive

  • NPH
  • Increased production - Choroid plexus tumour
61
Q

Hydrocephalus presentation / investigations / management

A

Raised ICP symptoms

  • Headache
  • N/V
  • Papilloedema

Investigations

  • CT - Dilatation of ventricles above lesion
  • LP - Diagnostic and therapeutic

Management

  • Eternal ventricular drain
  • VP shunt
62
Q

Huntington’s aetiology

A

Mutation of Huntingtin gene 4p16.3
AD
Trinucleotide repeat CAG
Degeneration of cholinergic and GABA neurons in BG

63
Q

Huntington’s presentation

A

Early

  • Personality changes - Apathy
  • Chorea / tics / myoclonus

Late

  • Seizures
  • Spasticity / clonus
  • Supranuclear gaze palsy

Psych

  • Dementia
  • Depression
64
Q

Huntington’s investigations

A

Genetic testing

MRI

  • Loss of corpus striatum volume
  • Large frontal horns of lateral ventricles
65
Q

Huntington’s management

A

Chorea

  • Benzodiazepines
  • Valproate

Dopamine depleting agents - Tetrabenzene

DBS
SSRI
Antipsychotics

66
Q

Reflex syncope

A

Vasovagal

  • Emotion
  • Stress
  • Standing too long

Situational

  • Coughing
  • Micturition
  • GI
  • Exercise

Carotid sinus hypersensitivity

67
Q

Cardiogenic syncope

A

All arrhythmias

Structural defects

  • MI
  • Valve disease
  • Aortic stenosis
  • Tamponade
  • Dissection

BBB
Brugada syndrome
Heart block
WPW

68
Q

Orthostatic hypotension

A

Dehydration

  • Infection
  • Haemorrhage

Drugs

  • Diuretics
  • Alcohol
  • Vasodilators

AI failure

  • Parkinson’s
  • LBD
  • Uraemia
  • Diabetic neuropathy
69
Q

Syncope investigations

A

Lying / standing BP
Change > 20/10 = Abnormal

Systolic BP < 90
24hr ECG

Cardiology exam
Neurology exam

Tilt table test

FBC - Anaemia?
Inflammatory markers
EEG

70
Q

NEAD

A

Disorder of movement, sensation or experience

Resembles an epileptic seizure without cerebral ictal discharge

More common in females
Attacks do not occur when patient is alone

71
Q

NEAD aetiology

A

Family history - Epilepsy?
Childhood abuse
Neglect

Psychiatric illness

  • Depression
  • Schizophrenia
72
Q

NEAD presentation

A

Pelvic thrusting
Post-ictal crying

Gradual onset
Long duration
Violent thrashing
Ability to control seizure location

73
Q

NEAD investigations and management

A

Prolactin - Normal
Video telemetry

Management - Talking therapy / CBT

74
Q

Stroke classification

A

Anterior - ACA/MCA

  • Weakness
  • Paraesthesia
  • Homonymous hemianopia
  • Higher cognitive disorder - Dysphasia?

Posterior - Vertebrobasilar

  • LOC
  • Homonymous hemianopia
  • Cerebellar disorder
  • CN palsy
  • Contralateral motor/sensory deficit

Lacunar - Perforating arteries

  • Pure motor
  • Pure sensory
  • Ataxic hemiparesis
  • Mixed sensory/motor
75
Q

Additional strokes

A

Weber - PCA

  • CN3
  • Contralateral hemiparesis

Wallenberg - Posterior inferior cerebellar artery

  • Ipsilateral sensory loss of pain
  • Loss of gag reflex
  • Hoarse voice
  • Horner’s syndrome

Lateral pontine syndrome - Anterior inferior cerebellar artery
- Same as Wallenberg
+ Ipsilateral face paralysis
+ Deafness

Locked in syndrome - Basilar artery

  • Unable to move except eyes
  • Extraocular muscles
76
Q

Aphasia

A

Wernicke’s - Superior temporal gyrus - MCA

  • Fluent
  • Impaired comprehension

Broca’s - Inferior frontal gyrus - MCA

  • Not fluent
  • Normal comprehension

Conduction aphasia - Arcuate fasciculus

  • Fluent
  • Normal comprehension
  • Poor repetition
  • Aware of errors

Global aphasia - All 3 areas

77
Q

Stroke investigations

A 
Glucose
U&E
Cardiac enzymes
Clotting - INR / PT
FBC
ECG

CT head - Non-contrast

78
Q

Ischaemic stroke management

A

Acute - ABCDE

  • Aspirin 300mg
  • Presentation < 4.5 hours - Thrombolysis (IV alteplase)
  • Presentation > 4.5 hours - Endovascular thrombectomy
Secondary prevention
- Aspirin 300mg - 2 weeks
- Clopidogrel 75mg - For life
- Statin if cholesterol > 3.5mmol/L after 48 hours
Anticoags - AF patients
79
Q

Haemorrhagic stroke management

A

Factor 7A

Reverse warfarin - Vitamin K
Reverse heparin - Protamine

Symptom control

  • Seizures - Lamotrigine
  • ICP - Mannitol
  • BP - BB

Surgical evacuation

80
Q

TIA definition

A

Transient episode of neurological dysfunction
Caused by focal brain, spinal cord, or retinal ischaemia

WITHOUT acute infarction

81
Q

TIA presentation and investigations

A

Presentation - Same as stroke
- Amaurosis fugax

Investigations

  • 24 hour ECG
  • MRI
  • Carotid doppler
82
Q

TIA management

A

Aspirin 300mg
Clopidogrel 75mg
Statin

Carotid endarterectomy
Lifestyle changes

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