Neurology Flashcards
1
Q
What is the condition characterized by reccurent seizures?
A
Epilepsy, seizures are transient episodes of abnormal electrical activity in the brain due to excessive and hypersynchronous firing of neurons.
2
Q
What are the types of seizures generally seen in adults?
A
- Generalised tonic-clonic seizures
- Partial seizures (or focal seizures)
- Myoclonic seizures
- Tonic seizures
- Atonic seizures
Each type has distinct characteristics and symptoms.
3
Q
What types of seizures are more common in children?
A
- Absence seizures
- Infantile spasms
- Febrile convulsions
These seizures often present differently than those in adults.
4
Q
What characterizes generalised tonic-clonic seizures?
A
They involve tonic (muscle tensing) and clonic (muscle jerking) movements and a complete loss of consciousness
Also known as grand mal seizures.
5
Q
What is an aura in the context of seizures?
A
An abnormal sensation that gives a warning that a seizure will occur
It may precede a generalised tonic-clonic seizure.
6
Q
What symptoms might occur during a generalised tonic-clonic seizure?
A
- Tongue biting
- Incontinence
- Groaning
- Irregular breathing
Aura might occur pre-ictally.
These symptoms vary among individuals.
7
Q
What is the post-ictal period?
A
A prolonged period after a seizure where the person is confused, tired, and irritable or low.
This occurs after generalised tonic-clonic seizures.
8
Q
What are partial seizures also known as?
A
Focal seizures
They occur in an isolated brain area.
9
Q
What defines simple partial seizures?
A
The patient remains aware during the episode
Complex partial seizures involve loss of awareness.
10
Q
What symptoms are associated with partial seizures?
A
- Déjà vu
- Strange smells, tastes, sight or sound sensations
- Unusual emotions
- Abnormal behaviours
Symptoms depend on the location of the abnormal electrical activity.
11
Q
What characterizes myoclonic seizures?
A
Sudden, brief muscle contractions like an abrupt jump or jolt
Patients remain awake during these seizures.
12
Q
What happens during tonic seizures?
A
There is a sudden onset of increased muscle tone, resulting in the entire body stiffening
This can cause a fall if the patient is standing.
13
Q
Aotnic seizures
A
Sudden loss of muscle tone, causing drop attacks.
Brief, retained awareness
14
Q
What defines absence seizures?
A
The patient becomes blank, stares into space, and abruptly returns to normal, 10 to 20s
15
Q
Infantile spasms/West syndrome
A
Rare, starts around 6m, clusters of full-body spasms
Tx: adrenocorticotropic hormone (ACTH) and vigabatrin
Poor prognosis
16
Q
What is the characteristic EEG finding in infantile spasms?
A
Hypsarrhythmia
This disorder is associated with developmental regression.
17
Q
What are febrile convulsions?
A
Tonic-clonic seizures that occur in children during a high fever
They are not caused by epilepsy or other pathology.
18
Q
What age group is most affected by febrile convulsions?
A
Children aged between 6 months and 5 years
They do not usually cause lasting damage.
19
Q
True or False: One in three children will have another febrile convulsion.
A
True
They slightly increase the risk of developing epilepsy.
20
Q
Three key features to classify seizures
A
- Where the seizures began
- Level of awareness during the seizure
- Other features of the seizure e.g. motor
21
Q
Ix for suspected epilepsy
A
- MRI for structual pathology e.g. tumour
- Electroencephalogram (EEG)
- ECG
- U+Es (Na, K, Ca, Mg)
- Blood glucose
- Blood, urine cultures, LP if sepsis, encephalitis or meningitis suspected
22
Q
Conservative management for epilepsy
A
- DVLA removes license until specific criteria are met, e.g. (epileptic seizure-free for a year, first seizure-free for 6m + low future risk)
- Taking showers rather than baths (drowning is a major risk in epilepsy)
- Particular caution with swimming, heights, traffic and dangerous equipment
23
Q
Medical mx for generalised seizures
A
- Sodium valproate - highly teratogenic - avoid in women of childbearing age.+
- Lamotrigine/Levetiracetam in women of childbearing age
- Absence seizure: Ethosuximide
+ Risk of neurodevelopmental conditions in children of men on SV, MHRA recommends avoidng SV in men and women < 55, under NICE review.
24
Q
Medical mx for partial/focal seizures
A
Lamotrigine or Levetiracetam
25
What areas should hx for an epileptic seizure focus on?
Before, during and after seizure, eye-witness account is important.
**Pre-ictal**
- Risk factors for epilepsy
- Seizure triggers: e.g. alcohol
- Aura: subjective feeling of warning pre-seizure
**Ictal**
- Length of the seizure
- Appearance: jerking suggests tonic-clonic, behavioural arrest suggests absence
- Progression: e.g. jacksonian march - seizure spreads from the distal part of the limb toward the face
- Consciousness
- Injury: tongue biting, head injury
- Urinary incontinence
**Post-ictal**
- Drowsiness, headaches, amnesia, confusion around 30 minutes
- Neurology: e.g. Todd’s paresis (weakness/paralysis in body after seizure)
26
DIffernetials for seizure
- Vasovagal syncope (fainting)
- Pseudoseizures (non-epileptic attacks)
- Cardiac syncope (e.g., arrhythmias or structural heart disease)
- Hypoglycaemia
- Hemiplegic migraine
- Transient ischaemic attack
27
Sodium valproate: MOA and side effects
Increases activity of gamma-aminobutyric acid (GABA), calms brain
Side effects: teratogenic (harmful in pregnancy), liver damage and hepatitis, hair loss, tremor, reduced fertility
Pregnancy - neural tube defects and developmental delay. Valproate pregnancy prevention programme if no alternative.
28
Status epilepticus
One seizure > 5mins, or multiple seizures without regaining conciouness in between
Medical emergency!
29
Management of status epilepticus
- Immediate: ABCDE (secure airway, high-conc O2, check BM, IV access)
- 1st line: benzodiazepine (e.g. IV lorazepam 4mg or rectal diazepam 10mg or buccal midazolam 10mg)
- Repeat after 5-10 minutes if the seizure continues
- 2nd line: IV levetiracetam, phenytoin or sodium valproate
- 3rd line: Phenonarnital and on-call anaesthetist
30
Extradural haemorrhage (EDH)
Bleeding into the potential space between the skull and the dura mater.
The blood collection is called extradural haematoma (EDH).
31
Most common cause of EDH
Blunt-force trauma, causes middle meningeal artery rupture
32
Presentation of EDH
Typically, young pt with traumatic head injury and ongoing headache.
Initial LOC then period of improved neurological synmptoms and consciouness then rapid decline as haematoma becomes larger.
Can be accompanied by bruising etc.
33
Glasgow Coma Score for assessing conciousness level
Eyes, Verbal and Motor Response
3 (completely unresponsive) to 15 (responsive)
Mild TBI: GCS 13-15; mortality 0.1%
Moderate TBI: GCS 9-12; mortality 10%
Severe TBI: GCS <9; mortality 40%.
34
Investigations for EDH
Non-contrast CT head - hyperdense biconvex collection often below temporal bone.
Others: BM, FBC, U+E & LFTs (if surgery needed), coagulation, group and save in case of surgery
35
Acute management of EDH
- Urgent neurosurgery opinion
- ABCDE approach
- Aim to reduce ICP (may need ICU)
- Bed position so head at 30 degrees
- Intubation if reduced GCS
- Oxygen (15L 100% through non-rebreather mask)
- Hypertonic saline/mannitol to reduce ICP
- Maintain temp, O2 and CO2 in normal range
## Footnote
Neuro observation + repeat imaging in hospital if small EDH
36
Surgical mangement for EDH
- Craniotomy (open surgery by removing a section of the skull)
- Burr holes (small holes drilled in the skull to drain the blood)
37
Meningitis
Inflammation of the meninges, the membranes covering the brain and spinal cord.
38
Most common causes of viral meningitis
- Herpes simplex virus (HSV, HSV-1 in Western world)
- Enterovirus e.g. coxsackie virus
- Varicella zoster virus (VZV)
39
Most common causes of bacterial meningitis
Children + adults
- Neisseria meningitidis aka meningococcus
- Streptococcus pneumoniae aka pneumococcus
Neonates
- Group B streptococcus (GBS)
- Listeria monocytogenes
## Footnote
N.meningitidis = gram -ve diplococcus.
Meningococcal meningitis = infection of meninges and CSF
Meningococcal septicaemia = infection in bloodstream, non-blanching rash
40
Presentation of meningitis in adults
- Fever
- Neck stiffness
- Vomiting
- Headache
- Photophobia
- Altered consciousness
- Seizures
| Children with meningcoccal septicaemia may have non-blanching rash
41
CSF analysis: bacterial meningitis results
- Appearance = Cloudy
Protein = High (>1g/L)
Glucose = Low (<50% serum glucose)
White Cell Count = High - 10-5000/mm3 (neutrophils)
Culture = +ve for bacteria
42
CSF analysis: viral meningitis results
Appearance = Clear
Protein = Mildly raised/normal (<1g/L)
Glucose = High (>60% serum glucose)
White Cell Count = High 1000/mm3 (lymphocytes)
Culture = Negative
43
Management of bacterial meningitis
Medical emergency!
Primary care
- Children with suspected meningitis and non-blanching = IM/IV benzylpenicillin+ + hospital
Hospital:
- Blood culture + LP +/- meningococcal PCR if meningococcus suspected, but DO NOT delay tx
- Under 3 months – cefotaxime + amoxicillin (covers listeria)
- Above 3 months – ceftriaxone
- Notifiable to UK Health Security Agency
| +<1y = 300mg, 1-9y = 600mg, >10y = 1200mg
44
Management for viral meningitis
Suspected meningitis unknown cause:
- Empirical abx
Confirmed:
- Aciclovir
- IV fluids
- Stop empirical abx
45
Meningitis: post-exposure prophylaxis
Contacts exposed to patient within 7 days of onset.
Guided by local health protection team, usually ciprofloxacin
46
Complications of meningitis
- Hearing loss (a key complication)
- Seizures and epilepsy
- Cognitive impairment and learning disability
- Memory loss
- Focal neurological deficits, such as limb weakness or spasticity
47
Raised Intracranial Pressure (ICP)
Increase in volume in the cranium, normal ICP 7-15mmHg supine
Causes:
- Primary/metastatic tumours
- Head injury
- Haemorrhage: subdural, extradural, subarachnoid, intracerebral
- Hydrocephalus
- Status epilepticus
- Idiopathic
48
Clinical features of raised ICP
- Trauma Hx
- Headache worse on cough + leaning forward
- Vomiting
- Altered GCS
- Cushing's response (reduced HR, increased BP, irregular respirations
- Pupil changes: constriction first, dilation later
- Reduced visual acuity, loss of peripheral visual field
- Papilloedema (swelling of optic disc) on fundoscopy
49
Investigations for raised ICP
- Urgent CT head to confirm dx
- U+E, FBC, LFT, glucose, clotting, blood culture +/- tox screen
50
Management of raised ICP
- Elevate head to 30 degrees
- Reduced GCS/seizure = intubation and ventilation with controlled hyperventilation (reduce pCO2 = vasoconstriction = reduced ICP)
- CSF drainage if needed
- IV mannitol or hypertonic saline
- Decompressive craniectomy if needed
51
Spinal cord compression: Cauda Equina Syndrome
- Surgical emergency
- Nerve roots of the cauda equina are compressed
- Emergency decompression surgery
52
What is the cauda equina?
Spinal cord ends L2/L3, cauda equina is collection of nerves that travel through the spinal canal after this.
Supplies:
- Sensation to lower limbs, perineum, bladder and rectum
- Motor innervation to lower limbs, anal and urethral sphincters
- Parasympathetic innervation of bladder and retum
53
Causes of cauda equina syndrome
- Herniated disc (MC)
- Metastasis
- Abscess
- Trauma
54
Red flags in a history that indicate cauda equina syndrome
- Saddle anaesthesia
- Loss of sensation in bladder/rectum
- Urinary retention/incontinence
- Faecal incontinence
- Bilateral sciatica/ leg motor weakness
- Reduced anal tone on PR
55
Management of cauda equina syndrome
Neurosurgical emergency
- Immediate hospital admission
- MRI scan to confirm/exclude
- Lumbar decompression surgery
Even if early intervention, patients can be left with bladder, bowel, sexual dysfunction
56
Metastatic spinal cord compression (MSCC)
When a metastatic lesion compresses spinal cord before it ends, different to cauda equina syndrome.
Similar symptoms: key feature is back pain worse on coughing or straining
Oncological emergency
- High dose dexamethasone for swelling + compression
- Analgesia
- Surgery
- Radio/chemotherapy
57
How to differentiate between Cauda Equina Syndrome and MSSC?
Cauda Equnia - LMN signs e.g. reduced tone and reflexes as compressed nerves are LMNs that have exited spinal cord
MSCC - tumour compresses nerves higher up = UMN signs e.g. increased tone, brisk reflexes
58
SPinal cord injury: cervical spine injury
Injury to the cervical spine, neck ligaments and spinal cord damage
Causes include road traffic accidents, sports injuries and assaults.
59
Classification of cervical spine injuries
Canadian C-spine rules to determine patients that need imaging:
Unable to rotate neck 45 degrees AND
High risk (at least one RF):
- > 65
- Dangerous mechanism (fall > 1m or 5 steps, high-speed motor crash, horse-riding injury)
- Paraesthesia in upper/lower limbs
Low risk:
- Minor rear-end motor accident
- Comfortable on sitting
- Walking after injury
- Delayed neck pain
No risk:
- Able to rotate neck 45 degrees + low RFs
60
Investigations for C-spine injuries
- High + low risk = 1st line is CT
- Neurological abnormalities = follow up with MRI
## Footnote
Neuro signs = focal neuro defects, paralysis, limb paraesthesia, incontinence
61
Maangement of C-spine injury
- Major truama centre
- High/low risk = full in-line spinal immobilisation before imaging
- IV morphine
- Neurosurgical/spinal surgeons
- Stable injury = longer periods of immobilisation using collar
- Unstable injury = surgery to realign, stabilise spine and relieve compression
62
Stroke (CVA)
- Ischaemic - reduced/blocked blood supply to brain due to blood clot (85%)
- Haemorrhagic - bleeding in or around the brain (intracranial haemorrhage. Uncontrolled hypertension is biggest RF!
## Footnote
Ischaemia = reduced blood supply, infarction = tissue death due to ischaemia
63
Risk factors for ischaemic stroke
- Hypertension
- Age ≥55 years
- Hx of TIA
- Hx of ischaemic stroke
FHx of stroke at a young age
- Smoking
- Diabetes mellitus
- Atrial fibrillation (3 - 5x risk)
- Comorbid cardiac conditions
- Carotid artery stenosis
- Sickle cell disease
- Dyslipidaemia
64
Bamford classification of strokes
- Total anterior circulation stroke (TACS)
- Partial anterior circulation stroke (PACS)
- Lacunar stroke
- Posterior circulation stroke
65
General symptoms of ischaemic stroke
- Sudden onset neuro symptoms
- Asymmetrical usually
- Limb weakness
- Facial weakness
- Sysphasia
- Visual field defects
- Sensory loss
- Ataxia/vertigo if posteror circulation
66
3 cardinal signs of anterior circulation stroke
- Hemiplegia (unilateral paralysis)
- Homonymous hemianopia (visual loss in same side of visual fields in both eyes)
- Higher cortical dysfunction, such as dysphasia or neglect (ignores one side of the body)
| Partial anterior circulation stroke = 2 out of 3
67
Clinical features of posterior circulation stroke
Cerebellar syndrome:
- Ataxia w/o limb weakness
- Fine motor defcits
- Diplopia
68
Clinical features of Lacunar stroke
- Small deep perforating arteries supplying internal capsule or thalamus
- Pure motor/sensory stroke or ataxic hemiparesis (unilateral weakness)
69
Assessment and tx of underlying causes of ischaemic stroke
TIA + stroke = assessed for carotid artery stenosis and AF:
- Carotid imaging USS, CT or MRI angiogram
- ECG/ambulatory ECG monitoring
Tx
AF = anticoagulation
Signifcant carotid artery stenosis - carotid endarterectomy
| Carotid artery stenosis and AF main RFs for stroke!
70
Management of ischaemic stroke
- Urgent CT head to exclude haemorrhagic stroke
- Exclude hypoglycaemia
- Aspirin 300mg for 2 weeks
- Admission to specialist stroke centre
- Thrombolysis with alteplase ≤4.5 hr within onset
Mechanical thrombectomy within ≤ 24 hrs of onset and confirmed proximal anterior/posterior circulation stroke
71
Secondary prevention of ischaemic stroke
- 1st line: daily clopidogrel (antiplatelet) 75mg for life
- High-dose statin 48 hours after
- Manage hypertension , diabetes , smoking and other cardiovascular risk factors
72
Transient ischaemic attack (TIA)
A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
Sudden and brief onset (mins)
Patient/witness report of focal neuro defcits e.g. unilateral weakness, paralysis, dysphasia, amaurosis fugax
73
Mangement of TIA
- Symptoms should have resolved by 24 hours
- Aspirin 300mg daily
- Referral for specialist assesment witihn 24 hours, within 7 days if > 7 days since episode
- Diffusion-weighted MRI scan
74
Investigations for haemorrhagic stroke
- Non-contrast CT head within 1 hour of arrival
- Serum glucose
- Serum electrolytes
- Serum urea and creatinine
- FBC
- LFTs - to exclude liver dysfunction as cause
- Clotting screen to exclude coagulopathy as cause
75
Management for haemorrhagic stroke
- Admission to neurocritical care and neurosurgery
- Reverse/stop anticoag.
- Raised intracranial pressure : consider intubation with hyperventilation, head elevation (30°) and IV hypertonic saline
- BP control <140/80 mm Hg
- Surgical intervention: decompression hemicraniectomy
76
Subarachnoid haemorrhage
Bleeding into subarachnoid space, usually due to ruptured cerebral aneurysm.
High motality (30%) and morbidity
77
Risk factors
- 45 - 70
- Women
- Black
- HTN
- Smoking
- Excess alcohol
- FHx
- Coacine
- Sickle cell anaemia
- Marfan syndrome
- Autosomal dominant PKD
78
Presentation of subarachnoid haemorrhage
"Worst headache of my life"
"Feel like someone hit me on the back of head with a baseball bat"
- Thunderclap headache
- Neck stiffness
- Photophobia
- Vomitting
- Neuro symptoms
79
Investigations for subarachnoid haemorrhage
1st line = CT head, hyper-attenuation (brighter) in subarachnoid space
CT less reliable > 6hrs symptoms onset
Normal CT does not exlude, LP 12 hrs after onset, as bilirubin build-up takes time. CSF shows:
- Raised RCC
- Xanthochromia (yellow CSF)
80
Management of subarachnoid haemorrhage
- Specialist neurosurgical unit
- Reduced GCS = intubation and ventilation
- MDT with supportive mx
- Surgical intervention if aneurysms to repair vessel and prevent rebleeding, endovascular coiling
## Footnote
Complication = hydrocephalus
Tx = LP, external ventricular drain, ventriculoperitoneal shunt
81
Subdural haemorrhage
Bleeding between dura and arachnoid mater
Caused by rupture of bridging veins in dura mater
More common in elderly and alcoholic patients due to brain atrophy = vessels more prone to rupture
82
Presentation of subdural haemorrhage
- Headache
- Nausea or vomiting
- Confusion
- Fluctuating GCS
- Behavioural change.
83
Investigations for subdural haemorrhage
CT head
Crescent shape not limited by cranial sutures, they can cross sutures
84
Management of subdural haemorrhage
- Conversative with monitoring and repeat imaginig if no significant midline shift or cerebral oedema
- Surgery: craniotomy if acute, Burr holes if chronic
