Neurology Flashcards

(132 cards)

1
Q

List risk factors for stroke

A

Hypertension

Diabetes

Atrial fibrillation

Smoking

Hyperlipidaemia

Sleep apnoea

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2
Q

Describe the different types of stroke

A

Ischaemic – blockage of blood vessels (85%)

Haemorrhagic – burst blood vessels (15%)

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3
Q

Describe the clinical presentation of large vessel stroke

A
  • 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
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4
Q

Describe the clinical presentation of a small vessel stroke

A

Lenticulostriate perforating arteries supplying deep white matter

No cortical signs

Cause sensory or motor loss, or both

Equally distributed - lacunar syndromes

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5
Q

Describe the clinical presentation of a posterior circulation stroke

A

Crossed signs

Cranial nerve findings

Headache

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6
Q

Describe brainstem stroke syndromes

A

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

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7
Q

Describe the causes of haemorrhagic strokes

A
  • Uncontrolled hypertension

> Spontaneous rupture of a small artery deep in the brain
Typically in the basal ganglia

  • Aneurysm
  • Arteriovenous malformation (AVM)
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8
Q

Describe the acute treatment of ischaemic stroke

A

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

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9
Q

What are the contraindications for the use of tPa

A

Haemorrhage

SBP > 185 or DBP > 110

Recent surgery, trauma or stroke

Coagulopathy

Seizure at onset of symptoms

NIHSS > 21

Age > 80

Glucose < 2.2

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10
Q

Describe the pathophysiology of MS

A

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

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11
Q

Describe the causes of MS

A

Genetics

Sunlight / vitamin D exposure

Viral trigger – EBV

Multifactorial – smoking

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12
Q

Which syndromes may develop into MS?

A
  • 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
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13
Q

Describe the investigations used in MS

A
  • 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
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14
Q

What is the definition of a relapse and a pseudorelapse in MS?

A

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

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15
Q

What is the steroid regime for an MS relapse?

A

1g of IV methylprednisolone for 3 days OR

500mg of oral methylprednisolone for 5 days and

PPI for gastroprotection

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16
Q

Describe treatments for MS

A

RRMS
> Alemtuzumab
> Natalizumab
> Anti-CD20: ocrelizumab, ofatumumab, rituximab
> Fingolimod
> Dimethyl fumarate
> Cladribine
> Stem cell transplants

Progressive MS
> PPMS - ocrelizumab
> SPMS - siponimod

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17
Q

Describe a relative afferent pupillary defect (RAPD) and its causes

A

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
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18
Q

List the different types of primary and secondary headaches

A

Primary
- Migraine
- Tension headaches
- Trigeminal autonomic cephalgias

Secondary
- Thunderclap headaches
- High pressure headaches
- Low pressure headaches
- Neuralgias

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19
Q

Describe tension type headaches

A

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

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20
Q

Describe the pathophysiology of migraine

A

Interaction between primary afferent nociceptive neurons / trigeminovascular system / brainstem / thalamus / hypothalamus / cortex

Calcitonin gene related peptide (CGRP)

Not a primary vascular problem

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21
Q

Describe the diagnostic criteria for migraine

A

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

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22
Q

Describe the phases of migraine

A

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

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23
Q

Describe the acute treatment of migraine

A

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

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24
Q

Describe migraine prophylaxis

A

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

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25
Describe the treatment of refractory or chronic migraine
Onabotulinumtoxin A > Chronic migraine > >15 headache days per month > MOH previously addressed > Failed on at least 3 prophylactics CGRP inhibitors – monoclonal antibodies > Erenumab
26
Describe cluster headaches
At least 5 attacks Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes when untreated Signs ipsilateral to the headache > Conjunctival injection or lacrimation > Nasal congestion or rhinorrhoea > Eyelid oedema > Forehead and facial sweating > Forehead and facial flushing > Sensation of fullness in the ear > Miosis or ptosis Sense of restlessness or agitation Occurring with a frequency between one every other day and 8 per day
27
Describe trigeminal neuralgia including its treatment
One-sided intense, stabbing paroxysmal facial pain Triggered by wind, chewing, touch Other symptoms - Facial muscle spasms - Autonomic symptoms > Lacrimation > Diffuse conjunctival injection > Rhinorrhoea Investigations > MRI >> Trigeminal nerve distorted and compressed by superior cerebellar artery Treatment > Carbamazepine > Surgical microvascular decompression
28
Describe raised pressure headaches
Characteristics > Worse on lying flat > Improve on sitting up > Worse in the morning > Persistent nausea/vomiting > Worse on valsalva e.g. coughing, laughing, straining > Worse with physical exertion > Transient visual obscurations with change in posture Examination findings > Optic disc swelling – papilloedema > Impaired visual acuity / colour vision > Restricted visual fields / enlarged blind spot > IIIrd nerve palsy > VIth nerve palsy – false localising sign > Focal neurological signs
29
Describe thunderclap headache including causes
First and worst headache – subarachnoid haemorrhage Severe sudden onset headache Typically maximum onset within 1 minute, typical duration >1h Medical emergency, same day specialist assessment Non-contrast CT scan (NCCT) within 12h onset > If CT normal, lumbar puncture > For blood products – oxybilirubin If CT/LP normal consider other investigations > MRI > MR/CT venogram > MR/CT angiogram Causes - Subarachnoid haemorrhage - Intracerebral haemorrhage - Aortic dissection – vertebral or carotid - Cerebral venous sinus thrombosis - Ischaemic stroke - Bacterial meningitis - Spontaneous intracranial hypotension - Pituitary apoplexy
30
Describe the course, tract and pathology associated with the olfactory nerve
Smell Course > Travels through the ethmoid bone and lays upon the cribriform plate > Arises from the cerebrum Tract > Olfactory cells of nasal mucosa > Olfactory bulbs > Pyriform cortex – temporal lobe, near hippocampus Pathology > Hyposmia > Normal ageing > Viral URTI > Chronic rhinitis or sinusitis > Head trauma > Neurodegenerative disorders – Parkinson's, Alzheimer's
31
Describe the function and tract associated with the optic nerve
Vision Enter: optic canal Arises from the cerebrum Tract > Retinal ganglion cells > Optic chiasm > Thalamus > Primary visual cortex – occipital lobe
32
Describe the examination of the optic nerve
Optic discs with ophthalmoscope > Papilloedema: raised ICP > Optic atrophy: previous optic neuritis Pupillary reflexes > Direct and consensual light reflexes > Swinging light test for RAPD > Accommodation reflex Visual acuity - Snellen chart Visual fields and blind spot: confrontation Colour vision: Ishihara colour plates
33
Describe the physiology of the pupillary light reflex
Light is shone into the the left eye and the travels via the optic tract and synapses at the pretectal nucleus Interneurones then synapse with both Edinger-Westphal nuclei Post-ganglionic fibres run with ciliary nerves and terminate on sphincter pupillae Pupillary constriction in both eyes (direct and indirect) when a light is shone in one
34
Describe different types of visual field defects
Optic - ipsilateral monocular visual loss Optic chiasm - bitemporal hemianopia Optic tract - contralateral homonymous (affecting both visual fields) hemianopia Parietal upper optic radiation - contralateral homonymous inferior quadrantanopia Temporal lower optic radiation - contralateral homonymous superior quadrantanopia Occipital visual cortex - contralateral homonymous hemianopia (macular sparing) Most common tumours impacting anterior visual pathways > Pituitary adenoma > Meningioma > Craniopharyngioma
35
Describe eye muscles and movements associated with them, as well as their assessment
Assessment – smooth pursuit – draw H shape in the air Oculomotor nerve > Superior rectus >> Elevation of eyeball >> Also adduction and medial rotation > Inferior rectus >> Depression of eyeball >> Abduction and lateral rotation > Medial rectus >> Adducts the eyeball > Lateral rectus >> Abducts the eyeball > Inferior oblique >> Elevation of the eyeball >> Abduction and lateral rotation Trochlear nerve > Superior oblique >> Depression of eyeball >> Abduction and medial rotation > Abducens nerve >> Lateral rectus
36
Describe the function and tract of the oculomotor nerve
Eye movements > Inferior oblique > Superior, medial and inferior rectus Levator palpebrae superioris – keeps upper eyelid open Lens accommodation: ciliary muscles Pupil constriction - parasympathetic > Ciliary muscles and sphincter pupillae Arises from the midbrain-pontine junction Nucleus > Motor >> Located in the midbrain at the level of the superior colliculus > Parasympathetic >> Dorsal midbrain – Edinger Westphal nucleus Exit: superior orbital fissure > Exits brainstem from the interpeduncular fossa of the midbrain > Passes through cavernous sinus > Enters orbit through superior orbital fissure
37
Describe complete 3rd nerve palsy
Ptosis Pupillary dilatation Eye in a "down and out" position Due to unopposed actions of lateral rectus and superior oblique
38
Describe the function and location of the trochlear nerve
Eye movements - superior oblique Arises from the midbrain > Level of inferior colliculus Exit: superior orbital fissure
39
Describe the function of the trigeminal nerve and its location
Arises from pons 3 branches - V1 - ophthalmic nerve > Branches >> Supraorbital nerve >> Nasociliary nerve >> Ciliary branches supply the cornea > Exit: superior orbital fissure > Enter: supraorbital foramen - V2 - maxillary nerve > Exit: foramen rotundum > Enter: infraorbital foramen - V3 - mandibular nerve > Exit: foramen ovale >> V3 meningeal branch exits through foramen spinosum > Enter: mental foramen > Muscles of mastication: >> Temporalis >> Masseter >> Pterygoids > Motor to muscles of mastication and general sensory to face
40
Describe the function and location of the abducens nerve
Eye movement (abduction - lateral rectus) Arises from the pontine-medulla junction Exit: superior orbital fissure
41
Describe the function and location of the facial nerve
Muscles of facial expression > Frontalis > Orbicularis occuli > Orbicularis oris Supplies secretory glands > Sublingual & submandibular glands > Lacrimal glands Supplies taste of anterior 2/3 of the tongue Corneal reflex > Lightly touch cornea with cotton wool > Afferent – CN V > Efferent – CN VII > Normal response is blinking > May be lost in pontine lesions Arises from the pontine-medulla junction Enter: internal acoustic meatus Exit: stylomastoid foramen
42
Describe the location and function of the vestibulocochlear nerve
Arises from the pontine-medulla junction 2 nerves > Vestibular nerve - balance >> Nerve endings within semicircular canals >> Reach cerebellum and spinal cord > Cochlear nerve - hearing > Reaches auditory cortex in the temporal lobes Enter: internal acoustic meatus
43
Describe the testing of the vestibulocochlear nerve
Rinne's test > Tuning fork is held at the mastoid process and then at the external auditory meatus > Patient is asked which is louder BC > AC – conductive deafness AC > BC – normal or sensorineural deafness Weber's test > Tuning fork is held at the vertex > Patient is asked which ear they hear the vibration loudest in Normal – same in both ears Conductive hearing loss – deaf ear Sensorineural hearing loss – good ear
44
Describe the function and location of the glossopharyngeal nerve
Sensory > Taste – posterior 1/3 of tongue > Proprioception for swallowing – pharyngeal wall > Blood pressure receptors – carotid sinuses Motor > Swallow and gag reflex – pharyngeal muscles > Lacrimation – lacrimal glands Parasympathetic > Saliva production – parotid glands Originates from the medulla, posterior to the olive Exit: jugular foramen
45
How is the glossopharyngeal nerve tested?
Motor Ask patient to open mouth and say "ahh" Watch for elevation of the soft palate Unilateral weakness of CN IX – deviation of uvula away from the lesion – glossopharyngeal palsy
46
Describe the function and location of the vagus nerve
Sensory > Chemoreceptors >> Blood oxygen concentration >> Carotid bodies > Pain receptors (dura) >> Respiratory and digestive tracts > Sensation >> External ear, larynx and pharynx Motor > Heart rate and stroke volume >> Pacemaker and ventricular muscles > Peristalsis >> Smooth muscles of the digestive tract > Air flow >> Smooth muscles in bronchial tubes > Speech and swallowing >> Muscles of larynx and pharynx – recurrent laryngeal nerve Parasympathetic > Smooth muscles and glands of the same area innervated by the motor component, as well as thoracic and abdominal areas Exit: jugular foramen
47
Describe the function and location of the spinal accessory nerve
Exit: jugular foramen Neck muscles - Sternocleidomastoid - Trapezius Head rotation and shoulder shrugging Originates from medulla, posterior to the olive
48
Describe the location and function of the hypoglossal nerve
Motor – speech and swallowing > Muscles of the tongue Originates from medulla, anterior to the olive Exit: hypoglossal canal
49
Describe a hypoglossal nerve palsy
Observe the tongue at rest and ask patient to stick out their tongue & move it from side to side Unilateral/bilateral wasting or fasciculations (at rest) Unilateral XIIth weakness causes the tongue to deviate towards the side of the lesion Slow and spastic tongue movements suggest pseudobulbar palsy
50
Describe internuclear ophthalmoplegia
Disorder of conjugate gaze Failure of adduction of affected eye with nystagmus on lateral gaze in contralateral eye Can be unilateral or bilateral Results from lesion of medial longitudinal fasciculus – connects IIIrd and VIth nerve nuclei Commonly seen in multiple sclerosis (MS)
51
Describe Horner's syndrome and its causes
Ipsilateral disruption of cervical / thoracic sympathetic chain Causes > Congenital > Brainstem stroke > Cluster headache > Apical lung tumour > Multiple sclerosis > Carotid artery dissection > Cervical rib > Syringomyelia Consists of > Miosis > Ptosis > Apparent enophthalmos > Anhydrosis
52
Describe herpes zoster ophthalmicus
Pain may precede vesicles Shingles affects ophthalmic division of trigeminal nerve > V2/V3 rarely affected Elderly and immunocompromised at risk Treated with oral aciclovir
53
Describe the radiological appearance of different types of brain haemorrhages
Extradural - Lenticular or "lens" shape - between dura and bone Subdural - Scalloped appearance; can have layers depending on freshness of bleed Subarachnoid - Blood between sulci
54
Describe Denis' 3 columns of spinal injury
To determine spinal stability: if 1 or more affected, unstable Anterior > Anterior longitudinal ligament > Anterior annulus > Anterior 2/3 vertebral body Middle column > Posterior 1/3 vertebral body > Posterior annulus > Posterior longitudinal ligament Posterior column > Posterior elements: pedicles, facets, laminae, spinous process > Posterior ligaments
55
Describe the functions of the different lobes of the brain
Frontal lobe > Emotions > Mood > Insight > Cognitive and creative function > Primary motor area separated from parietal lobe by central sulcus Parietal lobe > Sensation > Coordination of signals from other cortices > Primary sensory area separated from frontal lobe by central sulcus Occipital lobe > Vision Temporal lobe > Memory > Gustatory function > Smell > Hearing
56
List the components of the basal ganglia
Basal ganglia > Caudate nucleus > Striatum > Globus pallidus externa and interna > Substantia nigra pars compacta and pars reticulata > Subthalamic nucleus
57
Describe the anatomy of the ventricular system
Lateral two ventricles > Each one has a >> Frontal horn >> Temporal horn >> Occipital horn > Come close together in the midline but are separated by the septum pellucidum > Connect with third ventricle via interventricular foramina of Munro 3rd ventricle > Narrow space lying in the diencephalon between thalamus and hypothalamus > Connects to 4th ventricle via aqueduct of Sylvius (midbrain) 4th ventricle > Lies in the posterior fossa between brainstem and cerebellum > Communicates with subarachnoid space via lateral foramina of Luschka and median aperture of Magendie Most CSF produced by choroid plexus in lateral ventricle, some in 4th ventricles
58
Lis the functions of the CSF
Cushions brain against impact/movement and own weight Provides stable chemical environment for brain Nutrient & waste exchange between nervous tissue and blood
59
Describe the flow of CSF through the ventricular system
Fills lateral ventricles then flows centrally (third ventricle) via the intraventricular foramen of Munro Then, CSF flows through aqueduct of midbrain and opens up into fourth ventricle 4th ventricle is anterior to the cerebellum and posterior to the pons Resorbed into venous system via arachnoid granulations Presence of blood in CSF indicates subarachnoid haemorrhage
60
Describe the areas if the brain responsible for speech and comprehension
Wernicke's area – hearing and understanding speech > Receptive dysphasia Broca's area – speech production > Expressive dysphasia Connected via the arcuate fasciculus
61
Describe the anatomy of the spinal cord
- Cervical enlargement - Lumbosacral enlargement - Cone-shaped ending of spinal cord - conus medullaris - End of spinal cord L1/L2 - filum terminale - Cauda equina - free nerves
62
List the different sensory and motor tract
Light touch, vibration, proprioception – dorsal column medial lemniscal pathway Pain, temperature – spinothalamic tract Corticospinal tract - motor tracts > Fasciculus gracilis - lower limb > Fasciculus cuneatus - upper limb
63
Describe patterns of sensory loss
Generalised peripheral neuropathy – glove and stocking distribution Specific sensory roots – dermatomal distribution Single dorsal column lesion – unilateral distribution below level of injury Transverse thoracic spinal cord lesion – bilateral distribution below level of injury Unilateral cord lesion (Brown Sequard): ipsilateral loss of light touch and vibration, contralateral loss of pain sensation Central cord lesion: arm and chest distribution Mid-brainstem lesion: ipsilateral loss of sensation in face, contralateral loss of sensation in body Hemisphere (thalamic) lesion: ipsilateral loss of sensation in face and body
64
Describe the knee jerk reflex
Striking the patellar tendon causes stretching of the quadriceps muscle Afferent signal sent through sensory neurons up through dorsal root ganglion Enters dorsal horn, synapse onto motor neuron Efferent signal causes contraction of quadriceps Afferent signal also works through interneuron to have an inhibitory effect on motor neuron going to hamstring Relaxation of hamstrings Sensory neuron involved in reflex arc also synapses with an inhibitory interneuron This neuron synapses ipsilaterally with a motor neuron controlling antagonistic muscles Antagonistic muscles are relaxed, resulting in contraction of other muscle group - reciprocal innervation
65
Describe the reinforcement of reflexes
Jendrassik manoeuvre - teeth clenching or pulling interlinked fingers in opposite directions Combination of distraction and cortical inhibition from anterior horn cells
66
List the root levels for each reflex
Jaw jerk - cranial nerve V Biceps - C5/6 Tricep C6/7 Supinator C5/6 Knee L3/4 Ankle S1
67
Describe the differences between upper and lower motor neuron problems
Upper motor neuron > Increased / "brisk" > Localises to brain or spinal cord > Associated with >> Increased tone >> Extensor plantar response Lower motor neuron > Decreased or absent > Localises to peripheral nerve > Associated with >> Normal or decreased tone >> "Mute" or flexor plantar response
68
Describe subarachnoid haemorrhage and its causes and predisposing factors
Blood vessels reside in the subarachnoid space Aneurysms rupture into the subarachnoid space, producing a subarachnoid haemorrhage – acute cerebrovascular event Other causes > Arteriovenous malformation (AVM) > Tumour Predisposing factors > Smoking > Female sex > Hypertension > Positive family history > ADPCK > Ehlers-Danlos > Coarctation of the aorta
69
Describe the diagnosis of subarachnoid haemorrhage
History > Acute headache > Loss of consciousness > Seizures > Visual, speech and limb disturbance > Sentinel headache Clinical examination > Photophobia > Meningism > Subhyaloid haemorrhages > Vitreous haemorrhages – Terson's syndrome > Speech and limb disturbance > Cardiovascular problems e.g. pulmonary oedema
70
Describe the grading system used to grade the severity of subarachnoid haemorrhage
Grade I – GCS 15 Grade II – GCS 13-14 without deficit Grade III – GCS 13-14 with deficit Grade IV – GCS 7-12 Grade V – GCS 3-6
71
Describe the investigations used for subarachnoid haemorrhage
CT > Prognostic: Fisher grade > Based on the amount of bleeding on CT LP > Xanthochromia – yellowing of CSF due to bilirubin (takes 8-12h) Further investigations > CTA – eGFR > MRA – eGFR and gadolinium > DSA (digital subtraction angiography) – stroke, diabetics Other > U&Es – hyponatraemia > ECG changes > Elevated troponin > Echocardiography – Takotsubo cardiomyopathy
72
Describe the management of subarachnoid haemorrhage
Resuscitation > Bed rest > Fluids: 2.5-3.0L normal saline > Anti-embolic stockings Nimodipine: calcium channel antagonist > Prevents delayed ischaemic neurological deficit Analgesia Doppler studies Management > Endovascular – coils & other devices > Surgical clipping – early v late > Conservative
73
List the complications of subarachnoid haemorrhage
Rehaemorrhage Delayed ischaemia Hydrocephalus Hyponatraemia > Cerebral salt wasting syndrome (CSW) > SIADH Cardiovascular problems > Stunned myocardium > Elevation of troponin > Arrhythmia > Wall motion abnormalities > Sudden death > LVF - Takotsubo cardiomyopathy Seizures DVT/PE LRTI, UTI
74
Describe cerebral salt wasting syndrome (CSW)
Patients excrete large quantities of sodium and consequently fluid Intravascular volume depleted Important to establish volume status Give hypertonic saline + fludrocortisone
75
Describe Takotsubo cardiomyopathy
Apical wall hypokinesis – apex of myocardium fails to contract Associated with development of left ventricular dysfunction and pulmonary oedema Usually self-resolving
76
Describe the motor features seen in Parkinson's disease
Unilateral pill-rolling tremor > 4-6 Hz rest tremor > Becomes bilateral as disease progresses Postural instability Rigidity – increased tone, "cogwheel rigidity" Bradykinesia > Slowness in initiation of voluntary movement > Progressive reduction in speed and amplitude of repetitive action
77
List non-motor symptoms of Parkinson's disease
Dementia Depression, anxiety Urinary urgency / nocturia, constipation Erectile dysfunction Excessive salivation Low BP / postural hypotension Speech difficulties Hallucinations and delusions Seborrheoic dermatitis / sweating REM sleep behaviour disorder Restless leg syndrome Reduced olfactory function Fatigue / daytime somnolence Pain and sensory symptoms
78
Describe causes of parkinsonism
Drug-induced > Dopamine antagonists Progressive supranuclear palsy (PSP) > Also cognitive impairment, axial stiffness and difficulty with vertical gaze Multi systems atrophy (MSA) > Cerebellar dysfunction & autonomic dysfunction > Prominent bowel, bladder and BP difficulties Corticobasal disease (CBD) > One-sided symptoms and dystonia in affected area Lewy body dementia > Visual hallucinations, fluctuations in cognition Vascular parkinsonism > Microvascular changes within basal ganglia give rise to lower body parkinsonism > Leads to gait difficulties, UMN signs > Does not affect speech, swallowing, upper limbs
79
List the different drug types used in Parkinson's disease
- L-dopa - Dopamine agonists - MAO-B inhibitors - COMT inhibitors - Amantadine - Anticholinergics - Botulinum toxin
80
Describe the use of L-dopa in the management of Parkinson's disease including adverse effects
L-dopa + carbidopa – Sinemet L-dopa + benserazide - Madopar Dosing: 200-1000mg/day across 3-5 doses Adverse effects - Peripheral > Nausea, vomiting > Postural hypotension - Central > Confusion > Hallucinations
81
Describe the use of dopamine agonists in the management of Parkinson's disease including side effects
Bind to post-synaptic dopamine receptor Make patient more sensitive to endogenous dopamine Ropinirole, pramipexoxle, rotigotine, apomorphine Longer half-life than L-dopa but less effective Can be prescribed as monotherapy in early disease or adjunct later Side-effects > Fewer motor complications than L-dopa > Dopaminergic side effects > Daytime somnolence > Impulse control disorders – pathological gambling, hypersexuality
82
Give examples of MAO-B inhibitors
Selegiline, rasagiline Can be prescribed as monotherapy in early disease or adjunct later
83
Give examples of COMT inhibitors
Entacapone, opicapone Results in longer L-dopa half-life / duration of action Slow breakdown of Levodopa peripherally Co-prescribed with L-dopa Side-effects > Dopaminergic side-effects > Diarrhoea
84
Describe the use of amantadine, anticholinergics and botulinum toxin in the management of Parkinson's disease
Amantadine > Anti-dyskinetic effects > Side-effects: confusion and livedo reticularis Anticholinergics > Trihexyphenidyl, orphenadrine, procyclidine > Prescribed for anti-tremor effect > Side-effects >> Confusion >> Urinary retention >> Blurred vision >> Dry mouth Botulinum toxin > Roles in sialorrhoea, blepharospasm / eyelid-opening apraxia, other focal dystonia
85
Describe problems seen in advanced Parkinson's disease
Motor > On/off fluctuations > L-dopa-induced dyskinesia Axial > Gait difficulties – including gait freezing > Change in posture > Poor balance / falls > Speech / swallowing difficulties Cognitive > Dementia > Hallucinations / psychosis
86
Describe alternative treatments for advanced Parkinson's disease
Apomorphine pen injection or subcutaneous pump Intrajejunal duodopa infusion Deep brain stimulation (DBS) surgery > Allows electrical stimulation of subthalamic nucleus > Targeted, adjustable, non-destructive and reversible way of modulating pathological brain circuits > 3 implantable components >> Brain leads – electrodes at distal end >> Neurostimulator – implantable pulse generator (IPG) >> Extension wires
87
Describe Parkinson's disease emergencies
Motor > Severe OFF periods / severe dyskinesia > Parkinson-hyperpyrexia syndrome >> High temperature >> Muscle stiffness >> High CK >> Can cause renal failure >> Triggered by sudden reduction in Parkinson's medications – rare complication Non-motor > Acute psychosis > Impulsivity > Dopamine dysregulation (excessive L-dopa) > Dysautonomia >> Postural hypotension >> Dysphagia >> Intestinal pseudo-obstruction Falls Device-related - DBS ; apomorphine pump
88
Outline causes of loss of consciousness
Faints – lack of blood to the brain Fits – electrical discharge Other > Metabolic cause > Psychiatric / psychological > Trauma
89
Describe a seizure including the different phases
A seizure is a sustained and synchronised electrical discharge in the brain causing symptoms or signs Phases > PDS – large and prolonged depolarisation with generation of action potential spikes >> At onset of PDS, AMPA channel opens >> Na+ enters cell triggering depolarisation > NMDA channel then opens >> Allows Na+ and Ca+ entry >> Following depolarisation, there is opening of the potassium channels and activation of GABA channels with Cl- entering the cell >> Both influx of Cl- and efflux of K+ lead to hyperpolarisation of the cell > Tonic phase – very frequent discharges, muscles are stiff > Clonic phase – discharges come in clusters and reduce in frequency
90
Describe the excitatory and inhibitory firing of neurons
Excitation > EAA > Action on NMDA / AMPA / Kainate > Na+ / Ca2+ influx Inhibition > GABA/glycine > Action on GABA-R > Cl- influx
91
Describe the different types of seizure
Tonic seizure > Short-lived, <1 minute > Abrupt > Generalised muscle stiffening with rapid recovery Generalised tonic-clonic seizure > Bilaterally convulsive > Generalised stiffening > Subsequent rhythmic jerking of the limbs > Urinary incontinence > Tongue biting Absence seizure > Behavioural arrest > Formerly called petit mal seizures > Brief loss of awareness / responsiveness / blank stare > Sudden onset / termination - usually no post-ictal state > Most common in children, 50-100 / day Atonic seizure > Sudden onset of loss of muscle tone Myoclonic seizure > Brief, 'shock-like' involuntary single or multiple jerks Partial seizures (aka focal seizures) > With loss of awareness > With motor phenomena > With sensory phenomena > With psychological phenomena > With cognitive phenomena
92
Describe the causes and classification of epilepsy
Causes > Unknown > Vascular > Hippocampal sclerosis > Infection > Trauma > Other > MCD > Tumour > Degenerative Classification > Focal epilepsy – localised onset > Genetic generalised – generalised onset > Uncertain
93
Describe the management of status epilepticus
If seizure is not self-limiting and carries on > Initial therapy >> Benzodiazepine >> IV lorazepam >> IV/rectal diazepam >> Buccal midazolam Treat potential cause > IV glucose if hypoglycaemia > IV thiamine if alcohol abuse If seizure continues for further 5 minutes > Repeat benzodiazepine dosing > Administer usual AEDs where necessary If seizure continues > IV phenytoin or valproate If seizure continues > ITU admission > Sedation with general anaesthetic
94
Describe the long-term treatment of epilepsy
Sodium channel blockers > Reducing pre-synaptic excitability and the ability of action potentials to spread > Carbamazepine, oxcarbazepine, phenytoin, lamotrigine SV2A antagonists > SV2A required for release of neurotransmitter from vesicles > Inhibited by levetiracetam N-type calcium channel blocker > Calcium influx drives neurotransmitter release > Channel inhibited by pregabalin and gabapentin > The response of the GABAA receptor to GABA is enhanced by benzodiazepines, barbiturates, felbamate, topiramate GABA levels are increased by other AEDs > Tiagabine inhibits the GABA transporter > Vigabatrin inhibits GABA transaminase (GABAT) > Felbamate has action on Glu receptors, but its primary mode of action is via inhibition of voltage-gated Na+ channels and some action on GABA transmission > Topiramate also targets Glu receptors as part of a mixed mode of action, but its primary target is thought to be inhibition of voltage-gated Na+ (and Ca2+)
95
Describe the structural organisation of a peripheral nerve
Fasciculi - Each fascicle is a bundle of axons from individual cells - Surrounded by perineurium Epineurium - Surrounds peripheral nerve - Tough connective tissue
96
Describe the different types of nerve fibres
Large fibres (myelinated) > Motor nerves > Proprioception, light touch and vibration Thinly myelinated fibres > Light, touch and temperature Small fibres (unmyelinated) > Light touch, pain and temperature
97
Describe length-dependent axonal neuropathy
Diffuse involvement of peripheral nerves > Age > 50 years > Length dependent - starts in toes / feet > Symmetrical, slowly progressive > No significant sensory ataxia > Any weakness is distal and mild Causes > Diabetes > Alcohol > Nutritional - folate / B12 / thiamine / B6 deficiency > Immune-mediated: RA, lupus, vasculitis, polyarteritis nodosa > Metabolic / endocrine > Renal failure > Hypothyroidism > Drugs: isoniazid, cisplatin, amiodarone, gold > Infectious: HIV, Hep B & C > Inherited: Charcot-Marie-Tooth, Hereditary neuropathy with liability to pressure palsy (HNPP) > Neoplastic : myeloma > Paraneoplastic > Critical illness
98
Describe Guillain-Barre syndrome
Acute inflammatory demyelinating neuropathy Post-infectious autoimmune aetiology > Campylobacter > CMV > EBV Progressive ascending weakness over days Flaccid quadriparesis with areflexia Can have respiratory / bulbar / autonomic involvement Treatment - IV immunoglobulin or apheresis CIDP – chronic form > Steroid and IVIG responsive
99
Describe nerve conduction studies
Axonal v demyelinating motor studies Axonal – CMAP is half of the size of a normal curve Demyelinating > Normal size but delayed conduction > OR conduction block with temporal dispersion >> Area under the curve is the same but slower and takes longer to peak
100
Describe mononeuritis multiplex
Sequential or simultaneous development of neuropathy in 2 or more nerves Describes a cluster of conditions Most commonly affects > Common peroneal >> Weak ankle dorsiflexion >> Sensory disturbance lateral aspect of calf and foot > Radial >> Wrist / finger drop >> Sensory disturbance – dorsum of hand > Axillary >> Weakness of shoulder abduction >> Badge of sensory disturbance – inferior deltoid > Median >> LOAF weakness >> Sensory disturbance > Femoral >> Weak hip flexion and knee extension >> Sensory disturbance lateral calf and dorsum of foot Common causes > Diabetes > Vasculitic – Churg Strauss, polyarteritis nodosa > Rheumatological – RA, lupus, Sjogren's > Infective – Hep C, HIV > Sarcoidosis > Lymphoma Investigations > History and examination > Nerve conduction studies and EMG > MRI of plexus with contrast > LP Management > Treat underlying cause > Symptoms may be irreversible
101
List muscular dystrophies
- Duchenne and Becker Muscular Dystrophy - Emery-Dreifus type - Limb girdle type - Fascioscapulohumeral type - Oculopharyngeal type
102
Describe myasthenia gravis
Pathogenesis > Autoimmune disorder > Antibodies to acetylcholine receptor at post-synaptic NMJ > Association with other autoimmune disorders > May be associated with thymic hyperplasia or thymoma Affects young women in 20s and older men in 70s Signs and symptoms > Fatiguable weakness of ocular, bulbar, neck, respiratory and/or limb muscles Investigations > Antibodies to AChR present in 85% > Single fibre EMG and repetitive nerve stimulation abnormal Management > Pyridostigmine - Anti-acetylcholinesterase > Immunosuppressive therapies: steroids, IV immunoglobulin
103
Give examples of cognitive functions which may be affected in dementia
Memory > Repetitive questions or conversations > Misplacing personal belongings > Forgetting events or appointments > Getting lost on a familiar route Executive function > Poor understanding of safety risks > Inability to manage finances > Poor decision-making ability > Inability to plan complex or sequential activities Visuospatial > Inability to recognise faces or common objects > Inability to find objects in direct view despite good acuity > Inability to operate simple implements or orient clothing to body Language > Difficulty thinking of common words while speaking > Hesitation > Speech, spelling and writing errors
104
Give examples of bedside cognitive assessments
Folstein MMSE (30) Addenbrookes Cognitive Examination (100) > 4 domains >> Executive function >> Memory >> Language >> Visuospatial
105
Describe the areas of the brain responsible for executive function
Behaviour > Orbitofrontal > Obeying and recognising social cues > Appropriate behaviour Attention / working memory > Dorsolateral prefrontal cortex Motivation / goal-driven > Anterior cingulate
106
Describe the areas of the brain responsible for visual processing and how to test this
Ventral stream > Object recognition – visual agnosia > Facial recognition – prosopagnosia Dorsal stream > Position of object in space – dyspraxia Testing ACE-r > Pentagons > Cubes > 3D letters > Dots counting
107
Describe attention and how it is tested
Component of consciousness which allows filtering of information to allow one to focus on a particular stimuli Essential for all aspects of cognition Pathological process – delirium (or anxiety/depression) Testing > ACEr >> Orientation e.g. what is the day/month/year, spell WORLD backwards >> Serial 7s > Trail making (trails B) - learning and understanding rules > Proverbs > Verbal fluency > Estimates > Planning
108
Describe pathological processes associated with episodic memory and how it is tested
Pathological process > Early Alzheimer's disease >> Hippocampal atrophy >> Ventricular enlargement > Limbic encephalitis Testing ACEr > Anterograde memory - address learning > Retrograde memory – historical famous figures
109
Describe pathological processes associated with semantic memory and how it is tested
Semantic dementia (variant frontotemporal dementia) - anterior temporal atrophy > Loss of knowledge about the world including words Testing ACEr > Marked reduction category verbal fluency e.g. give a list of animals in one minute > Impairment of irregular words (dyslexia) e.g. pint
110
Describe the different forms of language, the pathological processes which can arise and how it is tested
3 forms > Speech – aphasia > Reading – alexia > Writing – agraphia Pathological processes > Semantic variant – semantic dementia >> Poor confrontation naming e.g. naming common objects >> Impaired single word comprehension >> Poor object/person recognition, surface dyslexia > Logopenic variant – Alzheimer's dementia >> Impaired single word retrieval - "thinking of right word" >> Impaired repetition, speech sound errors (phenomic) >> Spared object/person recognition, single word recognition > Non-fluent variant – progressive non-fluent aphasia (variant FTD) >> Effortful, halting, motor impairment of speech >> Phenomic errors >> Spared object/person recognition, single word recognition Testing using ACEr > Naming > Repetition > 3 stage command – comprehension > Reading
111
Describe the pathophysiology of Alzheimer's disease
Starts in temporal lobe – impairment of episodic memory Hippocampal atrophy and ventricular enlargement Spreads to parietal and frontal lobes – visuospatial dysfunction Global atrophy including language centres – language disorder
112
Describe Bell's palsy and its treatment
Unilateral facial weakness evolves over 48h often preceded by ear pain/distorted sounds > Decreased tear production – ocular dryness > Hyperacusis > Ageusia Causes > Unknown > Viral-associated ischaemia, demyelination >> Herpes zoster, herpes simplex >> EBV >> Lyme disease Treatment > Steroids – oral prednisolone > Artificial tears, eye patching >> Long-term: tarsorrhaphy > Physical therapy > May resolve spontaneously within weeks-months
113
List the main agents which cause CNS infection
Bacterial: meningococcus, pneumococcus, Listeria Viral: HSV, VZV, enterovirus (D-68), HIV, mumps Fungal: cryptococcosis Parasitic: toxoplasmosis
114
Describe the causative agents of meningitis
Bacterial or viral > Streptococcus pneumoniae – gram positive diplococci >> 70% underlying disorder >>> Middle ear disease >>> Head injury – CSF leak >>> Neurosurgery >>> Alcohol >>> Immunosuppression (HIV) >> Neurology >>> Focal signs >>> Seizures >>> VIII palsy >>> CAP >>> ENT >>> Endocarditis > Neisseria meningitidis – gram negative diplococci Subacute > Bacterial – Listeria, TB >> Listeria monocytogenes – gram positive rods >>> Immunosuppression >>> Pregnancy
115
Describe the signs and symptoms of meningitis
Inflammation of meninges +/- cerebrum (meningo-encephalitis) - inflammatory CSF Symptoms and signs > Headache > Neck stiffness/rigidity > Reduced GCS > Fever > Confusion indicative of cerebritis / encephalitis > Rash – purpuric +/- petaechial but macular early on (meningococcal)
116
Describe LP findings in meningitis
Bacterial > Low glucose > High protein > Neutrophils present > Lymphocytes in Listeria infection TB > Low glucose > High protein > Lymphocytes present Viral > Normal glucose > High protein > Lymphocytes present (also neutrophils early on – esp mumps meningitis) Fungal > Low glucose > High protein > Lymphocytes present
117
Describe treatment of suspected bacterial meningitis
Possible bacterial meningitis > IV ceftriaxone 2g 12 hourly OR benzyl penicillin > OR if true penicillin allergy: IV chloramphenicol > If age > 60, immunosuppressed, alcohol excess, liver disease or Listeria meningitis suspected - add IV amoxicillin to ceftriaxone OR if true penicillin allergy> add IV co-trimoxazole Bacterial meningitis strongly suspected > Add IV dexamethasone 10mg 6 hourly (4 days) Duration of antibiotics > Meningococcal – 5 days > Listeria – 21 days (IV amoxicillin – stop ceftriaxone) > Pneumococcal – 10-14 days > Haemophilus – 10 days If high likelihood of pneumococcal meningitis add steroids
118
Describe chemoprophylaxis for meningococcal meningitis
Given to contacts Ciprofloxacin Rifampicin
119
Describe viral encephalitis and its treatment
Confusion, fever +/- seizures HSV encephalitis > High mortality rate with neuro sequelae e.g. hearing loss, memory loss > Lymphocytic CSF > Normal glucose > PCR is positive EEG – temporal lobe changes Treatment - IV aciclovir 2-3 weeks (HSV, VZV)
120
Describe intracerebral TB
Subacute – weeks May be unmasked during TB treatment CN lesions usually CN III, IV, VI, IX Sample widely – early morning urines (EMUs), bronchoalveolar lavage (BAL) CSF may be normal Treatment for one year > Rifampicin > Pyrazinamide > Isoniazid > Ethambutol > Steroids
121
Describe HIV brain disease
Consequence of unrecognised/untreated infection and marked immunodeficiency > Encephalitis: responds to antiretroviral therapy > Dementia: does not respond to antiretroviral therapy > Neurosyphilis – secondary or tertiary >> Responds to penicillin > Opportunistic >> TB >> Cryptococcus >> Toxoplasmosis >> JC virus – progressive multifocal leuco-encephalopathy
122
Describe intracerebral toxoplasmosis
Toxoplasma gondii Signs and symptoms > Headache > Seizures > Focal CNS signs > Immunocompromised (HIV) > Multiple enhancing lesions – basal ganglia Investigations > IgG and IgM – blood > PCR – CSF Treatment > Sulphadiazine > Pyramethamine > Restore immune function
123
Describe cryptococcal meningitis
Immunodeficiency usual – HIV Space occupying lesion (SOL) or meningo-encephalitis (subacute) Papilloedema usually present > Will progress to optic atrophy and blindness if untreated Can cause pulmonary nodules and skin lesions CSF > India ink – classic large capsule > Cryptococcal antigen (also blood) > Culture Treatment > Amphotericin B > Flucytosine > Fluconazole, possible steroids > If raised ICP – shunt > Paradoxical worsening with ARVs in HIV
124
Describe the treatment used for acute alcohol intoxication and name complications of chronic alcohol abuse
Chlordiazepoxide PRN and IV Pabrinex (vitamin B1) Complications: Wernicke's encephalopathy progressing to Korsakoff's syndrome
125
Describe the Oxfordshire Community Stroke Project (OCSP) classification
4 subtypes of ischaemic stroke 1) Lacunar syndrome (LACS) > pure motor stroke OR pure sensory stroke OR sensorimotor stroke OR ataxic hemiparesis OR clumsy hand-dysarthria 2) Total anterior circulation syndrome (TACS) > hemiparesis AND higher cortical dysfunction (dysphasia or visuospatial neglect) AND homonymous hemianopia 3) Partial anterior circulation syndrome (PACS) > Isolated higher cortical dysfunction OR any 2 of hemiparesis, higher cortical dysfunction, hemianopia 4) Posterior circulation infarct (POCS) > Isolated hemianopia, brainstem or cerebellar syndromes
126
Describe the CHADS-VASc score and at what score do you anticoagulate and with what?
C – Congestive Heart Failure/ LV Dysfunction H – Hypertension A(2) – Age ≥ 75 D – Diabetes Mellitus S(2) – Stroke/TIA/Thromboembolism V – Vascular Disease (e.g. PAD, MI) A – Age (65-74) Sc – Sex Category (1 point for F) If CHA2DS-VASc Score ≥ 2: offer anticoagulation- (Edoxaban/Apixaban). If patient has a mechanical valve replacement: Warfarin
127
Discuss management of migraine - acute and prophylactic
Acute (1st line) - Simple analgesics (Paracetamol, Ibuprofen or Aspirin) UPTO 2 twice a week - Triptans (e.g. Sumatriptan) - Avoid if patient has CVD - Give with anti-emetics if vomiting - Consider anti-emetics if patient is vomiting (Metoclopramide or Prochlorperazine) If not working - try other Triptans and NSAIDs (2nd line) Prophylactic - Lifestyle: diet and hydration, avoid triggers, relaxation activities, headache diaries - Medication. Consider if: >4 disabling headaches per month Not resolved by acute medication, or risk of Medication overuse headache Offer EITHER of: - Propranolol - Amitriptyline - Topiramate - Candesartan - Flunarazine If ineffective after 3m, wean and try another If all failed: refer to neurology specialist avoid opiates
128
Summarise peripheral neuropathies - GBS, length dependent, myasthenia gravis
Guillain-Barre Syndrome (medical emergency) - Ascending weakness (length-dependent) and sensory loss - Typically after GI infection/ EBV - Treated with IVIg 2. Length dependent axonal neuropathies - Tend to have a glove-and-stocking distribution, symmetrical - Multiple causes (B12/B9, Isoniazid, Diabetes, alcohol, Charcot-Marie Tooth) 3. Neuromuscular Junction Disorders - Myasthenia Gravis (esp younger women, older men) - Fatiguable weakness: ptosis, quietening speech, respiratory difficulties - Ix: Antibodies to post-synaptic ACh receptors at the NMJ, possible mediastinal mass on CT - Treated with Pyridostigmine (anti-AChE)
129
Define Pellagra
Pellagra - A deficiency of niacin (vitamin B3). Characterized by the presence of glossitis and "the three Ds": diarrhea, dermatitis, dementia, and possibly death (the four Ds).
130
Discuss Bamford Stroke Classification
131
Describe symtpoms of stroke by location
ACA - Contralateral leg > arm weakness, sensory loss, urinary incontinence - Personality changes MCA -Arm > leg weakness, sensory loss - Hemineglect/ aphasia PCA - Contralateral hemianopia with macular sparing - Alexia, prosopagnosia etc Lacunar strokes - Pure sensory/motor/mixed (no cortical signs such as neglect, aphasia) Cerebellar strokes - Consider if vertigo (vomiting), tremors, slurred speech, ataxia, nystagmus etc
132
Describe Cushing's triad
Cushing's triad refers to signs which indicate increased intracranial pressure (ICP). These include bradycardia, widened pulse pressure and irregular respirations.