Neurology Flashcards
(251 cards)
1
Q
Define a stroke
A
A clinical syndrome of presumed vascular origin characterised by rapidly developing signs of focal and global disturbance of cerebral functions which lasts longer than 24 h OR leads to death.
2
Q
What are the 2 main type of stroke?
A
- Ischaemic
- Haemorrhagic
3
Q
What is the mechanism behind an ischaemic stroke?
A
Reduction or complete blockage of blood supply to a part of the brain, resulting in tissue hypoperfusion
4
Q
What is the mechanism behind a haemorrhagic stroke?
A
Occurs 2ary to a rupture of a blood vessel (usually arterioles and small arteries) or rupture of an abnormal vascular structure within the brain.
5
Q
What are the 5 main causes of an ishcaemic stroke?
A
- Embolism
- Thrombus
- Small vessel disease
- Systemic hypoperfusion
- Cerebral venous sinus thrombosis
6
Q
How can a thrombus lead to a stroke?
A
due to rupture of plaque within cerebral vessel
7
Q
How can an embolus lead to a stroke?
A
causes blockage of cerebral vessel
8
Q
How can small vessel disease lead to ischaemic stroke? What is the most common cause of this?
A
Chronic hypertension causes changes in the small vessels of the brain - middle layer of the vessel (tunica media) becomes enlarged and causes narrowing/occlusion of the vessels.
9
Q
How can systemic hypoperfusion lead to stroke?
A
Supply to entire brain is reduced 2ary to systemic hypotension e.g. in cardiac arrest
10
Q
How can cerebral venous sinus thrombosis lead to stroke?
A
Blood clots form in veins that drain the brain resulting in venous congestion and tissue hypoxia
11
Q
Is ishcaemic or haemorrhagic stroke more common?
A
Ischaemic (85%)
12
Q
What are some causes of haemorrhagic stroke?
A
Hypertension
Trauma
Bleeding disorders
Illicit drug use
Vascular malformations
13
Q
What are the 2 types of haemorrhagic stroke?
A
- Intracerebral haemorrhage
- Subarachnoid haemorrhage
14
Q
Location of intracerebral vs subarachnoid haemorrhage
A
Intracerebral → bleeding within brain (intraparenchymal and/or intraventricular)
Subarachnoid → bleeding outside of brain tissue between the pia mater and arachnoid mater
15
Q
Cause of intracerebral vs subarachnoid haemorrhage?
A
Intracerebral → hypertension
Subarachnoid → rupture of intracranial saccular aneurysm, anticoagulants, arterial dissections
16
Q
What is a silent stroke?
A
Radiological or pathological evidence of an infarction or haemorrhage not caused by trauma that doesn’t cause any noticeable symptoms
17
Q
Incidence of strokes in UK per year?
A
130,000 strokes every year in UK – 100,000 first time strokes and 30,000 recurrent events (once a person has had a stroke/TIA, they are at high risk of a further vascular event)
18
Q
What is the leading cause of death and disability in the UK?
A
Strokes
19
Q
Risk factors differ slightly for ischaemic vs haemorrhagic stroke. Give some risk factors for each:
A
20
Q
Is being male a risk factor for haemorrhagic or ischaemic stroke?
A
Haemorrhagic
21
Q
Are anticoagulants a risk factor for haemorrhagic or ischaemic stroke?
A
Haemorrhagic
22
Q
Is AF a risk factor for haemorrhagic or ischaemic stroke?
A
Ischaemic
23
Q
What test is used for the rapid assessment of potential stroke patients?
A
FAST
- Facial weakness - Can the person smile? Has their face fallen on one side?
- Arm weakness - Can the person raise both arms and keep them there?
- Speech problems - Can the person speak clearly and understand what you say? Is their speech slurred?
- Time to call 999
24
Q
Describe the scoring steps of the Glasgow Coma Scale
A
Eye opening:
- 4 - spontaneous
- 3 - to voice
- 2 - to pressure
- 1 - none
Motor response:
- 6 - obeying commands
- 5 - localises to pain
- 4 - normal flexion (withdraws from pain)
- 3 - abnormal flexion (flexes to pain)
- 2 - extension (extends to pain)
- 1 - none
Verbal response:
- 5 - orientated
- 4 - confused
- 3 - inappropriate words
- 2 - sounds
- 1 - none
Out of 15, cannot score <3
25
Give some potential differentials for a stroke
* Hypoglycaemia
* Drugs & alcohol toxicity
* Seizure
* Migraine with aura
* Demyelination (e.g. multiple sclerosis)
* Peripheral neuropathies (e.g. Bell's palsy)
* Trauma
* Systemic or local infection e..g sepsis, encephalitis, CNS abscess
* Tumour
* Dementia
* Subdural haematoma
26
Give some signs and symptoms of a stroke
Sudden onset of focal neurological symptoms cannot be explained by another conditions (e.g. hypoglycaemia):
* Unilateral weakness (arm \> leg)
* Numbness
* Unilateral sensory loss
* Speech disturbance - expressive dysphasia
* Ataxia
* Dysphagia
* Reduced level of consciousness e.g. confusion, syncope
* Pain
27
Bell's palsy vs stroke:
Bell's palsy → cannot raise eyebrow (i.e. upper AND lower unilateral facial paralysis)
Stoke → can raise eyebrow
28
What are some symptoms of a **posterior** stroke
* Nystagmus
* Vertigo
* N&V
* Head motion intolerance
* New gait unsteadiness
29
What is the 1st line (diagnostic) investigation for a stroke?
Head CT
30
In suspected strokes, a head CT should be performed immediately (within 1 hour) for people with which presentations? If none of these criteria are met, when should a CT head be performed?
* Indications for thrombolysis or early anticoagulation treatment
* On anticoagulation treatment
* A know bleeding tendency
* A depressed level of consciousness (GCS \<13)
* Unexplained progressive or fluctuating symptoms
* Papilloedema, neck stiffness or fever
* Severe headache at onset of stroke symptoms
If none of the above – scan within 24 hours
31
What bedside investigations should be done in a suspected stroke?
* 12-lead ECG - rule out arrhythmia (e.g. AF)
* Blood glucose - rule out hypoglycaemia
* Hydration status
* Swallow assessment
* CVS & focused neuro exam
32
What lab investigations should be done in a suspected stroke?
* FBC
* U&Es
* LFTs
* Calcium
* Specific to stroke:
* Plasma viscosity
* Cholesterol level
* CRP
* Clotting profile
* HbA1c
33
What imaging should be considered in stroke?
* CT head
* CXR
34
Why can a CXR be beneficial in stroke?
look for **aspiration** **pneumonia** if stroke has affected swallowing
35
What management steps should be taken while awaiting confirmation of diagnosis?
* **Avoidance of antiplatelet treatment until haemorrhagic stroke has been excluded!**
* Manage ABCDEs and give O2 while waiting
36
Management of ischaemic stroke?
* Thrombolysis → *Alteplase*
* Aspirin 300mg orally (or 600mg PR) ASAP (provided intracranial haemorrhage excluded)
* Thrombectomy
37
Should anticoagulants be given in an acute ischaemic stroke?
Anticoagulants are not recommended as an alternative to antiplatelet drugs in acute ischaemic stroke in patients who are in sinus rhythm.
However, parenteral anticoagulants may be indicated in patients who are symptomatic of, or at high risk of developing, **deep vein** **thrombosis** or **pulmonary embolism.**
38
What is the main drug used in thrombolysis?
Alteplase
39
When should alteplase be given in stroke?
if **within 4.5 hours** and **intracranial haemorrhage has been excluded** (CT head)
40
Once patient has been moved to stroke unit, further investigations & management plans can be carried out for other risk factors.
How can carotid stenosis be assessed? What is the management?
* Carotid dopplers - only done if fit for interventions
* **Carotid endarterectomy** within 2 weeks of neurological event achieves maximum stroke prevention
* Narrowing (stenosis) of internal carotid artery of 50-99% → refer urgently to vascular surgery
41
What is a carotid endarterectomy?
***Carotid endarterectomy*** is a surgical procedure to remove a build-up of fatty deposits (plaque), which cause narrowing of a carotid artery.
42
Management of a haemorrhagic stroke?
* Manage on stroke unit
* Ensure anticoagulants/antiplatelets are stopped
* Does anticoagulation need reversal?
* Manage hypertension – target 140-160 mmHg systolic
* Assess swallow and manage hydration
43
Circle of willis:
44
Vascular territories:
45
Functional areas of the brain:
46
Visual disturbances:
47
Which visual disturbance will a MCA stroke typically cause?
will usually cause **contralateral homonymous hemianopia** (i.e. left sided MCA will causes right-sided homonymous hemianopia).
48
Bamford stroke classification:
49
What is a transient ishcaemic attack (TIA)?
It is a transient (less than 24 hours, typically 30 minutes) period of neurological dysfunction without evidence of acute infarction.
50
How does a TIA differ from a stroke (signs & symptoms wise)?
Same signs & symptoms BUT completely resolves within 24 hours of onset
51
Investigations for TIA?
Same as stroke
52
Immediate management for TIA?
* **Aspirin 300mg _immediately_** unless contraindicated
* Give PPI to anyone with dyspepsia associated with aspirin use
* Specialist assessment
53
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space of the brain, located between the **arachnoid** and **pia mater** meningeal layers
54
What are some causes of a SAH?
* Traumatic injury e.g. road traffic collision
* Ruptured intracranial aneurysm - most common
* Arteriovenous malformation (AVM)
* SAH of unknown aetiology
* Rare disorders
55
Give some risk factors for a SAH
* Hypertension
* Smoking
* Family history
* Autosomal dominant polycystic kidney disease (ADPKDO)
* Age \>50 y/o
* Female sex (1.5x)
56
Prognosis of a SAH?
* Life-threatening conditions which can damage the brain through hypoxia, raised intracranial pressure and direct cranial injury
* Death rate 40-60%
57
Potential complications of a SAH?
Permanent neurological disabilities, coma, death
58
What headache is typically described with a SAH?
Sudden onset severe headache, reaching maximum intensity within seconds (‘**_thunderclap_ headache**’).
59
Symptoms of a SAH?
* Thunderclap headache (establish time to max intensity)
* N&V
* Photophobia
60
A reduced level of consciousness may be present with a SAH. Why?
can occur 2ary to raised intracranial pressure
61
Neck stiffness may be present with a SAH. Why?
2ary to meningeal infection
62
What is Kernig's test? Purpose?
A test used in physical examination to look for evidence of **irritation of the meninges****.**
The **inability to extend the knee** due to pain when the patient is supine, and the hip and knee are flexed to 90 degrees
63
What is a positive Kernig's sign caused by?
A positive Kernig’s sign is caused by irritation of **motor nerve roots** passing through inflamed meninges as they are under tension.
64
What conditions may a positive Kernig's sign be seen in?
* Meningits - bacterial, viral
* SAH
65
What imaging should be done in a suspected SAH?
* CT head scan
* CT angiogram
66
When would a lumbar puncture be indicated in SAH?
only necessary if SAH is suspected but CT scan does NOT show any evidence of **bleeding** or **raised intracranial pressure**
67
Management of SAH?
ABCDE Assessment:
* **Airway** – patients with reduced level of consciousness are at risk of occluding their airway (may require intubation)
* **Breathing** – record RR and SpO2
* **Circulation**:
* Record BP and pulse
* May require IV fluids to maintain BP
* May require electrolyte replacement (hyponatraemia common in SAH)
* Calcium channel blockers (e.g. nimodipine) must be given to reduced cerebral artery spasm and 2ary cerebral ischaemia
* **Disability**:
* Assess GCS – if \<8, requires anaesthetic input
* Invasive ICP monitory if GCS deteriorates
* **Exposure** - assess for trauma
68
Define peripheral neuropathy
A general term for any disorder affecting the **peripheral nerves**
69
Motor vs sensory peripheral neuropathy?
**Motor** → Damage to the peripheral nerves responsible for motor functions (e.g. foot drop) - a solely motor neuropathy is relatively uncommon
**Sensory** → Damage to the peripheral nerves responsible for causing symptoms of weakness, numbness, and pain.
70
What is the prototypical example of a solely motor neuropathy?
Progressive muscular atrophy (the LMN variant of motor neuron disease).
71
Give some causes of **motor** peripheral neuropathy
* Guillain Barre syndrome
* Hereditary motor neuropathies
* Acute intermittent porphyria
* Lead poisoning
* Paraneoplastic syndrome
72
What are causes of sensory peripheral neuropathy (ABCDE)?
* **A**lcohol toxicity
* **B**12/folate deficiency
* **C**hronic renal disease
* **D**iabetes mellitus (T1 & T2)
* **E**verything else e.g. vasculitis, paraneoplastic, viral infection
73
In what distribution does sensory peripheral neuropathy typically present?
Glove and stocking → with foot involvement preceding hand involvement
74
How common are peripheral neuropathies in the UK?
Almost 1 in 10 people aged 55 or over in UK
75
Mononeuropathy vs polyneuropathy?
Mononeuropathy refers to damage of a **single** **nerve**, whereas polyneuropathy refers to damage of **multiple** nerves
76
Is mono or polyneuropathy more common?
Poly
77
What is the most common cause of peripheral neuropathy in the UK?
Diabetes
78
What is the most common mononeuropathy?
Carpal tunnel syndrome
79
What is the most common _cause_ of mononeuropathies?
Physical injury/trauma is most common cause e.g. repetitive movements
80
What causes carpal tunnel syndrome?
It results from **pressure on the median nerve**, which passes through the carpal tunnel.
81
How does carpal tunnel syndrome present?
Numbness, tingling, unusual sensations, **pain in first 3 fingers on thumb side**, **worse at night,** difficulty performing actions, weakness.
82
Presentation of carpal tunnel syndrome vs ulnar nerve palsy?
Carpal → pain in first 3 fingers on thumb side
Ulnar → numbness in 4th and 5th digit
83
Fracture of the humerus can lead to palsy of which nerve?
Radial
84
What is the classic presentation of peroneal nerve palsy?
Foot drop
85
Give the 4 most common causes of polyneuropathy
1. Diabetes
2. Alcohol
3. Poor nutrition (B12/folate)
4. Guillain-Barre syndrome
86
Complications of peripheral neuropathy?
* Foot ulcers
* Gangrene
* Hypertension
* Arrhythmias
87
Prognosis of peripheral neuropathy?
* Curative treatment often rare
* Often **_progressive_**
* Prognosis dependent on underlying cause & which nerves are damaged
88
What are the 3 categories of the PNS?
1. Motor
2. Sensory
3. Autonomic
89
Do symptoms of peripheral neuropathy usually begin in the hands or feet?
Feet
90
Describe the presentation of symptoms of **motor** peripheral neuropathy (i.e. proximal or distal, extensor or flexor)?
**Distal** weakness of muscles
Typically involves **_extensor_** groups rather than flexor groups of muscles (think foot drop).
91
Describe the presentation of symptoms of **sensory** peripheral neuropathy
* Gradual onset of **_distal dysesthesia_**, pain and numbness in hands or feet → ‘**Glove** **and stocking pattern**’ is characteristic
* Sharp, stabbing, throbbing or burning
* **Distal** loss of pin, temperature and vibration perception
* Loss of **proprioception**
92
Describe ‘glove and stocking pattern’
The **distal** portions of the nerves are affected first (pattern occurs due to length of axon)
93
Describe the presentation of symptoms of **autonomic** peripheral neuropathy
* Orthostasis / posutral hypotension
* Impotence in males
* Gastroparesis
94
Describe the **signs** present in sensory peripheral neuropathy
* Distal loss of pin, temperature and vibration perception
* Loss of proprioception
95
Describe the **signs** present in motor peripheral neuropathy
Note - this is a LMN disease:
* Muscle wasting
* Fasciculations
* Tremors
* Reduced muscle tone (hypotonia)
* Distal weakness in peripheral neuropathy
* Hyporeflexia or areflexia e.g. absent ankle jerks
* Wasting and fasciculation of muscles
* Hypomimia (Parkinson’s)
* Ophthalmoplegia (MS, myasthenia gravis)
96
Describe the **signs** present in autonomic peripheral neuropathy
* Orthostatic hypotension
* Sweating problems
97
What bedside investigations should be conducted in peripheral neuropathy?
* Obs
* Urinalysis
* Blood glucose
98
What lab investigations should be conducted in peripheral neuropathy?
FBC, B12, TFTs, ANA & rheumatoid factor, HbA1c, cholesterol, ESR & CRP
99
Why may a CXR be indicated in peripheral neuropathy?
For **asymptomatic** **lung cancer** that can cause a purely sensory neuropathy.
100
What type of peripheral neuropathy would asymptomatic lung cancer present as?
Purely sensory
101
Nerve conduction studies that can be carried out in peripheral neuropathy. What would show in demyelinating neuropathies vs axonal neuropathies?
**Demyelinating** → _slower_ _conduction_ velocities or even conduction block
**Axonal** → _reduced_ _amplitude_ of compound motor or sensory nerve action potentials
102
What is the **pharmacological** management for peripheral neuropathies?
* Corticosteroids
* Immunosuppressants
103
What is Guillain-Barre syndrome?
An **ascending** inflammatory **demyelinating** _polyneuropathy_.
104
Causes of Guillain-Barre?
* Typically 1-3 weeks after infection (e.g. Campylobacter, mycoplasma, EBV).
* 40% of cases are idiopathic
105
Presentation of Guillain-Barre?
* Progressive ascending symmetrical limb weakness (affecting the lower limbs first)
* Paraesthesia may precede the onset of motor symptoms
* Respiratory muscles can be affected in severe cases
* LMN signs in lower limbs:
* Hypotonia
* Flaccid paralysis
* Areflexia
106
How do seizures differ from epilepsy?
Seizures are **_individual**_ occurrences of abnormal electrical activity in the brain. Epilepsy is a _**chronic_** neurological disorder that causes repeated seizure activity.
107
What is a seizure?
Seizures are transient episodes abnormal electrical activity in the brain.
108
How does a generalised seizure differ from a focal seizure?
**Generalised →** Affecting entire brain
**Focal** → Involving subsection of brain
109
What are the subtypes of generalised seizures?
* Tonic
* Tonic-clonic
* Atonic
* Myoclonic
* Absence
110
What is the most common type of generalised seizure?
Tonic clonic → most common where patient falls to ground stiff (tonic phase) followed by series of rhythmic jerks (clonic phase)
111
What is ‘2ary generalisation’ of a seizure?
Starts focal → localises to entire brain
112
How are focal seizures classified?
Subclassified on clinical features (part of brain they involve)
113
How long do generalised tonic clonic seizures last?
Sudden onset, typically lasts \<5 minutes
114
Give some features of a tonic clonic seizure (during and after)
* Loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements
* During:
* Lateral tongue biting
* Urinary incontinence
* After:
* **Post-ictal** **confusion** (though may recall onset, especially if 2ary generalised)
* May be left with residual focal neurological deficit (Todd’s Paresis)
115
What is Todd's Paresis?
Todd's paralysis is **a neurological condition experienced by individuals with epilepsy, in which a seizure is followed by a brief period of temporary paralysis**
116
Who are absence seizures most common in?
Children (but 90% will grow out of them)
117
How do absence seizures present?
* Patient becomes blank, stares into space and then abruptly returns to normal
* During episode, they are unaware of surroundings and won’t respond
* Typically last only 10-20 seconds
118
Differentials of a seizure?
* Syncope (vasovagal, arrhythmogenic)
* Pseudoseizures
119
Define epilepsy
An umbrella term for a condition where there is a tendency to have seizures. A diagnosis of epilepsy is made by a specialist based on the characteristics of the seizure episodes.
120
What is the main investigation used to diagnose epilepsy?
Electroencephalogram (EEG)
121
What does an EEG do?
n this test, electrodes are attached to your scalp with a paste-like substance or cap. The electrodes record the electrical activity of your brain.
122
What other investigations should be done in epilepsy to rule out other pathologies?
* ECG (e.g. AF)
* MRI brain (tumours)
* Blood electrolytes: Na, K, Ca, Mg
* Blood glucose (rule out hypoglycaemia, diabetes)
* Blood cultures, urine cultures, lumbar puncture (meningitis, sepsis, encephalitis)
123
What is the 1st line drug choice for **tonic clonic** seizures?
Sodium valproate
124
What is the 2nd line drug choice for **tonic clonic** seizures?
Lamotrigine or carbamazepine
125
What is the 1st line drug choice for **focal** seizures?
Lamotrigine or carbamazepine (opposite of tonic clonic)
126
What is the 2nd line drug choice for **focal** seizures?
Sodium valproate (or levetiracetam)
127
What is the 1st line drug choice for absence seizures?
Sodium valproate (or ethosuximide)
128
Which 2 anti-epileptics should be monitored carefully due to their interactions with other drugs?
Phenytoin and carbamazepine (inducers of the P450)
129
Are anti-epileptics safe during pregnancy?
No - teratogenic (lamotrigine is a good choice for women of childbearing age)
130
Define status epilepticus
A seizure lasting \>5 minutes or multiple seizures within a 5-minute period with incomplete resolution.
131
Complications of status epilepticus
Medical emergency, may lead to permanent brain damage or death.
132
Management of patients with status epilepticus?
ABCDE approach
* A – Secure airway
* B:
* Check O2 sats give high-concentration O2
* Check respiratory function (RR etc)
* ABG
* C:
* Assess cardiac function
* Gain IV access (insert cannula)
* Routine venous bloods: FBC, U&Es, LFTs, CRP, calcium and magnesium, clotting
* D:
* Check blood glucose levels
* Gain IV access (inset cannula)
* IV lorazepam → repeated after 10 minutes if seizure continues
* If seizure persists, the final step is infusion of IV phenobarbital or phenytoin:
* Intubation required
* Transfer to intensive care
133
What drug should be given in status epilepticus?
IV lorazepam
134
Define Parkinsonism
Umbrella term for the **clinical syndrome** involving **_bradykinesia_** with at least one of the following: rigidity, tremor, and postural instability.
135
What are the differentials for parkinsonism?
* **Idiopathic Parkinson’s disease** (this is the prototypical) parkinsonian syndrome
* **Multiple system atrophy (MSA)**
* **Dementia with Lewy Bodies:**
* **Progressive supranuclear palsy (PSP)**
* **Vascular Parkinsonism**
* **Drugs**
* **Wilson’s disease**
136
How could vascular parkinsonism differ from Parkinson's disease?
Vascular tends to be tremor negative and localised to lower limbs
137
Which drugs can lead to parkinsonism?
Antipsychotics and metoclopramide (dopamine antagonist)
138
What class of drug is metoclopramide?
Antiemetic → Dopamine antagonist
139
What is the most common neurodegenerative condition in the UK?
Alzheimer's
140
What is the pathophysiology of Parkinson's disease?
Progressive loss of **dopaminergic** **neurons** in the substantia nigra of the basal ganglia → the fall in dopamine levels results in symptoms.
141
What is the function of basal ganglia structures?
.Basal ganglia structures are responsible for **coordinating habitual movements** (e.g. walking, looking around), **controlling voluntary movements** and **learning specific movement patterns**.
142
What is the function of dopamine?
Dopamine is a neurotransmitter produced by the substantia nigra which transmits signal from the substantia nigra to other parts of the basal ganglia via the **nigrostriatal pathways** (these pathways control smooth, purposeful movement)
143
What are the 3 cardinal features of Parkinson's dsiease?
1. Resting tremor
2. Rigidity
3. Bradykinesia
4. (postural instability)
144
How is the tremor seen in Parkinson's often described as?
‘**Pill rolling tremor’** – looks like patient is rolling a pill between their fingertips and thumb
145
Is a pill rolling tremor more pronounced on rest or movement?
More pronounced when **resting** and improves on voluntary movement
Tremor worsened if patient is distracted (e.g. asking patient to do a task with the other hand)
146
Is the tremor seen in Parkinson's disease symmetrical or asymmetrical?
Asymmetrical (can help differentiate from other forms of Parkinsonism)
147
Frequency of Parkinson's disease tremor?
Occur at frequency of 4-6 Hz (occurs 4-6 times a second)
148
What 2 types of rigidity can be seen in Parkinson's disease?
1. Lead pipe
2. Cog-wheel
149
Describe cogwheel rigidity
If you take their hand and passively flex and extend their arm at the elbow, you will feel a tension in their arm that gives way to movements in small increments (like little jerks) → i.e. jerky movement
150
Describe lead pipe rigidity
stiffness continues throughout the movement
151
What is cogwheel rigidity caused by?
tremor superimposed on hypertonia
152
Give some presentations of bradykinesia in Parkinson's disease
* **Slowness in initiation** of voluntary movement
* **Reduction in speed** during repetitive actions
* Shuffling gate – small steps when walking
* Difficulty turning, have to take lots of little steps
* Reduced facial movements and expressions (hypomimia)
* **Handwriting gets smaller and smaller** (classic presenting complaint in exams)
153
How may postural instability in Parkinson's disease present?
* Poor balance
* Difficulty going from sitting to standing
* Gait
* Frequent falls
154
Some other motor signs of Parkinson's disease:
* Reduced blink rate
* Hypomimia (expressionless face)
* Hypophonia (quiet speech)
* Drooling
* Micrographia (reduction in size of handwriting) – draw out spiral and ask them to draw one next to it
* Reduced arm swing
* Festination – tendency to pick up speed as patient travels in a particular direction (resulting in shuffling gait)
* Freezing (e.g. when walking through a doorway)
155
Some non-motor signs of Parkinson's disease:
* Depression
* Sleep disturbance and insomnia
* Loss of sense of smell (anosmia)
* Cognitive impairment and memory problems
* Hallucinations
* Falls
156
Some autonomic signs of Parkinson's disease:
* Weight loss
* Dysphagia
* Constipation
* Orthostatic hypotension
* Drooling
157
A common exam task challenges you to distinguish between the tremor of Parkinson’s disease and a benign essential tremor:
158
Parkinson's tremor vs benign essential tremor → symmetry
P → asymmetrical
BET → symmetrical
159
Parkinson's tremor vs benign essential tremor → frequency
P → 4-6 Hz
BET → 5-8Hz
160
Parkinson's tremor vs benign essential tremor → affected by rest
P → worse at rest
BET → improves at rest
161
Parkinson's tremor vs benign essential tremor → intentional movement
P → improves
BET → worse
162
Parkinson's tremor vs benign essential tremor → alcohol
P → no change with alcohol
BET → improves with alcohol
163
How does alcohol affect a benign essential tremor?
Improves it
164
Diagnosis of Parkinson's disease?
Clinical diagnosis using UK Parkinson’s disease brain bank criteria:
* Bradykinesia plus at least one of:
* Rigidity
* Tremor
* Postural instability
165
What is the 1st line pharmacological treatment for Parkinson's disease?
Levodopa
166
What 2 drugs can levodopa often given alongside?
1. _Carbidopa_ (**co****-careldop**a = levodopa + carbidopa)
2. _Benserazide_ (co-benyldopa = levodopa + benserazide)
167
Why is levodopa given alongside carbadopa or benserazide?
These drugs are **peripheral decarboxylase inhibitors** i.e. stop levodopa being broken down in the body before it gets the chance to enter the brain
168
What is the main side effect of levodopa?
Dyskinesia
169
Define meningitis
Inflammation of the meninges.
170
Define meningococcus
Neisseria meningitidis bacteria.
171
Define meningococcal septicaemia
When **Neisseria** **meningitidis** bacterial infection is in the bloodstream (this causes classic ‘non-blanching’ rash).
172
Define meningococcal meningitis
When Neisseria meningitidis bacteria infect the meninges and the CSF.
173
Meningitis can be infective or non-infective. What are some causes of non-infective meningitis?
* Malignancy (leukaemia, lymphoma, other tumours)
* Chemical meningitis
* Drugs (NSAIDs, trimethoprim)
* Sarcoidosis
* SLE
* Behcet’s disease
174
What is the most common cause of meningitis?
Viral → enteroviruses
175
What are the 2 most common cause of **bacterial** meningitis in adults and children?
1. Streptococcus pneumoniae
2. Neisseria meningitidis
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What is the most common cause of **bacterial** meningitis in neonates?
Group B Strep (streptococcus agalactiae)
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how is group B strep usually contracted by neonates?
usually contracted during birth from GBS bacteria that can live harmlessly in vagina
178
Who does listeria monocytogenes usually cause bacterial meningitis in?
often in patients at extremes of age
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Give some examples of enteroviruses
Echoviruses, Coxsackie viruses A and B, poliovirus
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What is the most common cause of viral meningitis?
Enteroviruses
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Give some other causes of viral meningitis
* HSV2 (more associated with meningitis)
* HSV1 (more associated with meningoencephalitis/encephalitis particularly affecting the temporal lobes)
* Paramyxovirus – can be a complication of mumps infection
* Measles and rubella viruses – can cause meningoencephalitis
* Varicella Zoster virus – can be a complication of chickenpox
* Rabies virus
* Arboviruses
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What is the most common cause of fungal meningitis?
**Cryptococcus neoformans**
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Presentation of meningitis in children/adults?
* Headache
* N&V
* Fever
* Photophobia
* Neck stiffness
* Non-blanching rash → seen in meningococcal septicaemia
* Focal neurology
* Seizures
184
Presentation of meningitis in neonates?
Presentation can be non-specific:
* Hypotonia
* Poor feeding
* Lethargy
* Hypothermia
* Bulging fontanelle
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Immediate management of **viral** meningitis?
**IV aciclovir**
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Immediate management of **bacterial** meningitis?
IV ceftriaxone 2x daily
+ IV amoxicillin in young/old patients → to better cover listeria
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Investigations that can be done in meningitis?
* Blood tests:
* FBC
* U&Es
* Clotting
* Glucose
* ABG
* Blood cultures
* CT head
* Lumbar puncture
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CSF features in bacterial vs viral meningitis → appearance
Bacterial → cloudy
Viral → clear
189
CSF features in bacterial vs viral meningitis → protein
Bacterial → high
Viral → mildy raised or normal
190
CSF features in bacterial vs viral meningitis → glucose
Bacteria → low
Viral → normal
191
CSF features in bacterial vs viral meningitis → WCC
Bacteria → high (neutrophils)
Viral → high (lymphocytes)
192
CSF features in bacterial vs viral meningitis → culture
Bacterial → bacteria
Viral → negative
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What is the key complication of meningitis?
Hearing loss
194
What can be given to to reduce frequency and severity of hearing loss and neuro damage?
Steroids (dexamethasone)
195
Other complications of meningitis:
* Seizures and epilepsy
* Cognitive impairment and learning disability
* Memory loss
* Focal neurological deficits e.g. limb weakness or spasticity
* Septic shock
* Disseminated intravascular coagulation
* Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
* Death
196
Define encephalitis
A histological diagnosis characterised by inflammation of the ‘encephalon’ (or brain parenchyma)
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Who is encephalitis most commonly seen in?
Bimodal age distribution seen – highest incidence in those \<1 y/o and \>65 y/o
198
What is the most common cause of encephalitis?
Viral - HSV1
199
Presentation of encephalitis?
* Altered mental state (encephalopathy)
* High fevers
* New onset seizures
* Flu-like prodromal illness
200
Main investigation for encephalitis?
MRI head
201
Management for viral encephalitis?
IV aciclovir
202
What is the most common type of headache?
Tension headache
203
What 2 signs i giant cell arteritis associated with (as well as headache)?
1. Temporary **monocular** blindness
2. Temporal tenderness
204
When taking a headache history, what red flags should you ask about?
* Neck stiffness, photophobia, fever → **meningitis**
* Occipital headache of sudden onset, reaching max intensity within 5 mins → **subarachnoid haemorrhage**
* Dizziness **→ stroke**
* Recent head trauma → **subdural** **haemorrhage**
* Posture dependent - e.g. worse lying down → **raised ICP**
* Headache worse on coughing → **raised ICP**
* Vomiting → **raised ICP**
* Pregnancy → **pre-eclampsia**
* Sleep disturbance
* Tenderness in temporal region & jaw claudication → **giant cell arteritis**
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why is fundoscopy an essential part of a headache assessment?
Look for **papilloedema**
206
What does papilloedema indicate?
Raised ICP which can be due to brain tumour, benign intracranial hypertension, intracranial bleed
207
How does a tension headache present?
**Mild ache** across the **forehead** and in a **band-like pattern** around the head.
This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles (i.e. tenderness of the scalp muscles)
208
Are there any visual changes with a tension headache?
NO
209
Triggers for a tension headache?
* Stress
* Depression
* Alcohol
* Skipping meals
* Dehydration
210
Management of a tension headache?
* Reassurance
* Basic analgesia
* Relaxation techniques
* Hot towels to local area
211
What is a 2ary headache?
Give a similar presentation to a tension headache but with a _clear cause_:
* Underlying medical condition e.g. infection, obstructive sleep apnoea, pre-eclampsia
* Alcohol
* Head injury
* Carbon monoxide poisoning
212
Define sinusitis
A headache associated with inflammation in the **ethmoidal**, **maxillary**, **frontal**, or **sphenoidal** sinuses.
213
Presentation of sinusitis?
* Headache
* Facial pain behind the nose, forehead, and eyes
* Tenderness over the affected sinus
* Usually resolves within 2-3 weeks
214
Is most sinusitis viral or bacterial?
Viral
215
Management of sinusitis?
* Nasal irrigation with saline
* Prolonged symptoms can be treated with nasal steroid spray
* Abx sometimes required
216
What is an analgesic headache?
Headache caused by long-term analgesia use
217
Presentation of an analgesic headache?
Similar non-specific features to a tension headache, these are 2ary to continuous or excessive use of analgesia.
218
management of analgesic headache
Withdrawal of analgesia (challenging in patients with chronic pain and those who believe analgesia is necessary to treat the headache).
219
What does a hormonal headache tend to be related to?
Low oestrogen
220
When does a hormonal headache typically come on?
* 2 days before and first 3 days pf menstrual period
* Around menopause
* Pregnancy
221
When does a hormonal headache in **pregnancy** typically come on? How can this be differentiated from a headache related to pre-eclampsia?
* Hormonal headache - Worse in **first few weeks** and improves in last 6 months
* Headaches in _2_nd _half_ of pregnancy should prompt **investigation for pre-eclampsia**
222
Management for hormonal headache?
Oral contraceptive pill
223
What is cervical spondylosis?
Common condition caused by degenerative changes in the cervical spine.
224
Presentation of cervical spondylosis?
* Neck pain, usually made worse by movement
* Headache
225
What is important to exclude before a diagnosis of cervical spondylosis?
other causes of neck pain e.g. inflammation, malignancy, infection, spinal cord, or nerve root lesions.
226
Give some differentials of a headache
* Tension headaches
* Migraines
* Cluster headaches
* Sinusitis
* Giant cell arteritis:
* Associated with temporary monocular blindness and temporal tenderness
* Treat with high-dose steroids
* Glaucoma
* Intracranial haemorrhage
* Subarachnoid haemorrhage
* Hormonal headache
* Trigeminal neuralgia
* Meningitis
* Encephalitis
* Analgesic headache
* Cervical spondylosis
* Raised intracranial pressure (brain tumours)
227
What is trigeminal neuralgia thought to be caused by?
Compression of nerve
228
Triggers for trigeminal neuralgia?
Cold weather, spicy food, caffeine, citrus fruits, eating, talking, touching the face
229
Are the majority of trigeminal neuralgia cases unilateral or bilateral?
Unilateral (90%)
230
Which neurodegenerative disease can be associated with trigeminal neuralgia?
Multiple sclerosis → Around 5-10% of people with _multiple sclerosis_ have trigeminal neuralgia
231
Presentation of trigeminal neuralgia?
* **_Intense facial pain_** that comes on spontaneously in the trigeminal nerve distribution → often described as an **electricity-like** shooting pain
* Lasts anywhere between a few seconds to hours
232
1st line treatment for trigeminal neuralgia?
carbamazepine
(then potentially surgery to decompress or intentionally damage the trigeminal nerve)
233
What **red flags** can be seen in a headache history in the context of raised intracranial pressure (ICP)?
* Worse in morning
* Worse on bending over
* Improves after vomiting and lying down
* Neurological deficits → due to compression of cranial structures by a space-occupying lesion (tumour, haemorrhage)
234
1ary investigation in raised ICP?
CT head
235
What is a migraine?
Complex neurological condition that causes headaches and other associated symptoms. They occur in ‘attacks’ that often follow a typical pattern.
236
4 types of migraines:
* Migraine without aura
* Migraine with aura
* Silent migraine (migraine with aura but without a headache)
* Hemiplegic migraine
237
Triggers for migraines?
* Stress
* Bright lights
* Strong smells
* Certain foods e.g. chocolate, cheese, caffeine
* Dehydration
* Menstruation
* Abnormal sleep patterns
* Trauma
* Oral contraceptives
238
Are migraines unilateral or bilateral?
Unilateral
239
Presentation of a migraine?
* **Unilateral**, throbbing headache
* Headache symptoms:
* Last between 4-72 hours
* Moderate to severe intensity
* Pounding or throbbing in nature
* Usually unilateral but can be bilateral
* Photophobia
* Phonophobia – discomfort with loud noises
* With or without aura
* N&V
240
If an aura is **not** present, what criteria is required to diagnose a migraine?
* At least 5 headaches lasting 4-72 hours with;
* N/V or photo/phonophobia AND 2 of;
* Unilateral headache
* Pulsating character
* Impaired or worsened by daily activities
241
What is an aura? Give some examples
This is the term used to describe the visual changes associated with migraines. There can be multiple types:
* Sparks in vision
* Blurring vision
* Lines across vision
* Loss of different visual fields
242
Management of migraines?
* Dark, quiet room & sleep
* Paracetamol
* Triptans (e.g. sumatriptan)
* NSAIDs
* Antiemetics (if vomiting occurs) → metoclopramide is most effective in migraines
* Prophylaxis:
* Propranolol
* Topiramate (teratogenic)
* Amitriptyline
243
What class of drug are triptans?
5HT receptor agonists (serotonin receptor agoinsts)
244
Indications for triptans?
Migraines
245
Which antiemetic is most effective in migraines?
Metoclopramide
246
Which medications can be used in the prophylaxis of migraines?
* Propanolol
* Topiramate
247
What criteria makes up the definition of a **total anterior circulation stroke**?
All 3 of:
1. Contralateral homonymous hemianopia
2. Contralateral limb weakness
3. Higher cerebral dysfunction e.g. dysphasia
248
What criteria makes up the definition of a **partial anterior circulation stroke**?
2 out of 3 of:
1. Contralateral homonymous hemianopia
2. Contralateral limb weakness
3. Higher cerebral dysfunction e.g. dysphasia
249
What criteria makes up the definition of a **posterior anterior circulation stroke**?
At least 1 of:
1. Cranial nerve palsy and contralateral/sensory deficit
2. Bilateral motor/sensory deficit
3. Conjugate eye movement disorder (gaze palsy)
4. Cerebellar symptoms (vertigo, nystagmus, ataxia)
5. Isolated homonymous hemianopia
250
What criteria makes up the definition of a **lacunar stroke**?
1 of the following:
1. Pure sensory
2. Pure motor
3. Sensori-motor
4. Ataxic hemiparesis)
(no loss of higher cerebral function)
251
What symptom **has** to be present for a diagnosis of Parkinson's to be made?
Bradykinesia
