Neurology Flashcards

Question

Investigations & Management of SAH

Answer 1

Observations & Examination, Bloods inc G&S, clotting, Imaging (CT head) If CT head normal - LP in 12hrs (detect bilirubin) Initial management - A to E survey, ?airway management if needed Medical - analgesia, anti-emetics, IV fluids & monitoring, regular neurological observations, nimodipine Surgical/aneursym management - coiling/clipping

Answer 2

Rupture of bridging veins, bleeding between dura & surface of brain acute - within 72hrs, subacute 3-20days, chronic after 3 weeks Usually caused by trauma (fall, HI) but can be caused by aneurysm rupture, AVM etc RFs: elderly, alcoholics, anticoagulated, HTN, presence/hx of aneurysms

Answer 3

History of trauma & HI with decreased level of consciousness (ACUTE) Worsening headaches for 7-14days after injury, altered mental state (SUBACUTE) Headache, fluctuating confusion, cognitive impairment, focal weakness, seizures (CHRONIC) ``` Seizures Weakness Vomiting Reduced consciousness Sudden neurological sx ```

Answer 4

Urgent CT head - confirm diagnosis, crescent shaped • History/examination/observations - inc neuro examination, pupils & A-E survey • Bloods - FBC (Hb, plt), U&Es, LFTs (alcohol), clotting, G&S, bone profile • Imaging - CT head ○ Crescent shaped ○ Acute subdural bleeds = hyperdensity = paler Chronic subdural bleeds = hypodense = darker

Answer 5

Management: Initial A to E survey; C spine, D inc pupil check & GCS, signs of raised ICP Conservative If small & minimal midline shift Closely monitor with neuro obs, manage & prevent ICP Ensure normal sats, normal temp, normal CO2, adequate sedation and paralysis, ICP monitoring Seizure management Surgical Stopping bleeding/evacuation of chronic subdurals Burr Holes

Answer 6

Bleeding into extradural space - above dura mater Trauma - high impact, high energy trauma Causes temporal/parietal bone fracture which leads to damage/tear of MMA ``` Mechanism of Injury Anticogulation/antiplatelet use Alcohol excess Liver dysfunction Coagulopathy ```

Answer 7

``` · History of trauma, brief LOC followed by a lucid interval · Headache · Nausea & vomiting · Seizures Speech difficulties ``` ``` • Reduced GCS/consciousness • Confusion • Focal neuro deficits • Unequal pupils • Herniation CSF leak ```

Answer 8

Plain CT head - shows blood in extradural space, forms lemon shape, midline shift • Bedside; neuro obs & examination, history, BM & ECG • Bloods; FBC (Hb, plt), U&Es, LFTs (alcohol), clotting, G&S, CM, bone profile Imaging; CT head +/- full trauma screen e.g. whole body CT

Answer 9

``` Trauma call & primary survey Any resuscitation that is appropriate Admit to HDU Discuss with specialist neuro team Surgery - decompression ```

Answer 10

Chronic, immune mediated, neuroinflammatory condition which involves demyelination of central nervous system (UMN) Relapsing-remitting Primary progressive MS Secondary progressive ms

Answer 11

• Genetics ○ Increased risk if family hx ○ Twins - 1 in 5, if identical twin is affected --> shows GxE • Vit D levels ○ Live further away from the equator = increased risk ○ Patients with MS have lower Vit D levels - ?cause vs effect ○ Some genetic components linked to development of MS & involved in Vit D • Viral - EBV prevalance • Obesity Sex - female

Answer 12

``` Visual Symptoms • Optic neuritis - unilateral deterioration visual acuity & colour perception, pain on eye movement • Blurred vision Motor symptoms + UMN symptoms on examination • Limb weakness • Spasms • Stiffness & heaviness Sensory symptoms • Pins & needles • Numbness • Burning Autonomic • Urinary urgency • Hesitancy • Incontinence • Impotence ```

Answer 13

• Acute attacks - high dose steroids e.g. Methylprednisolone 500mg PO for 5/7 ○ Although will get better on own, steroids quicken recovery Preventing relapses - beta interferon, DMARDs

Answer 14

Neurodegenerative disease - loss of DAnergic neurones within substantia nigra (basal ganglia)

Answer 15

Bradykinesia, rigidity, resting tremor & postural instability Mask-like expression, micrographia, shuffling gait, gabellar tap

Answer 16

``` SNCA DJ-1 - support/chaperone LRRK2 - mutations inhibit autophagy PINK1 PARKIN ```

Answer 17

Clinical diagnosis - history & examination DX by specialist using criteria DAT scan - reduced MRI/CT - r/o other pathologies Bloods - serum ceruloplasmin to r/o Wilson's Disease in young onset Levodopa trial

Answer 18

Essential tremor - intention tremor, symmetrical Progressive supranuclear palsy Multiple systems atrophy - autonomic sx Dementia with Lewy Body - LBD cognitive symptoms within one year of motor features.

Answer 19

Medical - symptomatic therapy with DA replacement • L-DOPA - levodopa + carbidopa (peripheral DOPA decarboxylase inhibitor) • DA agonists - ropinirole • MAO inhibitors - selegiline • COMT inhibitors - entacapone Surgical • Deep Brain stimulation

Answer 20

A chronic neurological disorder which is characterised by recurrent seizures Criteria 1: ≥2 unprovoked (or reflex) seizures occurring more than 24 hours apart Criteria 2: 1 unprovoked (or reflex) seizure with a probability of further seizures felt to be at a similar recurrence risk to patients with ≥2 unprovoked seizures over the next 10 years. Criteria 3: A diagnosed epilepsy syndrome

Answer 21

Based on seizure type, epilepsy type & syndrome Seizure type - onset(focal/generalised), awareness, clinical features Epilepsy type - focal, generalised, both or unknown Syndrome - can be classified into syndromes based on further findings e.g. onset age, EEG findings

Answer 22

• Cerebrovascular disease • Head trauma • Cerebral infections • Family history: epilepsy or neurological illness • Premature birth • Congenital malformations of the brain Genetics conditions associated with epilepsy

Answer 23

syncope, pseudoseizures, migraine associated disorders, paroxysmal movement disorders, sleep disorders

Answer 24

* ECG * Bloods: FBC, U&E, LFT, Glucose, Bone profile * Other: depending on suspected aetiology and age of presentation * EEG * MRI Brain

Answer 25

Patient Education & Safety Anti-epileptics - focal (lamotrigine-carbamazepine), generalised (sodium valproate - lamotrigine) Other options inc: Levetiracetam, Phenytoin * women of child bearing ages - sodium valproate * interactions of contraception - CYPP450

Answer 26

Continuous epileptic activity which failed to self terminate - lasting >5mins In SE there is prolonged seizure activity either due to failure of the mechanisms responsible for seizure termination, or from the initiation of mechanisms which lead to abnormally prolonged seizures

Answer 27

``` ® Part of epilepsy syndrome ® Hypoglycaemia ® Infection (meningitis/ encephalitis) ® Intracranial haemorrhage ® Electrolyte imbalance (hypo/hyper Na+, Ca2+) ® Drug-related · withdrawal – benzodiazepines, opioids · toxicity – tricyclic antidepressants ```

Answer 28

· Pre-hospital: PR Diazepam (10-20mg) repeat 15mins if continuing or give buccal midazolam 10mg · Primary survey; protect airway, breathing & circulation · Check glucose & respond accordingly Next steps: IV lorazepam  phenytoin infusion  GA General principles of management (for us) ® ABCDE ® 2x Benzodiazepines + Call a senior doctor ® Phenytoin / phenobarbitone Rapid sequence induction

Answer 29

Inflammation of brain parenchyma Infectious - viral (HSV), bacterial, fungi Non-infectious - AI, paraneoplastic & post infectious

Answer 30

``` • Infectious (common) ○ Herpes Simplex Virus (HSV) ○ Others include: arboviruses (e.g. West Nile virus), varicella-zoster virus, Epstein-Barr virus, and human immunodeficiency virus (HIV) ○ Bacterial causes - mycoplasma, TB ○ Fungi - histoplasmosis ○ Parasites ``` • Non-infectious ○ Paraneoplastic ○ Post-infectious ○ Auto-immune (NMDA & VGKC)

Answer 31

Classic presentation - new onset fever, headache & altered mental state +/- focal neurological deficits Can be highly variable dependent on underlying cause & area of brain that was been affected fever, headache, seizures, altered mental status, behavioural changes

Answer 32

• Bedside - observations, urinalysis, ECG & sputum cultures ○ Mostly to r/o other causes of infection e.g. UTI • Bloods - FBC, U&Es, bone profile, LFTs, CRP, cultures & coagulation • Imaging - CXR & CT head/MIR r/o stroke, SOL ``` More specialist: • Neuroimaging • EEG • CSF analysis (Lumbar Puncture) - CT first if worried about SOL Serological testing - antibodies ```

Answer 33

Principle treatment of HSV encephalitis is IV aciclovir * HSV encephalitis --> IV aciclovir * Antimicrobials or antivirals directed to cause * Immunosuppressive therapies (e.g. steroids) can be used to treat paraneoplastic, autoimmune, and post-infective causes but it is essential an infection is excluded before these are initiated.

Answer 34

Acute inflammatory demyelinating polyneuropathy affecting PNS - progressive &ascending Immune mediated

Answer 35

• Idiopathic (40%) • Post-infection (1-3 weeks) ○ Bacterial - campylobacter jejuni *most common identifiable trigger* ○ HIV ○ Herpes Simplex • Malignancy (lymphoma, Hodgkin's Disease)

Answer 36

Progressive symptoms of <1mth duration of: - Ascending symmetrical limb weakness (lower>upper) - Ascending paraesthesia May have a history of recent illness e.g. D&V, gastroenteritis Examination: Motor - hypotonia, flaccid paralysis, areflexia Sensory - impaired in multiple modalities

Answer 37

Differentials: Lyme disease, sarcoidosis, thiamine deficiency, porphyria and neoplasms

Answer 38

The diagnosis of GBS is suspected based on the clinical presentation. Investigations aim to confirm a diagnosis of GBS and exclude differentials. Specialist investigations needed: lumbar puncture & nerve conduction studies

Answer 39

Acute: high dose IV immunoglobins or plasmapheresis may reduce duration or severity Supportive: airway & cardiac monitoring, DVT prophylaxis, long term recovery help e.g. OT, physio

Answer 40

Condition a/w hemisection of the spinal cord, characterised by loss of temperature, pain, touch on one side (spinothalamic - sensory, contralateral) & paralysis on the other (corticospinal - motor, same side, iplatera) `Causes; Spinal fractures, Gunshot wounds, Stab wounds, Crush injury, Inflammatory diseases, Tumours, Vertebral disc herniation, Vascular reasons include hemorrhage or ischemia. Diagnostic imaging - MRI ****EXAMPLE: R side of spine taken out - loss of sensory on L side & motor loss on R*****

Answer 41

Down & Out eye fixed & dilated pupil ptosis Causes include: aneurysm of posterior communicating artery, infarction of nerve (diabetes), midbrain infarction or tumour

Answer 42

Dermatome - area of skin supplied by single spinal nerve (sensory) Myotome - group of muscles innervated by single spinal nerve (motor)

Answer 43

C4 - ''shrug shoulders'' C5 - shoulder ABduction, (elbows out & stop me from pushing them down), boxers pose (stop me from pulling them out) C6 - shoulder aDDuction, (elbows out & stop me from pushing up), boxers pose (stop me from pulling them out), wrist flexion C7 - elbow extension (boxers pose & push against me), wrist flexion C8 - thumb ABduction (thumbs to sky & stop me from pushing them down) T1 - finger ABduction (index finger, stop me pushing it in)

Answer 44

L2 - hip flexion (raise leg up to sky) *L5/S1 - hip extension (push down into bed)* L3 - knee extension (try & straighten leg) *S1 - knee flexion* L4 - ankle dorsiflex (upwards) L5 - big toe extension S1 - ankle plantar flex (pedal)

Answer 45

Triceps - C7 Biceps - C5/C6 Supinator - C5/C6

Answer 46

Knee jerk - L3/L4 ''kick the door'' Ankle jerk - S1 Plantar - L5/S1

Answer 47

Definition: Inflammation of the meninges - outer membranes covering brain & spinal cord Aetiology & Risk factors: Can be due to number of infectious (viral vs bacterial) & non-infectious causes Bacterial Meningitis • Bacterial - Neisseria meningitidis (meningococcus, gram -ve diplococcus) ○ Meningococcal septicaemia - bacterial infection has entered bloodstream § Cause of classic non-blanching rash, indicated DIC & subcutaneous haemorrhages ○ Meningococcal meningitis - in the brain • Bacterial - Streptococcus pneumoniae • Bacterial (neonatal) - Group B Streptococcus ○ Usually contracted during birth from GBS vaginal bacteria Viral Meningitis - tends to be milder & often only requires supportive treatment. Aciclovir can be used to treat suspected or confirmed HSV meningitis • Herpes simplex virus (HSV) • Enterovirus • Varicella zoster virus (VZV ``` Presentation/Clinical Features: Signs & Symptoms • Fever • Neck stiffness • Vomiting • Headache • Photophobia • Altered consciousness • Seizures • Non-blanching rash (meningococcal septicaemia) ``` O/E - Kernig's test & Brudzinski's test In Neonates • Hypotonia • Poor feeding • Lethargy • Bulging fontanelle • Hypothermia • LP should be performed in all children: ○ Under 1 months presenting with fever ○ 1 – 3 months with fever and are unwell ○ Under 1 years with unexplained fever and other features of serious illness Investigations & Diagnosis: Bedside/Community • ABCDE - if critically unwell • Focused history: ○ important to determine any preceding illnesses that increase risk of meningitis (e.g. sinusitis, otitis media, contact with an affected patient) • Allergy status • Formal examination ○ assess for meningeal irritation, look for non-blanching rash and signs of sepsis (e.g. hypotension, tachycardia) • Throat Swab • Respiratory viral screen (nasopharyngeal swab) • STAT IM BENZYLPENICILLIN DOSE (1200 mg - adults, age adjusted for children) ``` Bloods • FBC, U&Es, LFTs, bone profile, coagulation, CRP • Blood cultures • Venous blood gas • Meningococcal PCR ``` Imaging • CT head - usually done as part of work up, normally to r/o any contraindications for an LP ○ Some indications e.g. immunocompromised patient, hx of CNS disease, new onset seizures etc Special Tests • LUMBAR PUNCTURE (L3/L4)- every patient w/ suspected meningitis should undergo an LP & CSF evaulation ○ Ideally before abx, however difficult to implement in practise ○ Looks at: cell count & differential, protein, glucose, MC&S, viral PCR, save sample ○ May be able to isolate pathogen to tell if viral vs bacterial, but can also look at results of CSF § Bacterial = v high WCC, normal/reduced glucose & neutrophils § Viral = high WCC, normal glucose & lymphocytes Management: Depends on aetiology - usually treated for bacterial meningitis as really don't want to miss it Bacterial • 1st line = ceftriaxone (3rd gen cephalosporin) ○ It should be used with caution in patients with penicillin allergy due to cross-reactivity ○ If there is a severe penicillin allergy (e.g. anaphylaxis) it should be avoided. • 2nd line = chloramphenicol Viral • Majority secondary to enterovirus & don't require any specific treatment • Supportive measures inc rest, hydration, analgesia & anti-pyretic agent • Aciclovir used if concern of encephalitis or HSV infection

Answer 48

Multiple Sclerosis - autoimmune T cell mediated chronic demyelination in CNS, occurs sporadically throughout brain & spinal cord, lesions must be disseminated in time & space (UMN lesions) Myaesthenia Gravis - autoimmune disorder characterised by muscle weakness & fatiguability, antibodies against AChR (LMN lesions) Motor Neurone Disease or ALS - progressive selective loss/degeneration of neurones in the upper & lower motor tracts, sensory neurones are spared, eye movements never affected (LMN AND UMN)

Answer 49

WEBER'S - normal = equal - sensioneural loss = louder in 'good ear' - conductive loss = louder in bad ear RINNE'S - normal = AC > BC - sensioneural = AC > BC due to both air and bone conduction being reduced equally - conductive hearing loss = BC > AC