Neurology Flashcards

Question

List signs and symptoms of spinal cord compression/cauda equina

Answer 1

- Bilateral sciatica - Leg weakness - LMN at level of the lesion, UMN below the lesion (eg. Hyperreflexia, hypertonic) - not cauda equina - Urinary hesitance or incontinence - Faecal incontinence - Sensory disturbance including saddle anaesthesia - Reduced anal tone

Answer 2

- Sudden onset, central spinal pain - Relieved on lying down - History of trauma - Risk factors including steroid use

Answer 3

- Age over 50 - Gradual onset - Night pain - Localised spinal tenderness - Unexplained weight loss - History of cancer

Answer 4

- Fever - History of infection (TB, recent UTI) - Diabetes - IV drug use - HIV infection - Immunosuppressive therapy

Answer 5

Cauda equina - Flaccid paralysis asymmetrical - Decreased or absent reflexes - Saddle anaesthesia which is asymmetrical - Faecal incontinence/urinary retention Spinal cord compression (UMN) - Spastic paralysis, symmetrical - Increased reflexes - Specific anatomical level of sensory defect which si symmetrical - Faecal/urinary incontinence

Answer 6

- Physiological - Essential (hereditary) - Parkinsons - Intention

Answer 7

- Fine, fast postural tremor | - Similar to hyperthyroidism, alcohol/caffeine excess, side effect of beta agonist bronchodilators

Answer 8

- Postural, worse when arms are outstretched - Improved by alcohol and rest, worsened by stress, caffeine and sleep deprivation - Titubation (head nodding) - Family history (autosomal dominant) - Presents over age 40

Answer 9

- Slow, coarse, pill rolling - Worse at rest - Reduced with voluntary movement - Upper limbs more affected - Asymmetrical - Doesn't affect head

Answer 10

- Absent at rest - Maximal on movement and approaching target - Cerebellar pathology

Answer 11

An acute, unilateral facial nerve weakness or paralysis of rapid onset (less than 72 hours) and unknown cause.

Answer 12

Herpes simplex virus, varicella zoster virus, and autoimmunity may contribute to the development of Bell's palsy, but the significance of these factors remains unclear.

Answer 13

- Affects 20–30 people per 100,000 each year. | - It most common between 15 and 45 years of age.

Answer 14

- Eye injury - Face pain - Dry mouth - Intolerance to loud noises - Abnormal facial muscle contraction during voluntary movements - Psychological sequelae

Answer 15

- Rapid onset (less than 72 hours). - Facial muscle weakness (almost always unilateral) involving the upper and lower parts of the face. This causes a reduction in movement on the affected side, often with drooping of the eyebrow and corner of the mouth and loss of the nasolabial fold. - Ear and postauricular region pain on the affected side. - Difficulty chewing, dry mouth, and changes in taste. - Incomplete eye closure, dry eye, eye pain, or excessive tearing. - Numbness or tingling of the cheek and/or mouth. - Speech articulation problems, drooling. - Hyperacusis.

Answer 16

Made when no other medical condition is found to be causing facial weakness or paralysis

Answer 17

- Keep the affected eye lubricated by using lubricating eye drops during the day and ointment at night. The eye should be taped closed at bedtime using microporous tape, if the ability to close the eye at night is impaired. - For people presenting within 72 hours of the onset of symptoms, prescription of prednisolone should be considered. - Antiviral treatment alone is not recommended, but it may have a small benefit in combination with a corticosteroid; specialist advice is recommended if this is being considered.

Answer 18

A neurological disorder characterized by a symptom triad of miosis, partial ptosis), and facial anhidrosis.

Answer 19

Cluster headache is a rare but severe headache disorder which may be: - Episodic cluster headache — attacks occur in periods lasting from 7 days to 1 year and are separated by pain-free periods lasting at least 1 month. - Chronic cluster headache — attacks occur for more than 1 year without remission, or with remission periods lasting less than 1 month. - Often occur at the same time of day, waking the person from sleep Most common trigeminal autonomic cephalalgia

Answer 20

- The aetiology of cluster headaches is not fully understood — acute attacks involve activation in the region of the posterior hypothalamic grey matter. - Acute cluster headache may be inherited as an autosomal dominant condition in about 5% of people. - Factors such as previous head trauma, cigarette smoking and alcohol intake have been associated but no causal relationship identified. - There may be an interaction between genetic and environmental factors.

Answer 21

- Estimated one-year prevalence of 53 per 100,000 adults and a lifetime prevalence of 124 per 100,000. - The typical age of onset of cluster headache is 20 to 40 years. - 70% of patients report onset before 30 years of age. - Males are affected about four times more than females overall. - The male-to-female ratio is markedly higher for chronic cluster headache (15:1) than for episodic cluster headache (3.8:1). - Most people (80-90%) have episodic cluster headache with recurrent bouts separated by remission periods of more than a month.

Answer 22

- Unilateral periorbital pain. - Ipsilateral autonomic symptoms such as conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhoea, eyelid oedema, forehead and facial sweating or flushing. - Pain may be described as pulsating, boring, burning, or pressure-like. - Attacks last between 15 and 180 minutes. - Trigger for attacks (eg. alcohol, histamine, physical exertion, sleep or the smell of volatile substances such as perfume or petrol)

Answer 23

During an attack the person is characteristically restless or agitated, cannot lie still and may pace the floor.

Answer 24

Clinical diagnosis - At least five attacks of severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes and - Headache associated with at least one of: ipsilateral conjunctival injection and/or lacrimation; nasal congestion and/or rhinorrhoea; eyelid oedema; forehead and facial sweating or flushing; a sensation of fullness in the ear; or miosis and/or ptosis; and/or a sense of restlessness or agitation. - Attacks occur between one every other day and eight per day for more than half of the time when the disorder is active. - The headache is not better accounted for by another ICHD-3 diagnosis.

Answer 25

- Guillain-Barre syndrome is an acute inflammatory demyelinating polyneuropathy (AIDP). - It typically comes on several weeks after viral infection, usually, GI or URTI . HIV is also known to be a cause.

Answer 26

- 1-2 per 100 000/ 1 in 50000 per annum | - In 40% of cases, no cause is found

Answer 27

- It typically comes on several weeks after viral infection, usually, GI or URTI (also sometimes flu vaccine [controversial]). Causal pathogens include campylobacter jejune, CMV and HIV - HIV is also known to be a cause. - The viral infection causes the production of auto-immune antibodies against peripheral nerves. Myelin is damaged, and transmission is reduced or even blocked.

Answer 28

- Symmetrical muscle weakness, that usually begins in the lower legs, and ascends to the upper limbs, and even the face. - Usually it progresses over about 4 weeks before recovery - It may advance very quickly, affecting all limbs at once, and resulting in paralysis - Pain is common - Difficulty swallowing, breathing, moving - Miller Fischer syndrome optjalmoplegia, areflexia and ataxia with no muscle weakness

Answer 29

- Trunk, respiratory and cranial nerves can also be affected – again helping differentiate from other neuropathies. - Autonomic signs – sweating, tachycardia, dysrythmias, respiratory involvement - Sensory signs often absent, reflexes absent or reduced - Reduced power, problems with balance and coordination

Answer 30

- Lumbar puncture – increased protein in the CSF, white cell count normal (albuminocytologic dissociation) - Nerve conduction studies/ EMG – slowed. MRI spine. - FVC to monitor lung function - if less than 2 call ITU - Bloods (anti-ganglioside antibodies in Miller Fischer and 25% GB)

Answer 31

Myasthenia Gravis is an acquired, autoimmune disease of the neuromuscular junction due to antibodies produced against nicotininc acetylcholine receptor(fatigability)

Answer 32

- Antibodies attack the Acetylcholine receptor. - Therefore, the nerve signal is not fully transmitted, and the resultant muscle weakness is a result of incomplete stimulation, rather than an inherent disorder within the muscle. - Strong association with disorders of thymus, with 75% patients having thymus hyperplasia/atrophy - Personal or family history of autoimmune diseases. - Under 50 commoner in females, over 50 commoner in males

Answer 33

- The prevalence of Myasthenia Gravis is about 1 in 5,000. | - Although anyone is susceptible to it, there are two main subgroups, young women (20-35) and older men (60-75).

Answer 34

- Ocular- Diplopia and ptosis - Bulbar-Dysphagia, Dysphonia, Dysarthria and weak/droopy face - Proximal muscle weakness- Shoulders and Thighs - Axial weakness – Neck and trunk, but also muscles involved in Respiration - Generally periods of remission and crises - Weakness is worse with use (therefore, worst at the end of the day) - Limb reflexes are usually normal or brisk, and there are no sensory abnormalities. - Muscle wasting is usually not present, unless there is severe disease, or the patient has had the condition for a long time. - Fatiguability

Answer 35

- TENSILON test, in which patients are given two drugs, Edrophionium, which prevents breakdown of acetylcholine, and atropine to prevent cardiac side effects associated with Edrophionium. If the patient has myasthenia gravis, then within seconds there is a dramatic symptomatic improvement, however this goes after a couple of minutes. - Blood tests for serum acetylcholine receptor antibodies are positive in over 85% of patients with Myasthenia gravis, and there may also be other autoantibodies present, usually against muscle, joints or the thyroid. - Electromyography is used to measure how fatigable a muscle is. Electricity is used to repeatedly stimulate a muscle, fatigue can be seen. Single fibre electromyography is usually preferred, as stimulating a single motor unit (remember those, a motor neurone and the muscle fibres it supplies), a variability called a ‘jitter’ can be found. - CT/ MRI scans are used to image the thymus, looking in particular for hyperplasia and thymoma - Spirometry is important as it gives an indication as to how badly affected the respiratory muscles are. In some crises respiratory function is compromised, and urgent medical attention is needed. - Ptosis improves after ice compression

Answer 36

- Central facial nerve palsy causes weakness or paralysis of the contralateral face that spares the muscles of the forehead, due to bilateral upper motor neuron innervation of the upper face. - Peripheral facial nerve palsy affects all muscles of facial expression on the ipsilateral side.

Answer 37

Parkinson's disease is a chronic, progressive neurodegenerative condition resulting from the loss of the dopamine-containing cells of the substantia nigra.

Answer 38

- Parkinsonism is an umbrella term for the clinical syndrome involving bradykinesia together with at least one of the following: rigidity, tremor, and postural instability. - Parkinson's disease is the most common form of parkinsonism. - Other causes of parkinsonism include drug-induced, cerebrovascular disease, Lewy body dementia, multiple system atrophy, and progressive supranuclear palsy.

Answer 39

- Not fully understood - Mainly genetic risk factors - Loss of dopaminergic neurones in the substantia nigra associated with lewy bodies in the basal ganglia, brainstem and cortex

Answer 40

- Parkinson's disease is a common condition in elderly people, with a prevalence of 1–2% in people older than 65 years of age. - 3.5% in 85-89 years

Answer 41

- Bradykinesia - Hypokinesia (reduced facial expression, arm swing, or blinking, difficulty with fine movements such as buttoning clothes and opening jars, or small, cramped handwriting (micrographia), slow, shuffling, festinating gait, narrow, or difficulty turning in bed.) - Stiffness or rigidity predominantly affecting the side of onset (lead-pipe rigidity, which describes the constant resistance felt when a limb is passively flexed in the presence of increased tone without tremor, cogwheel rigidity, which describes the regular intermittent relaxation of tension felt when a limb is passively flexed in the presence of tremor and increased tone.) - Rest tremor, which usually improves on moving, with mental concentration, and during sleep, may affect the thumb and index finger ('pill-rolling'), the wrist, or the leg. It may also affect the lips, chin, and jaw, but rarely involves the head, neck, or voice. - Balance problems and/or gait disorders. - Postural instability is suggested by the 'pull test' — a tendency to fall backwards after a sharp pull from the examiner. This may be suggestive of Parkinson's disease if unrelated to primary visual, cerebellar, vestibular, or proprioceptive dysfunction. Unilateral in early disease, becomes bilateral General symptoms: - Depression, anxiety, and fatigue. - Reduced sense of smell. - Cognitive impairment. - Sleep disturbance. - Constipation.

Answer 42

- History - Signs and symptoms - Examination - Exclude other causes of parkinsonism (eg. drug induced, cerebrovascular, lewy body dementia...) - Consider MRI to rule out other causes - Dopaminergic agent trial (improvement in symptoms)

Answer 43

- Multiple sclerosis (MS) is an acquired, chronic, immune-mediated, inflammatory condition of the central nervous system (CNS) that can affect the brain, brainstem, and spinal cord. - The inflammatory process causes areas of demyelination (damage to white matter), gliosis (scarring), and neuronal damage throughout the CNS. - Onset usually in young adulthood

Answer 44

- Relapsing-remitting MS (most common pattern of disease — about 85% of people - exacerbations of symptoms are followed by recovery and periods of stability) - Secondary progressive (gradual accumulation of disability unrelated to relapses, which become less frequent or stop completely, about two thirds of people with RMS progress to SPMS) - Primary progressive MS (steady progression and worsening of the disease from the onset, without remissions occurs in about 10–15% of people with MS)

Answer 45

- Cells of the immune system, mainly T-cells, attack oligodendrocytes, resulting in focal or diffuse areas of inflammation that is thought to cause secondary damage, primarily to axons. - Re-myelination of axons may occur in remissions, but may be partial or transient. - Progressive damage to affected cells in the nervous system leads to irreversible loss of function of affected nerves, resulting in permanent symptoms and signs.

Answer 46

- Genetics (20% blood relative with MS) - Vitamin D deficiency - Smoking - Diet and obesity in early life - Latitude (prevalence increases further from euator) - Epstein Barr virus - Female gender (2-3 times more common in women) - Associated with HLA-DR2

Answer 47

- Most common non-traumatic cause of neurological disability in people under 40 - 2.3 million people worldwide in 2016 - Mean age of diagnosis is 30, most common 20-50 - RRMS affects 85% of people with MS - 2-3 more times common in women - More common in northern populations in UK

Answer 48

- Loss or reduction of vision in one eye with painful eye movements (optic neuritis, partial or total unilateral vision loss with pain behind the eye) - Diplopia. - Ascending sensory disturbance and/or weakness. - Balance problems, unsteadiness, or clumsiness. - Altered sensation radiating down the back and sometimes into the limbs on neck flexion (Lhermitte's symptom). - Urinary symptoms (urgency, frequency, retention) - Speech and swallowing difficulties - Fatigue - Heat intolerance - Sexual dysfunction

Answer 49

- Optic neuritis (loss of colour discrimation, disc may appear pale or swollen. RAPD) - Transverse myelitis (sensory and motor symptoms, focal muscle weakness reduced sensation and muscle tone initially reduced) - Cerebellar signs (ataxia, vertigo, dysmetria) - Brainstem signs (ataxia, oscillopsia, nystagmus, internuclear opthalmoplegia (inability to adduct one eye with nystagmus in abducting eye)) - Dysarthria and dysphagia

Answer 50

- Diagnosed by consultant neurologist based on McDonald criteria - FBC, inflammatory markers, liver, renal function, calcium, HbA1c, thyroid function, B12 and HIV should be tested to exclude differentials - 2 lesions separated in time and space - MRI showing plaques, especially in the corpus callosum. GAD enhanced shows new lesions up as brighter - LP abnormal immunoglobulins (oligoclonal bands) - VIsual evoke potentials are slowed

Answer 51

- Spasticity is where there is a lot of resistance in the muscle and it eventually gives way. This is caused by upper motor neuron lesions. It is called clasp knife rigidity - Rigidity is sustained resistance, also called lead pipe rigidity. It is extrapyramidal. When caused by parkinsons it is called cog wheel rigidity

Answer 52

``` Eye 1- does not open eyes 2- opens eyes in response to pain 3-opens eyes in response to voice 4- opens eyes spontaneously ``` ``` Verbal 1 - Makes no sounds 2 - Makes sounds 3 - Words 4 - Confused, disoriented 5 - Oriented, converses normally ``` Motor 1 - Makes no movements 2 - Extension to painful stimuli (decerebrate response) 3 - Abnormal flexion to painful stimuli (decorticate response) 4 - Withdrawal to painful stimuli 5 - Localizes to painful stimuli 6 - Obeys commands

Answer 53

0 - No contraction 1 - Flicker or trace of contraction 2 - Active movement with gravity eliminated 3 - Active movement against gravity 4 - Active movement against gravity and resistance 5 - Normal power

Answer 54

- Squint - Ptosis - Facial droop - Asymmetrical or abnormal eye position and pupils

Answer 55

- Fasciculations - Muscle wasting - Scars - Neurofibromas

Answer 56

- A subdural haematoma (SDH) is a collection of clotting blood that forms in the subdural space. - May be acute SDH. - A subacute SDH (this phase begins 3-7 days after the initial injury). - A chronic SDH (this phase begins 2-3 weeks after the initial injury). - A simple SDH is when there is no associated parenchymal injury. - A complicated SDH is when there is associated underlying parenchymal injury, such as contusion.

Answer 57

- Infants (tearing of bridging veins in the subdural space, physical abuse) - Elderly (cerebral atrophy causing tension on veins) - Alcohol (thrombocytopenia, blunt head trauma) - Anticoagulation treatment - Falls

Answer 58

- 1/3 people with severe head injury - More common with increasing age 7.35 per 100000 population age 70-79 - Infants 12.5 per 100000

Answer 59

- Gradual onset of headache - Acute - shortly after head injury, fluctuating consciousness, patient may initially appear well - Chronic - 2,3 weeks after trauma, symptoms are progressive, anorexia, nausea or vomiting. - Neurological deficit (limb weakness, speech difficulties, drowsiness or confusion or personality changes) - Headache

Answer 60

- GCS - Vital signs - Neuro exam - FBC, U and Es, LFTs - Coagulation screen - Cross match blood - CT scan of head (crescent of blood around outer edge of brain) - Subacute uses contrast or MRI

Answer 61

- Papilloedema - Bradycardia and hypertension - Raised intracranial pressure - Seizures

Answer 62

- ABCDE - If under 10mm and no significant neurological dysfunction observe + antiepileptics (levetiracetum) + lower ICP (raised head of bed, analgesics and sedation - Over 10mm irrigation, evacuation, burr hole craniostomy (preferred if chronic) - Craniotomy (preferred if acute), duraplasty - Find cause of trauma

Answer 63

- Death due to cerebellar herniation - Cerebral oedema - Recurrent haeatoma during recovery - Seizures - Wound infection, subdural empyema, meningitis - Permanent neurological or cognitive deficit due to pressure effects - Coma

Answer 64

- Complicated (parenchymal brain injury) mortality 50% - Uncomplicated mortality 20% - Chronic treated surgically mortality 5% - Infants 19% mortality

Answer 65

- Rise in pressure around the brain (CSF)

Answer 66

- Localised mass lesions: traumatic haematomas (extradural, subdural, intracerebral). - Neoplasms: glioma, meningioma, metastasis. - Abscess. - Focal oedema secondary to trauma, infarction, tumour. - Disturbance of CSF circulation: obstructive hydrocephalus, communicating hydrocephalus. - Obstruction to major venous sinuses: depressed fractures overlying major venous sinuses, cerebral venous thrombosis. - Diffuse brain oedema or swelling: encephalitis, meningitis, diffuse head injury, subarachnoid haemorrhage, Reye's syndrome, lead encephalopathy, water intoxication, near drowning. - Idiopathic intracranial hypertension. (abnormal movement and visual perimetry, normal visual acuity)

Answer 67

- Headache (nocturnal, starting when waking, worse on coughing or moving head, associated with altered mental state) - Lethargy, irritability, abnormal social behaviour - Coma - Vomiting - Motor changes

Answer 68

- Irregularity or dilation of one pupil - Fundoscopy showing papilloedema, flame shaped haemorrhages, retinal haemorrhages - Unilateral ptosis or third and sixth nervepalsy - Raised blood pressure, widened pulse pressure - Cushings peptic ulcer (epigastric pain) - Cushings reflex (paradoxical bradycardia and raised blood pressure, often with irregular breathing) - Cushings triad - widened pulse pressure, respiratory irregularity, bradycardia

Answer 69

- CT (urgent) - MRI - Check blood glucose, renal function, electrolytes and osmolality - ECG showing t wave inversion

Answer 70

- 1 per 100000 in general population | - Increased risk in individuals with chronic hypertension or obesity

Answer 71

- In conductive hearing loss, bone conduction is greater than air on affected side and webers sounds louder on the affected side - In sensorineural, air conduction greater than bone in both ears and webers sounds louder on unaffected side

Answer 72

A primary neoplasm affecting the brain or spinal cord

Answer 73

- Around 9000 new primary brain and central nervous system cancers are diagnosed each year in the UK. - A full time GP is likely to diagnose approximately one person every 3–5 years. - It is seen in both sexes, and is one of the more common cancers in childhood and young people.

Answer 74

- New-onset seizures - Headache (raised ICP - bilateral, gradual, throbbing or bursting, worse in the morning, coughing or sneezing) - Nausea - Drowsiness - Progressive deafness (vestibular schwannoma) - Visual change (parietal lobe - homonymous hemianopia) - Personality change (frontal lobe)

Answer 75

- Papilloedema - Paresis of limbs - Speech disorders/dysphasia (very common) - Cerebellar signs – think DASHING (dysdiadochokinesis and dysmetria, ataxia, slurred speech, hypotonia, intention tremor, nystagmus, gait abnormality) - Visual symptoms (bitemporal hemianopia) - Cranial nerve 6 palsy (common due to its long intracranial course)

Answer 76

- Familial syndromes (Neurofibromatosis type 1 and 2, von Hippel-Lindau and Li-Fraumeni) - Ionising radiation/X-ray exposure - Multiple endocrine neoplasia type 1 (MEN-1) - Immunosuppression/EBV/HIV (primary CNS lymphoma) - Previous history of cancer

Answer 77

- Full Blood Count - Urea and Electrolytes - Calcium - Liver Function Tests - C-Reactive Protein (raised in infection and malignancy) - Both CT and MRI are used to help assess tumour size, adjacent structures, surrounding oedema, mass effect and secondary haemorrhage - A CT chest, abdomen and pelvis (CAP) should be performed if metastases are suspected - A biopsy is the only definitive way to diagnose a tumours tissue type (histology and cytogenetics) - Lumbar puncture should be avoided until neuroimaging has ruled out evidence of raised intracranial pressure. - This reduces the risk of brain herniation (commonly referred to as coning).

Answer 78

Bleeding into the subarachnoid space.

Answer 79

- Incidence is about 8 per 100 000 commonest age 35-65 - 1/3 present purely with a headache - 5-11% misdiagnosed - 80% rupture of an aneurysm - 15% AV malformations

Answer 80

- High BP - Smoking - Known berry aneurysm – Or disease that causes aneurysm – e.g. polycystic kidney disease, co-arctation of the aorta, Ehlers-Danlos Syndrome - Family history – increases risk by 3-5x

Answer 81

- Sudden onset severe headache, often at the back of the head 'thunderclap' - Neck stiffness (meningism) - Impaired consciousness (drowsiness / coma) – usually occurs very shortly after the onset of symptoms, but can occur several hours later. - CNS deficits can become permanent within minutes. If it lasts more than several hours it is highly unlikely to ever resolve. - Sentinel headache – is experienced by about 6% of patients, and is a prodromal headache thought to be the result of a small leak before rupture of an aneurysm or malformation. Similar to a migraine - Vomiting

Answer 82

- Kernig sign (back hurting when knee and hip flexed, resistance to straightening) - Extensor plantar responses - Cranial nerve signs - Hemiplegia

Answer 83

- Diagnosis is by urgent non contrast CT, or if this is normal with a high sense of suspicion, CSF. - CT – is able to detect >90% of lesions within 48 hours of onset of symptoms. - Often star shaped lesion on CT – or the blood fills in giral patterns around the brain the ventricles - If CT is negative, but SAH is highly suspected, consider : Lumbar puncture from 12 hours after symptom onset– contraindicated in raised ICP features include: - Blood – detected via the presence of bilirubin. Previously, people would use the level of RBCs as an indicator, however, it is unreliable to use the rule: if blood remains constant in 3 separate samples = SAH, if blood declines = tap trauma. - Xanthochromia - yellow appearance of CSF if it is left to stand for a few hours

Answer 84

- A facial pain syndrome in the distribution of ≥1 divisions of the trigeminal nerve. - It is characterised by some combination of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes and/or a constant component of facial pain, without associated neurological deficit. - The pain can be precipitated by trigger areas or factors, and repeat attacks are typically stereotyped in the individual.

Answer 85

- 4 to 13 per 100,000 based on US and UK population studies. - This means that 12,000 to 40,000 new cases are diagnosed in the US annually. - There is a slight female predominance at all ages, and rates appear to increase with age, with reported incidence rates as high as 74 to 88 per 100,000 in elderly (>75 years of age) populations

Answer 86

- Compression in 80-90% of patients - Demyelinating disease (20 times more prevalent in MS) - Other brainstem lesion (infarcts and amyloid or calcium deposition)

Answer 87

- Increased age - MS - Female - Hypertension

Answer 88

- Facial pain. - Classic unlateral paroxysms of facial pain lasting seconds to minutes - Intense, sharp, superficial, stabbing or burning - Triggers such as teeth brushing, eating, cold and touch - Most patients asymptomatic between episodes

Answer 89

- Unremarkable

Answer 90

- Clinical suspicion - STN is distinguished from CTN by measuring trigeminal reflexes - Exclude other causes with Oral x rays, MRI

Answer 91

- Classic - sharp, shooting, electric shock-like pain. Pain should be episodic >50% of the time. - Atypical - aching, throbbing, burning pain >50% of the time with a constant background. - Trigeminal neuropathic pain - secondary to unintentional trigeminal injury (facial trauma, oral surgery, ear, nose and throat surgery, skull base surgery, posterior fossa surgery, stroke). - Trigeminal deafferentation pain 'anaesthesia dolorosa' - secondary to intentional denervating procedure (e.g., neurectomy, gangliolysis, rhizotomy, nucleotomy, tractotomy). - Symptomatic TN - pain is a symptom of underlying pathology (tumour, inflammatory demyelination, etc.). Associated with MS or compression secondary to local tumour. Younger age of onset, involvement of the first division of trigeminal nerve, unresponsiveness to treatment, and abnormal trigeminal evoked potentials should be disregarded as useful for disclosing symptomatic TN. - Post-herpetic TN resulting from an outbreak of facial herpes zoster. - Atypical facial pain - somatoform pain disorder, requires evaluation with psychological testing prior to confirmation

Answer 92

- Surgically - pressure effect. Presses on parasympathetic fibres and causes pupil to dilate - Medical is down to microischaemia, and therefore the middle part of the nerve is the most likely to be ischaemic, therefore only the motor function is affected. Down and out pupil before the dilated pupil - Not needed anymore imaging is used instead

Answer 93

Binocular ocular - Misalignment - Resolves on covering of one eye - Description of the diplopia is useful - Determine lesion location - Do blood work ESR Monocular - Cataracts - Macular degeneration

Answer 94

A syndrome characterised by a relatively sudden, temporary, and self-terminating loss of consciousness, associated with the inability to maintain postural tone, with rapid and spontaneous recovery.

Answer 95

- 1% of A&E - 15% of children - Most common cause of syncope, peaks in young patients and then again in older patients

Answer 96

- Nausea - Lightheadedness - Diaphoresis - Diminished vision or hearing - Fatigue afterwards

Answer 97

- Pallor - Bradycardia - Palpitations

Answer 98

- Provocative factor - Previous episodes - Prolonged standing - Emotional stress - Dehydration/hypovolaemia - Preceding nausea and/or vomiting - Preceding episode of severe pain

Answer 99

Should all be normal - 12 lead ECG - Hb - Plasma blood glucose - B-human chorionic gonadotrophin - Cardiac enzymes - D dimer - Serum cortisol - Urea or serum creatinine - Tilt testing to reporduce an episode - Carotid sinus massage

Answer 100

Duloxetine

Answer 101

- Infection (HIV) - Inflammation/ autoimmune (vasculitis, CTD, inflammatory demyelinating neuropathy) - Toxic/ metabolic (drugs, alcohol, B12 deficiency, diabetes, hypothyroidism, uraemia, amyloidosis) - Tumour/malignancy (paraneoplastic, paraproteinaemia) - Hereditary sensory motor neuropathy

Answer 102

- Blurred optic disc margins - Blurred vision - Pain on eye movement

Answer 103

``` - Weakness, stiffness and muscle spasms in the legs Caused by: - Vascular - Infection - Inflammation (transverse myelitis) - Toxic/metabolic - Tumour/malignancy ```

Answer 104

Compression of lateral femoral cutaneous nerve

Answer 105

- Reassure - Avoid tight garments - Lose weight - If persistent carbamazepine, gabapentin

Answer 106

- Post-ictal - Dysphasia (receptive or expressive) - Dementia (vascular, alcoholic, alzheimers disease, inherited) - Depressive pseudodementia - Hypoglycaemia - Vascular (headache, collapse, subdural haematoma) - Infection (temp, intracranial, extra-cranial) - Inflammation - Malignancy - Metabolic/toxic (drugs, U&Es, LFTs, vitamin deficiencies, endocrinopathies)

Answer 107

- DOB - Age - Time - Year - Place - Recall (street) - Recognize doctor/ nurse - Prime minister - Second WW - Count backwards from 20 to 1

Answer 108

- Aspirin - Dont treat BP acutely (unless over 220/110) - ECG, echocardiogram - Carotid doppler - Risk factor modification

Answer 109

- Low glucose - Heart - vasovagal, arrythmia, outflow obstruction, postural hypotension - Brain - seizure

Answer 110

- Global prevalence of 15% - Following adolescence more common in women - Prevalence declines with age - Affects 1 in 6 people - Most common age 18-44, unemployed, older and disabled people

Answer 111

Clinical diagnosis (ICHD) Normal in migraine - ESR - Lumbar puncture - CSF - MRI brain - CT brain

Answer 112

- Hypertension - Rupture of aneurysm - Haemorrhagic necrosis (tumour, infection) - Venous outflow obstruction - Trauma - Altered haemostasis

Answer 113

- Internal carotids form the middle and anterior cerebral arteries. - Middle cerebral artery supplies lateral aspects of the brain - Anterior cerebral artery supplies medial strip - Basilar and vertebral arteis for posterior cerebral arteries, which supply the occipital lobe, brainstem and cerebellum

Answer 114

- Small vessel disease - Cardio-embolic (AF) - Large vessel atherosclerosis

Answer 115

- Aphasia - Right hemiparesis - Right sided sensory loss - Right visual field defect - Poor right conjugate gaze - Dysarthria - Difficulty reading, writing or calculating

Answer 116

- Neglect of left visual field - Extinction of left field stimuli - Left sided sensory loss - Left hemiparesis - Left visual field defect - Poor left conjugate gase - Dysarthria - Spatial disorientation

Answer 117

- Motor or sensory loss in all 4 limbs, or symptoms in the same side if cerebellar - as cerebllum ipsilateral supply - Crossed signs - Limb or gair ataxia - Dysarthria - Dysconjugate gaze (diplopia) - Nystagmus (vertigo) - Bilateral visual field defects - Brainstem LOC

Answer 118

- Pure motor - Pure sensory - Sensorimotor - Ataxic hemiparesis - Dysarthria clumsy hand syndrome (no abnormalities of higher brain function, sensation or vision)

Answer 119

- Contralateral hemiparesis (arm more than leg) - Contralateral hemisensory loss - Hemianopia - Visual and sensory innattention - Dysphasia - Neglect - Dysarthria - Dysphagia

Answer 120

- Supportive care + monitoring - Blood pressure control - Reversal of anticoagulant (warfarin with prothrombin complex anticoagulant, and phytomenadone) - Once discharged, VTE prophylaxis

Answer 121

- Infection - Deep venous thrombosis/pulmonary embolism - Seizures - Delirium - Aspiration pneumonia

Answer 122

- Mortality is significantly higher than for ischaemic stroke, in the range of 35% to 40%. - Only 20% to 30% of all patients are well enough to live independently by 3 to 6 months. - Haemorrhage volume is the strongest predictor of outcome. - Advanced age, impaired consciousness at presentation, and rupture of the haematoma into the ventricular system are also associated with worse outcomes

Answer 123

- Deep venous thrombosis - Haemorrhagic transformation of ischaemic stroke - Alteplase-related orolingual oedema (stop alteplase, antihistamine and corticosteroid) - Depression - Aspiration pneumonia - Malignant MCA - cerebral oedema leads to coning ie. brain is pushed downwards. Treatment is remove part of skull to create space

Answer 124

- In 2013, a total of 3.3 million individuals died of ischaemic stroke worldwide. - Between 1990 and 2010, ischaemic stroke mortality decreased 37% in high-income countries and 14% in low- and middle-income countries. - Alteplase treatment carries 6% haemorrhage risk, however alteplase improves outcome

Answer 125

- The formation of thrombus (clot) within the cavernous sinus, which can either be septic or aseptic. - Septic CST is a rapidly evolving thrombophlebitic process with an infectious origin (typically from the middle third of the face, sinuses, ears, teeth, or mouth), affecting the cavernous sinus and its structures. - Aseptic CST is usually a thrombotic process that is a result of trauma, iatrogenic injuries, or prothrombotic conditions

Answer 126

Septic - Sinusitis - Infection (facial, periorbital) - Mucormycosis (highly invasive fungal infection, which usually occurs in immunocompromised patients, especially those with diabetes or neutropenia) - Bacterial meningitis. - Sepsis (other sources). Causes of aseptic CST: - Trauma (e.g., supra-orbital, mandibular, or basilar skull fracture). - Post-surgical causes (e.g., rhinoplasty, cataract extraction, skull base procedures, and dental extraction). - Hyper-coagulable state - Malignancy (e.g., rhabdomyosarcoma and nasopharyngeal carcinoma). - Vascular abnormalities (e.g., carotid-cavernous fistula). - Miscellaneous aetiologies (e.g., ulcerative colitis, volume depletion, or heroin overdose). - Idiopathic.

Answer 127

- Women age 20-30 - COCP - Recent history of acute sinusitis - History of facial infections - History of peri-orbital infection - Genetic prothrombotic condition - Acquired and other prothrombotic states - History of otitis media, mastoiditis, or petrositis - History of dental or oral infection - History of sepsis - Immunosuppression - History of head and neck trauma - Use of oral contraceptives - History of malignancy - History of recent head or neck surgery - Vascular abnormalities - Ulcerative colitis - Volume depletion - Heroin overdose

Answer 128

- Rapid onset of signs and symptoms (acute septic CST) - Headache - Fever - Peri-orbital oedema - Mental state changes (e.g., confusion, drowsiness, coma) - Clinically detectable primary infection site - Meningismus (nuchal rigidity, photophobia, and headache)

Answer 129

- Chemosis and proptosis - Lateral gaze palsy - Ophthalmoplegia - Profound sepsis (acute septic CST) - Ptosis and mydriasis - Papilloedema and/or retinal-vein dilatation - Decreased corneal reflex - Hypo- or hyper-aesthesia in the distribution of the ophthalmic and maxillary nerves - Positive Kernig's (flex knee and hip, pain on knee extension) or Brudzinski's (neck stiffness) signs - Seizures - Loss of visual acuity

Answer 130

- Inflammation of the meninges caused by infection (leptomeningeal, pia mater and arachnoid) - Common bacteria include streptococcus pneumonia, neisseria meningitidis, haemophilius influenzae - Fungi - Viral - most common cause of aseptic meningitis

Answer 131

- Viral 2.73 per 100000 - Bacterial 1.24 per 100,000 - Fungal is more common in HIV patients

Answer 132

- Animal exposure is rare - HIV - Neurosurgery - Corticosteroid use - Chronic disease - Impaired immunity - Infants and neonates - Central vascular catheters - Sinonasal disease - Antibacterial usage - IV drug use - Mosquito exposure - Pools and ponds - Extended labour/previous babies had meningitis

Answer 133

- Headache severe, acute - Nausea and vomiting - Photophobia - Neck stiffness - Fever - Rash - Fungal can cause seizures, gait disturbances, confusion

Answer 134

- Kernig sign (flex knee and hip, pain on extension) - Brudzinski sign (neck stiffness) - Fungal/bacterial neurological signs, facial palsy, abnormal eye movement and balance problems - Petechial rash (non-blanching)

Answer 135

- Blood culture, PCR, blood glucose, FBC, urea, creatinine, electolytes, LFT, coagulation screen, HIV, CRP - Lumbar puncture - CSF protein, lactate, glucose, microscopy, PCR - Neuroimaging (may be meningial involvement, parenchymal lesions)

Answer 136

- Supportive care - Antibiotics (bacterial - IV or IM benzylpenecillin in community, broad in A&E (vancomycin, amoxicillin, cephotaxime, cephtriaxone), in neonates no vanco - Corticosteroids - Hospital transfer - Antiretroviral therapy (HIV or viral), CSF drainage, antifungal therapy (fungal) - Antiviral therapy Those who have been exposed to meningococcal meningitis (eg. live with someone who is newly diagnosed) Rifampin is the prophylaxis)

Answer 137

- Persistant headache and malaise, neuro-developmental deficits in infants (viral) - Anaemia, neurological effects, raised ICP, cerebrlal infarction, hydrocephalis, spinal arachnoiditis (fungal) - Shock, raised ICP, hydrocephalus, cognitive and behavioural problems, DVT, hearing loss, subdural effusion, seizures (bacterial) - Sensorineural deafness most common complication following bacterial meningitis

Answer 138

- 1/3 of adults who have bacterial meningitis have cognitive impairment. - Mortality rate 20% in bacterial meningitis - HIV associated poor prognosis - Viral generally good, may recur in up to 20% patients

Answer 139

- Broca aphasia is difficulty speaking due to inability to produce language. Broca area is in the frontal lobe (posterior inferior frontal gyrus on the left) - Wernicke is difficulty understanding speech (left posterior superior temporal gyrus)

Answer 140

A rare but devastating illness which leads to progressive paralysis and eventual death. Most commonly causes amyotrophic lateral sclerosis

Answer 141

- MND is relatively uncommon with an annual incidence of about 2 cases per 100,000 population. Prevalence is about 5-7 per 100,000. General practitioners can expect to see one or two cases in their career. - It can occur at any age but is more common in people aged over 50. The male to female ratio is 2:1. - About 5-10% of cases are inherited. - The mean age of onset is 43-52 years in familial and 58-63 years in sporadic cases of ALS. - Male sex, increasing age and hereditary disposition are the main risk factors.

Answer 142

- Amyotrophic lateral sclerosis (ALS) 60%, one limb initially, a neurodegenerative disorder, characterised by progressive muscle weakness that can start in limb, axial, bulbar, or respiratory muscles and then generalises relentlessly, causing progressive disability and ultimately death, usually from respiratory failure. - Progressive bulbar palsy - about 2 in 10 people with MND have this type. The muscles first affected are those used for talking, chewing and swallowing. See separate article Bulbar and Pseudobulbar Palsy for more details. - Progressive muscular atrophy - this is an uncommon form of MND. The small muscles of the hands and feet are usually first affected, but muscle spasticity is absent. - Primary lateral sclerosis - this is another rare type of MND. It mainly causes weakness in the leg muscles. Some patients with this type may also develop clumsiness in the hands or develop speech problems.

Answer 143

- Genetic predisposition or family history - Age >40 years - Military service - Professional athletic activity - Cigarette smoking - Agricultural chemical exposure - Lead exposure

Answer 144

Limb weakness - usually affects the upper limbs: - Causes patients to drop objects or have difficulty manipulating objects with one hand (turning keys, writing and opening bottles). - Wrist drop, stiffness, weakness or cramping of the hands may also occur. - Patients may also notice a change in the appearance of their hands (due to wasting of the intrinsic muscles). - Fasciculations of the muscles of the limbs may be noticed prior to weakness developing. - However, occasionally problems in the leg or legs may occur: - Foot drop (early). - Gait disorder. - A sensation of heaviness of one or both legs. - A tendency to trip. - Difficulty in rising from low chairs and climbing stairs. - Excessive fatigue when walking. Bulbar onset: - The first sign is usually slurring of the speech (impaired tongue movement). - Wasting and fasciculation of the tongue. - Dysphagia (usually a late feature with significant speech difficulties). - Accompanying emotional lability (inappropriate laughing or crying) - as with pseudobulbar palsies. - Other symptoms are difficulty eating, drooling, dysarthria, dysphonia, choking events with meals, nasal regurgitation of fluids or pulmonary aspiration. Respiratory onset can present with: - Dyspnoea and orthopnoea. - Clinical features resulting from hypoventilation overnight (for example, waking, unrefreshing sleep, hypersomnolence and early morning headaches). Rarer features: - Pain or sensory disturbance is not unknown but is not a common feature of the disease; it is usually the absence of pain or sensory disturbance that helps to distinguish MND from radiculopathies (nerve root pathology) that can cause a similar presentation in peripheral limbs. - Symptoms due to impaired respiratory muscle function usually occur late in the disease but can occasionally be a presenting feature, causing 'air hunger'. Acute respiratory failure has been reported. - Some patients with pseudobulbar palsy may have 'emotional incontinence', an over-reaction to sad or funny events that they are aware of as being abnormal. - Cognitive impairment is not a normal feature but can affect some patients with bulbar palsy.

Answer 145

- LMD dysfunction in the limbs manifests as weakness, atrophy, fasciculations and hyporeflexia. - The thighs are often a site of marked fasciculation. - UMN dysfunction manifests as weakness predominating in the arm extensors and leg flexors with evidence of hypertonia, hyper-reflexia and upgoing plantar responses; the bulbar muscles may also show spasticity with an exaggerated jaw jerk. - Ocular, sensory or autonomic dysregulation signs are usually late features of the disease.

Answer 146

Presence of: - Evidence of LMN degeneration by clinical, electrophysiological or neuropathological examination. - Evidence of UMN degeneration by clinical examination. Progressive spread of symptoms or signs within a region or to other regions, as determined by history or examination. Together with the absence of: - Electrophysiological and pathological evidence of other disease processes that might explain the signs of LMN and/or UMN degeneration. - Neuroimaging evidence of other disease processes that might explain the observed clinical and electrophysiological signs, normal nerve conduction study

Answer 147

- Electromyography (EMG - diffuse ongoing chronic denervation) - Repetitive nerve stimulation (modest decrease) - MRI brain and spine (normal) - Anti-GM1 antibodies (-ve) - Voltage-gated calcium-channel antibodies (-ve) - Acetylcholine receptor antibodies (-ve) - Vitamin B₁₂ (normal) - Creatine kinase (high) - Lumbar puncture (normal) - HIV test - Genetic testing

Answer 148

- Focal - Generalised - Unknown onset - Motor - Non motor - Retained or impaired awareness for focal seizures

Answer 149

- Convulsive seizure that continues for a prolonged period of time (>5 mins), or convulsive seizures occuring one after the other with no recovery between - Emergency - Non convilsive is continuous EEG activity but no mental status change

Answer 150

- 3.6-6.6 per 100000 population | - Non convulsive 2.6-7.8 per 100000

Answer 151

- Epilepsy - Any neurological insult or systemic abnormality capable of inducing a seizure - Drug withdrawal due to poor ACT adherence - Hypoxia, stroke, metabolic abnormalities

Answer 152

- Longer than 5 minutes or repeated - Tonic clonic involving stiffening of the whole body merging into vigorous shaking - Altered level of consciousness, confusion, or change in personality (non-convulsive)

Answer 153

- Poor ACT adherence - Alcohol use disorder/withdrawal - Toxic/metabolic - Cortical structural damage - Recreational drug use

Answer 154

- Glucose - ABG - Urea - Creatinine - Liver function tests - Sodium, calcium, magnesium - FBC - CRP - Clotting screen - Anticonvulsant drug levels - Chest x-ray - CT head - Lumbar puncture - Toxicology screen

Answer 155

Convulsive - in hospital - Assess and treat ABC - Supportive care and monitoring (intubation, thiamine, ocygen, glucose, acidosis, monitoring) - Benzodiazepine (consider levetiracetam, if that doesnt work phenytoin, then phenoarbital if necessary) - ICU Convulsive - community - Benzodiazepine and supportive care - Hospital transfer Non-convulsive - Refer to neurology

Answer 156

- Focal neurological deficits - Cognitive dysfunction - Behavioural problems - Fractures - Sudden death in epilepsy

Answer 157

- In hospital mortality 3.45% | - Patients often continue to have neurological deficits, especially in memory and other cognitive areas

Answer 158

Loss of consciousness and a phasic tonic stiffening of the limbs (either symmetrically or asymmetrically), followed by repetitive clonic jerking. The vast majority of these types of seizure are self-limiting without intervention.

Answer 159

- Half of all epilepsy pateitns have at least one generalised tonic clonic seizure - 25% of all seizures - Occur more frequently in generalised onset epilepsies and in those who suffer one seizure type

Answer 160

- Focal neurological deficits (structural lesion, or before/after seizure) - Premonitory sensation or experience (feat, epigastric, deja vu) - Temporary hemiparesis - Temporary aphasia - Fever, nuchal rigity, altered mental status - Neurocutaneous findings (ash leaf spots, fibromas, angiofibromas)

Answer 161

- IV or rectal benzodiazepine acute sezure. 2nd line fosphenytoin/phenytoin and supportive care - If ongoing, anticonvulsant monotherapy (valproic acid, lamotrigine, topiramate, oxcarbazepine, carbamazepine, pneytoin)

Answer 162

- Idiosyncratic medication reactions - Worsening seizures - Medication side effects - Status epilepticus - Efficacy failure

Answer 163

- Respond well - 60% freedom from seizures if no syndromic diagnosis - 50% focal onset will respond by becoming seizure free - If generalised onset, 60-70% of patients seizure free

Answer 164

- A specific type of seizure characterised by abrupt cessation of activity and responsiveness with minimal, if any, associated movements. - Absence seizures are further subdivided into typical, atypical, and absence with special features. - Typical absence seizures are approximately 5 to 10 seconds in duration, have minimal postictal confusion, precipitated by hyperventilation and sometimes by photic stimulation. - Atypical absence seizures have a less distinct beginning and end and are not usually precipitated by hyperventilation or photic stimulation - Absence seizures with special features include myoclonic absence and eyelid myoclonia, characteristic of Jeavons syndrome.

Answer 165

- Genetic with multifactoral inheritence - Atypical absence seizures may be secondary to a variety of congenital or acquired brain disorders, such as hypoxia-ischaemia, trauma, central nervous system infection, cortical malformations, or inborn errors of metabolism.

Answer 166

- 4000 children (younger than 18 years) are diagnosed with absence epilepsy annually in USA - 1500 children with juvenile myoclonic epilepsy (JME) annually in the US

Answer 167

- Family/genetic history of childhood absence epilepsy or juvenile myoclonic epilepsy - Acquired brain injury: for example, hypoxia-ischaemia, trauma, infection - Other congenital inborn errors of metabolism, structural defects, chromosomal abnormalities - Developmental delay or mental retardation - Female sex

Answer 168

- Staring episode, lasting 5 to 10 seconds; several times per day with no aura/postictal state - Childhood onset - Normal physical examination - Hyperventilation-induced seizure - Simple automatisms (eyelid blinking, upward eye deviation, or lip smacking is often obtained) - Recent decline in school performance - Complex automatisms - Early onset (before age 4 years - stereotypical/repetitive hand movements, walking/circling behaviour is obtained)

Answer 169

- EEG (generalised 3 Hz spike-and-wave in typical absence; generalised 1.5 to 2.5 Hz spike-and-wave in atypical absence; generalised 4 to 6 Hz spike-and-wave in juvenile myoclonic epilepsy (JME)) - MRI brain - Metabolic disorder screen - CSF and serum glucose

Answer 170

- Ethosuximide or valproic acid or lamotrigine - 2nd line topiramate or zonisamide or levetiracetam - GLUT1 deficiency advise ketogenic diet - If ongoing specialist referal

Answer 171

- Cognitive impairment long term - Generalised tonic-clonic seizures (GTCS) - Accidental injuries variable - Status epilepticus variable

Answer 172

- CAE remission 68% - JME seizure control for whole life - If mixed with myoclonic, absence resolve after 5 years, 50% neurological impairment

Answer 173

- The electrical and clinical manifestations of seizures that arise from one portion of the brain. - Focal aware seizures (formerly known as simple focal seizures) are those in which consciousness is preserved. - Focal impaired awareness seizures (formerly known as complex focal seizures) are characterised by loss of awareness, memory loss for the clinical event, and impaired responsiveness at the time of the event.

Answer 174

- 45.9 million have epilepsy globally - Most common under 20 and over 60 - 61.4 in 100000 person years - Higher in low/middle income countries

Answer 175

- Traumatic brain injury. - Closed head injury (skull fracture or >30 minutes of unconsciousness or amnesia) - Central nervous system (CNS) infection. - Brain tumours. Low-grade tumours seem more epileptogenic than high-grade tumours - Stroke. Risk of seizure activity is at least 3 times higher after a stroke - Alzheimer's disease - Perinatal injury. - Family history. Related to the development of focal epilepsy, although this is not a simple relationship. - Male

Answer 176

- Movement of one side of the body or one specific body part - Premonitory sensation or experience (fear, epigastric sensation, déjà vu, jamais vu) - Automatisms (picking at clothes, smacking of the lips) - Temporary aphasia - Staring and being unaware of surroundings - Postictal focal neurological deficit (Todd's paralysis, aphasia) Persistent focal neurological deficit - Poor memory - Stigmata of neurocutaneous syndromes

Answer 177

- Blood glucose - FBC - Electrolyte panel - Toxicology screen - Lumbar puncture and cerebrospinal fluid analysis - CT head - MRI brain - Electroencephalogram (EEG focal spikes or sharp waves with associated slowing of the electrical activity in the area of the spikes)

Answer 178

- Lamotrigine OR levetiracetam OR oxcarbazepine - Second options: lacosamide, eslicapasepine, brivaracetam - Tertiary: zonisamide, valproic acid, gabapentin - 4th line in under 60 resective epilepsy surgery or neurostimulation

Answer 179

- Head trauma - Bone fracture - Memory loss - Sudden unexpected death in epilepsy (SUDEP)

Answer 180

- Nearly two-thirds of patients with focal seizures achieve adequate seizure control with anticonvulsant drugs, either monotherapy or polytherapy. Most patients are treated with anticonvulsants for at least 2 years. - Tapering of anticonvulsants may be considered when a patient has remained seizure-free for 2 years - Patients with remote symptomatic epilepsy (e.g., seizures beginning 2 years after an open head injury) tend to relapse after withdrawal of anticonvulsants. Tapering should be done gradually, as rapid taper may result in a withdrawal seizure.

Answer 181

- Status migrainosus (72 hour migraine, IV fluids magnesium sulfate, NSAIDS) - Migrainous infarction (treat as cerevrovascular accident) - Migraine-triggered seizure - Depression - Chronic migraine - Persistent aura without infarction

Answer 182

- Most patients with episodic migraine do well with treatment. - In population-based surveys the frequency of migraine headaches decreases with age. - The prognosis is guarded for patients who have developed complications of migraine or who have co-morbidities or a long-standing history of medication overuse. - The goals of treatment should shift from elimination of pain to improvement in function

Answer 183

- Tension across forehead - Cluster behind eye - Migraine half the face - Glaucoma inside the eye

Answer 184

- Mental tension - Stress - Missing meals - Fatigue - Somatisation - Female sex - Age 20-39 years - Lower socioeconomic status - Analgesic overuse

Answer 185

Peptic ulcer secondary to NSAID use

Answer 186

- Clinical diagnosis (typical headache without nausea and vomiting, normal neurological examination) - Consider CT sinus to excuse sphenoid sinusitis, MRI brain, lumbar puncture - all normal

Answer 187

- NIHSS (NIH stroke sclare). Assess severity of the stroke. Measures level of consiousness, gaze, visual, facial palsy, motor arm, motor leg (for drift), language, ataxia. - Rosier scale - recognition of stroke in the ER (LOC, seizure, face weakness, arm weakness, speech disturbance) - Modified rankin score (disability after stroke from no symptoms to death) - Bamford classification

Answer 188

Total anterior circulation ischaemic stroke (middle and anterior) ALL 3 - Unilateral weakness - Homonymous hemianopia - Higher cerebral dysfunction (dysphasia, visuospatial disorder Partial anterior circulation stroke (only part of anterior circulation) 2 of - Unilateral weakness/sensory defecit - Homonymous hemianopa - Higher cerebral dysfunction Posterior circulation syndrome (brain supplied by the posterior circulation (e.g. cerebellum and brainstem)) One of: - Cranial nerve palsy and a contralateral motor/sensory deficit - Bilateral motor/sensory deficit - Conjugate eye movement disorder (e.g. horizontal gaze palsy) - Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia) - Isolated homonymous hemianopia Lacunar stroke (LACS) (a subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions (e.g. dysphasia).) One of: - Pure sensory stroke - Pure motor stroke - Senori-motor stroke - Ataxic hemiparesis

Answer 189

- Brain tumours - Toxic/metabolic disorders (eg. hypoglycaemia, hyponatraemia) - Atypical migraine - Encephalitis/meningitis - Progressive multifocal leukoencephalopathy (JC virus, immunosuppressed patients)

Answer 190

Bacterial - Turbid - Neutrophils (polymorphs) - Low glucose - High protien Viral - Clear - Raised mononuclear lymphocytes - Normal glucose - Normal or raised protein TB - Fibrin web - Raised mononuclear lymphocytes - Low glucose - High protein

Answer 191

- Pregnancy - Hypokalaemia - Infection - Over treatment - Change in climate - Emotion - Exercise - Gentamicin - Climate - Opiates - Tetracycline - Quinine - Beta blockers

Answer 192

- Compression pupil is dilated - Vascular cause pupil is spared - Both cause down and out and ptosis

Answer 193

- Parkinsons is asymmetrical - Parkinsons does not have dominant atypical features (autonomic, visual abnormalities) - Parkinsons responds to L-DOPA

Answer 194

- Flick middle fingernail, the thumb with flex and adduct involuntarily

Answer 195

1st line sodium valproate | 2nd line carbamazepine