Neurology Flashcards
Define Bell’s palsy?
Bell’s palsy is an idiopathic syndrome that causes damage to the facial nerve leading to a lower motor neuron facial palsy.
What causes Bell’s palsy?
The aetiology of Bell’s palsy remains unknown. Viral infections, particularly reactivation of herpes simplex virus type 1 (HSV-1), have been implicated as a possible cause.
Other viral pathogens, such as Epstein-Barr virus (EBV) and varicella-zoster virus (VZV), have also been suggested as potential triggers.
However, the exact mechanisms by which these viruses lead to facial nerve dysfunction are not fully understood.
Clinical features of Bell’s palsy?
Acute (but not sudden) onset of unilateral lower motor neuron facial weakness (classically affecting the forehead as this area has bilateral nervous supply from both sides of the brain)
Mild to moderate postauricular otalgia, which may precede the paralysis.
Hyperacusis
Nervus intermedius symptoms, such as altered taste and dry eyes/mouth.
Patients may subjectively describe “numbness” or “heaviness” without objective facial somatosensory disturbances.
What are the investigations for Bell’s palsy?
The diagnosis of Bell’s palsy is primarily clinical, based on the characteristic signs and symptoms.
However, in some cases, additional investigations may be considered to exclude other potential causes or to assess the severity of nerve dysfunction. These investigations may include:
Otoscopy to assess if any vesicular lesions are present in the external auditory meatus
Full blood count (FBC)
Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
Viral serology (e.g. HSV-1, EBV, VZV)
Lyme serology (if suggestive symptoms or exposure)
Electromyography (EMG)
Imaging studies (e.g. CT or MRI Head)
What is the short term management for Bell’s palsy?
The management of Bell’s palsy includes:
Prompt administration of oral steroids: 50mg of oral prednisolone or prednisone once daily for 10 days, followed by a taper.
Supportive treatments:
Artificial tears and ocular lubricants to manage dry eyes.
Eye patch/tape to prevent corneal exposure and injury.
What may be considered in treatment for Bell’s palsy?
Although the pathophysiology of Bell’s palsy has not been definitively linked to active herpes virus infection, empirical treatment with aciclovir may be considered, particularly in cases where the clinical distinction between Bell’s palsy and Ramsay-Hunt syndrome is difficult.
What is the long term management of Bell’s palsy?
Pain management with analgesics or anticonvulsants may be necessary in cases of severe otalgia or neuropathic pain.
Physical therapy, including facial exercises and massage, may be recommended to maintain muscle tone and prevent contractures during the recovery phase.
Psychological support and counseling may be beneficial for patients experiencing emotional distress or body image concerns due to facial weakness.
What percentage of patients with Bell’s palsy have a complete recovery?
Complete recovery: Approximately 70-80% of patients with Bell’s palsy achieve complete recovery of facial function without residual deficits.
Most improvement occurs within the first 3 months, with the greatest recovery seen within the first 6 weeks. However, some patients may continue to show gradual improvement even beyond this timeframe.
What two factors can decrease the likelihood of recovery for Bell’s palsy?
Age and severity: Older age and more severe initial facial weakness are associated with a higher risk of incomplete recovery.
Define a brain abscess?
A brain abscess is a collection of pus within the brain parenchyma. It is a very serious condition which can lead to significant morbidity and mortality, especially if left untreated.
What causes brain abscesses?
Brain abscesses are usually result from direct extension of an infection. This may be sinusitis, dental or cranial procedures or injury. Sometimes, the bacteria may spread through the bloodstream, for example a septic embolus from endocarditis. The most commonly isolated bacteria is Streptococcus, though other pathogens such as oral bacteria, Staphylococci, gram-negatives, TB, fungi and parasites can also cause brain abscesses, particularly in susceptible people
What are the signs and symptoms of brain abscesses?
Signs of infection: fever, nausea & vomiting, meningism
Raised intracranial pressure: headache, third nerve palsy, papilloedema, seizures
Focal neurology depending on location of abscess
What are the investigations for brain abscesses?
Bloods - including FBC, CRP, clotting, VBG, cultures
Cross-sectional imaging:
MRI is most sensitive for brain abscess, and will show an enhancing lesion.
If stroke is suspected, an urgent CT head will be required as per local pathways.
Neurosurgical aspiration/excision & cultures
What is the management for brain abscesses?
It is important to remember that when a patient is acutely unwell, start with an A-E assessment and consider initiating the sepsis six if the patient is showing signs. Call for help early - the exact team will depend on local protocols & clinical context. If the the patient is displaying acute neurological symptoms, initiate the stroke pathway as per local guidelines.
Exact management will be guided by seniors in neurology/neurosurgery & microbiology, but may include:
Neurosurgical intervention: aspiration or excision
Medical: antibiotics - initially a 3rd-generation cephalosporin + metronidazole. This may differ based on culture results and immune status of the patient. Typically, antibiotics continue for several weeks.
Symptom management - for example anticonvulsants for seizures, dexamethasone for severely raised intracranial pressure
What are the complications of brain abscesses?
Sepsis
Raised intracranial pressure & herniation
Permanent neurological deficits
Death
What are risk factors for brain abscesses?
Risk factors for brain abscess include:
Sinusitis
Dental, head & neck procedures
Cardiac defects & endocarditis
Poor immune response including HIV, immunocompromise
What would a CT reveal in a brain abscess?
ring enhancing lesion
Define brain metastases?
Brain metastases are secondary brain tumours that occur following spread from a tumour away from the central nervous system.
What causes brain metastases?
Malignancies usually spread to the brain haematogeneously. Cells seed into the brain’s small blood vessels and are often protected from anti-cancer therapies by the blood-brain barrier.
What are the most common primary malignancies that metastasise to the brain?
Lung cancer
Breast cancer
Colorectal cancer
Melanomas
Renal cell carcinoma
Signs and symptoms of brain metastases:
Brain metastases may occur in people with a known cancer, or may be their first presentation of malignancy. Symptoms can be due to local interruption of the nerve pathways or due to raised intracranial pressure. Key clinical features include:
Headaches
Seizures
Altered mental status, including confusion
Cerebellar signs, including ataxia
Nausea and vomiting
Visual disturbance
Focal neurology
Patients may also have signs of the primary malignancy, for example breathlessness and haemoptysis for lung cancer.
What are the investigations for brain metastases?
In a patient presenting with acute neurological features, it is important to rule out acute intracranial events, for example stroke. Therefore, a head CT is often employed first-line.
According to NICE, MRI is the best and initial imaging modality for diagnosing brain metastases. Further investigations may be necessary to identify the primary malignancy, for example chest imaging and biopsy.
What is the management for brain metastases?
Management of brain metastases requires a multidisciplinary approach. There are many factors to consider including the nature of the metastases, the patient’s age, performance status and primary tumour.
Systemic anti-cancer therapy is advised for people who have brain metastases likely to respond effectively, for example, germ cell tumours or small-cell lung cancer
Symptomatic management involves corticosteroids (usually dexamethasone) to reduce oedema, anti-seizure medications and antiemetics. Specific treatment for raised intracranial pressure may be necessary as well. Therapeutic options include radiotherapy (targeted, and sometimes whole-brain), chemotherapy and surgical resection.
Following treatment, patients will often have serial imaging follow up to assess any ongoing symptoms/potential progression
What is chronic fatigue syndrome also referred to as?
Myalgic encephalomyelitis