Neurology Flashcards
What is Glia?
Supportive cells throughout the CNS and PNS supporting Neurones, each with different functions.
What are astrocytes?
Glia cells that connect neurones and blood capillaries to form the BBB
What are Satellite cells?
Located in the PNS provide neuronal support
What are microglia?
Immune and Phagocytic functions
What are Ependymal Cells?
They line the CSF filled ventricles and the central canal of the spinal cord
What are oligodendrocytes?
Oligodendrocytes in the CNS provide the Myelin sheath
What are Schwann Cells?
Schwann Cells in the PNS provide the Myelin Sheath
Describe the clinical findings of Relative Afferent Pupillary Defect.
Pupiliary defect:
Light shone on unaffected eye causes full and symmetrical constriction of both eyes, when light swings to AFFECTED eye, the constriction is still symmetrical but REDUCED.
Caused by:
Damage between the Retinal Ganglion and Lateral Geniculate Body.
What is the Lateral Geniculate body?
Located in the Thalamus, it provides a relay station for all the axons of the retinal ganglion cells where the neurons from the lateral geniculate body project, by way of the optic radiations, the occipital lobe, which is the primary cortical area for vision.
What can Relative Afferent Pupillary Defect indicate?
-optic neuropathy
-optic neuritis
-optic nerve compression (orbital tumours or dysthyroid eye disease) –trauma
-asymmetric glaucoma.
What is Miosis?
Pupiliary Defect:
Excessive Constriction of pupil
Causes:Commonly associated with HORNER’s SYNDROME due to a LESION of the sympathetic chain between the hypothalamus and eye.
What can Miosis indicate?
HORNER’s SYNDROME due to …
-Pancoast tumour (lung cancer)
-Trauma
-Thoracic Aortic Aneurysm
How would you confirm Horner’s Syndrome?
4% cocaine eye drops will dilate the unaffected eye BUT NOT the AFFECTED eye.
What is Fixed Dilated Pupil?
Pupiliary defect:
Permanent dilation of pupil that does not constrict on light impulse.
Causes:
Due to sphincter pupillae damage
A patient has Fixed Dilated Pupil. What needs to be excluded?
Third Nerve Palsy
What are the causes of Fixed Dilated Pupil?
-THIRD NERVE PALSY!
-Surgical mistake
-Physical trauma
-Tumour
-Posterior Artery Aneurysm
-Uncal Herniation
A patient has unilateral enlarged pupil / fixed dilated pupil. What could this be due to and how is this medical complaint considered?
Uncal Herniation
=Neurosurgery Emergency
What is Uncal Herniation?
Uncal herniation occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another. This is usually caused by something increasing the pressure e.g Bleeding in the brain or Tumour
What is Horner’s Syndrome?
Due to a disruption in the sympathetic nerve supply presenting with these triad symptoms :
1.Partial ptosis (drooping or falling of upper eyelid)
2.Miosis (constricted pupil)
3.Facial anhidrosis (loss of sweating)
What are the causes of Horner’s Syndrome?
Most common: Carotid Artery Dissection
(Disruption to the Sympathetic Chain)
Blockage or damage to the sympathetic nerves that lead to your eyes.
The underlying causes of nerve damage CAN VARY WIDELY, from a middle ear infection to a carotid artery dissection or apical chest tumor.
What is Papilloedema?
An INCREASE OF INTRACRANIAL PRESSURE caused by an accumulation of CSF expanding the ventricles (DUE TO HYPERTENSION USUALLY DUE TO MALIGNANCY) and increasing the overall pressure which affects the optic nerves : and causes the SWELLING of THE OPTIC DISC.
A patient presents with headaches and nausea. Upon Fundoscopy, you see that the Optic disc is swollen. What would you do next and why?
Sounds like PAPILLOEDEMA
=1.CT scan of brain
2.If imaging normal, do Lumbar Puncture as Intracranial Hypertension is suspected
What is Mydriasis?
Excessive dilation of the pupil
What are the clinical signs of Third Nerve Palsy?
(See imaging power point)
1.Myadriasis
2.Ptosis
3.Cycloplegia of affected eye
-Exotropia (eye looking outward)
-Hypotropia (one eye always looking upward)
=Issues with accomodation
Additional associated symptoms:
-Fixed dilated pupil and Horizontal Diplopia
A patient presents with Myadriasis, Ptosis and Cycloplegia of her right eye. What artery could have been responsible for ‘this’ and why?
Presentation = Third Nerve Palsy
=Posterior Communicating Artery (runs close to third nerve so an aneurysm of this artery can cause Third Nerve Palsy.
What is Cycloplegia?
Paralysis of accomodation (because of paralysis in the ciliary muscles which are responsible for accomodation).
What is accomodation of the eye?
The eyes ability to focus on images far away AND up close
=Pupil should constrict when something is close (tip of pen) and dilate when far away. If this doesn’t happen : CYCLOPLEGIA
A patient presents with symptoms indicating Third Nerve Palsy however the MR angiography is normal. What is the next step?
Repeat the MR angiography
=Vasospasms of an aneurysm (constriction of the blood vessel) can give a falsely normal MR so repeat it again.
What nerve does Third Nerve Palsy affect?
Oculomotor
What muscle does the Trochlear Nerve innervate and what are the actions of that muscle?
Superior Oblique Muscle of the eye
=Abducting, Depressing and Internally Rotating the eye
What is the most common cause of 4th Nerve Palsy?
Trauma
-due to its long and slender coarse it is very vulnerable to damage
How does 4th Nerve Palsy present?
(See Imaging Power Point)
-Vertical Diplopia
-Excyclotorsion
Can also have :
torsional diplopia, head tilt, and ipsilateral hypertropia.
What is Vertical Diplopia?
Double Vision
=Vertical meaning that the overlapping image will be on top of the other
What is Horizontal Diplopia?
Double Vision
=Horizontal meaning that the overlapping image will be side by side
What is Excyclotorsion?
Affected eye deviates upward and rotates outward when looking in the opposite direction
e.g affected right eye looking left will look upward and rotate outwards
What is the Bielschowsky test and what result would you expect for a patient with 4th Nerve Palsy?
Check head tilting
=Hyperdeviation head tilt
What are the clinical signs of Sixth Nerve Palsy?
-Esotropia ( either one or both of your eyes pointing inward)
-Horizontal Diplopia (double vision with images side by side)
What are the common causes of 6th Nerve Palsy?
-Microvascular Disease (from Diabetes Mellitus and Hypertension)
-External Compression (from acoustic neuroma and raised intracranial pressure)
What is an Acoustic Neuroma?
Acoustic neuromas, also known as vestibular schwannomas, are noncancerous tumours that grow in the ear, and that can affect hearing and balance.
-Cause is largely unknown but regarded to be due to environmental factors such as radiation
What muscle is innervated by the Abducens Nerve?
The 6th cranial nerve innervates the ABDUCTOR MUSCLE OF THE EYE
A patient has Arcuate Scotoma. What Nerve is affected and what are the 4 potential causes of it?
Optic Nerve (1)
1.Glaucomatous Cupping
2.Vitamin B12 deficiency
3.Trauma
4.Optic Neuritis
A patient has Centrocecal scotoma. What Nerve is affected and what are the 4 potential causes of it?
Optic Nerve (1)
1.Glaucomatous Cupping
2.Vitamin B12 deficiency
3.Trauma
4.Optic Neuritis (due to Multiple Sclerosis)
A patient has complete unilateral loss of visual field. What Nerve is affected and what are the 4 potential causes of it?
Optic Nerve (1)
1.Glaucomatous Cupping
2.Vitamin B12 deficiency
3.Trauma
4.Optic Neuritis
What is a scotoma?
Visual blind spot
What is a Centrocecal scotoma?
Blind spot in the centre of the visual field
A patient has Bilateral Hemianopia. What Nerve is affected and what are the potential causes of it?
BRAIN TUMOURS:
-Pituitary tumour
-Craniopharyngioma (tumour between pit. gland and hypothalamus)
-Meningioma (benign tumour arising from the meningeal layers of brain)
=due to issue where the OPTIC NERVES cross at the Optic Chiasm.
A patient has Contralateral Homonymous Hemianopia. What are the potential causes of it?
Tumour, Multiple Sclerosis (MS)
What does Homonymous eye defect mean?
Same visual field in both eyes
A patient has Contralateral Superior Quadrantanopia.What are the potential causes of it?
-Mass lesion in the temoral lobe
-Stroke
A patient has Homonymous Hemianopia. What is the most likely cause of it?
Stroke
What does Hemianopia mean?
A hemianopia is where there is a loss of one half of your visual field
What characterises Parinaud Syndrome?
-Vertical Gaze palsy (cannot look up or down!)
-Convergence Nystagmus
OR
-Diplopia
What is meant by Convergence Nystagmus?
Quick jerking movements of eyes looking inwards
What causes Parinaud Syndrome?
Pineal Gland tumour compressing the vertical gaze centre.
What are the 3 main reasons for patients presenting with Vertigo?
Benign Paroxysmal Positional Vertigo
Meniere’s Disease
Vestibular Neuronitis
A patient presents with hearing loss and vertigo. What could be the most likely cause?
-Meniere’s Disease
OR
-Labyrinthitis
A patient presents with persistent vertigo. What is the most likely cause?
-Vestibular Neuronitis
-Labyrinthitis
What is an Otolith?
Calcium carbonate stone of the ear
What is the pathophysiology of Benign Paroxysmal Positional Vertigo (BPPV)?
Otoliths (stones) get dislodged in the semi-circular canals which produces the sensation of vertigo.
What is the cause of Benign Paroxysmal Positional Vertigo (BPPV)?
Idiopathic HOWEVER
-Most likely to be due to trauma / head injury when it presents in younger people
Who is most likely to present with Benign Paroxysmal Positional Vertigo (BPPV)?
-Over age 50 years
-WOMEN more affected than men
What other disorders is Benign Paroxysmal Positional Vertigo (BPPV) associated with (i.e can present with)?
-Meniere Disease
-Vestibular Neuronitis
A patient has Benign Paroxysmal Positional Vertigo (BPPV). What would you believe to make their symptoms better or worse?
-Provoked by head movement
-WORSEN: Head tilted / on one side/ when waking in the morning
-RESOLVES: When head is kept straight and still
What 2 symptoms if present with vertigo would rule out Benign Paroxysmal Positional Vertigo (BPPV)?
-Hearing loss
-Tinitus
Describe the onset of symptoms of Benign Paroxysmal Positional Vertigo (BPPV)?
Episodic lasting under a mintue and often resolve temporarily when head is kept still.
What investigation(s) are done for a suspected Benign Paroxysmal Positional Vertigo (BPPV)?
Dix-Hallpike test
=A positive test diagnoses BPPV and no more investigations are required.
HOWEVER - if severe neck issues such as Rheumatoid Arthritis or Cervical Spondylosis etc …Cannot do this test and will need to be referred for ENT specialist.
What is the Dix-Hallpike test?
Manoeuvre :
1.Patient lies on side (ear on bed and other facing ceiling) and looks up
2.Look for Nystagmus (jerking of eye)
=If Nystagmus present this is a POSITIVE test and diagnosed BPPV.
What is the management for Benign Paroxysmal Positional Vertigo (BPPV)?
-Epley Manoeuvre (moving head both sides 45 degrees)
-Brandt-Daroff exercises (lying down and looking to one side with eyes closed and doing it on the other side)
=These should be done until 2 consecutive days without symptoms
What lifestyle advice should be given to a patient with a new diagnosis of Benign Paroxysmal Positional Vertigo (BPPV)?
-Avoid driving
-Avoid any tasks that can be adversely affected by vertigo (e.g painting of ladder - you could fall!!)
What is the pathophysiology of Meniere’s Disease?
Somewhat unknown (interplay between genes and enviroment) cause of the EXTENSIVE EXPANSION of the membranous labyrinth which causes the sensation of vertigo.
What is the classical triad of symptoms for Meniere’s Disease?
-Vertigo
-Tinnitus
-Fluctuating Hearing Loss (sensorineural in nature)
What is meant by Aural Fullness?
The feeling of ear pressure or a clogging sensation of the ear
Who is usually affected by Meniere’s Disease?
40-50years
Other than the classical triad of symptoms what other symptoms are associated with Meniere’s Disease?
Aural fullness
Anxiety and Depression
Describe the onset of symptoms in patients with Meniere’s Disease?
ACUTE attack lasting minutes - hours (MOST COMMONLY BEING 2-3HRS)
-These attacks can occur in clusters but often there is a remission period of months before the next one
What investigations are required for a patient with suspected Meniere’s Disease?
NO investigations
-The triad of symptoms ALL being present is enough for diagnosis after REFERAL TO AN ENT SPECIALIST
A patient has been diagnosed with Meniere’s Disease? What advice and legal action is required from you as a doctor?
-Advise not to drive
=Inform the DVLA
-Advise not to perform work that could be adversely affected
What is the management of Meniere’s Disease?
1.Betahistine (to reduce frequency of attacks) to be tried
2.If SEVERE: Admission for IV Labyrinthine Sedatives
3.Prochlorperazine = for use during ACUTE ATTACKS
What are the contraindications for Betahistine?
-Phaeochromocytoma (adrenaline secreting tumour)
-TRY to avoid during Pregnancy and Breastfeeding
A patient is being considered to be put on Betahistine. What should be considered and therefore increase monitoring of the patient’s tolerance of the medication?
Asthma
History of peptic ulcer
Allergic dermatitis
Vomiting
List 3 common side effects of Betahistine.
Gastrointestinal discomfort
headache
nausea
What is Labyrinthitis?
Inflammation of the inner ear
(can also be referred to as Vestibular Neuronitis)
What causes Labyrinthitis?
Inflammation due to a viral (usually being an upper respiratory infection) or bacterial infection.
What are the viral pathogens that can cause Labyrinthitis?
-Varicella-Zoster Virus
-Cytomegalovirus
-Measles
-Mumpes
-Rubella
What are the bacterial pathogens that can cause Labyrinthitis?
Otitis Media
Cholesteatomas
Complication of late-stage syphillis
What is the most common cause of Labyrinthitis in those 30-60years?
Viral
What is the presentation of Labyrinthitis?
-Sudden onset of vertigo associated with nausea and vomiting (can persist up to 72hrs)
-Ongoing Sensorineural hearing loss
-Ongoing tinnitus
What are the main presenting differentiators between Meniere’s Disease and Labyrinthitis?
-Meniere’s usually can be associated with AURUL FULLNESS while Labyrinthitis is not usually associated with it
-Meniere’s mostly presents with the MAIN SYMPTOM being the Vertigo while Labyrinthitis presents with Hearing loss / Tinnitus as the main symptom
What investigations are required for Labyrinthitis?
-Physical exam (Weber and Rinne tests
What type of medication is Prochlorperazine?
Antipsychotic that can also be used to treat severe nausea
What is the management for Labyrinthitis?
For 3 days only (as correcting for too long can affect the body’s compensatory mechanism and therefore disrupt recovery)
-Antihistamines (e.g Cinnarizine)
-Prochlorperazine (anti psychotic)
What does the term palsy mean?
Paralysis accompanied with involuntary tremors
Who is more likely to present with Bell’s Palsy?
Pregnant Women
Describe the presentation of the facial palsy of Bell’s Palsy.
UNILATERAL Palsy (one side of face)
SUDDEN onset
What are the contraindications of Prochlorperazine?
-Avoid oral route in child under 10 kg –CNS depression (substance overdoses, poisoning)
-Comatose states
-Phaeochromocytoma (adrenaline secreting tumour)
A patient is being considered for being put on Prochlorperazine. What underlying health condition should make you monitor them to ensure it is being tolerated?
HyPOthyroidism
When prescribing Prochlorperazine for the elderly, what illness could it potentially worsen?
Parkinsonism or Lewy Body Disease
A patient presents with a facial palsy that is recurrent and bilateral. What differential diagnoses would you consider?
-Sarcoidosis
-Lyme Disease
-Guillain Barre syndrome
-HIV
What is Bell sign?
When the eye rolls when the patient attempts to close it
What is the presentation of a patient with Bell’s Palsy?
-Sudden onset
-Unilateral facial weakness
-Ear ache / preauricular pain
-Eye dryness
-Inability to close eyes fully
-Bell sign (eye rolls when patient tries to close it)
-Hyperacusis (reduced tolerance to sound)
What is Hyperacusis?
Reduced tolerance to sound
-Normal level sounds sound VERY loud
-Loud sounds cause discomfort or pain
How would you differentiate between Bell’s Palsy and stroke based on presentation?
Stroke is an Upper Motor Lesion (Upper spares upper) while Bell’s is Lower.
= Stoke : Can wiggle forehead
=Bell’s palsy : Frozen forehead
What is the prognosis for Bell’s Palsy?
Recovery in 6-9mnths
(only a small number of people are left with permanent effects)
What is the general management for Bell’s Palsy?
-Prednisolone for 10 days
-Eye drops
What is the presentational difference between Ramsay Hunt Syndrome and Bell’s Syndrome?
Ramsay Hunt as well as unilateral facial palsy would also cause PAIN of the face while Bell’s doesn’t
What is the most common cause of Ramsay Hunt Syndrome?
Herpes Zoster Virus
What is usually prescribed to treat Herpes Zoster Virus?
Aciclovir
What is the treatment for Ramsay Hunt Syndrome?
Aciclovir (for the virus) and Steroids
What is the prognosis for Ramsay Hunt?
Less likely (than Bell’s Palsy) to fully recover
How is Postural Hypotension diagnosed?
If there is a change greater than 20/10 on lying / standing BP after standing for 3minutes
A patient on the ward has fainted. What should immediately be done?
Increase salt and water intake
What is cardiac syncope?
A transient loss of consciousness as a result of inadequate cardiac output leading to cerebral hypoperfusion.
What are the causes of cardiac syncope?
-Bradycardia / Tachycardia
-Pacemaker ICD malfunctions
-Structural abnormalities (check with Echo)
-
Who are at an increased risk of epilepsy?
-Family history
-Learning disabilities
-Previous neurological infections
What are the 2 definitions for Status Epilepticus?
-Continuous seizure for 30minutes or longer
-Recurrent seizures without regaining consciousness lasting 30 minutes or longer
What are the 6 groups of seizures?
-Simple Focal (Partial)
-Complex Focal (Partial)
-Secondary Generalised (Focal (partial) progressing to generalised tonic-clonic seizures)
-Absence seizures
-Myoclonic seizures
-Tonic Clonic (grand-mal) seizures
What does simple and complex refer to in terms of seizures?
Simple : Maintaining consciousness
Complex: Impaired consciousness
A pregnant patient has been diagnosed with Epilepsy. What is the treatment?
Lamotrigine
What is Todd Paresis?
Focal weakness of a body part (one side) after a seizure (usually upper or lower limbs).
=This is most likely associated with Epilepsy
Named after the dude who discovered it and also created Hot Toddy’s!
Describe the presentation of simple focal seizures.
-Consciousness retained
-focal motor usual symptoms (muscle jerking)
-can get sensory (tasting/smelling things not there during seizure)
What part of the brain is most commonly affected in a Simple Focal Seizure?
Temporal lobe
Describe the presentation of complex focal seizures.
-May have preceeding aura:
(Unexpected tastes,smells, parasthesia (numbness / tingling) or rising abdominal sensation
-Lip smacking and chewing
-Unable to recall that they just had a seizure
Describe the presentation of Secondary Generalised seizures.
-UNIlateral jerks
-UNIlateral head turning
-Todd Paresis
Describe the presentation of Absence seizures.
-BEGINS IN CHILDHOOD
-Sharp onset and offset - lasting no longer than 30seconds
-Child just stares for a few seconds
-Eyelid Twitching
-May occur dozens - hundreds of times daily
Describe the presentation of Myoclonic seizures.
-Brief shock-like contraction of the limbs
-Conscious attained
Describe the presentation of Tonic-Clonic seizures.
-Stiffening
-Rhythmic limb jerking
-Associated with TONGUE BITING, INCONTINENCE, LOSS OF CONSCIOUSNESS
What investigations are to be done for a pateint after a seizure?
-Bloods (incl LFT)
-U&Es
EEG AFTER 2nd seizure
-MRI (IF FOCAL ONSET)
What characteristics of a seizure suggest a focal origin?
smacking your lips.
rubbing your hands.
making random noises.
moving your arms around.
picking at clothes or fiddling with objects.
chewing or swallowing.
What is considered first line for Focal Seizures?
Lamotrigine or Levetiracetam
(=Broad-spectrum anti-epileptics)
What is the drug of choice for Absence seizures?
Ethosuximide
Carbamazepine is sometimes prescribed for focal seizures. What type of seizure can it worsen?
May worsen myoclonic seizures.
When is Carbamazepine indicated?
Focal seizure, Diabetic Neuropathy
What are common side effects of Levetiracetam?
Mood disorders, Anxiety, and Suicidal ideation
Name 2 examples of Narrow Spectrum Epileptic medications.
Carbamazepine
Phenytoin
Name 4 Broad spectrum anti-epileptic medications.
Levetiracetam
Lamotrigine
Sodium Valporate
Topiramate
What is the main difference between Narrow and Broad spectrum anti-epileptics?
Narrow is mainly for focal while Broad can be used for a wider range (e.g incl Myoclonic)
What is the difference between a primary and secondary headache?
Primary is not associated with anything else while secondary has an attributable cause.
A patient has a headache after intercourse / exertion. What should be excluded first and what is it most likely to be?
RED FLAG: Subarachnoid Haemorrhage
Most likely: Primary Post-Coital or Exertional Headache
What are the 3 main types of Primary Headaches?
-Tension-type headaches
-Cluster headaches
-Migraine
What are the 7 causes of Secondary Headaches?
-Trauma
-Vascular event
-Infection
-Raised intracranial pressure
-Space-occupying lesion
-Disorders that can worsen primary headache
-Medication overuse
What drugs are common causers of Medication overuse headaches?
-Triptans (for cluster headaches)
-Opioids
-Ergots (for throbbing headaches)
-Combination analgesic medication (e.g Co-codamol)
-Paracetamol
-NSAIDs
-Aspirin
What is the definition of a migraine?
Episodic primary headache that CAN present with aura or prove to be chronic.
Who is most likely to suffer Migraines?
Women (3x more likely than men)
What is the pathophysiology of migraines?
Inflammation of Trigeminal sensory neurones causing increased vascular permeability and platelet activation which increases their SENSITIVITY and interpret normal arterial blood flow through the meningeal arteries as PAINFUL
What is the diagnostic criteria for a Migrain WITHOUT aura?
Presentation of 3 or more of these symptoms: POUND
Pulsatile nature
One day’s duration
Unilateral (mainly)
Nausea or vomiting
Disability
What is the presentation for a Migraine WITH aura?
Headache with
-TRANSIENT HEMIANOPIC DISTURBANCES (loss of vision field)
-SPREADING SCINTILLATING SCOTOMA (blind spot)
Aura may include:
-Paraesthesisa
-Numbness of hand, face, upper lips
What mediation in particular would you want to ask a women is on if she presents with Migraine?
Combined Oral Contraceptive Pill.
This contraception is CONTRAINDICATED in women with Migraines WITH Aura
What is the management for a migraine (with/without aura).
-Oral Triptan and NSAIDs (/paracetamol)
Note: Naming for Triptans ends in -triptan
+IF attacks happen >2/month
=Propanolol or Topiramate
A pregnant women has migraines 3 times a month. What medication CANNOT be given to her and what can be given?
CANNOT: Topiramate (Teratogenic!)
CAN: Propanolol
A pregnant patient with Bradycardia has migraines more than twice a month. What would be prescribed as Prophylaxis to prevent migraines?
-Acupuncture
What supplements may reduce the frequency of Migraines?
Riboflavin and Magnesium
A patient describes a ‘tight band’ around head when stressed. What is this?
Tension headache
A patient has chronic recurrent Tension headaches. What would you prescribe?
Tricyclic antidepressants:
Amitriptyline
(titrate down over time)
Describe a cluster headache.
Intense pain coming from within / behind eye
Presents with:
-red watery eye
-nasal congestion
-headache
Who is most likely to have a Cluster Headache?
Men
What is the duration of onset and when do Cluster Headaches classically happen?
-Occur frequently at night
-Can last up to 3hrs!!
What 2 lifestyle factors are linked to Cluster headaches?
smoking and alcohol
What is treatment for an acute attack of a cluster headache?
-100% Oxygen
-Subcutaneous / Nasal Triptan (e.g Sumatriptan)
What are the 2 differentials for Cluster headaches and how do you differentiate them?
1.Chronic Paroxysmal Hemicranias
=Responsive to indomethacin (while Cluster headaches WONT)
2.Short Lasting Unilateral Neuralgiform
=Occur up to HUNDREDS OF TIMES in 24hrs
What is the prophylaxis treatment for cluster headaches?
Verapamil (Calcium Channel Blocker)
What are the main contraindications for Verapamil (calcium channel blocker)?
-Acute Porphyrias (can exacerbate and cause Porphyrias Crisis)
Think: Heart pumping
-Atrial Fibrillation
-Wolf-Parkinson’s-White Syndrome
-Impaired Left ventricular syndrome
-AV block
-Hypotension
-Elderly with postural hypotension (increases risk of falls)
Who is most likely to present with Trigeminal Neuralgia?
-Young patients with MS
-Older patients
Describe the typical presentation of Trigeminal Neuralgia.
Pain in Trigeminal area (jaw area)
=DISABLING CONDITION
-SUDDEN
-Painful, sharp stabbing pain
Note: COMMONLY BILATERAL
What are the secondary causes of Trigeminal Neuralgia?
-Compression from vein or artery
-Arteriovenous Malformation
-Compression from tumour
How is Trigeminal Neuralgia diagnosed?
MRI (to exclude secondary causes)
What is the first line treatment for Trigeminal Neuralgia?
Carbamazepine
What are the common side effects of Carbamazepine?
Dizziness
Drowsiness
Small risk of : Agranulocytosis
What is the next management step for a patients with Trigeminal Neuralgia who is not responsive to Cabamazepine treatment?
-Percutaneous Radiofrequence Coagulation
-Microvascular Decompression /Rhizotomy
=dampen pain signals
What are the common side effects of Calcium Channel blockers?
Abdominal pain; dizziness; drowsiness; flushing; headache; nausea; palpitations; peripheral oedema; skin reactions; tachycardia; vomiting
Name 2 pathological reflexes and would it be upper or lower motor neurone damage?
Upper motor:
Hoffman reflex (upper limbs)
Babinski reflex (lower limbs)
What are the 3 regions of the brain stem?
-Midbrain
-Pons
-Medulla Oblongata
What are gyri and sulci?
Gyri = ridges
Sulci = Depression
What is the Corpus Callosum?
White matter connecting the 2 cerebral hemispheres
What is meant by the cortex in the brain?
The surface of each cerebral hemisphere
What is the Longitudinal Fissue?
=Runs in between the 2 hemispheres
What is the central sulcus?
Located between the frontal and parietal lobes
What is the Pre-Central Gyrus and where is it located?
This is the PRIMARY MOTOR CORTEX
-Located in the frontal lobe towards the parietal lobe
What is the Post-Central Gyrus and where is it located?
This is the PRIMARY SENSORY CORTEX
-Located at the front of the parietal lobe towards the frontal lobe
Name the 3 meningeal layers (from the outer layer to the inner layer)
1.Dura Mater
2.Arachnoid Mater
3.Pia Mater
What are the 2 layers of the Dura Mater?
-Outer Periosteal
-Inner Meningeal
What are Dural Partitions and what do they do?
The folds between the Outer Periosteal and Inner Meningeal layers (of the dura mater)
= They restrict rotary displacement of the brain
Name 4 of the Dural Partitions.
-Falx Cerebri
-Tentorium Cerebelli
-Falx Cerebelli
-Diaphragma Sellae
What is the Terpion?
Where all the bones meet and therefore is the most vulnerable part of the skull
What Artery in the brain is most at risk of damage and why?
The Middle Meningeal Artery
=It lies between the Terpion (at risk area) and the Dura Mater
What are Fontanelles?
Soft spots of bone not fused in new borns
When do the Fontanelles fuse?
Anterior = 7-8mnths
Posterior = 2mnths
Where is primary motor control located and what is it responsible for?
Pre-central gyrus of frontal lobe
=voluntary movements (sends signals to muscles)
Where is primary sensory control located and what is it responsible for?
Post-central gyrus of parietal lobe
=processing sensory information from skin to produce sensations related to temperature, pressure and pain
Where is Primary Auditory control located and what is it responsible for?
Temporal lobe
=analysis of auditory information
Where is primary visual area control located and what is it responsible for?
Occipital lobe
=receives and processes visual information
What is Brocca’s Area and where is it located?
Production of speech
=Frontal lobe of left cerebral hemisphere
What is Wernicke’s Area and where is it located?
Language development
=Temporal lobe of left cerebral hemisphere
What does the Forebrain contain?
-Cerebral Hemispheres
-Thalamus
-Hypothalamus
What does the Hindbrain contain?
-Pons
-Medulla Oblongata
-Cerebellum
What communicates with the Thalamus to coordinate movement?
Basal Ganglia
What is the dorsal horn?
The dorsal horn is found at all spinal cord levels and is comprised of sensory nuclei that receive and process incoming somatosensory information. From there, ascending projections emerge to transmit the sensory information to the midbrain and diencephalon.
What is another name for the Dorsal Horn?
Substantia Gelatinosa
What does Ipsilateral mean?
Same side
(i.e opposite of Contralateral)
Where is a lesion of the Dorsal Column Lemniscal Pathway usually located?
Spinal cord
What are 2 common causes of a lesion of the Dorsal Column Lemniscal Pathway?
-B12 Deficiency
-Tabes Dorsalis (complication of syphilis)
How does a lesion of the Dorsal Column Lemniscal Pathway present?
=Ipsilateral loss of :
-Touch
-Vibration
-Proprioception
!Can still perform tasks requiring tactile information due to the few fibres in the Anterolateral system still functioning
At what level do the 1st order neurones of the Dorsal Column Lemniscal Pathway start?
T6
Where in the spinal cord do the 1st order neurones of the Dorsal Column Lemniscal Pathway travel?
Dorsal Columns
Where in the brainstem would neurones from the Dorsal Column Lemniscal Pathway travel?
Medial Lemniscus
Summarise the Dorsal Column Lemniscal Pathway.
=carries FINE TOUCH SIGNALS FROM PNS TO CNS
1.1st order neurons enter spinal cord at T6 and synapse in the Medulla Oblongata
2.2nd order neurones start in MO and synapse in Thalamus
3.3rd order neurons start in the Thalamus and synapse in the Ipsilateral Primary Cortex of the brain
How does injury to the Anterolateral System present?
=Contralateral loss of pain and temperature sensation
Summarise the Anterolateral system pathway.
=carries Touch & Pressure (anterior) and Pain & Temperature (lateral)
1.1st order neurones enter spinal cord and ascend 2 vertebral levels before synapsing at the Dorsal Horn
2.2nd order neurons split into 2 concurrent tracts (anterior and lateral) that travel to the Thalamus
3.3rd order neurones start in the Thalamus and synapse in the Ipsilateral Primary Sensory Cortex
When are the Spinocerebellar tracts most likely to be damaged?
WITH a Descending Motor injury
(not usually occurring in isolation)
Where in the primary sensory centre in the cortex of the brain is the information processed?
Sensory homunculus
What is another name for pain?
Nociception
When pain presents as fast and sharp, what kind of pain could it be?
Mechanical and Thermal
When pain presents as slow and dull what type of pain could it be?
All types- Chemical, Mechanical and Thermal
Describe the Nociceptor stimulus pathway when due to tissue damage.
Tissue damage causes Calcium to enter which activates TRPV1 Chloride channels = negative ions leaving the cell causes depolarisation which opens enough sodium channels to cause Action Potential.
Describe the Nociceptor stimulus pathway when due to inflammatory signals e.g prostaglandin and bradykinin.
Gprotein coupled receptor causes Calcium release from ER causing activation of Cl- ion channels so Cl- leaves the cell causing depolarisation and therefore Na+ channels on the axons open and cause an Action Potential.
What are the 2 nerves carrying nociceptor signals and speed of conduction as well as the type of pain felt?
Myelinated (rapid signal= fast and sharp) and Unmyelinated neurones (slow signal=slow and dull)
What is another name for Unmyelinated neurones?
C fibres
What is another name for Myelinated neurones?
Alpha delta neurons
Where do the signals usually come from for Myelinated vs Unmyelinated nociceptor neurons?
Myelinated: Skin (superficial)
Unmyelinated : Deep tissue (joints and organs)
Why does pain from Kidney stones present on the same side as the organ and what pain pathway is it?
Gracile Fasciculus pathway (part of the ascending tract) :
Alpha delta fibres (myelinated) carry signals from deep in the body and the information is processed in the thalamus. The fibres DO NOT CROSS OVER and therefore the pain is ipsilateral. Therefore is it hard to pinpoint where the pain is.
A patient has tooth ache. How the pain signalled?
C fibres (unmyelinated) from the trigeminal nerve cross over in the spinal cord into thalamus and into somatosensory cortex to detect exactly where it is
e.g tooth pain
What are the autonomic responses to pain controlled by parasympathetic and sympathetic?
Parasympathetic:
-Bradycardia
-Syncope
-Hypotension
-Urination
-Nausea
Sympathetic:
-Fear
-Pupillary dilation
-Pallor
-Sweating
What is Neuropathic pain?
Pain that is chronic in nature persisting for >3 months and often unresponsive to analgesia.
=Damage to nerves NOT the tissues
How does Neuropathic pain present?
Burning, tickling, dull aches that can be associated with Hyperalgesia or Allodynia.
What is Hyperalgesia?
Increased intensity of pain sensation for a given nociceptive stimulus (that is quite small)
What is Allodynia?
Sensation of pain to stimulus that should not give pain (e.g light touch)
What is meant by sensitisation of peripheral nerves?
Sensitisation of peripheral nerves.
=Increased Prostoglandin release, increases expression of sodium channels and therefore INCREASED NOCICEPTOR SENSITIVITY
What is meant by central sensitisation?
Increased sensitivity of nerves of the spinal cord
1.increased glutamate release and glutamate release causing =Hyperalgesia
2.Rewiring of spinal cord causing
=Allodynia
Describe Descending Pain Pathway in response to pain.
1.Periventricular nuclei in the hypothalamus signals to the 2.Periaqueductal Gray (PAG) which signals via Enkephalin release to the
3.RMN which signals via Serotonin release to the
4.Dorsal Horn inhibitory neurones to inhibit the pain signal via GABA or Enkephalin release
i)GABA
ii)Enkephalin
What does the Descending Pain Pathway do?
Reduces pain signals by decreasing the amount of action potentials and releasing natural opioids.
i.e the body’s natural mechanism to combat pain
Describe the action of Enkephalin released by inhibitory neurons of the Dorsal Horn.
=2 pathways
1.opens Potassium channels to Hyperpolarise and reduce ability to reach Action Potential
2.Inhibits Calcium channels (as it increases neurotransmitters so by inhibiting will mean less signal firing)
Describe the action of GABA released by inhibitory neurons of the Dorsal Horn.
Hyperpolarises by activation of Cl-channels and Cl- enter (so harder to depolarise so less likely to set up action potentials)
How does rubbing a wound help reduce the pain?
Mechanoreceptors signal to brain which descending and deals with the pain (descending pain pathway)
What are the 4 forms of analgesia?
1.Opioids
2.NSAIDs
3.Local Anaesthetics
4.Anti-depressants
Why can Anti-depressants be used to treat pain?
Emotional response to pain makes pain worse.
How do opiods work?
Same as Enkephalin acting on opioid receptors and hyperpolarising the neurons to decrease transmission of signal in the spinal cord
When are opiods used?
For severe pain :
-Surgical pain
-Child birth
-Unresponsive pain
-End of life care (as it has a sedative effect)
Side effects of opiods
Constipation: activates opioids in bowels which opposes gut motility
Vomiting : stimulation of chemoreceptors in medulla
Respiratory depression : Centre in medulla issue, CO2 buildup
What are the withdrawl effects of opioids?
Nausea
Muscle aches
Diarrhoea
Trouble sleeping
Low mood
How do NSAIDs work?
Inhibits COX receptors which inhibits Prostagandin release and therefore causes a decrease in sensitivity
What is the main side effect of NSAIDs?
Blocking Cox receptors protect the stomach as well so NSAIDs can cause GI bleeding, ulcers
When do you give a low vs high dose of aspirin?
High dose for preventing pain
Low dose for issues such as heart attack and stroke
How do Local Anaesthetics work?
Binds and Stops Sodium channels opening so no Action Potentials
How would a Topical local anaesthetic work on an area with a bacterial infection and why?
No effect due to bacterial infection ionising the anaesthetic making it acidic and therefore it cannot reach the sodium channels.
What should be given with a local anaesthetic and why?
Vasoconstrictor such as Adrenaline / Noradrenaline
=keeps the effects of the anaesthetic LOCAL and not widespread
How do Antidepressant work to treat pain?
Increases serotonin which is involved in the descending pain pathway which increasesinhibition of pain signals.
Where does the spinal cord extend to and from?
From the : Foramen Magnum
To the: L1-2 (adults), L3-4 (children)
Where do the nerves leave the spinal cord from?
Vertebral foramens
What is the Cauda Equina?
‘the horse’s tail’ of nerves of the spinal cord after the vertebra
What does the Midbrain contain and therefore is responsible for?
-Eye movement: Nuclei for CN III and IV
-Eye pupil diameter and accomodation: Edinger-Westphal nucleus
-Eye reflexes : Neurons responsible
What is meant by Basal Ganglia?
Interconnecting nuclei within the forebrain, diencephalon and midbrain important for INITIATION AND CONTROL OF VOLUNTARY MOVEMENT including:
-Caudate nucleus
-Subthalamic nucleus
-Substantia Nigra
What is meant by the Limbic system?
Interconnected and interacting structures controlling EMOTIONAL BEHAVIOURS
What is the hippocampus important for?
Memory
What allows storage of new memories ?
Hippocampus has Neurogenesis occuring in the denate gyrus
What is meant by Anterograde amnesia?
Lesion in hippocampus causing memory storage of new memories to not be turned into long memories.
Note: memories from before the lesion are unaffected
What is the Amygdala responsible for?
Emotional learning (fear memory and reward memory e.g addiction)
What neurotransmitter is the most common excitatory in the CNS?
Glutamate
What is the role of the middle ear?
1.Critical Damping = It stops the sound vibrating when the sound stops
2.Amplifies the signal to the oval window
What are the common causative organisms of the meninges?
Remember mnemonic
NHS
-Neisseria meningitidis
-Haemophilus Influenzae (type B)
-Streptococcus pneumoniae
What type of bacteria is Neisseria meningitidis?
Gram negative diplococcus (in pairs)
How is Neisseria meningitidis spread?
Person-person with outbreaks commonly in families, semi-closed environments e.g prisons or university accomodation
What is another name (s) for Neisseria meningitidis?
Meningococcus or Meningococci.
What type of bacteria is Haemophilus Influenzae (type B)?
Gram negative cocco-bacillus
What type of bacteria is the Streptococcus Pneumoniae?
Gram positive diplococcus
What less common bacterial causative organism can cause meningitis and in what groups of people?
Listeria Monocytogenes
=Elderly, Neonates and Immunocompromised persons
What can Listeria Monocytogenes cause?
Meningitis and Sepsis
What type of bacteria is Listeria Monocytogenes?
Gram positive rod shaped
In developing countries what type of meningitis is more likely to occur?
Tuberculosis causing
-associated with miliary TB
How is Listeria transmitted?
Food-bourne
What advice is given to pregnant women to avoid Listeria?
Don’t eat unpasteurised soft cheeses (they could carry Listeria).
What bacteria is tested for in the vagina of a pregnant woman to ensure that it doesn’t cause Meningitis of the baby during child birth?
Streptococcus Agalactiae aka Group B Streptococcus (GBS)
A pregnant patient’s urine sample comes back positive with Group B Streptococcus. What does that mean and what should be done?
Can cause meningitis for baby which can be caught during child birth.
=Prophylactic antibiotics at the time of delivery (Intravenous penicillin G)
What is the most common fungal cause of meningitis?
Cryptococcus Neoformans
Who is more likely to get Cryptococcus Neoformans causing meningitis?
Those immunocompromised:
-HIV/AIDs
-Chemotherapy
How is Cryptococcus Neoformans causing meningitis diagnosed?
-Indian ink staining CSF showing the capsule surrounding the Cryptococcus.
-Culture and antigen detection test of CSF
Who is most likely to suffer from Toxoplasma?
Immunocompromised patients particularly those with HIV with a low CD4 count
How is Toxoplasma transmitted?
Domestic cats in the UK
What can a Ziehl Neelsen stain identify?
Mycobacteria such as TB
What would you notice in a CSF sample with a patient with Bacterial infection of the CNS?
High neutrophils making the CSF look visibly cloudy
What would you notice in a CSF sample with a patient with a Viral infection of the CNS?
High number of T-lymphocytes, and the fluid will look clear.
What is the drug of choice for Meningitis?
Ceftriaxone
A patient has suspect Meningitis but their lab results are pending. What should be done?
EMERGENCY !
Don’t wait- give IV Ceftriaxone
When can Ceftriaxone not be given and what is given instead?
Penicillin allergy
=Chloramphenicol
What is the drug of choice for Meningitis in Neonates?
Cefotaxime as Ceftriaxone can cause Bilirubin accumulation
What is offered to those who were in close contact with a patient with Meningococcal Meningitis?
Prophylaxsis = Ciprofloxacin
Give an example of an organism that can cause Meningitis accompanied with Encephalitis.
Toxoplasma Gondii
Describe the presentation of a patient with Encephalitis.
-Altered consciousness
-Can lead to coma
-Unusual behaviour
-Confusion
-Seizures may be present
-Fever may be present by not accompanied by a significant rise in CRP and WBC
What viruses of the CNS also cause a characteristic vesicular rash?
Herpes Simplex Virus
Varicella zoster virus (chickenpox)
What is the most common cause of Viral Encephalitis in the UK and what is the pathophysiology?
Herpes Simplex latent virus that reactivates in the trigeminal ganglia and causes infection of the temporal lobes
A patient is febrile and has altered consciousness. What is the most likely diagnosis?
Encephalitis
What are the key investigations for Encephalitis?
CT scan or MRI
=indicates raised intracranial pressure (due to inflammation of brain and meninges)
ECG (sometimes used)
Note: CSF lumbar puncture is contraindicated in patients with high Intracranial pressure
Why is lumbar puncture contraindicated in patients with high intracranial pressure?
Coning
=Life threatening due to Sudden drop in pressure when needle draws CSF can draw brainstem structures throughh the foramen magnum
How does Encephalitis appear on an ECG?
Sharp wave potentials
What is the management for Viral Encephalitis?
-IV ACICLOVIR (Antiviral to target Herpes Simplex and Varicella zoster virus) for 3 weeks
Supportive:
-Ventilation
-Fluid management
-Management of seizures if present
-Steroids for reducing swelling
What are the 3 forms of Aciclovir and what are they generally used to treat?
-Oral : Mild infections
-Topical : Herpetic rashes (cold sores)
-IV: Encephalitis
Summarise the mechanism of action of Aciclovir.
It is a viral analogue of Deoxyguanosine that competes to be incorporated into viral DNA and therefore stops the DNA from replicating. It is much more attracted to viral Herpes Simplex DNA polymerase than human DNA polymerase :)
What herpes virus is common in organ transplant patients?
Cytomegalovirus (CMV)
What prophylaxis is given to organ transplant patients to protect against Cytomegalovirus?
Valaciclovir
What are causes of headaches that present with a fever?
-System illness (flu / vaccine)
-Paranasal Sinusitis (upper resp. tract infection / dental pain)
-Meningitis (viral and bacterial)
-Encephalitis
Where are aneurysms most likely to occur?
Where arteries branch
What is the presentation of Meningitis?
PROGRESSIVE headache with fever
Non blanching rash
Neck stiffness
Photophobia
+Lethargy later on
Give 3 examples of Primary headaches.
Tension, Migraines, Cluster headaches
Describe the presentation of Idiopathic Intracranial Pressure.
-Headache:
–>Non-pulsitile, bilateral headache worsening in the morning or after bending forwards and can be associated with morning vomitting
-Visual disturbances (transient visual darkening)
-Bilateral papilloedema (on fundoscopy)
Who is most likely to have Temporal Arteritis?
Older population over 50
What is an Idiopathic stabbing headache?
Most usually benign headache characterised with stabbing like pain
What 2 signs are tested for upon clinical exam of a suspect meningitis?
Kernig’s and Brudzinski’s sign
=lying patient flat and do leg exercises
A patient has been diagnosed with Meningitis. Other than a doctor’s duty of care to the patient what else should be done?
Meningitis long term prophylaxis for close contacts and notify Public Health agency for contact tracing
What serious issue could a Postural headache indicate?
CSF fluid leak
What are Dural Venous Sinuses?
They are spaces / pathways in the brain located between the periosteal and meningeal layers of the dural mater.
Where does the blood flow come from to the Dural Sinuses?
Diploie of the skull, the inner ear and from the CNS.
Where is the Confluence of Sinuses located?
Back of the occipital lobe
Describe the flow of blood starting from the Superior Sagittal Sinuses.
1.Superior Sagittal Sinus to
2.Confluence of Sinuses to
3.Right Transverse Sinus to
4.Right Sigmoid sinus (merging with left SS to become)
5.Internal Jugular Vein
Describe the flow of blood starting from the Inferior Sagittal Sinuses.
1.Inferior Sagittal Sinus to
2.Straight Sinus to
3.Left Transverse Sinus to
4.Left sigmoid sinus (merging with left SS to become)
5.Internal vein
Where are the Right and Left Transverse Sinuses located?
Posterior cranial fossa
Describe the flow of blood from the Cavernous Sinus.
1.Cavernous Sinus to
2.Superior sagittal Sinus
3.Junction between Left transverse and Left Sigmoid sinus
4.Petrosal Sinuses to
5.Internal Jugular vein
Where are the Cavernous Sinuses located?
Just lateral to the sphenoid bone
Where do Cavernous Sinuses receive their tributaries from?
Opthalamic veins
Sphenoparietal sinuses (along the lesser wing of sphenoid bone)
Where is CSF secreted?
By Choroidal Epithelial cells of the choroid plexus in the lateral, 3rd and 4th ventricles
What is meant by the Ventricular System?
The pathway by which CSF flows in the brain
Where is CSF reabsorbed?
Arachnoid Granulations which protrude through the meningeal layer of the Dura Mater to access the Sinuses
Describe the flow of CSF.
1.Lateral Ventricle to
2.Interventricular Foramana to
3.3rd Ventricle to
4.Cerebral Aqueduct to
5.Lateral Apertures to
6.Subarachnoid space to
(some reabsorbed)
7.Median Apertures to
8.Spinal cord (Central Canal)
What would an obstruction of the Cerebral Aqueduct mean?
Blockage of CSF meaning that it can’t leave the Subarachnoid space
=Hydrocephalus
What procedure should be considered for a patient with Hydrocephalus?
Peritoneal Shunt
=drains the CSF into the Peritoneal cavity (abdomen)
Define the Central canal.
Carries the CSF along the spinal cord
What are the key risk factors of a brain haemorrhage due to an aneurysm?
-Smoking
-Hypertension
-Polycystic kidney disease
-Connective tissue disorders (since they affect the integrity of the blood vessels)
What is the investigation for Subarachnoid Haemorrhage (starting with first line)?
1.CT brain AS SOON AS POSSIBLE (as the bleed will disperse and you’ll miss the diagnosis)
2.Lumbar puncture
=look for bilirubin (Xanthochromia - yellow CSF)
3.CT Angiogram (if CT brain is positive to find what artery is responsible)
What blood vessel is most likely to have had an aneurysm to cause a brain haemorrhage?
Right middle cerebral artery
Where do you do a lumbar puncture?
Iliac crest at L4
List the contraindications of doing a lumbar puncture.
-Coagulopathy
-Local infection at puncture site
-Focal neurology and abnormal conscious level
When can you do a lumbar puncture and when is it too late?
Can: Within 2 weeks of a headache
Cannot: After 2 weeks because you won’t be able to detect the bleeding anymore
A patient had a haemorrhage due to an aneurysm. What is the main treatment?
Coiling
When is Vasopasm most likely to happen and why?
During Subarachnoid haemorrhage due to oxygen present since its due to arterial bleeds while a head injury is due to venous bleeds
What is the Vasospasm treatment?
Bolus IV Saline / Colloid
What are complications of a Subarachnoid Haemorrhage?
-Hydrocephalus
-Seizures
-Low sodium
-Pulmonary oedema / pneumonia
What is the prognosis for a Subarchnoid haemorrhage?
Poor- most survivors are dependant with only 20% of survivors regaining full quality of life. Note that 30% don’t even make it to hospital!
What are the causes of Intracerebral Haemorrhage?
-Hypertension
-Vascular Lesions
-Neoplastic
-Coagulation disorders
-Cerebral venous thrombosis
-Haemorrhagic transformation of ischaemic stroke
-Vasculitis
-Substance abuse
-Amyloid
What veins are most likely to be a cause of a haemorrhage in a Hypertensive emergency?
Small vessels deep in the brain (that supply the motor pathways)
What investigations are to be done for a suspect
Idiopathic Intracranial Hypertension and what results would you expect?
-Fundoscopy (bilateral papilloedema)
-CT and MRI of brain (increased intracranial pressure)
-Lumbar puncture (will reveal opening pressure above 20cmH20 but no differences in the CSF profile)
What is the management for Idiopathic Intracranial Hypertension?
1.Encourage weight loss
2.Acetozolamide (Carbonic Anhydrase inhibitor)
3.Topiaramate (anti-seizure med) and Candesartan (ARB)
Who is most likely to present with an Idiopathic Intracranial Hypertension?
Young, obese women
What is Temporal Arteritis?
Inflammatory disease of the arteries specifically the arteries at the temples.
What is another name for Temporal Arteritis?
Giant Cell Arteritis
What is the presentation of Temporal Arteritis?
-Temporal headache
-Pain on temples
-Jaw claudication (pain chewing food)
-Transient monocular blindness
-Systemic features (fever, fatigue, weight loss and malaise)
Who is most likely to be affected by Temporal Arteritis?
Females over 60
What will be found on presentation on a patient with Temporal Arteritis?
-Thickened, tender temporal artery on examination, which may be pulseless
-Scalp tenderness
-(Rarely) arterial bruits, asymmetrical blood pressure and absent pulses
What are the key complications of Temporal Arteritis?
-Permanent monocular blindness
-Stroke
-Aortic aneurysms
How do patients describe Monocular blindness?
Curtains closing on their vision
What investigations are to be done for Temporal Arteritis and results?
1.Inflammatory markers (present)
2.Histology : Granulomatous inflammation with infiltration of inflammatory cells including giant cells
3.Doppler Ultrasonography (halo sign within vessel wall)
What is the management of Temporal Arteritis?
-High dose steroids to prevent blindness and stroke
(titrate down over time with methotrexate to lower the dose)
-Low dose aspirin
If on long term steroids:
+Bisphosphonates (protect against Osteoporosis)
+PPIs (protect against gastric ulcers)
A patient has a new onset headache. What are the categories within this?
-Thunderclap
-Fever
-Focal
-Persisting
-Provoked
What are the differentials of a thunderclap headache?
-Subarachnoid Haemorrhage
-Pituitary Apoplexy
-Spontaneous Intracranial Hypotension
Summarise how you would differentiate between the 3 types of thunderclap headache simply based on symptoms?
Subarachnoid: MOST SEVERE
Pituitary Apoplexy : With drowsiness often progressing to coma
Spontaneous Intracranial Hypotension: Positional headache
How is the diagnosis of a Subarachnoid haemorrhage confirmed?
CT without contrast
-If CT negative Xanthochromia in CSF will confirm it
A patient has a Subarachnoid Haemorrhage. What should be done?
-Angiography with catheter to localise bleed
-Endovascular coiling
-Post op: Nimodipine
What is the management for Pituitary Apoplexy?
Hydrocortisone (GIVEN ASAP AS IT COULD BE FATAL)
-do an mri
What investigation should be done for Spontaneous Intracranial Hypotension?
MRI of whole spine
What is the management of Spontaneous Intracranial Hypotension?
Bed rest fluids, caffeine and pain relief (if it doesn’t improve - Epidural blood patch)
What is the most likely diagnosis of a Fever new onset headache and what is the red flag diagnosis to rule out?
Most likely = Systemic
Red flag: Meningitis
What is meant by a new onset focal headache?
One part of brain being affected can present as MOVEMENT CHANGES, PARALYSIS, WEAKNESS, LOSS OF MUSCLE CONTROL, INCREASED MUSCLE TONE, LOSS OF MUSCLE TONE OR INVOLUNTARY MOVEMENTS (E.G TREMOR)
What are the 2 main possibilities for a focal new onset headache?
-Migraine with aura
-Stroke
How do you differentiate between migraine with aura and stroke upon presentation?
Migraine aura resolves while stroke aura persists
