Neurology Flashcards
(132 cards)
List risk factors for stroke
Hypertension
Diabetes
Atrial fibrillation
Smoking
Hyperlipidaemia
Sleep apnoea
Describe the different types of stroke
Ischaemic – blockage of blood vessels (85%)
Haemorrhagic – burst blood vessels (15%)
Describe the clinical presentation of large vessel stroke
- Cortical signs
> Right brain: right gaze preference, neglect
> Left brain: left gaze preference, aphasia - MCA
> Arm > leg weakness
> LMCA: aphasia
> RMCA
> Neglect
> Topographical difficulty
> Apraxia
> Constructional impairment
> Anosognosia (lack of insight - doesnt uderstand or perceive illness)
- ACA
> Leg > arm weakness, grasp
> Muteness, perseveration (stay on same thought), abulia (lack of willpower)
> Personality change - PCA
> Contralateral hemianopia
> Memory loss/confusion
> Ataxia
Describe the clinical presentation of a small vessel stroke
Lenticulostriate perforating arteries supplying deep white matter
No cortical signs
Cause sensory or motor loss, or both
Equally distributed - lacunar syndromes
Describe the clinical presentation of a posterior circulation stroke
Crossed signs
Cranial nerve findings
Headache
Describe brainstem stroke syndromes
Combination of cranial nerve abnormalities and crossed motor/sensory findings e.g.
> Double vision - diplopia
> Facial numbness or weakness (CN V)
> Slurred speech
> Difficulty swallowing
> Ataxia
> Vertigo
> Nausea and vomiting
> Hoarseness
Describe the causes of haemorrhagic strokes
- Uncontrolled hypertension
> Spontaneous rupture of a small artery deep in the brain
Typically in the basal ganglia
- Aneurysm
- Arteriovenous malformation (AVM)
Describe the acute treatment of ischaemic stroke
tPa – tissue plasminogen activator (alteplase)
> Must be used within 4.5 hours of onset
>Reduces disability risk by 30% but an ICH risk
Mechanical clot retrieval - thrombectomy
Aspirin
Double statin dose
What are the contraindications for the use of tPa
Haemorrhage
SBP > 185 or DBP > 110
Recent surgery, trauma or stroke
Coagulopathy
Seizure at onset of symptoms
NIHSS > 21
Age > 80
Glucose < 2.2
Describe the pathophysiology of MS
Idiopathic inflammatory demyelinating disease of the CNS
Acute episodes of inflammation are associated with focal neurological deficits
Demyelination results in loss of neurological function
> Weak leg
Visual loss
Urinary incontinence
Deficits usually develop gradually, last more than 24h and may gradually improve over days to weeks
MS is diagnosed when there is evidence of 2 or more episodes of demyelination disseminated in space and time
Describe the causes of MS
Genetics
Sunlight / vitamin D exposure
Viral trigger – EBV
Multifactorial – smoking
Which syndromes may develop into MS?
- Optic neuritis
> Painful visual loss that comes on after a few days
> Can resolve after a few weeks
> 30% will develop MS within 5 years, 15% within 15 year - Clinically isolated syndromes
> Single episode of neurological disability due to focal inflammation of brain or spinal cord
> Can be a first attack of MS or be due to infection
> Can include optic neuritis and transverse myelitis - Transverse myelitis
> Inflammation of the spinal cord
> Leg weakness, sensory loss, incontinence, sexual dysfunction
> Causes: MS, viral infections - Radiologically isolated syndromes
> Incidental findings that look like MS; may or may not develop MS
Describe the investigations used in MS
- MRI brain + cervical spine with gadolinium contrast
> Dawson’s finger: radiographic feature of demyelination, reflects perivenular inflammation
> Evidence of demyelination in 2 regions e.g. periventricular and spinal cord - dissemination in space
> If enhancing and non-enhancing areas of demyelination – dissemination in time
- Lumbar puncture
> Oligoclonal bands in CSF - Bloods (exclude other conditions)
> B12/folate
> Serum ACE (sarcoidosis)
> HIV, Lyme and syphilis serology
> ESR/CRP
> ANA/ANCA/RF
> Aquaporin-4 antibodies: if transverse myelitis / optic neuritis
> Calcium (sarcoidosis) - Visual evoked potentials
> Measure conduction of nerve signals in optic nerve to identify subclinical optic neuritis
What is the definition of a relapse and a pseudorelapse in MS?
Relapse
> New neurological deficit lasting >24h in the absence of pyrexia or infection
Pseudo-relapse
> Reemergence of previous neurological symptoms or signs related to an old area of demyelination in the context of heat or infection
What is the steroid regime for an MS relapse?
1g of IV methylprednisolone for 3 days OR
500mg of oral methylprednisolone for 5 days and
PPI for gastroprotection
Describe treatments for MS
RRMS
> Alemtuzumab
> Natalizumab
> Anti-CD20: ocrelizumab, ofatumumab, rituximab
> Fingolimod
> Dimethyl fumarate
> Cladribine
> Stem cell transplants
Progressive MS
> PPMS - ocrelizumab
> SPMS - siponimod
Describe a relative afferent pupillary defect (RAPD) and its causes
Aka Marcus Gunn Pupil
Pupil remains dilated in one eye despite exposure to bright light – swinging light test
Shows unilateral optic nerve or retinal dysfunction
Causes
- Disease of retina
> Retinal detachment
> > Floaters
Flashes of light
Shadow in vision field
> Retinal ischaemia
- Optic nerve disease
> Optic neuritis
> > Pain with eye movement
Loss of vision
> Inflammation from multiple sclerosis
- Severe glaucoma
> Headaches
Nausea/vomiting
Eye redness
Blurred vision
- Trauma
List the different types of primary and secondary headaches
Primary
- Migraine
- Tension headaches
- Trigeminal autonomic cephalgias
Secondary
- Thunderclap headaches
- High pressure headaches
- Low pressure headaches
- Neuralgias
Describe tension type headaches
At least 10 episodes of headache occuring on <1 day/month on average
Lasting from 30 minutes to 7 days
Characteristics
> Bilateral location
> Pressing or tightening (non-pulsating) quality
> Mild or moderate intensity
> Not aggravated by routine physical activity
> No nausea or vomiting
> No more than one of photophobia or phonophobia
Describe the pathophysiology of migraine
Interaction between primary afferent nociceptive neurons / trigeminovascular system / brainstem / thalamus / hypothalamus / cortex
Calcitonin gene related peptide (CGRP)
Not a primary vascular problem
Describe the diagnostic criteria for migraine
At least 5 attacks
Headache attacks lasting 4-72h when untreated
Characteristics
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravated by routine physical activity
At least one of the following
- Nausea and/or vomiting
- Photophobia and phonophobia
Describe the phases of migraine
Prodrome: hours-days
- Yawning
- Polyuria
- Depression
- Irritability
- Food cravings
- Poor concentration
- Sensitivity to light and sound
- Poor sleep
Aura: 5-60m
- Visual
- Sensory
- Language
- Motor
Headache: 4-72h
- Throbbing headache
- Nausea
- Vomiting
- Photophonophobia
- Worse with activity
Postdrome: 24-48h
- Depression
- Euphoria
- Poor concentration
- Fatigue
Describe the acute treatment of migraine
Avoid opiates
Simple analgesics – aspirin 900mg or ibuprofen 400-600mg
Triptans
> Sumatriptan 50-100mg
> All oral triptans are gastrically absorbed – may not work if patient is vomiting
> Only work once headache starts
Early or persistent vomiting
> Add antiemetic – metoclopramide 10mg or prochlorperazine 10mg
> Consider nasal zolmitriptan or subcutaneous sumatriptan
No response
> Try other triptans OR triptan + NSAID
Describe migraine prophylaxis
Lifestyle advice, triggers
Prophylaxis if >4-5 disabling headaches per month
Use headache diaries
For each medication, determine efficacy at 3 months
> If ineffective, wean medication and try another one
> If effective, continue 6-12 months
Agents
> Propranolol
> Topiramate
> Amitriptyline
> Candesartan
> Flunarazine