Neurology Flashcards
1
Q
What are the features of motor neuron disease?
A
Can present with both UMN and LMN signs Fasciculations Absence of sensory signs/sx Wasting of small hand muscles/tibialis anterior No cerebellar/external ocular muscle effects Sphincter dysfunction late feature
2
Q
What is the commonest presentation of MS?
A
Optic neuritis
3
Q
What are the features of MS?
A
Visual: Optic neuritis Optic atrophy Internuclear ophthalmoplegia Sensory: Pins and needles Numbness Trigeminal neuralgia Lhermitte’s (paraesthesiae in limbs on neck flexion) Motor: Spastic weakness (most commonly legs) Cerebellar: Ataxia Tremor Other: Urinary incontinence Sexual dysfunction Intellectual deterioration
4
Q
What are risk factors for MS?
A
EBV Low Vit D Smoking Obesity in adolescence Female gender
5
Q
If you suspect MS what should you do?
A
Refer to neurology Bloods incl. FBC, inflammatory markers, LFTs, U&Es, Ca, glucose, TFTs, B12, HIV
6
Q
What is the treatment for a relapse of MS?
A
Oral methylprednisolone 0.5g daily for 5 days
7
Q
What is an essential tremor?
A
Autosomal dominant Postural tremor Worse if arms outstretched
8
Q
What improves essential tremor?
A
Alcohol and rest
9
Q
What is the management of essential tremor?
A
Propanolol 1st line Primidone sometimes used
10
Q
What are the features of Wernicke’s encephalopathy?
A
Confusion Ataxia Nystagmus Opthalmoplegia PEripheral Neuropathy
11
Q
What causes Wernicke’s encephalopathy?
A
Thiamine deficiency Persistent vomiting Stomach Ca Dietary deficiency
12
Q
What can occur if Wernicke’s encephalopathy is not treated?
A
Korsakoff syndrome
13
Q
What is korsakoff syndrome?
A
Nystagmus Opthalmoplegia Ataxia + Amnesia + Confabulation
14
Q
What is the management of cluster headaches
A
Sumatriptan subcut (6mg) or nasal (10-20mg) 100% O2 for 15-20mins
15
Q
What are the features of Bells palsy?
A
LMN facial nerve palsy Affects forehead May have pain, altered taste, dry eyes, hyperacusis
16
Q
What is the management of Bells palsy?
A
Pred 1m/kg for 10d if seen within 72hr of onset of symptoms Consider eye lubricants/artificial tears
17
Q
What causes Brown-Sequard syndrome?
A
Lateral hemisection of the spinal cord
18
Q
What does ipsilateral weakness, ipsilateral loss of proprioception and vibration sensation, and contralateral loss of pain and temp sensation suggest?
A
Brown-Sequard syndrome
19
Q
Definition of encephalitis
A
Inflammation of brain parenchyma
20
Q
Triad for acute encephalitis
A
Fever Headache Altered mental status
21
Q
Causes of encephalitis
A
Vacterial Bacterial Toxins Autoimmune disorders
22
Q
Features of viral encephalitis
A
Symptoms of meningitis (fever, headache, neck stiffness, vomiting) followed by altered consciousness, confusion, drowsiness, seizures and coma May have features of increased intracranial pressure
23
Q
What is CIDP
A
Chronic inflammatory demyelinating polyneuropathy cause of peripheral neuropathy antibody mediated inflammation results in segmental demyelination of peripheral nerves
24
Q
Features of CIDP
A
Males more commonly affected than females Similar to Guillain-Barre syndrome (GBS), with motor features predominating Insidious onset, over weeks to months - often thought of as the chronic version of GBS
25
High protein content in CSF suggests
CIDP
26
Treatment of CIDP
High dose steroids
27
Migraine features
* **Headache**- usually **unilateral, pulsating or throbbing**, lasts 4-72hrs
* **Worsened by routine activity**
* Photophobia
* Phonophobia
* Nausea
* Vomiting
* Can occur **with or without aura** (transient focal neurological symptoms e.g. zigzag lines, scotoma, pins and needles).
28
Management of migraines
_Conservative_
* **Headache diary**
* **Avoid triggers**
* **Lifestyl**e - good sleep hygiene, stress management, hydration, exercise, regular meals, healthy weight
* If medication overuse headache, restrict acute medication
_Medical_
* **Simple analgesia**- ibuprofen, aspirin or paracetamol
* Triptan alone or with paracetamol/NSAID e.g. **sumatriptan** 50-100mg
* Consider **anti-emetic** e.g. metoclopramide 10mg or prochlorperazine 10mg
* Avoid COCP in migraine with aura
29
Indications for preventative treatment in migraine?
* Migraine attacks are having a significant impact on QOL/daily function, or are prolonged and severe despite optimal treatment
* Acute treatments contraindicated/ineffective
* Patient at risk of medication overuse headache
30
Preventative treatments for migraine
* **Propanolol** 80-160mg daily
* **Topiramate** 50-100mg daily
* **Amitriptyline** 25-75mg at night
31
Features of **tension-type headache**
* **Generalised headache** usually described as a **pressure or tightness around the head** which often spreads into or arises from the neck
* **Mild-moderate intensity**, can last **minutes to days**
* **Not aggravated by routine physical activity** e.g. walking
* **Pericranial tenderness** which may be elicited on manual palpation
32
**Management** of **tension-type headache**
* **Simple analgesia** e.g. paracetamol, aspirin, NSAIDs
* **Avoid opioids**
* **Identify and manage comorbidities** e.g. mood disorder, chronic pain, sleep disorders
* **Avoid medication overuse**
* Preventative treatment- chronic tension headaches. Acupuncture or low dose amitriptyline.
33
**Features** suggestive of a **serious cause of headache**
* **New severe or unexpected headache**:
* Sudden onset severe headache reaching max intensity withing 5mins- intracranial haemorrhage, venous sinus thrombosis, hypertensive encephalopathy, verterbral artery dissection.
* New onset headache and ages \>50yrs- GCA/SOL
* **Progressive or persistent headache/headache that has changed dramatically**- consider mass lesion/subdural haematoma
* **Fever, impaired consciousness, seizure, neck pain/stiffness, photophobia**- consider meningitis/encephalitis
* **Papilloedema**- consider SOL, cerebral venous sinus thrombosis, benign intracranial HTN
* **New-onset neurological deficit, change in personality and new-onset cognitive dysfunction-** consider cerebrovascular event, malignancy or SOL e.g. haematoma
* **Atypical aura or aura in patient on COCP**- consider cerebrovascular event
* **Dizziness**- ischaemic/haemorrhagic stroke
* **Visual disturbance**- migraine, acute closure glaucoma, temporal arteritis
* **Vomiting**- migraine, mass lesion, brain abscess, carbon monoxide poisoning
* **Headache worse on standing**- CSF leak
* **Headache worse on lying down**- SOL or cerebral venous sinus thrombosis
* Recent trauma- subacute or chronic subdural haematoma
34
Cause of **shingles**
**Reactivation** of **varicella-zoster virus** causing viral infection of **nerve cells**
35
Complications of shingles
Post-herpetic neuralgia
Secondary infection
Scarring
Ocular complications
36
Features of **shingles**
**Prodrome**- including **abnormal sensation** in affected skin and sometimes headache, malaise and fever.
**Rash**- usually **unilateral**. Macules and papules develop into vesicular lesions in **dermatomal distribution** which burst and form ulcers and crusts.
Pain- **intense neuralgic pain** over affected area
Healing within 2-4 weeks, lesions typically crust over within 7-10d
37
Management of shingles
* **Paracetamol/codeine/ibuprofen for pain**
* Amitriptyline/gabapentin/pregabalin/duloxetine if severe pain
* **Aciclovir** within72 hrs of rash onset if \>50yrs, non-truncal involvement, moderate/severe pain or rash
38
Shingles is infectious until...
All vesicles have crusted over (usually 5-7d after rash onset)
39
Shingles vaccine is offered to...
All people aged 70-75, 78, or 79 years
40
**Causes of blackouts** (transient spontaneous LOC followed by complete recovery)
**Neurally mediated reflex syncope** (incl. vasovagal, carotid sinus syndrome, situational syncope)
## Footnote
**Orthostatic hypotension**
**Cardiac abnormalities**
**Epilepsy**
41
**Vasovagal syncope is suggested by** absence of (?) and presence of (?)
**Absence of features to suggest an alternative diagnosis**
AND
**Presence of the 3 P's:**
**Posture**- blackout occured after prolonged standing
**Provoking factors**- such as pain/medical procedure
**Prodromal symptoms**- such as sweating or feeling warm/hot
42
Features of orthostatic hypotension
Light-headedness
Dizziness
Weakness
Tunnel vision
Symptoms worse on standing
Relieved by sitting/lying down
43
Features suggestive of epilepsy as cause of blackout
Bitten tongue
Head-turning to one side during blackout
Loss of bowel and bladder control
Unusual posturing
Prolonged limb-jerking
Confusion following event
Prodromal deja vu or jamais vu
44
Features suggesting **cardiac cause of blackout**
ECG abnormality
Evidence of heart failure
Blackouts occuring during exertion
Palpitations
FHx of sudden cardiac death in people \<40yrs
Inherited heart condition
New/unexplained breathlessess
Heart murmur
45
**Features** suggesting a **non-epileptic seizure**
Duration over two minutes
Gradual onset, fluctuating course
Violent thrashing movements
Dide-to-side head movement
Asynchronous movements
Eyes closed
Recall for period of unresponsiveness.
46
Types of **psychogenic seizures** (3)
* **Dissociative seizures** are involuntary and happen unconsciously. This is the **most common type of NES** and the person has no control over the seizures.
* **Associated with psychiatric conditions** that cause seizures - eg, panic attacks.
* **Factitious seizures** - eg, Münchhausen's syndrome, fabricated or induced illness by carers.
47
What are **reflex anoxic seizures**?
**Paroxysmal, spontaneously-reversing brief episodes of asystole** triggered by pain, fear or anxiety.
Anoxic seizures are **non-epileptic events caused by a reflex asystole** due to **increased vagal responsiveness**.
They are **often misdiagnosed as epilepsy**.
48
Typical **presentation** of **reflex anoxic seizures**
* During the episode, the **child becomes suddenly pale and limp, will fall if standing and loses consciousness**.
* This is followed by **stiffening and clonic jerking of the limbs**.
* The episode is usually **brief** (30-60 seconds) and **recovery is rapid**.
* There **may also be upward eye deviation and urinary incontinence**.
* On recovery, the **child may feel tired and washed-out** for some time.
* Reflex anoxic seizures **do not cause tongue-biting** and this may be useful in the differentiation from epilepsy.
49
**Definition** of **epileptic seizure**
An **epileptic seizure** is the **transient occurrence of signs or symptoms** due to **abnormal electrical activity** in the **brain**, leading to a **disturbance of consciousness, behaviour, emotion, motor function or sensation**.
50
Epileptic seizure classification
Focal seizures:
* Simple focal
* Focal dyscognitive
* Focal seizure evolving to generalised tonic-clonic convulsions
Generalised seizures:
* Abscence
* Myoclonic
* Clonic
* Tonic
* Tonic-clonic
* Atonic
Unclassified
51
Investigations in someone presenting with a seizure
Bloods- glucose, electrolytes, calcium, renal function, LFTs, urine biochemistry
EEG- if seizure likely epileptic
MRI- to identify structural abnormalities
52
Types of generalised seizure
* **Tonic seizures** that cause **impairment of consciousness and stiffening**; the trunk may be either straight or flexed at the waist.
* **Clonic seizures** that cause **jerking and impairment of consciousness.**
* **Tonic–clonic seizures** that cause **stiffening and jerking and impairment of consciousness**.
* Typical **absence seizures**, which begin in childhood.There is a sharp onset and offset with no residual symptoms. **Normal activity is interrupted and the child stares for a few seconds**. The eyelids may twitch and some very small jerking movements of the fingers may occur (but these are usually not noticed). The duration is typically 5–10 seconds and usually less than 30 seconds; absence seizures may occur dozens or even hundreds of times daily in some children.
* **Myoclonic seizures** that cause **brief, shock-like contraction of the limbs, without apparent impairment of consciousness**.
* **Atonic seizures** that cause **sudden brief attacks of loss of tone**, associated with **falls** and **impairment of consciousness**.
53
Features of focal seizures
* **Focal motor seizures** that cause a **jerking movement**, typically beginning in the face or one hand, and spreading to involve the limbs. They may also present with apparently purposeful movements such as turning the head, eye movements, lip smacking and mouth movements, drooling, or rhythmic muscle contractions. Limb weakness may occur for several hours after the seizure.
* **Focal sensory seizures**, including temporal lobe seizures that may cause sensory, autonomic, emotional, cognitive, or other changes. Consciousness may be fully retained (simple partial seizures) or impaired (complex partial seizures) during an attack.
* **Secondarily generalized seizures** start with a **focal seizure** before **spreading to cause a generalized seizure**.
54
Primary care management of suspected seizure
**Urgent referral to neurology**
**Advise family/carers** how to **recognise and manage seizures**
Advise them to **stop driving** until have seen specialist
Keep a **seizure diary**
**Avoid swimming, take care when bathing**
55
**Management of epileptic seizure**
(in primary care/community)
For people having a **tonic-clonic seizure**, note the time, and if it lasts **less than 5 minutes**:
* Look for an epilepsy identity card or jewellery.
* **Protect them from injury** by:
* Cushioning their head with your hands or soft material.
* Removing harmful objects from nearby, or if this is not possible, moving the person away from immediate danger.
* Do not restrain them or put anything in their mouth.
* **When the seizure stops, check their airway and place them in the recovery position.**
* Observe them until they have recovered.
* Examine for, and manage, any injuries.
* Arrange **emergency admission if it is their first seizure.**
For people having a **tonic-clonic seizure lasting more than 5 minutes**, **or who have more than three seizures in an hour**, in addition to the above measures:
Treat with one of the following:
* **Buccal midazolam** as first-line treatment in the community.
* **Rectal diazepam** if preferred, or if buccal midazolam is not available.
* **Intravenous lorazepam if intravenous access is already established and resuscitation facilities are available.**
* Call for an ambulance if seizures not responding or are prolonged/recurrent.
56
When should antiepileptics be started?
* **Following a second epileptic seizure**
* After the first seizure if:
* Patient has neurological deficit
* Brain imaging shows structural abnormality
* EEG shows unequivocal epileptic activity
* Patient/family/carers consider risk of further seizure unacceptable
57
What are the **first line AEDs** for **generalised** and **focal seizures**?
_Generalised seizures:_
**Sodium valproate**
_Focal seizures:_
**Carbamazepine** or lamotrigine
58
What is carotid sinus hypersensitivity?
**An exaggerated response to carotid baroreceptor stimulation**
Defined by response to gentle carotid sinus massage for 5-10 seconds:
* **At least 3 second asystole** (cardio-inhibition)-70-75% of cases
* **Lowering of BP by at least 50mmHg** (vasodepression)- 5-10%
* A combination of the above- 20-25%
59
Triggers for carotid sinus hypersensitivity?
* Shaving
* Head turning
* Neck extension
* Tight collars
60
