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Medicine year 3 TCD > Neurology > Flashcards

Flashcards in Neurology Deck (83)
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1
Q

Most common bacterial causes of community acquired meningitis in 6-60 year olds?

A

Neisseria meningitidis
Streptococcus pneumoniae

2
Q

Returning travellers at risk of which meningitis pathogen?

A

Penicillin resistant streptococcus pneumoniae

3
Q

Presenting symptoms of meningitis

A

Fever
Neck stiffness
Change in mental status (GCS <14)
Vomiting
Photophobia (discomfort in bright light)
Usually of sudden onset

4
Q

What extra symptom can bacterial meningitis present with

A

Non blanching rash due to septicaemia. Small red/purple spots that do not blanch. this type of rash is petechial rash and is caused by bleeding under the skin.

5
Q

What tests can be done to check for meningitis?

A
  1. Kernig’s Test- patient lies on back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees.
    Creates a slight stretch in meningies- in meningitis will produce spinal pain or resistance to this movement.
  2. Brudzinski’s test- patient lies on back, use your hands to lift their head and neck off the bed and flex their chin to their chest. Positive test is when patient involuntarily flexes their hips and knees.
6
Q

Gold standard for diagnosing meningitis

A

Lumbar puncture- CSF culture

LP- needle inserted into the L3-L4 intervertebral space.

LP should be done within the hour of hospital arrival before abx.

7
Q

Contraindications for lumbar puncture

A

raised intracranial pressure, shock, extensive or spreading purpura, convulsions, sig bleeding risk, severe respiratory/cardiac compromise.

8
Q

CSF analysis findings for bacteria and viruses

A

Bacteria in CSF will release proteins and use up the glucose. So bacterial findings are: cloudy appearance, low glucose, high proteins, raised neutrophils.

Viruses don’t use glucose but may release a bit of protein. Viral findings are: clear/cloudy appearance, normal glucose, normal/high proteins, raised lymphocytes

9
Q

Meningitis- IV antibiotics for <3 month olds

A

Cefotaxime + Amoxicillin

10
Q

Meningitis IV abx for > 3 months

A

Cefotaxime

11
Q

Meningitis IV abx >50 years

A

Cefotaxime + amoxicillin

12
Q

What medication is given to reduce frequency and severity of hearing loss and neuro dmg in meningitis>

A

Dexamethasone is given 4x daily for 4 days to kids over 4 months if the LP is suggestive of bacterial meningitis

13
Q

Post-exposure prophylaxis of someone exposed to a patient w/ meningococcal infections

A

single dose of ciprofloxacin given ASAP ideally within 24 hrs of the initial diagnosis

14
Q

Viral meningitis- most common causes

A

Herpes simplex virus
Enterovirus
Varicella zoster virus

15
Q

viral meningitis treatment

A

Aciclovir can be used to treat suspected or confirmed HSV meningitis

16
Q

What type of headache is a mild ache across the forehead and in a band like pattern around the head?

A

Tension headaches

17
Q

Tension headache treatment

A

Basic analgesia: acutely- aspirin, paracetamol or an NSAID are first line
Prophylaxis- NICE recommend up to 10 sessions of acupuncture over 5-8 weeks

18
Q

What type of pain is sinusitis

A

facial pain behind the nose, forehead and eyes

19
Q

sinusitis predisposing factors

A

nasal obstruction, recent local infection, swimming/diving, smoking

20
Q

sinusitis management

A

analgesia
Nasal irrigation w/ saline
inhaled corticosteroids may be considered if teh symptoms have been present for over 10 days
Oral abx are occasionally required for severe presentationss

21
Q

cervical spondylosis presents with what?

A

neck pain, usually worsened by movement
headache

22
Q

Trigeminal neuralgia presentation

A

90% of cases are unilateral. Presents w/ intense facial pain that comes on spontaneously and last anywhere bwt a few seconds to hours. Electricity- like shooting pain.

23
Q

Trigeminal neuralgia treatment

A

Carbamazepine is first line.
Surgery to decompress or intentionally dmg the trigeminal nerve is an option

24
Q

What is migraine?

A

Migraine is a wave of electrical activity thru the brain that can cause a variety of symptoms

25
Q

Migraine types

A

W/ aura
W/o aura
silent migraine (w/ aura but w/o a headache)
Hemiplegic migraine

26
Q

Migraine heaadache symptoms

A

Headaches last bwt 4 and 72 hrs
Pounding or throbbing nature
Usually unilateral
Discomfort w/ lights (photophobia)
Discomfort w/ loud noises (phonophonia)
W/ or w/o aura
Nausea and vomiting

27
Q

What is aura? Types of aura?

A

Visual changes associated w/ migraines
Multiple types of aura:
Sparks in vision
Blurring vision
Lines across vision
Loss of different visual fields

28
Q

What is hemiplegic migraine

A

Can mimic stroke
Symptoms include:
Typical migraine symptoms
Sudden or gradual onset
Hemiplegia (unilateral weakness of the limbs)
Ataxia (poor muscle control that causes clumsy voluntary movements)
Changes in consciousness

29
Q

What is typical migraine aura

A

aura is progressive, may occur hours prior to the headache, includes a transient hemianopic (loss of half of visual field for less than 24 hours) disturbance or a spreading scintillating scotoma (jagged crescent)

30
Q

Acute management of migraines

A

First line- offer combo therapy of oral triptain (serotonin receptor agonist eg sumatriptan 50mg) and an NSAID, or an oral triptan and paracetamol

If not effective, offer a non-oral preparation of metoclopramide and consider adding a non oral NSAID or triptan

31
Q

When and what migraine prophylaxis is offered

A

Should be given if patients are experiencing 2 or more attacks monthly.

Give either topiramate (teratogenic) or propranolol (in women)
Can also give amitriptyline

Can recommend a course of up 10 sessions of acupuncture over 5-8 weeks
supplementation w/ vitamin B2 (riboflacin) may reduce frequency and severity

if triggered by menstruation, prophylaxis w/ NSAIDs or triptans can be used as a preventative measure.

32
Q

Intracranial bleed risk factors

A

head injury
hypertension
aneurysms
brain tumours
anticoagulants eg warfarin

33
Q

intracranial bleed presentation

A

sudden onset headache
seizures
weakness
vomiting
reduced consciousness
other sudden onset neuro symptoms

34
Q

Principles of management of intracranial bleed

A

immediate CT head
admit to specialist stroke unit
discuss w/ specialist neurosurgical centre to consider surgical treatment
consider intubation, ventilation and ICU care if reduced consciousness
correct severe hypertension but avoid hypotension

35
Q

Subdural haemorrage- what is it caused by and where does it occur

A

caused by rupture of the bridging veins- bleeding into the outermost meningeal layer. Occur bwt the dura mater and arachnoid mater

36
Q

Subdural haemorrhage presentation

A

sudden onset headache
seizures
weakness
vomiting
reduced consciousness
other sudden onset neuro symptoms

37
Q

subdural haemorrhage- risk factors

A

elderly or alcoholics, these patients have more atrophy in their brains making vessels more likely to rupture

38
Q

how does subdural haemorrhage look on CT

A

crescent shape and can cross over the sutures

39
Q

how are subdural haemorrhages classified, and how do they differ on CTs

A

Acute- fresh blood caused by high impact trauma. CT shows hyperdense (bright) crescent shape. management= conservative if small/incidental, surgical options are monitoring of intracranial pressure and decompressive craniectomy.
Chronic- present for weeks to months. Rupture of the small bridging veins within the subdural space rupture and cause slow bleeding. CT- hypodense (dark) crescents. Managements- if small/incidental then conservatie. Surgical decompression w/ burr holes if patient’s confused, has an associated neurological deficit or has severe imaging findings.

40
Q

What is extradural haemorrhage

A

blood bwt the skull and the dura

41
Q

what usually causes extradural haemorrhage

A

Trauma- caused by rupture of middle meningeal artery in the temporo-parietal region, can be associated w/ a fracture of the temporal bone.

42
Q

Typical extradural haemorrhage presentation

A

young patient w/ traumatic head injury w/ ongoing headache.
Have a period of improved neuro symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents. the brief regain in consciousness is called the LUCID INTERVAL.

43
Q

How does extradural haemorrhage look on CT

A

biconvex (or lentiform), hyperdense shape around the surface of the brain. They’re limited by the cranial suture lines of the skull (can’t cross over the sutures)

44
Q

Management of extradural haemorrhage

A

No neurological deficit- cautious clinical and radiological observation is appropriate. Definitive treatment is craniotomy and evacuation of the haematoma

45
Q

Management of extradural haemorrhage

A

No neurological deficit- cautious clinical and radiological observation is appropriate. Definitive treatment is craniotomy and evacuation of the haematoma

46
Q

Subarachnoid haemorrhage what is it

A

bleeding into the subarachnoid space, where the CSF is, bwt the pia mater and the arachnoid membrane. Usually the result of a ruptured cerebral aneurysm eg Berry aneurysm

47
Q

Subarachnoid haemorrhage typical history

A

Sudden onset occipital headache that occurs during strenuous activity- sudden, severe, thunderclap headache.
Other features:
neck stiffness
photophobia
vision changes
neuro symptoms eg speech changes,

48
Q

Subarachnoid haemorrhage investigations

A

CT head is first line. Blood will cause hyperattenuation in the subarachnoid space.

Lumbar puncture is used to collect a CSF sample if the CT head is negative. Red cell count will be raised. Xanthochromina- yellow contour of CSF caused by bilirubin

Angiography (CT or MRI) can be used once a subarachnoid haemorrhage is confirmed to locate the source of bleeding

49
Q

Subarachnoid haemorrhage management

A

Specialist neurosurgical unit
Pts w/ reduced consciousness may require intubation and ventilation.
Supportive care as part of MDT
Surgical intervention may be used to treat aneurysms. Aim is to repair the vessel and prevent rebleeding. Coiling- inserting a catheter into the arterial system, placing platinum coils into the aneurysm and sealing it off from the artery.
Nimodipine is a CCB used to prevent vasospasm- this is when a brain blood vessel narrows, blocking blood flow.
Antiepileptic meds can be used to treat seizures.

50
Q

what is an intracerebral haemorrhage?

A

collection of blood within the substance of the brain

51
Q

causes of intracerebral haemorrhage

A

hypertension
vascular lesion
trauma
brain tumour or infarct

52
Q

how do intracerebral haemorrhages present?

A

Present similarly to an ischaemic stroke (sudden numbness/weakness of the face/arm/leg, especially on one side of the body), or w/ a decrease in consciousness

53
Q

How do intracerebral haemorrhages look on CT

A

Hyperdensity (bright lesion) within the substance of the brain

54
Q

Epilepsy symptoms and signs

A

As well as seizure activity, patients may also bite their tongue, or experience incontinence of urine.
Following a seizure pts typically have a postictal phase where they feel drowsy and tired for around 15 mins

55
Q

Epilepsy investigations/diagnosis

A

diagnosis is made by a specialist based on characteristics of the seizure episodes.
EEG can show typical patterns in diff forms of epilepsy and supp the diagnosis. MRI, ECG.

56
Q

Generalised Tonic Clonic Seizures are what?

A

loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) episodes. May be associated tongue biting, incontinence, groaning and irregular breathing. prolonged post-ictal period where person is confused/drowsy after

57
Q

Generalised Tonic Clonic Seizures management

A

Men- sodium valproate
Women- lamotrigine

58
Q

Focal seizures are what?

A

start in temporal lobes- can present in many ways eg hallucinations, memory flashbacks, deja vu, doing strange things on autopilot.

59
Q

focal seizures management

A

first line- lamotrigine
second line- carbamazepine

60
Q

absence seizures what are they

A

patient becomes blank, stares into space and abruptly returns to normal, typically happen in kids

61
Q

absence seizures management

A

Ethosuximide

62
Q

atonic seizures what are they

A

brief lapses in muscle tone. may be indicative of Lennox- Gastaut syndrome

63
Q

atonic seizures management

A

males: sodium valproate
females: lamotrigine

64
Q

myoclonic seizures what are they

A

present as sudden brief muscle contractions, pt usually remains awake

65
Q

myoclonic seizures management

A

males: sodium valproate
females: levetiracetam

66
Q

epilepsy driving?

A

can’t drive for 6 months following a seizures.

67
Q

epilepsy pregnancy

A

breastfeeding is safe except barbiturates. take advice from neurologist prior to becoming pregnant

68
Q

sodium valproate side effects

A

Teratogenic, liver dmg and hepatitis, hair loss, tremor

69
Q

ethosuximide side effects

A

night terrors, rash

70
Q

lamotrigine side effects

A

Steven Johnson syndrome or DRESS syndrome- life threatening skin rashes. Leukopenia

71
Q

what is status epilepticus

A

medical emergency. seizures lasting > 5 mins or over 3 seizures in an hour

72
Q

status epilepticus management

A

secure airway,
high conc oxygen
check blood glucose
IV lorazepam 4mg, repeated after 10 mins if seizure continues
If seizures persist: IV phenoarbital or phenytoin.
Community options- Buccal midazolam
Rectal diazepam or intranasally/under the tongue

73
Q

raised intracranial pressure symptoms

A

papilloedema
new onset headache- worse on coughing, straining, bending down. Vomiting. transient visual obscuration.
Cushing’s triad: widening pulse pressure, bradycardia, irregular breathing

74
Q

raised intracranial pressure treatment

A

head elevation to 30 degrees
controlled hyperventilation- aim to reduce pCO2 -> vasoconstriction of cerebral arteries -> reduced ICP.
Drain from intraventricular monitor. repeated lumbar puncture.

75
Q

Syncope causes

A

Primary syncope (simple fainting): dehydration, missed meals, extending standing in warm environment
Secondary causes: hypoglycaemia

76
Q

Syncope investigations

A

ECG- assess for arrhythmia and QT interval for long QT syndrome, WPW, LVH, heart block

77
Q

syncope management

A

trigger avoidance, reassurance

78
Q

brain tumour presentation

A

asymptomatic when small
focal neuro symptoms depending on location
often present w/ symptoms and signs of raised ICP
Frontal lobe- unusualy changes in personality/behaviour/ decision making.
Parietal lobe- sensory symptoms, dressing apraxia, visual field defects
Temporal lobe- Dysphasia (can’t put right words in a sentence), visual field defects
Occipital lobe- visual fields
posteiror fossa (dysmteria- can’t control distance, speed and range of motion to perform coordinated movements)

79
Q

what type of tumour is pituitary tumours and what can it cause

A

beningn
can press on the optic chiasm causing a specific visual field defects- bitemporal heminanopia (loss of outer half of visual fields in both eyes)
can cause hormone defficienes or release excess hormones leading to acromegaly, cushings, thyrotoxicosis

80
Q

what’s the 2ww suspected cancer referral for brain tumours

A

headache w/ features of raised ICP - actively wakes patient from sleep but not migraine or cluster, precipitated by Valsalva manouevres, Papilloedema

Chronic episodic course- other symptoms of raised ICP headache, vomtiing w/o other obvious cause

81
Q

brain tumour management

A

surgery dpeends on grade and behaviour

82
Q

GCA symptoms

A

severe unilateral headache typically around temple and forehead
scalp tenderness eg when brushing hair
jaw claudication
blurred/double vision
irreversible painless complete sight loss- rapid

83
Q

GCA management

A

40-60 mg prednisolone daily
aspirin
PPI
refer to vascular surgeon, rheumatology, urgent ophthalmology review as emergency same day