Neurology Flashcards by Zachary Dodsworth

Two types of stroke? Percentage of each?

Main way to differentiate between each?

Ischaemic - 80%
Haemorrhagic - 20%

Head CT

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Two mechanisms of ischaemic stroke?
Where does each occur?
1: comes from? other example?
2: mechanism? which vessels?

Will have a core and a ____?

Embolism (away from brain) - clot form the heart (A-fib), cholesterol
Thrombotic (within brain vessel) - atherosclerosis, generally in larger vessels (IC, BA, MCA)

Penumbra - preserved by collateral circulation, may survive

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Two mechanisms of haemorrhagic?
1: often occurs at?

Increased ______ pressures increases risk of ___?

Tissue ischaemic is because of two reasons?

Berry (saccular) aneurysms: often at ACA, PCA, MCA at junctions
Arteriovenous malformations (rare defect)

Increased intracranial pressures increases risk of brain herniation

Tissue ischaemia - lack of flow & leaked blood irriates other vessels

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Lacunar strokes:
mechanism?
aneurysms?
which vessels?
vessels feed what?

chronic HTN causes hyaline arteriolosclerosis (protein thickening)

Charcot-Bouchard

Lenticulostriate - occur on branch of MCA

Feed internal capsule and basal ganglia

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When would a watershed strokes occur?

SHOCK - or other general decreased blood flow

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What are the risk factors for forming Berry aneurysms? (3)

Chronic HTN, PKD, connective tissue disorders

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How would different arteries affected by stroke present clinically?
MCA (3)
ACA (1)
PCA (1)
Basilar (1)

What is the 4 letter pneumonic?

MCA - face, upper body, Broca’s (speech)
ACA - lower body
PCA - vision: homonymous hemianopia
Basilar artery - locked-in syndrome (bilateral loss of corticospinal tracts)

Face, Arms, Speech, Time (FAST)

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Risk factors for ischaemic stroke:
Major heart problem?
2 basic others?

Atrial fibrillation

Metabolic syndrome - diabetes, obesity, HTN, low HDL cholesterol, high triglyceride
Smoking

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Acute treatment for ischaemic stroke (2) vs haemorrhagic stroke (3)
Surgery? (2 x 2)

ISCHAEMIC - Aspirin (stops further clots), Thrombolytics (eg, tPA)

Surgery: MERCI or suction

HAEMORRHAGIC - Anti-hypertensives, Elevate head, Anti-convulsant

Surgery: clips, coil embolisation

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What defines a TIA over a stroke?
______ long term problems
______ risk of ______

TIA - resolves in 24 hours

Minimal long term problems

Large increase risk of stroke occuring

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Prevention of further strokes:
Lifestyle - 3 points
Medications - 3 points
Surgery - 1 point

Lifestyle - blood pressure (exercise, salt, alcohol), smoking, medical conditions
Medications - blood pressure, statins, anti-platelet or anti-coagulants
Surgery - carotid endarterectomy

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EPIDURAL HAEMATOMA:
Occurs where?
Normal mechanism?
4 symptoms?
Clinical point to differentiate from subdural?
Diagnosis - scan? shows what?
Management - 3 key points?

Occurs in epidural space - between skull and periosteal dural mater

Damage to middle meningeal arteries - temporal bone fracture

Headache, N/V, High BP, Focal neural symptoms

Lucid interval present - good period followed by deterioration

CT scan - lens shape haematoma not crossing suture lines

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SUBDURAL HAEMATOMA:
Occurs where?

Mechanism - what vessel? situation? 2 risky populations? baby?

Symptoms? (4- classic)

Diagnosis - scan, shows what?

Management: if there is a ______, then evacuate the haematoma

Occurs in sub-dural space - between dural and arachnoid maters

Bridging vessels
Trauama, Falls, MVC
Elderley (brain atrophy), Alcoholics (vein damage)
Shaken baby syndrome

CT-head: Concave (crescent) that can cross suture lines
Hyperdense (acute) Hypodense (chronic)

Midline shift >5mm, then evacuate

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SUBARACHNOID HAEMATOMA:
Occurs where?
Mechanism?
Symptoms - classic? meningitis like (2)?
Diagnosis - scan? if positive, then what?
Management - two strategies?

Occurs in subarachnoid space - in between arachnoid mater and pia mater

Berry (saccular) aneurysm ruptures in circle of Willis

“thunderclap” headache - severe, sudden
Neck stiffness, photophobia

CT-Head, positive, 4-vessel angiography

Supportive - bed rest, lower BP
Surgery - coil embolisation (preferred) or clips (out of date)

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INTRACEREBRAL HAEMATOMA:
Occurs in where? (4)
3 example arteries supplying these areas?
3 causes of these arteries being damaged?
Sudden neurological defecits like hemiparesis? hemiplegia?
Management - increased _____ needs to be controlled. If there is _____ evacuation needed

Occurs in various places - thalamus, basal ganglia, cerebellum, PONS

Lenticulostriate, thalamo-geniculate, pontine branches

Hypertension, AV malformations, Amyloidosis

Hemiparesis - half side weakness
Hemiplegia - half side paralysis

Increased INTRACRANIAL PRESSURE needs to be controlled
If MASS EFFECT is present, evacuate

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What is amaurosis fugax? What condition does it often occur in?

Emboli in retinal artery
Cannot see - “curtain descending over my vision”

Association with TIAs

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What does the ABCD2 score predict? What does each letter represent?

Risk of stroke after a TIA has occured

Age
Blood pressure
Clincial features of the TIA
Duration & Diabetes

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What specifically is inflamed in meningitis?

Two types of spread, that can cause the infection

LEPTOMENINGES - pia mater and arachnoid mater

DIRECT - skin, nose, fracture, spina bifida
HAEMATOGENOUS - blood

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Bactaeria in meningitis:
Newborns (4)
Children & young adults (2)
Elderly and immunocomprimised (2)

• Newborns -
Group B streptococci,
E. Coli,
Listeria monocytogenes, Haemophilus influenzae

Children & young adults - Neisseria meningitidis, Streptococcus pneumoniae
Older adults & elderly - Streptococcus pneumoniae, Listeria monocytogenes

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3 viral causes of meningitis?

3 other categories of causes (non-bacterial)
What is different in these presentations?

Enterovirus (coxsackie)
HSV
HIV

FUNGAL - Cryptococcus genuses, Coccidioides genuses (chronic)
TUBERCULAR - Mycobacterium tuberculosis (chronic)
PARASITIC - Plasmodium falciparum (chronic)

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Classic triad of MENINGITIS symptoms?
Other symptoms?

What are the two signs that will be positive in meningitis?

Classic triad - headaches, photophobia, neck stiffness
Fever often present

Two tests:
Kernig’s sign - knee at 90, straightened at knee, causes back pain
Brudzinski’s sign - neck flexed, causes knees to be flexed

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CSF in bacterial meningitis:
Colour?
WBC?
Protein?
Pressure?
Glucose?

Noted differences in VIRAL and FUNGAL/TB

Signs of infection:
CSF - cloudy (should be gin clear)
WBC - increased (bacterial = neutrophils, lymphocytes = viral)
Protein - increased
Pressure - increased
Glucose - decreased

Viral - normal proteins, normal gram-staine, normal pressure, clear (not cloudy), massive WBC increases

Fungal/TB - fibrin web

Neisseria meningitis:
Microscopy vs S. pneumoniae
Causes a skin \_\_\_\_, looks like?
Notifiable to?
Why is it common in university students?

GRAM -VE, DIPLOCOCCI
Streptococcus pneumoniae is POSITIVE

Capillary damage and/or DIC
- non-blanching, purpuric, petechiae rash

Family carriers - move to a new house

Tell Public Health England

Treatment of meningitis:
In community?
Two classic broad spectrum?
Other antibiotic used in cover?
What is used other than antibiotics?

IN COMMUNITY - IM Benzylpenicillin, send to hospital

Commonly 3rd generation
cephalosporins:
Ceftriaxone, Cefotaxime

Amoxicillin covers Listeria

Steroids used - reduces brain swelling (inflammation)

Important differential of meningitis? | How is viral meningitis treated?

Subarachnoid haemorrhage Supportive w/ acyclovir

``` Encephalitis is inflammation of ____? Normal cause (2)? + a rarer cause? ```

``` of the BRAIN PARENCHYMA Often viral (HSV, sometimes Varicella Zoster), sometimes bacterial ```

Symptoms of encephalitis: Early symptoms (4) Late symptoms: (3) Can still have _____ signs and symptoms, but ______ is often altered

Early symptoms - fever, headache, lethargy, behaviour changes Late symptoms - focal signs, seizures, coma Can still have MENINGITIS signs and symptoms, but CEREBRAL FUNCTION is often altered

Normal treatment for encephalitis? (2) | What would the lumbar puncture show in this condition?

Supportive Often IV acyclovir (anti-viral) Would show raised lymphocytes

``` What organism cause tetanus? Found where? Mechanism of the disease? What to do if there is a risk injury? Two classic presentation points? ```

Clostridium tetani Found in soil Bacteria produce toxins - travel along axons and interfere with neurotransmitter release Vaccintion if there is a risk injury Risus sardonicus (satanic smile) Complete muscle spasm Could be localised?

Rabies is what type of infection? Cause by? "Travels ____" Has a varaible ______ Treatment: 2 options? If it becomes _____

Viral infection Inoculation throguh skin with saliva of rabid animal Travels retrogradely along nerve Pre or Post-exposure prophylaxis If symptomatic - it's fatal

Name the 3 primary headaches? Name 4 secondary headaches? What is the name of the painful cranial neuropathy?

Primary - migraine, cluster, tension type Secondary - meningitis, subarachnoid haemorrhage, GCA, chronic medication overuse (aspirin, paracetamol, NSAIDs, triptans, etc) Painful cranial neuropathy - trigeminal neuralgia

``` MIGRAINE: What side? Severity? Character of pain? Onset? How long? 4 associated symptoms? Worsens with? ```

Often unilateral, Moderate/severe, Throbbing, Gradual onset Duration: 4-72 hours N/V, Photophobia, Phonophobia Worsens with activity

``` Migraine treatment: Normal (3 - 2 drugs and 1) Severe (1 - drug) Preventative? (2 - drugs) Reduce _____? Examples of this? ```

NSAIDs/Aspirin, Antiemetic, Hydration Severe - oral triptan (eg, Sumatriptan) is given. Has come contraindications - vascular diseases Preventive - topiramate (anti-convulsant) or propranolol (beta-blocker) Reduce triggers: Chocolate, Hangovers, Orgasms, Cheese, OCP, Lie-ins, Alcohol, Tumult (loud noises), Exercise

``` TENSION TYPE: What side? Severity? Character of pain? How long? Associated symptoms? ```

Bilateral Mild to moderate Waxes and wanes Pressure or tightness band Massive variable time - 30 minutes to 7 days Little associated - sometimes photophobia or phonophobia Triggers - missed meals, stress, overexertion, lack of sleep, depression

Can you name some triggers of TENSION TYPE headache? (5) What is the go to medication? _____ relief?

Triggers: missed meals, stress, overexertion, lack of sleep, depression Paracetamol or NSAIDs Stress relief

``` CLUSTER: What side? Where? Severity? Character of pain? Onset? How long? Point about activity? Associated points (3) - trigeminal autonomic features ```

``` Unilateral - around eye Severe Deep continous pain Begins quickly Short (15-180 minutes) Often causes restlessness and agitation ``` Horner's syndrome (ptosis + miosis) Lacrimation Nasal charge

What is the main medicatino for CLUSTER headache? | 2 preventative drugs?

Treatment: SC SUMATRIPTAN | Preventive - topiramate or propranolol

``` RAISED ICP: Headache is worse when (1) Headache is worse when (1) Headache is worse when (3) Association with _/_ What is papilloedema? ```

Worse on waking Worse on coughing, sneezing, straining Postural - worse lying down Nausea/Vomiting Papilloedema (may be absent if acute): swollen optic disks

Type of pain in trigeminal neuralgia? Lasting how long? | What is the main medication of trigeminal neuralgia? Next step?

Electrifying/Lightning/Stabbing pain - lasting a few seconds Medication - CARBAMAZEPINE (anti-convulsant) Phenytoin, Gabapentin (neuropathic pain analgesia) Surgery is a final option

Can have what before a migraine? What percentage of migraines? 3 points about it

Episodic migraines Aura: 20% without, 80% with Visual symptoms - flashing lights, zigzags Sensory disturbances - tingling in hands and feet Language aura and motor aura

What would you see in a biopsy of someone with GCA? Which vessels does GCA affect? Why is it difficult to biopsy?

Giant cells in the elastic lamina Branches of the carotid - eg, TEMPORAL, opthalmic, facial, occipital... Segmental - need a long piece, and may not be present

``` How would someone with GCA present: 3 general symptoms Temporal specific? Opthalmic specific? Facial specific? Occipital specific? ``` 3 signs related to the temporal arteries?

Malaise, fever, anaemia Temporal - headache (often localised) Opthalmic - visual disturbances (amaurosis fugax) Facial - jaw claudication Occipital - scalp tenderness PALPABLE, TENDER and REDUCED PULSATION of temporal arteries

3 points on epidemiology of GCA? | What is major lab result that would be seen in GCA?

Women > Men, Almost always >50, Common in Scandinavia Increased ESR!! (also CRP)

What is the go to treatment of GCA? Why does this need to be done quickly?

Corticosteroids Eg - prednisolone Because of the complication: BLINDNESS (important to treat quick - don't wait for biopsy)

What is the definition of an epileptic seizure? Too much ____? Too little ____ ?

neurons synchronously active (paroxysmal discharge of cerebral neurons) Too much excitation - lots of glutamate Too little inhibition - too little GABA

``` What is the other name for a partial seizure? What does it effect? What are the two subtypes? Basic characteristics of each subtype? What is a Jacksonian March? ```

Focal seizure Effects ONE hemisphere or ONE area Simple - remain conscious (small area, strange sensations and jerking) Complex - impaired consciousness (imapired awareness, may not remember) A simple partial seizure spreads from the distal part of the limb toward the ipsilateral face

``` What can a generalised seizure progress from? Definitions of the following? TONIC ATONIC CLONIC TONIC-CLONIC MYOCLONIC ABSENCE Which of these is most common? ```

Can progress from a PARTIAL SEIZURE * TONIC - flexed, fall backwards * ATONIC - relaxed, fall forwards * CLONIC - convulsions * TONIC-CLONIC - sudden tense muscle, followed by convulsions * MYOCLONIC - short muscle twitches * ABSENCE - lose and regain consciousness, "space out", commonly presents in childhood Tonic-Clonic is most common

If seizures last greater than 5 minutes what are these called? What is the usually type of seizure? What is the emergency treatment used? How does this work?

If seizures last greater than 5 minutes - STATUS EPILEPTICUS Usually TONIC-CLONIC Medical emergency - treated with BENZODIAZEPINES (enhances GABA)

What are the three diagnostic tests that can be done in epilepsy? What are the two symptoms that could occur after seizures?

MRI & CT - brain scan for abnormalities EEG - detect electrical signals Postical confusion Todd's Paralysis (paresis in arms or legs for around 15 hours after seizure)

``` Management of epilepsy: Focal/partial medication? Generalised medication? Nerve _____? Epilepsy _____? Diet ____? Avoid ____? eg ____ ```

* Focal - CARBAMAZEPINE * Generalised - SODIUM VALPORATE (teratogenic) Nerve Stimulation Epilepsy surgery Ketone diet Avoid triggers - eg flashing lights

``` Differential of seizures: EPILEPTIC - Time ____ symptoms 3 more ```

``` 30-120 seconds Positive symptoms - tingling and movement Tongue biting Head turning Muscle pain ```

Differential of seizures: NON-EPILEPTIC - Time 4 more

``` 1-20 minutes in duration (longer than epileptic) Eyes closed Crying or speaking Pelvic thrusting History of psychiatric illness ```

Differential of seizures: Syncope Time 4 more

``` 5-30 seconds Sweating Nausea Pallor Dehydration ```