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Neurology 5 Flashcards

1
Q

What is the most common cause of a SAH?

A

Trauma

Other causes are spontaneous

  • Berry Aneurysm
  • AVM
  • Arterial dissection
  • Pituitary apoplexy
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2
Q

What changes may you see on ECG with a SAH?

A

ST elevation

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3
Q

What are some of the complications that can occur with SAH?

A

Re-bleeding

Cerebral ischemia
- vasospastic action *Nimodipine given to counter act

Hydrocephalus
- arachnoid granulation and blood obstruction

SIADH

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4
Q

Which system is involved causing pain in a migraine?

A

Trigeminovascular system

  • spreading cortical depression
  • Release of CGRP
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5
Q

What are some triggers for migraines?

A

Sleep (too much to little)

Hormone changes
- menstrual cycle

Stress
- includes a let down period after intense stress

Eating
- alcohol

Weather changes

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6
Q

What features can help differentiate a Aura migraine from a TIA?

A

Positive symptoms

  • scotoma
  • tingling
  • TIA tend to have complete vision loss as oppossed to distorted vision

Onset time
- migraines tend to build up

Migraine typically has pain associated

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7
Q

What are the duration of times of antibiotic therapy for meningitis?

A

N. meningitides: 5 days

S. Pneumonia: 10-14 days

L. Monocytogenes: 21 days

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8
Q

What are some poor prognostic indicators in meningitis?

A

> 60 years old

S. Pneumonia infection

Low GCS

Focal neurology

Bleeding

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9
Q

What is the ABCD2 score?

A

Score used to assess if a patient needs to be managed as in patient (seen within 24 hours) or outpatient Due to risk of further risk of stroke.
>4 need to be admitted and seen within 24 hours

A- Age >60 
B - Blood pressure >140
C - Clinical condition (weakness?) 
D - Duration of symptoms 
D - Diabetes
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10
Q

When is the best time to give Alteplase?

A

within first 90mins is best but can be given within 4.5 hour window

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11
Q

What scoring system can be used to assess severity of strokes?

A

NIH Stroke Scale

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12
Q

Why is an extensive stroke not treated with thrombolysis even if within the 4.5hours?

A

Extensive stroke demonstrates large necrosis which is a big risk factor for haemorrhage

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13
Q

When treated with thrombolysis how many will benefit and how many will ?

A

1/3rd will improve

1% will have worse outcomes

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14
Q

What is the criteria for endarterectomy following a stroke?

A

Males: >50% stenosis

Females: >70% stenosis

  • has to be symptomatic (i.e. had a stroke)
  • done within 2 weeks of the event
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15
Q

Why is anti-coagulation not started straight away in patients with an embolic stroke?

A

Anti-coagulation increases the risk of bleeding

- in a similar way thrombolysis increases risk

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16
Q

If someone has signs of a posterior circulatory stroke but no findings on CT what should be done next?

A

MRI scan

CT scan can’t rule out posterior stroke

**any Brainstem signs you need an MRI

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17
Q

What type of nystagmus is suggestive of a central cause?

A

Bidirectional nystagmus

- beats to both sides

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18
Q

RTC and patient presents with Horner’s syndrome, what has occurred?

A

Carotid dissection

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19
Q

How is a carotid dissection treated?

A

Anti-coagulation

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20
Q

In terms of onset of weakness - if a patient describe s a progressive weakness over 24-72 hours what is the likely underlying pathology?

A

Inflammatory

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21
Q

If you have a lesion in the internal capsule what kind of symptoms can you expect?

A

Dense hemiparesis of the face and body on contralateral side
- all the motor fibres pass through there

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22
Q

If you have a lesion in the thalamus what symptoms can you expect?

A

Hemisensory loss

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23
Q

If you have a lesion within the medulla what symptoms can you expect?

A 
Dysphagia
Dysarthria 
Dysphonia 
Wasting of tongue 
Lack of soft palate risen when saying "ahh"

*this is because cranial nerves 9,10,11 exit from the medulla.

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24
Q

What is a prognostic indicator on how well someone will do following a spinal transection?

A

Their ability to use truncal muscles.

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25
What is a positive Romberg's sign indicative of?
Sensory neuro-ataxia - they've lost proprioception input
26
Give some differentials for length dependent polyneuropathy:
Diabetes Alcohol Multiple myeloma B12 deficiency Autoimmune: - RA - Lupus Drugs: - Isoniazid - Amiodarone Kidney disease Hypothyroidism
27
What are some of the risk factors for a SAH?
``` Female Smoking HTN Polycystic kidney disease Ehlor Danlos Family history Coarctation of aorta ```
28
What is a sign seen in the eyes which is very characteristic of a SAH?
Subhyaloid haemorrhage causing vitreous detachment
29
Once a SAH has been established what tests should then be conducted to establish the cause?
CT angiogram - assess for aneurysms * digital subtraction to view the vessels can also be done. * assess eGFR * a digital subtraction graph can be done if CT not appropriate
30
What investigations other than a CT Scan do you want to order in a SAH?
Bloods: - U&Es - hyponatraemia - Troponin levels X-rays: - Echocardiogram (Takusubo) - pulmonary oedema ECG - non-specific ST elevation
31
What are the complications of a SAH and some treatments used:
Re-haemorrohage - 10% within the first 72 hours * immediate repair can help Delayed Ischemia - peaks around day 7 * nimodipine is used to reduce * Inotropic may be needed * microvascular dilation Hydrocephalus - due to arachnoid granulation irritation * needs shunted SIADH - can become fluid depleted by passing lots of water * hypertonic saline Takotsubo cardiomyopathy - large catecholamine release Troponin rise - due to catecholamine release DVTs * Mechanical compression * use of LMWH is controversial and should be with held 24 hours between surgeries
32
What is the mortality rate in SAH?
50% 1/3rd who survive will require dependent care
33
What are the pathological processes behind cervical myelopathy?
Disc prolapse Facet joint degeneration Osteophyte formation Cervical stenosis Malignancy
34
What kind of symptoms occur in radiculopathy?
Lower motor sign Pain is the biggest sign first.
35
How does an UMN lesion affect the bladder and sphincter complex?
Spastic bladder - urgency - strangury - incontinence Bowel: - constipation * unable to open
36
What condition will inhibit an approach from the front to treat cervical myelopathy? and what is the surgery called that is conducted from the front?
Posterior longitudinal calcification Anterior cervical discectomy with fusion
37
Name three operation which can be conducted to fix a cervical myelopathy and what would help you decide to take an anterior or posterior view?
Anterior cervical discectomy with fusion Posterior laminectomy Cervical foraminotomy Decision: - Where the most amount of compression is i. e. if anterior then anterior approach
38
What are the red flags of lumbosacral radiculopathy?
Foot drop Bilateral leg pain Bladder/ bowel dysfunction Saddle anaesthesia Known cancer
39
What are the treatment options for lumbosacral radiculopathy?
Physiotherapy Analgesia - Duloxetine - Gabapentin - TCAs Nerve root blocks Surgical: - Lumbar microdiscectomy ** definitive management
40
Contrast a LMN bladder and an UMN bladder and list one condition it is seen with:
UMN: - hyperactive - inability to fill and relax - Strangulation - Urgency * cervical myelopathy ``` LMN: - Atonic - Drippling Progresses to retention and incontinence *cauda equina syndrome ```
41
What test can you do to establish if there is bladder dysfunction in cauda equina syndrome?
Post- void ultrasound scan Residual of >100mls is suggestive of dysfunction
42
What is the definitive management for cauda equina?
Lumbar microdiscectomy +/- Laminectomy (done if unsure its decompressed) *should be conducted with 24 hours - as soon as possible
43
What criteria can be used to help establish which patients are likely to benefit from surgical surgery who have a spinal tumour?
Patchel criteria
44
What are the two types of haemorrhagic transformation?
Petechial - not of much clinical significance * usually antiplatelet therapy is withheld for one day following this Intraparenchymal - carries worse prognosis **this is why a repeat CT is done following thrombolysis therapy 19-24 hours later
45
What are the two main types of primary intracerebral bleeds?
Hypertension - this is centrally located bleeds Cerebral amyloid angiopathy * seen with susceptibility weighted MRI - there are peripherally located
46
Where is the most common place for a SAH to occur?
Anterior communicating Artery
47
What imaging modality should be utilised for follow up of a coil in SAH?
MRI in CT there is too much artefact
48
On imaging how do you differentiate between atrophy and hydrocephalus?
In hydrocephalus the sulci are squished as well Low density is found around the ventricles - this is CSF leaking out into the parenchymal In atrophy the sulci are equally enlarged
49
What are the layers of the scalp and what is the vein that passes through from the scalp to the superior sagital sinus?
SCALP - Skin - Connective tissue - Aponeurosis - Loose aorola tissue - Peritoneum Emissary vein - source of infection **above the aponeurosis it will not be influenced by the pull of the frontalis muscle thus can be fixed with glue
50
List some signs of myasthenia gravis:
``` Diplopia Proximal muscle weakness (neck, limb girdle) Dysphonia Dysphagia Ptosis ``` * pernicious anaemia * Thyroid disease
51
What are the core symptoms of Parkinson's disease?
Tremor at rest Rigidity Bradykinesia Postural instability - due to poor postural reflexes
52
What tests do you want to order to help diagnose Myasthenia Gravis?
Bloods: - ACh receptor antibodies - Anti- Muscle specific Kinase receptor (MuSK) - Low Density lipoprotein receptor - 4 X-rays: - CXR (thyoma) Special tests: - Pulmonary function - Spirometry looking at FVC * single fibre EMG
53
What are some triggers to a myasthenia crisis and how is it treated?
Drug - gentamicin - beta blockers - over dose of Acetylcholinesterase inhibitors - pregnancy ``` Treatment: - Ventilator support or BiPAP - plasmapheresis or - IV immunoglobulin ```
54
What drug is given in an overdose of an Acetylcholinesterase inhibitor?
Glycopyrronium
55
What symptoms would point away from Parkinson's disease and to one of the Parkinson plus syndromes?
Early onset dementia - fluctuation in consciousness - Hallucinations Early postural instability and postural hypotension - Multisystem atrophy Multiple early falls Symmetrical presentation `Levodopa non-responsiveness
56
What drug can be given as a rescue medicine for sudden "off" freezing in Parkinson's? and how is it delivered?
Apomorphine | - Sub cut
57
What are the two common dopamine agonists used in Parkinson's disease? why are these preferred over other dopamine agonists and what are some side effects to them?
Ropinirole Pramipexol Typically used initially in young persons with Parkinson's due to reduced efficacy of L-DOPA as time goes on. Preferred over other domapine agonists as they can cause fibrotic reaction of the heart Side effects: - N&V - Postural hypotension - Increased compulsivity - Hypersexuality - Psychotic features
58
When a patient is admitted with Parkinson's disease - what important question should you ask them? and list some consequences of not:
Establish when they take their medication - it is important this is given at the same time of day each day. Missing dosages or changing dosages can result in: - neuroleptic malignancy syndrome
59
What are COMT inhibitors used for and name two:
Help reduce the on-off effects of levadopa *typically used in late disease - Entacapone - Tolcapone
60
What are some side effects of levadopa?
Dyskinesia On-off affect Psychosis Hallucinations
61
What anti-emetic can be given for Parkinson's?
Domperidone (even though it is a dopamine antagonist - it doesn't cross the BBB)
62
What features would suggest a Psychogenic non-epileptic seizure?
Gradual onset Hip thrusting Crying after seizure Rarely occurs alone
63
How do posterior circulating strokes present?
``` Brainstem signs or Cerebellar signs or Unconsciousness or Isolated homologous hemianopia ```
64
Outline the pathological mechanisms of traumatic brain injury:
Diffuse neural exonal injury - can be opposite side of injury (contrecoup) Neuronal and axonal damage directly from blow Brain hypoxia Oedema build up afterwards
65
What are some long term consequences of trauma to the brain?
Incomplete recovery - cognitive impairment Post-traumatic epilepsy Post-traumatic syndrome - recurring headaches - dizziness Hydrocephalus BPPV
66
What is the treatment for idiopathic intracranial hypertension?
Acetazolamide
67
Which class of antibiotics can lower the seizure threshold in epileptics?
Quinolones
68
What is the management for an extra-dural haemorrhage and give some differentials:
Differentials: - epilepsy - Carbon monoxide poisoning - Carotid artery dissection Management: - ABCDE (early intubation is needed) - Clot evacuation - Ligation of bleeding vessel * control if ICP - Ventilation - Mannitol
69
What is conduction aphasia?
Where speach is fluent but they have difficulty repeating what is said to them - comphrension is present
70
What investigations would you consider in someone presenting with a seizure?
``` Blood glucose ECG - rule out cardiac FBC - infection? U&Es/ Toxicology Head CT ``` Later on: - EEG * EEG doesn't diagnose unless it is occurring but can help with prognosis i.e. to look at normal activity
71
Following one seizure how likely is a person to have another?
40% *if there is abnormal EEG this rises to 60%
72
What are some risk factors for a epilepsy?
Family history Birthing injury/ preterm Meningitis Febrile convulsions - especially if out-with normal ages Head injuries
73
When asking about seizures at night - what kind of things do you want to think about?
If they wake up with muscle aches Tongue biting through the night
74
When treating cauda equina - what initial things are done?
Dexamethasone Urinary catheter *** Whole spinal MRI

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