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Phase 3a > Neurology > Flashcards

Neurology Flashcards

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1
Q

What is the cause of cluster headaches?

A

Unknown cause

Superficial temporal artery SM hyperactivity of 5HT

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2
Q

What are the risk factors of cluster headaches?

A

Being male >5:1

Smoking

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3
Q

What are the symptoms of cluster headaches?

A

Severe UNILATERAL pain, around one eye
‘Suicide headaches’
Ipsilateral autonomic features: lacrimation, facial flushing, rhinorrhoea, miosis, ptosis

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4
Q

How long do cluster headaches last (acute phase and cycles) and how often are they?

A

15-160 minutes
Once/twice a day
Often nocturnal
Clusters last 4-12wks, then pain-free periods for months/years

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5
Q

Treatment of cluster headaches?

A

100% OXYGEN for 15 minutes via non-rebreathable mask

SUMATRIPTAN SC 6mg at onset

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6
Q

What are the triggers of cluster headaches?

A

Alcohol
Histamine/nitroglyceride
Disrupted sleep
Sometimes heat, exercise, solvents

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7
Q

What are the red flag signs for headaches (requiring further investigation)?

A

Change in pattern of headache
Onset >50yrs
Onset of seizures
Headache with systemic illness
Personality change
Symptoms suggestive of raised ICP (headache in the morning, on coughing/sneezing/straining)
Acute onset of worst headache ever (?Intracranial aneurysm)

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8
Q

Prophylaxis of cluster headaches?

A

Verapamil
Prednisolone
Lithium
Melatonin

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9
Q

What are the symptoms of trigeminal neuralgia?

A

SUDDEN, UNILATERAL, STABBING pain in trigeminal nerve distribution - ‘electric shock’
Lasting seconds-minutes
A few-100’s of attacks a day
Pain can go into remission for weeks/months, but remission gets shorter as time progresses

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10
Q

What is the cause of trigeminal neuralgia?

A

Compression of the 5th CN - most commonly mandibular/maxillary division
Most commonly by a loop of artery/vein, in 10% of cases by tumour, MS, skull base abnormalities etc

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11
Q

Epidemiology/RF of trigeminal neuralgia?

A

Peak incidence 50-60yrs
More common in females
May be genetic predisposition

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12
Q

Triggers for trigeminal neuralgia:

A

Light touch to face - person, wind
Eating
Bathroom - shaving, brushing teeth
Dental procedures

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13
Q

Ix for trigeminal neuralgia:

A

CLINICAL Dx

MRI sometimes needed - to exclude secondary causes

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14
Q

Mx for trigeminal neuralgia:

A

CARBAMAZEPINE
Or lamotrigine/phenytoin/gabapentin
If drugs fail: SURGERY - Microvascular decompression

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15
Q

What is the likely cause of migraines?

A

Primary brain disorder resulting from altered modulation of normal sensory stimuli and trigeminal nerve dysfunction

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16
Q

What are the symptoms of migraines?

A

Aura - lasting 15-30 minutes
Within 1hr - unilateral, pulsating headache (lasting 4-72hrs)
Prodrome: Precedes headache by hrs/days - yawning, cravings, mood/sleep changes
Aura: Visual, somatosensory (abnormal sensation spreading from fingers-face), motor (stammering/ataxia), speech
Nausea/vomiting
Photo/phonophobia

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17
Q

What are the main types of migraine?

A

Aura + headache
Aura, no headache
Episodic severe headache without aura e.g. premenstrual

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18
Q

What are the triggers for migraines?

A 
CHOCOLATE
Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptives
Lie-ins
Alcohol
Tumult (noisy/violent commotion)
Exercise
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19
Q

Management of migraines:

A 
Lifestyle changes
Step 1: NSAIDs +/- anti-emetic
Step 2: Rectal analgesia +/- anti-emetic
Step 3: Anti-migraine drugs
- Triptans
- Botulinum toxin type A injections - last resort
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20
Q

Information about Triptans

A

Have largely replaced Ergotamine
Triptans selectively stimulate seretonin receptors in brain
CI in:
- People with uncontrolled HTN
- People with/at risk of coronary heart disease/cerebrovascular disease
- People with coronary vasospasm (Prinzmetal’s angina)
Rare SEs:
- Arrythmias
- Angina +/- MI

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21
Q

Prevention of migraines:

A

Remove triggers
If 2+/month or not responding to drugs:
1st line: Propanolol, amitriptyline, topiramate or Ca+ channel blockers
2nd line: Valproate, pizotifen, gabapentin

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22
Q

What is a tension headache and how is it treated?

A

Bilateral, non-pulsatile headache +/- scalp muscle tenderness - no vomiting/sensitivity to head movements
Tx - Massage or anti-depressants may be helpful

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23
Q

What are the 4 causes of stroke?

A

Small vessel occlusion or thrombosis in situ
Cardiac emboli (e.g. increased risk in AF, endocarditis, MI - emboli comes from the heart)
Atherothromboembolism (e.g. from carotids - emboli comes from a vessel)
CNS bleeds (e.g. due to increased BP, trauma, aneurysm rupture)
Other causes: Sudden BP drop of >40mmHg, carotid artery dissection, vasculitis, anti-phospholipid syndrome etc)

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24
Q

Risk factors for stroke

A 
Increased BP
Smoking
DM
Heart Disease (vascular, ischaemic, AF)
Past TIA
the Pill
Alcohol etc
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25
What are the different sites of infarcts that cause a stroke?
``` Cerebral infarct (50%) - contralateral sensory loss/hemiplegia, initially flaccid becoming spastic, dysphagia, homonymous hemianopia Brainstem infarct (25%) - wide range of effects, including quadriplegia, disturbed gaze/vision, locked-in syndrome Lacunar infarct (25%) - occlusion of small penetrating arteries in the basal ganglia, internal capsule, thalamus, and pons ```
26
Immediate management (1st hour) for suspected stroke?
1) Protect the airway 2) Pulse, BP & ECG 3) Blood glucose 4) Urgent CT/MRI - if thrombolysis considered, cerebellar stroke, unusual presentation, high risk of haemorrhagic stroke - -- otherwise can wait (aim <24hrs) - -- Diffusion-weighted MRI is most sensitive, but CT helps to rule out a primary haemorrhage 5) Thrombolysis (consider if <4.5 hours) 6) 'Nil by mouth' - consider only if swallowing may be dangerous, do NOT over hydrate (risk of cerebral oedema) 7) Antiplatelet agents - once hemorrhagic stroke excluded, give aspirin
27
Thrombolysis in acute non-hemorrhagic stroke:
If neuroimaging performed, expert clinicians available and pt seen within 4.5 hours -> consider reperfusion with IV RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR (ALTEPLASE) - May cause small increase in (usually minor) intracranial haemorrhage - Always do CT 24hrs post-lysis to check for bleeds
28
In which groups is thrombolysis contraindicated?
``` Major infarct/haemorrhage on CT Mild/non-disability defect Arteriovenous malformation (AVM) or aneurysm Severe liver disease, portal hypertension or varices etc ```
29
Primary prevention of stroke
Control RFs | Lifelong anticoagulation for - rheumatic/prosthetic heart valves on L side, consider in chronic AF
30
Secondary prevention of stroke
Control RFs Antiplatelet agents - Clopidogrel Anticoagulation after stroke from AF - start warfarin if indicated 2 weeks after stroke
31
Investigations for stroke (in the longer term) to determine management + identify risks for further strokes
Look for: 1) Hypertension 2) Cardiac source of emboli - 24hr ECG (AF), CXR (enlarged L atrium), Echo 3) Hypo/hyperglycaemia, dyslipidaemia 4) Vasculitis (raised ESR, ANA +ve) 5) Prothrombiotic states (thrombophilia, antiphospholipid syndrome) 6) Hyperviscosity (polycythaemia, SCD) 7) Thrombocytopaenia 8) Genetic tests
32
Complications of stroke:
``` Aspiration pneumonia Pressure sores Contractures (shortening of muscle tissue) Constipation Depression ```
33
Cardiac causes of stroke (source of >30%):
``` Non-vascular AF - do CHADS2 score External cardioversion Prosthetic valves Acute MI Paradoxical systemic emboli - via venous circulation with patent foramen ovale, ASD, VSD Cardiac surgery Valve vegetation from SBE/IE ```
34
What is a transient ischaemic attack?
TEMPORARY occlusion of part of the cerebral circulation | Symptoms last <24hrs
35
What are the signs of a TIA?
Features mimic a stroke in the same arterial territory
36
What do multiple stereotypical TIA suggest?
Critical intracranial stenosis (commonly the superior division of the MCA)
37
In TIA, if emboli pass to the retinal artery, what can this cause?
Amaurosis fugax (one eye's vision is progressively lost - like curtains descending)
38
Investigations of TIA?
``` Bloods - FBC, ESR, U&Es, glucose, lipids CXR ECG Carotid doppler +/i angiography CT/diffusion-weighted MRI Echo ```
39
Management of TIA?
TIMING is crucial - assess ABCD2 score Risk of stroke in 90 days dramatically decreases if treated in 72hrs Control CVS RF: BP, smoking, lipids, DM Antiplatelet drugs: Clopidogrel/aspirin Warfarin if cardiac emboli Carotid endarterectomy - if >70% stenosis at the origin of the internal carotids artery, surgery should be performed within 2 weeks of TIA Avoid driving for 1 month
40
Causes of unilateral vision loss?
Vascular: - central retinal artery/vein occlusion - Anterior ischaemic optic neuropathy (can be arteritic: due to ischaemia of the arteries supplying the nerve, or non-arteritic) Optic neuritis Retinal detachment (flashes/floaters) Vitreous haemorrhage (flashes/floaters - associated with diabetic retinopathy/macular degeneration) Acute angle closure glaucoma (pressure in eye rises suddenly - painful red eye, nausea + vomiting)
41
What is papilloedema?
Optic disc swelling caused by increase in ICP
42
What changes will you see on fundoscopy for Anterior Ischaemic Optic Neuropathy?
Swollen optic disc | This is a cause of vision loss that occurs in GCA, also has non-arteritic causes
43
Fundoscopy findings for central retinal artery occlusion?
This artery supplies the whole retina | Findings: Pale optic disc, cherry red spot at macula
44
Fundoscopy of central retinal vein occlusion?
Dilatation of branch veins Multiple retinal haemorrhages Cotton wool patches
45
Investigations for unilateral vision loss?
History + exam Visual evoked potential (VEP)/MRI (optic neuritis) Fluorescein angiography (CRVO) Tonometry - intraocular pressure measure (glaucoma) USS - vitreous haemorrhage/retinal detachment
46
What are the symptoms of optic neuritis?
Reduced visual acuity over a few days PAIN on eye movements Exacerbated by heat/exercise Afferent pupillary defect (light swing test) Dyschromatopsia (can't see colours normally)
47
What is the cause of optic neuritis?
Inflammation of the optic nerve, often associated with MS, can occur as clinically isolated syndrome, other causes - infection (lyme, syphilis, HIV), B12 deficiency, arteritis
48
What is the 'course' of optic neuritis?
Vision usually recovers in about 6 weeks
49
Treatment of optic neuritis?
Steroids
50
What are the requirements for a diagnosis of MS?
Multiple CNS lesions, causing symptoms that: Last >24 hours Are disseminated in time (>1m apart) and space (clinically/on MRI)
51
Typical features of MS:
``` Usually MONOSYMPTOMATIC Visual loss (optic neuritis) Numbness/tingling in the limbs Sensory disturbances Cerebellar symptoms Bladder involvement/sexual dysfunction Lhermitte’s (electric shock sensation that runs down the back -> limbs) & Uhthoff’s phenomenon (worsening of symptoms due to heat/exercise) Fatigue Cognitive impairment ```
52
What are the signs of cerebellar disease?
``` DANISH Dysdiadochokinesis Ataxia Nystagmus Intention Tremor Slurred Speech Hyptonia ``` (Ataxia is a lack of muscle coordination that impedes speech or movement)
53
Signs of MS:
``` UMN signs Spastic paraparesis (of the lower limbs) Brisk reflexes Cerebellar signs Optic atrophy Relative afferent pupillary defect Internuclear opthalmoplegia (decreased adduction of ipsilateral eye, nystagmus on abduction of contralateral eye) ```
54
Investigations of MS:
``` MRI - lesions of high T2 signal intensity in the white matter of the brain - typically periventricular LP - oligoclonal bands of IgG in CSF Evoked potentials (VEP) ```
55
Pathophysiology of MS
Inflammatory, degenerative Loss of myelin with axon preservation Axonal loss may contribute to fixed and progressive deficits
56
Differential diagnosis of blackouts?
Syncope Epilepsy Non-epileptic attacks Narcolepsy, cataplexy, brain tumour, psychogenic seizures, hypoglycaemia, TIA, Migraine etc
57
Syncope definition
Syncope is an abrupt and transient loss of consciousness associated with loss of postural tone that follows a sudden fall in cerebral perfusion
58
Causes of syncope:
Neurogenic syncope Orthostatic syncope Cardiac syncope
59
What is neurogenic syncope?
Caused by enhanced parasympathetic tone and decreased sympathetic tone: Two elements: 1. cardio-inhibitory response = drop in HR and contractility 2. vasodepressor response = dilatation of blood vessels
60
What are the causes of neurogenic syncope?
Vasovagal syncope - prolonged standing, emotional stress, pain, sight of blood Situational syncope - after/during micturition, coughing, straining Carotid Sinus syncope - pressing a certain spot in the neck
61
What can cause orthostatic syncope (postural hypotension)? What specific condition should you test for with postural hypotension?
Primary (multisystem atrophy) Secondary (diabetes, drugs) Condition: Parkinsons
62
Causes of cardiac syncope?
Arrhythmias | Valvular heart disease
63
Definition of seizure
Clinical manifestations of sudden synchronised discharge of cerebral neurones
64
Definition of epilepsy
Recurrent, unprovoked tendency to experience seizures
65
Difference between syncope and seizures; triggers
Syncope - Stress/fear, prolonged standing, heat, venepuncture, cough, micturition Seizures - Sleep deprivation, flashing lights, menstruation, alcohol and alcohol withdrawal
66
Difference between syncope and seizures; prodrome
``` Syncope - Hot, visual crowding and loss, feel faint, can feel dizzy (looks pale) Seizures - aura (strange feeling in gut, deja vu, strange taste/sound, flashing lights) ```
67
Investigation of seizures:
``` Cardiac examination 12-lead ECG - check for prolonged QT Blood tests (FBC) EEG MRI brain ```
68
Investigations if syncope suggested:
24 hr tape Tilt table Autonomic function tests
69
Treatment of partial seizures:
1st line: Carbamezapine | 2nd line: Lamotrigine
70
Treatment of generalised seizures:
1st line: Sodium Valproate / Lamotrigine | For G T-C: 2nd line: Carbamezapine / Topiramate
71
Treatment of seizures that are unresponsive to medication:
If focal area easily identifiable, consider neurosurgical resection (70% chance seizure-free)
72
What are the early signs of stroke?
- None - Hyperdense MCA - Loss of grey white matter differentiation and sulcal effacement (disappear) - Hypodense basal ganglia
73
Complications of stroke
Raised ICP (cerebral oedema, haemorrhage) Aspiration Depression Cognitive impairment
74
What are the roles of the CHA2DS2 VASC or ABCD2 score?
CHADS2 - Calculates the stroke risk in patients with AF (within 1 year) ABCD2 - Calculates the risk of short-term stroke after TIA

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