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Flashcards in Neurology Deck (23):
1

Headache | Differentials

Neurological
Non-neurological

[Neurological]
Tension headache; bilateral, tight-band, stress
Migraine; unilateral, pulsating, photophobia/phonophobia, aura, hours, caffeine, medication-overuse, menstruation
Cluster headache; unilateral, debilitating retro-orbital pain, eye redness/watering, minutes
Raised ICP; triggered by exertion/position, learning forward
SAH; thunderclap headache
Meningitis; fever, photophobia, neck stiffness, rash
Trigeminal neuralgia; brief, stabbing pain, brushing teeth/chewing

[Non-neurological]
Sinusitis; facial pain, rhinorrhoea, nasal obstruction
AACG; painful red eye, vision loss, haloes around lights
Temporal arteritis; unilateral, scalp tenderness, jaw claudication

2

Neurology | History taking

Headaches
Fits, faints, funny turns
Memory loss
Vision and hearing
Speech and swallowing
Numbness, tingling
Weakness
Balance
Co-ordinaton
Bladder disturbance, incontinence

3

CNS localisation | Syndromes

Hemisphere
Brainstem

Spinal cord syndromes;
Cervical
Thoracic
Hemisection
Transverse

CNS motor = UMN signs, weakness

Hemisphere; contralateral hemiparesis + hemisensory loss
Brainstem; ipsilateral head, contralateral below head

[Spinal cord syndromes]
Cervical; UMN UL/LL, sensory loss to neck
Thoracic; UMN LL, sensory loss to abdomen
Hemisection; 'Brown-Séquard syndrome' ipsilateral motor + dorsal column sensory, contralateral spinothalamic
Transverse; loss of all modalities below lesion

4

Guillain-Barre Syndrome | Clinical features

Motor
Sensory
Autonomic

Autoimmune inflammatory polyneuropathy
Preceding GI/URT infection; Campylobacter jejuni

Ascending symmetrical weakness UL/LL (distal to proximal)

LMN signs; areflexia
Respiratory failure; SOB
Bulbar involvement; bilateral facial palsy, slurred speech, dysphagia, diplopia, ptosis
Peripheral neuropathy
Autonomic dysfunction; tachycardia, hypotension

5

Guillain-Barre Syndrome | Investigations

FBC, CRP, U&Es, LFTs

Nerve conductions studies; slowed
LP; elevated CSF protein
Spirometry

6

Guillain-Barre Syndrome | Management

IV immunoglobulin (IVIG)
Plasma exchange

Supportive Tx; BP, intubation/ventilation, neuropathic pain, rehabilitation

7

Facial nerve palsy | Management

Non-pharmacological
Pharmacological

RF; pregnancy

[Non-pharmacological]
Self-limiting, resolves within 3-4/12
Eye protection; glasses during the day, lubricating eye drops during the day, thicker ointment at night, tape shut

[Pharmacological]
If onset within 72hrs:
PO high-dose prednisolone
± acyclovir

8

Epilepsy | Management

Advice
Pharmacological
Surgical

Contraception
Pregnancy

[Advice]
Avoid putting yourself in dangerous situations where LOC could be fatal
Heights, cycling in traffic, operating heavy/dangerous machinery, bathing alone, near deep water, parents supervising children with epilepsy

[Pharmcological]
Focal; carbamazepine
Generalised; valproate, lamotrigine

[Surgical]
Lobectomy; if well-defined structural cause

[Contraception]
Carbamazepine decreases the efficacy of OCPs
Advised to use alternative method; condoms, depot, IUD, IUS
COCP reduces efficacy of lamotrigine

[Pregnancy]
Preconception counselling, ↑x folic acid, higher risk of complications
Pregnancy reduces efficacy of lamotrigine
Dose titration and serum level initially
Optimal therapy; lowest dose for best seizure control and fewest SE
Safe; levetiracetam, lamotrigine

9

Epilepsy | DVLA standards

Syncope
Epileptic seizure
Breakthrough seizures

Counselling

Syncope; no restrictions, no notify
Epileptic seizures; stop driving until seizure free for 1yr
Breakthrough seizures; stop driving for 6/12

[Counselling]
Persuade patient to self-report
Patient's own safety
Safety of their own family and children
Doctor's duty to protect members of the public
Responsible for someone else's death
Criminal offence in the given circumstances
Invalidation of any insurance
Duty to breach confidentiality and inform the DVLA/police

10

Multiple sclerosis | Clinical features

Lesions;
Optic nerve
Cerebellum
Brainstem
Spinal cord

Motor
Sensory
Balance
Sphincters

Autoimmune inflammatory demyelinating disease
Episodic neurological dysfunction in ≥2x areas of CNS separated in time and space

Optic neuritis; unilateral, graying, blurred vision, impaired colour vision (red desaturation), painful EOM, RAPD
Brainstem lesion; diplopia (INO), vertigo, nystagmus, facial weakness/numbness, dysphasia, dysarthria
Spinal cord lesion; paraparesis etc.

Peculiar sensory disturbance; hemibanding, Lhermitte's sign, patch of wetness/burning, neuropathic pain
Motor; LL weakness (often foot), UMN signs, spasticity
Ataxia; imbalance, poor coordination
Bladder/bowel dysfunction; frequency, constipation, sexual dysfunction

11

Multiple sclerosis | Investigations

Diagnostic criteria

FBC, CRP, ESR
U&Es, LFTs
TFTs
Calcium, glucose
Serum B12
Metabolic screen

LP and CSF analysis; OCB +ve
MR brain
MR spinal cord

Revised McDonald criteria 2010

12

Multiple sclerosis | Management

Acute relapse
Ongoing RR
Secondary progressive sx

Rehabilitation

Fatigue; exercise, regular sleep pattern
Vision; often resolves

[Acute relapse]
High-dose corticosteroids
1. PO methylprednisolone
2. IV methylprednisolone
3. ± plasma exchange

[Ongoing RR]
Disease-modifying drugs (DMDs)
1. SC/IM beta interferon

[Secondary progressive sx]
Antispasticity; baclofen
Neuropathic pain; gabapentin
Antidepressants; sertraline
Anticholinergics/overactive bladder; oxybutinin

[Rehabilitation]
MS specialist nurse
Physiotherapy; spasticity, myalgia
OT; mobility aids, function, home adaptations
Psychotherapy, CBT; cognition, memory, depression
SALT

13

Multiple sclerosis | Differentials

Neurological
Non-neurological

[Neurological]
Spinal cord compression
Devic's syndrome; neuromyelitis optica
Vitamin B12 deficiency; reversible cause
Lyme disease

[Non-neurological]
Sarcoidosis; granulomas
SLE; antibodies

14

Investigations | CSF analysis

Herpes simplex
TB
GBS
Myelopathy
Raised ICP

Herpes simplex encephalitis; raised RBC, lymphocytosis
TB; Very high OP, very high protein, very low glucose, lymphocytosis
GBS; raised protein
Myelopathy (MS/transverse myelitis); OCB +ve
Raised ICP; high OP

15

Migraine | Triggers & Management

Self-help advice
Acute attack
Prophylaxis

Triggers; stress, menstruation, hormonal pills, altered sleep pattern, strenuous exercise, relaxation after stress
Food; chocolate, cheese, caffeine, alcohol

Headache diary; identity triggers

[Management]
Lifestyle advice; avoid triggers
Lying down in a dark room, sleeping
Being sick, eating
OTC painkillers; aspirin, ibuprofen, paracetamol
Warn of SE medication-overuse headaches

{Acute attack}
1. PO triptan + NSAID/aspirin/paracetamol; sumatriptan, or monotherapy
2. + antiemetic; metoclopramide, domperidone

{Prophylaxis}
1. Propranolol; exacerbates asthma, preferred in women of childbearing age
1. Topiramate; also 1st line, preferred in asthmatics, not in young women

16

Psychogenic non-epileptic attack | Clinical features

'Pseudoseizure'

Maintains consciousness
Back arching
Bilateral violent shaking
'Slumping' attack
Overly upset/emotional on coming around
Prolonged unresponsiveness 'pseudosleep'
No confusion

17

MND
Myasthenia gravis

Proximal fatiguable weakness
Eyes; diplopia, ptosis
Facial; dysarthria, dysphagia, facial weakness

18

Headache | Management

Cluster
GCA

Cluster; high-flow oxygen 100% 15L + SC sumatriptan
Prophylaxis; verapamil, prednisolone
GCA; PO high-dose prednisolone, Tx before investigation, high risk of vision loss

19

Transverse myelitis |

Acute onset, malaise, loss of appetite
Weakness and change in sensation below affected spinal level
But may produce UMN spasticity
Bladder/bowel/sexual dysfunction

LP + CSF analysis; OCB +ve

20

Epilepsy | Classification

Generalised > motor vs. non-motor
Focal > aware vs. impaired awareness

Focal may progress to bilateral tonic clonic seizures

Epileptic seizures are stereotypical taking the same form each time with the same sequence of events
Tend to cluster, may arise in sleep

21

Encephalitis

Fever, headache, confusion
Seizures + focal neurology (speech disturbance)
Meningism
+ personality change
+ reduced consciousness/coma

HSV-1 commonly
May cause raised ICP, midline shift, brain herniation

LP + CSF analysis; lymphocytosis 95%, viral PCR, MC&S
MR brain; inflammation, oedema, swelling, usually temporal lobes

[Management]
1. IV acyclovir within 6hrs
Treat before results return
2. + supportive care; ICU bed, intubation and ventilation, etc

If raised ICP; dexamethasone + mannitol

If high risk of 'coning' then surgery; decompressive craniectomy

22

Multiple sclerosis | Counselling

Affects the brain and spinal cord

Our nerve cells are covered in a protective layer like the insulation on wires, called myelin

Autoimmune condition whereby immune system (which normally fights off infection and anything foreign entering out bodies) gets confused and starts attacking our own body
In this case it attacks the myelin sheaths

This disrupts the electrical signals that travel to and from the brain, they may slow down, get distorted, or never transmit at all

Symptoms depend on where in the brain/spinal cord the attacks occur
May have vision loss, weakness, odd sensations, clumsiness

In the early stages, our myelin repairs itself which is why you can get a relapsing course

It is unknown what causes MS but is likely to be a combination of genetic and environmental factors
There appears to be a link between geographical location (northern hemisphere) and MS, ?Vit D

Must inform DVLA
Work and benefits
Exercise and diet
Complementary therapies

Everyone's MS is different

No cure, treatment aims to control symptoms, reduce inflammation and delay the progression

Combination of therapy, physical and psychological, plus medication if you choose it
To optimise QoL

It is not a life-ending but chronic, meaning you will have it for life

23

Multiple sclerosis | Indications for DMDs

'Active' disease
If 2x relapses in 2yrs
Or CIS + MR evidence of new lesion