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Phase 2a Green Conditions > Neurology > Flashcards

Neurology Flashcards

1
Q

What is a TIA?

A
  • sudden onset
  • brief episode of neurological deficit
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2
Q

Pathophysiology of TIA

A
  1. temporary, focal cerebal ischaemia
  2. lack of O2 and nutrients to brain
  3. without infarction → no irreversible cell death
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3
Q

Features of a TIA

A
  • symptoms are maximal at onset
  • usually lasts 5-15 mins
  • classical definition = lasts <24hrs
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4
Q

Risk factors for TIA

A
  • age
  • HTN
  • smoking
  • diabetes
  • a fib
  • the pill
  • males
  • black people
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5
Q

Causes of a TIA

A

atherothromboembolism from carotid artery

cardioembolism

  • in a fib
  • after an MI
  • valve disease/prosthetic valve

hyperviscosity

hypoperfusion

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6
Q

Presentation of a TIA

A
  • amaurosis fugax
  • aphasia
  • hemiparesis
  • hemisensory loss
  • hemianopic visual loss
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7
Q

What symptoms do not indicate a TIA on their own?

A
  • syncope
  • dizziness
  • temporary loss of consciousness
  • temporary memory loss
  • gradual onset
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8
Q

What scoring tool measures the risk of a stroke after a TIA?

A

ABCD2 score

  • age
  • BP
  • clinical features
  • duration of TIA
  • DM
  • gives 2 day risk
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9
Q

Investigations for TIA

A
  1. diffusion weighted MRI/CT brain
  2. carotid imaging → doppler US then angiography if stenosis found
  • bloods
  • ECG
  • echo
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10
Q

Management of TIA

A
  • loading dose 300mg aspirin
  • control BP/cholesterol
  • no driving for 1 month
  • antiplatelet therapy = daily 75mg aspirin
  • anticoagulation if AF
  • carotid endarterectomy
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11
Q

What is a stroke?

A
  • rapid onset neurological deficit
  • lasting over 24hrs
  • poor blood flow to brain → cell death
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12
Q

What are the 2 types of stroke?

A

ischaemic 85%
- blood clot in blood vessel to brain

haemorrhagic 15%
- bleed in small blood vessel in/around brain

urgent CT/MRI to determine type → guides treatment

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13
Q

Risk factors for ischaemic stroke

A
  • age
  • male
  • HTN
  • smoking
  • diabetes
  • recent/past TIA
  • IHD/AF
  • the pill
  • black/asian
  • PVD
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14
Q

Causes of ischaemic stroke

A
  • small vessel occlusion by thrombus
  • atherothromboembolism
  • cardioembolism
  • hyperviscosity
  • hypoperfusion
  • vasculitis
  • fat emboli from long bone fracture
  • venous sinus thrombosis
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15
Q

Presentation of cerebral infarcts

A

depends on site

ACA
- contralateral weakness and sensory loss of lower limb

MCA

  • contralateral motor weakness/sensory loss
  • speech issues
  • contralateral hemiplegia
  • UMN facial weakness
  • dysphagia
  • homonymous hemianopia
  • visuo-spatial deficit
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16
Q

Presentation of brainstem infarcts

A

depends on site

  • quadriplegia
  • facial numbness/paralysis
  • vision disturbances
  • speech impairment
  • vertigo → N&V
  • locked-in syndrome
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17
Q

What are lacunar infarcts?

A
  • small infarcts
  • occlusion of a single perforating artery supplying a subcortical area

occurs in

  • internal capsule
  • basal ganglia
  • thalamus
  • pons
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18
Q

Presentation of lacunar infarcts

A

depends on site → one of:

  • sensory loss
  • unilateral weakness
  • ataxic hemiparesis
  • dysarthria
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19
Q

Management of ischaemic strokes

A
  • exclude haemorrhagic stroke
  • loading dose 300mg aspirin
  • antiplatelet therapy → 300mg aspiring daily for 2 weeks then clopidogrel
  • anticoagulation if AF
  • thrombolysis → IV alteplase within 4.5hrs
  • mechanical thrombectomy

acute stroke unit

  • rehabilitation
  • swallowing/feeding support
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20
Q

What are the 4 types of haemorrhagic stroke?

A
  • intracerebral haemorrhage
  • subarachnoid haemorrhage
  • extradural haemorrhage
  • subdural haemorrhage
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21
Q

What is an intracerebral haemorrhage?

A
  • sudden bleeding into brain tissue
  • rupture of blood vessel in brain
  • leads to infarction (O2 deprivation)
  • pooling blood increases ICP
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22
Q

Risk factors for intracerebral haemorrhage

A
  • HTN
  • age
  • alcohol
  • smoking
  • diabetes
  • anticoagulation
  • thrombolysis
  • secondary to ischaemic stroke
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23
Q

Pathophysiology of increased ICP

A
  • pressure on skull/brain/blood vessels
  • CSF obstruction
  • midline shift
  • tentorial herniation
  • coning
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24
Q

Presentation of intracerebral haemorrhage

A

similar to ischaemic stroke

pointers to haemorrhage

  • sudden loss of consciousness
  • severe headache
  • meningism
  • coma
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25
Investigations for intracerebral haemorrhage
- same as ischaemic stroke - CT/MRI brain = essential
26
Management of intracerebral haemorrhage
- stop anticoagulants immediately → reverse effects with clotting factor replacement - BP control - reduce ICP → mechanical ventilation, IV mannitol
27
What is a subarachnoid haemorrhage?
spontaneous bleeding into subarachnoid space
28
Risk factors for SAH
- HTN - known aneurysm - previous aneurysmal SAH conditions associated with berry aneurysms - PKD - coarctation of aorta - connective tissues diseases
29
Causes of SAH
- aneurysmal rupture → Berry aneurysms - ateriovenous malformations - idiopathic - traumatic injury
30
Pathophysiology of SAH
- tissue ischaemia - raised ICP - space-occupying lesion → puts pressure on brain - blood irritates meninges → can obstruct CSF outflow - vasospasm
31
Complications of SAH
- rebleeding - hyponatraemia
32
Symptoms of SAH
- sudden onset excruciating headache → thunderclap, occipital - N&V - collapse - loss of consciousness - vision changes - coma
33
Signs of SAH
signs of meningeal irritation - neck stiffness - Kernig's sign - Brudzinski's sign - retinal, subhyaloid, vitreous bleeds - focal neurological signs - high BP
34
Investigations for SAH
ASAP brain CT - star shaped sign lumbar puncture - only if normal ICP - xanthochromia → yellowish CSF MR/CT angiography to find source of bleeding
35
Management of SAH
- IV fluids - ventricular drainage if hydrocephalus - nimodipine reduces vasospasm - surgery if aneurysm → endovascular coiling/surgical clipping
36
What is a subdural haematoma?
- bleeding into subdural space - rupture of bridging vein - usually due to head trauma - massive latent interval
37
Risk factors of subdural haematoma
- babies → traumatic injury - brain atrophy → dementia, elderly, alcoholics - prone to falls - anticoagulants
38
Pathophysiology of subdural haematoma
- bleeding forms haematoma then stops weeks/months later - haematoma autolyses → increase in oncotic/osmotic pressure → water sucked in → haematoma enlarges - rise in ICP - midline structures shifted away from side of clot
39
Symptoms of subdural haematoma
- fluctuating levels of consciousness - drowsiness - headache - confusion - insidious physical/intellectual slowing
40
Signs of subdural haematoma
- raised ICP - seizures - localising neurological signs
41
Investigations for subdural haematoma
CT scan - haematoma → banana shaped - midline shift MRI
42
Management of subdural haematoma
surgery - remove haematoma → clot evacuation - craniotomy - burr hole washout IV manittol reverse clotting abnormalities address cause
43
What is an extradural haematoma?
- bleeding into extradural space - after trauma to temple → fracture → rupture of MMA - lucid interval
44
Risk factors for extradural haematoma
- young people - male
45
Pathophysiology of extradural haematoma
after lucid interval - rise in ICP - pressure on brain - midline shift → tentorial herniation/coning
46
Presentation of extradural haematoma
after lucid interval - rapidly declining GCS - headache - vomiting - seizures - coma - deep/irregular breathing → coning - death → respiratory arrest
47
Investigations for extradural haematoma
CT scan - haematoma → lemon shaped - midline shift skull xray → fracture lines
48
Management of extradual haematoma
- stabilise - urgent surgery → clot evacuation/ligation of bleeding vessel - IV mannitol - airway care
49
What are the red flags for headaches?
- worst headache ever - other neurological signs - onset \>50 - severe, quick onset - abnormal pattern of migraine
50
What is a migraine?
- recurrent throbbing headache - often preceded by an aura - associated with N&V, visual changes most common cause of episodic headache
51
Risk factors for migraines
- family history - female - age → first in adolescence
52
Causes of migraines
CHOCOLATE - chocolate - hangovers - orgasms - cheese - oral contraceptives - lie-ins - alcohol - tumult - exercise
53
Presentation of migraine
prodrome - yawning - craving - mood/sleep changes aura - precedes attack, variety of symptoms - visual disturbances - parasthesia
54
Diagnosis of migraine
2+ of: - unilateral pain - throbbing-type pain - moderate to severe intensity - motion sensitivity and 1+ of: - N&V - photo/phonophobia
55
Investigations for migraine
- bloods - CT/MRI → look for red flags - lumbar punture
56
Management of migraines
conservative = avoid triggers mild - NSAIDs → naproxen/ipubprofen - antiemetic severe = oral triptans eg sumatriptan - not if IHD, uncontrolled HTN - SE → arrythmias, angina
57
Prophylaxis of migraines
- beta blockers - acupuncture - amitriptyline = TCA - topiramate = anticonvulsant
58
What are cluster headaches?
- episodic headaches with pain free periods - most disabling primary headache
59
Risk factors for cluster headaches
- smoking - alcohol - male - 20-40 - autosomal dominant gene
60
Presentation of cluster headaches
pain - rapid onset excruciating - classically around the eye - can be temples and forehead - unilateral, localised to one area - rises to a crescendo over few minutes - lasts 15-160mins, 1/2 x a day - watery bloodshot eye - facial flusing - rhinorrhoea - miosis +/- ptosis
61
Management of cluster headaches
- 15L 100% O2 for 15mins via non-rebreather mask - triptans → sumatriptan
62
Prevention of cluster headaches
1. verapamil CCB - prednisolone - stop smoking/drinking
63
What is a tension headache?
- most common chronic daily headache - can be episodic or chronic
64
Triggers of tension headaches
- stress - sleep deprivation - bad posture - hunger - eyestrain - anxiety - noise - clenched jaw
65
Presentation of tension headaches
1+ of: - bilateral - pressing/tight and non-pulsatile - mild/moderate intensity - +/- scalp tenderness no aura, vomiting, sensitiy to movement can have pressure behind eyes
66
Management of tension headaches
- avoid triggers - symptomatic relief → aspirin, PCM, ibuprofen - analgesia no more than 6days/month → can cause medication overuse headaches
67
What is epilepsy?
- recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain - manifesting in seizures
68
Criteria for diagnosing epilepsy
1 of: - at least 2 unprovoked seizures more than 24hrs apart - one unprovoked seizure and probability of future seizures - diagnosis of an epilieptic syndrome
69
What is a seizure?
- convulsions - motor signs of abnormal electrical discharges - epileptic seizures = convulsions due to epileptic syndromes
70
Causes of epilepsy
- idiopathic - cortical scarring - tumours/space-occupying lesions - strokes - alzheimer's - alcohol withdrawal → delirium tremens
71
Risk factors for epilepsy
- family hisotry - premature babies - abnormal cerebral blood vessels - drugs eg cocaine
72
What are the components of a seizure?
- prodrome - aura - post-ictal
73
What is prodrome?
- precedes seizures by hrs/days - weird feeling eg mood/behaviour changes
74
What is aura?
- part of seizure - patient is aware, often precedes other manifestations - eg strange feeling, deja vu, strange smells, flashing lights - can imply partial seizure
75
What is post-ictal
- period after seizures - headache, confusion, myalgia, sore tongue - post-ictal Todd's palsy - dysphagia after temporal lobe seizure
76
What is post-ictal Todd's palsy
temporary weakness after focal seizure in motor cortex
77
What are the types of seizures?
- primary generalised seizures - partial focal seizure - partial seizure with secondary generation
78
What are primary generalised seizures?
- whole cortex affected - bilateral and symmetrical motor manifestations - loss of consciousness/awareness
79
Types of primary generalised seizures
- tonic = high tone → rigid/stiff limbs - clonic = muscle jerking - tonic clonic = muscle jerking and rigidity - myoclonic = isolated jerking - atonic = loss of muscle tone - absence = childhood, goes blank → risk of developing tonic clonic
80
What are the 3 types of partial focal seizures?
- single lobe features - simple partial seizure - complex partial seizure
81
Features of single lobe feature seizures
- underlying structural disease - limited to one lobe - progress to generalised seizures
82
Features of simple partial seizures
- does not affect consciousness/memory - no post-ictal signs - motor/sensory/autonomic/pyschic signs
83
Features of complex partial seizures
- memory affected - mainly temporal lobe - post-ictal confusion = common if temporal
84
Characteristics of temporal lobe seizures
- memory, understanding speech/emotion - aura - anxiety/out of boy experiences - automatisms
85
Characteristics of frontal lobe seizures
- motor, thought processing - jacksonian march - post-ictal Todd's palsy
86
Characteristics of parietal lobe seizures
- sensation - sensory disturbances → tingling/numbness
87
Characteristics of occipital lobe seizures
- vision - visual phenomena eg spots, lines, flashes
88
Diagnosis of epilepsy
- EEG → supports diagnosis - MRI/CT head → exclude space-occupying lesions - bloods → exclude metabolic disturbances - genetic testing
89
Management of epilepsy
- sodium valproate - if fertile female = lamotrigine - myoclonic = levetiracetam/topiramate - absence = ethosuximide - partial = lamotrigine/carbamazepine
90
What is status epilepticus?
- continuous seizure lasting over 5mins OR - repeated seizures with no recovery in between - treatment = IV lorazepam then phenytoin
91
What are features of non-epileptic seizures?
- metabolic disturbances - longer - don't occur in sleep - no incontinence/tongue biting - pre-ictal anxiety signs - no muscle pain
92
What is meningitis?
- inflammation of the meninges - almost always due to infection - notifiable disease
93
Risk factors for meningitis
- students - travel - immunocompromised - pregnancy
94
Causes of bacterial meningitis
- neonates = group B strep - children \<2 = strep pneumoniae - 2-50 = n.meningitis, s.pneumoniae 50+ = s.pneumoniae, listeria meningitis acute emergency
95
Causes of viral meningitis
- enterovirus - HSV
96
Causes of fungal meningitis
- cryptococcus - candida → immunocompormised HIV
97
Why is Neisseria meningitidis important?
- can cause meningococcoal septicaemia - non blanching purpuric rash - necrosis - high mortality
98
Symptoms of meningitis
- triad → fever, headache, neck stiffness - purpuric rash - photo/phonophobia - papilloedema - raised ICP - seizures
99
Signs of meningitis
- Kernig's +ve - Brudzinski's +ve - glass test → blanching/non-blanching rash
100
What is Kernig's sign?
resistance to extension of leg while hip is flexed
101
What is Brudzinski's sign?
flexion of hips and knees in response to neck flexion
102
Treatment of meningitis
- ABCDE and support - empiric therapy = IV benylpenicillin - asses GCS 1. ceftriaxone/cefotaxime - add IV benzylpenicillin for rash - if penicillin allergy = chloramphenicol - if immunocompromised = amoxicillin/ampicillin
103
Prophylaxis for meningitis
- rifampicin and ciprofloxacin - viral = acyclovir
104
What is Guillain-Barre syndrome?
- acute polyneuropathy → rapid damage of peripheral nerves - results in demyelination/axonal degeneration - common cause = post-GI infection
105
What infections commonly cause GBS
- campylobacter jejuni - EBV - CMV - mycoplasma - HIV
106
Symptoms of GBS
- weakness - paraesthesia - hyporeflexia - sudden onset toe-nose weakness - absent reflexes - pain in legs, back - sensory loss in lower extremities - urinary hesitancy
107
Investigations for GBS
- bloods - lumbar puncture → protein in CSF - spirometry - ECG - slow conduction velocities
108
Treatment for GBS
- IV Ig - plasma exchange - LMW heparin → DVT prophylaxis - avoid corticosteroids
109
What is Parkinson's disease?
- destruction of dopaminergic neurons - too little dopamine - affects ventral tier of zona compacta in substantia nigra
110
Causes of Parkinson's
- drug induced → dopamine antagonists - encephalitis - exposire to toxins eg manganese
111
Presentation of Parkinson's
- bradykinesia - resting tremor - rigidity - parkinsonian gait - sleep disorders - depression - monotonous voice - difficulty with fine/repetitive movement - cog-wheel walk b-amyloid plaques
112
Diagnosis of Parkinson's
clinical diagnosis 1. diagnosis of Parkinsonian syndrome 2. exclusion criteria 3 supportive criteria DaTscan
113
Treatment of Parkinson's
young onset, biologically fit - Da agonist = ropinirole - MOA-B inhibitor = rasagiline - L-DOPA = co-careldopa biologically frail, comorbidities - L-DOPA - MOA-B inhibitor
114
What is Huntington's disease?
- progressive neurodegenerative disorder with 100% penetrance - loss of main inhibitory neurotransmitter GABA - cell loss within basal ganglia and cortex
115
Pathophysiology of Huntington's
- less GABA = less regulation of dopamine to striatum - increased dopamine → excessive thalamic stimulation → increased movement (chorea)
116
Inheritance of Huntington's
- autosomal dominant - increased in CAG repeats on chromosome 4
117
Presentation of Huntington's
- hyperkinesia - chorea - dystonia - incoordination - psychiatric issues - depression - cognitive impairment, behavioural difficulties - irritability, agitation, anxiety
118
Investigations for Huntington's
- MRI/CT → loss of striatal volume - genetic testing - tests for SLE, thyroid disease, Wilson's, dementia
119
Treatment for Huntington's
- poor prognosis - most common cause of death = pneumonia then suicide - benzodiazepines/valproic acid for chorea - SSRIs for depression - haloperidol, risperidone for psychosis
120
What is Alzheimer's
- most common type of dementia - EC deposition of b-amyloid plaques - tau-containing IC neurofibrillary tangles - damaged synapses - atrophy
121
Risk factors of Alzheimer's
- over 65 - Down's - reduced cognitive activity - depression/loneliness - ApoE E4 allele homozygosity
122
Presentation of Alzheimer's
- memory → episodic and semantic - language → difficulty understanding/finding words - attention/concentration issues - psychiatric changes - disorientation
123
Diagnosis of Alzheimer's
- mini-mental state examination - bloods - memory clinic assessment - MRI
124
Treatment of Alzheimer's
- no cure - supportive therapy - medications to manage symptoms → AChEi
125
What is multiple sclerosis?
- cell mediated autoimmune condition - repeated episodes of inflammation of nervous tissue in brain and SC → DC4 mediated destruction - results in loss of myelin sheath in CNS
126
What are the types of MS?
relapse-remitting MS secondary progressive MS - follows from relapsing-remitting - gradually worsening symptoms - fewer remissions primary progressive MS - from beginning of disease - symptoms develop and worsen over time acute attacks followed by periods of remyelination → these periods become shorter/less frequent
127
Symptoms of MS
- pyramidal weakness - spasric paraparesis - changes in sensation - fatigue - chronically increasing bladder movement - cognitive impairment - dizziness - depression
128
Signs of MS
- UMN signs - loss of colour vision - Lhermitte sign - Uhthoff phenomenon
129
Diagnosis of MS
- symptoms disseminated in time and space - GOLD STANDARD = MRI → GD-enhancing plaques - lumbar puncture - McDonald criteria - bloods
130
Treatment of MS
- notify DVLA - supportive care relapses - acute = methylprednisolone - chronic = DMARDs, biologicals
131
What is motor neurone disease?
- group of neurodegenerative disorders - selective loss of neurones in motor cortex, cranial nerve nuclei, anterior horn cells - progressive, ultimately fatal - only affects motor, not sensory
132
Risk factors for MND
- smoking - exposure to heavy metals
133
Types of MND
- ALS → most common - PLS - PMA - PBP
134
Signs and symptoms of MND
- mixed UMN and LMN presentation - LMN signs predominate → weakness, atrophy, muscle fasciculations - wrist/foot drop - wasting in hands - gait disorders - excessive fatigue
135
Diagnosis of MND
El Escorial criteria
136
Treatment of MND
- supportive therapy - riluzole slows progression - end of life care
137
Features of ALS
- SOD1 gene - loss of neurons in motor cortex and anterior horn - UMN and LMN signs - babinski response - asymmetric - corticobulbar signs = worse prognosis
138
Features of PBP
- CN 9-12 → UMN and LMN - worst prognosis - dysphagia - flaccid tongue - hoarse, nasal speech
139
Features of PMA
- anterior horn cells affected - LMN only - distal muscles affected then proximal
140
Features of PLS
- rare - progressive tetraparesis - UMN only
141
What is myasthenia gravis?
- disorder of neuromuscular transmission - caused by binding of autoantibodies to component of NMJ → acetylcholine receptor - can be inherited - 30s for women, 60-70s for men
142
Signs and symptoms of myasthenia gravis
muscle weakness - worse on exertion, better with rest - marked in proximal muscles → small muscles of hand, deltoid, triceps, bulbar, chewing muscles - ocular manifestations - no muscle wasting - seizures
143
Diagnosis of myasthenia gravis
- mostly clinical - detect ACh receptor antibodies - +ve tensilon test → tensilon improves muscle weakness
144
Treatment of myasthenia gravis
treat symptoms - AChEis - pryidostigmine - methotrexate - ciclosporin - tacrolimus stop exacerbating drugs
145
What drugs can exacerbate myasthenia gravis?
- ciprofloxacin - azithromycin - propanolol - atenolol - verapamil - lithium - statins - chloroquine - prednisolone
146
What is syncope
- temporary loss of consciousness - due to disruption of blood flow to brain → fall - syncopal episodes AKA vasovagal episodes/fainting
147
Causes of primary syncope
- dehydration - missed meals - extended standing in warm environment - vasovagal response to stimuli → surprise, pain, blood
148
Causes of secondary syncope
- hypoglycaemia - dehydration - anaemia - infection - anaphylaxis - arrhythmias - valvular heart disease
149
Signs and symptoms of syncope
- hot/clammy - sweaty - heavy - dizzy/light headed - vision going blurry/dark - headache
150
Investigations for syncope
- history - ECG/24hr ECG - echo - bloods
151
Management of syncope
- primary = avoid triggers - secondary = manage underlying pathology
152
What is a nerve lesion?
- damage to a nerve through compression, trauma, infection etc - results in interruption of axonal continuity
153
What are the 3 categories of peripheral nerve injuries?
- stretch related - lacerations - compressions
154
Signs and symptoms of nerve lesions
depends on nerve affected - numbness/ tingling - muscle weakness - dropping objects - sharp pains
155
Investigations for nerve lesions
- neurological exam - MRI
156
Treatment of nerve lesions
- splint/braces - physical therapy - exercise - analgesia - surgery if severe

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