Neurology Flashcards
1
Q
What is an ischaemic stroke?
A
Ischaemic infarction due to occlusion of a vessel by embolism of a thrombus
2
Q
What is a haemorrhagic stroke?
A
Bleeding from brain vasculature
3
Q
Risk factors for ischaemic stroke
A
HTN, smoking, DM, heart disease, peripheral vascular disease, hypercholesterolaemia, raised clotting factors
4
Q
What is the main risk factor for haemorrhagic stroke?
A
HTN
5
Q
Signs and symptoms of an ACA territory stroke/TIA
A
o Leg weakness and sensory disturbance
o Gait apraxia
o Incontinence
o Drowsiness
o Akinetic mutism - decrease in spontaneous
speech and movement
6
Q
Signs and symptoms of an MCA territory stroke/TIA
A
o Contralateral upper limb weakness and sensory
loss
o Hemianopia
o Aphasia
o Dysphasia
o Facial Droop
7
Q
Signs and symptoms of PCA territory stroke/TIA
A
o Contralateral homonymous hemianopia o Cortical blindness o Visual agnosia - can’t interpret visual information o Prosopagnosia o Dyslexia o Unilateral headache
8
Q
Symptoms of a hemorrhagic stroke
A
Severe headache, nausea/vomiting, sudden loss of consciousness
9
Q
What is the act fast campaign?
A
Stroke management outside of hospital: o Facial asymmetry o Arm/leg weakness o Speech difficulty o Time to call 999
10
Q
1st line investigations for suspected stroke
A
CT head
11
Q
Initial management of ischaemic stroke
A
• 300mg aspirin (2 weeks)
• Thrombolysis:
o Up to 4.5 hours post onset of symptoms
o Alteplase – IV to break up clot
• Thrombectomy
12
Q
Contraindications for thrombolysis
A
Surgery in last 3 months, recent arterial puncture, history of active malignancy, brain aneurysms, anticoagulation, clotting disorders, severe liver disease, acute pancreatitis
13
Q
Risk management after ischaemic stroke
A
o Anti-platelet – aspirin and clopidogrel
o Cholesterol – statins
o AF – warfarin, NOAC’s
o Antihypertensives – ACE-i
14
Q
Management of haemorrhagic stroke
A
Treat as SAH, stop anticoagulants
15
Q
What is a transient ischaemic attack (TIA)?
A
An ischaemic neurological event with symptoms lasting <24hrs
16
Q
Causes of TIA
A
• Carotid atherothromboembolism
• Cardioembolism – post-MI, AF, diseased/prosthetic
valve
• Hyperviscosity – polycythaemia, sickle-cell, myeloma
17
Q
Investigations for suspected TIA
A
- Bloods – FBC, ESR, U&Es, glucose, lipids
- Carotid Doppler ± angiography
- CT head
- Echocardiogram
18
Q
Management of TIA
A
- Control CV RF’s
- Antiplatelets – aspirin 300mg (2 weeks)
- Anticoagulation if cardiac source
- Carotid endarterectomy
19
Q
What are the DVLA regulations on driving after a stroke/TIA?
A
Prohibited for 1 month
20
Q
What is a subarachnoid haemorrhage (SAH)?
A
Bleeding into the space between the arachnoid and the pia mater
21
Q
Epidemiology of SAH
A
Usually 35-65yrs
22
Q
Symptoms of SAH
A
o Sudden-onset excruciating headache, ‘thunder clap’
o Vomiting, collapse, seizures, coma
o Preceding ‘sentinel’ headache
23
Q
Signs of SAH
A
o Neck stiffness
o Kernig’s sign (6hrs after) – inability to straighten leg
when hip flexed 90 degrees
o Retinal subhyaloid and vitreous bleeds
o Pupil changes
24
Q
Causes of SAH
A
o Berry aneurysm – 90%
o Arteria-venous malformation – 15%
o Encephalitis, vasculitis, tumour
25
Risk factors for SAH
Previous aneurysm, smoking, alcohol misuse, HTN, FH, bleeding disorders
26
Investigations for suspected SAH
o Urgent CT – star pattern within 24hrs
o Lumbar Puncture (12 hours after symptoms) –
bloody or increase in pigments (bilirubin) -> straw
coloured
o CT angiography
27
Management of SAH/haemorrhagic stroke
o Re-examine CNS often – BP, pupils, GCS
o Fluids
o CCB (nimodipine) – reduces vasospasm
o Dexamethasone – cerebral oedema
o Surgery – endovascular coiling vs surgical clipping
(craniotomy)
28
Differential diagnosis for suspected SAH
Meningitis, migraine
29
Differential diagnosis for suspected TIA
Migraine with aura, hypoglycaemia, focal epilepsy
30
What are the main complications of SAH?
- Cerebral ischaemia
- Rebleeding
- Hydrocephalus
- Hyponatreamia
31
Cause of subdural haematoma
Trauma – can be minor or forgotten (up to 9 months ago) -> rupture of bridging veins
32
Risk factors for subdural haematoma
Age, falls, anticoagulation
33
Symptoms of subdural haematoma
```
o Fluctuating level of consciousness
o Gradual physical or intellectual slowing
o Headache
o Personality change
o Unsteadiness
```
34
Signs of subdural haematoma
Raised intracranial pressure, seizures
35
Investigations for subdural haematoma
CT/MRI – crescent-shaped collection of blood over one hemisphere
36
Management of subdural haematoma
o Reverse clotting abnormalities
| o Surgery if >10mm - craniotomy
37
Cause of extradural haematoma
Skull fracture -> rupture of middle meningeal artery and vein
38
Signs and symptoms of extradural haematoma
o Lucid interval – hours-days
o Increasingly severe headache, vomiting, confusion,
seizures, hemiparesis
o -> pupil dilation, coma, bilateral limb weakness,
breathing irregular -> death
39
Differentials for subdural haematoma
Stroke, dementia, CNS masses
40
Differentials for extradural haematoma
Epilepsy, carotid dissection, CO poisoning
41
Investigations for suspected extradural haematoma
o CT – biconvex/lens-shaped, +/- midline shift
o Skull x-ray
o DO NOT LP
42
Management of extradural haematoma
o Surgery – craniotomy, clot evacuation ± ligation of
bleeding vessels
o Mannitol IVI
43
What is an epileptic seizure?
Paroxysmal event in which changes of behaviour, sensation or cognitive processes are caused by excessive, hypersynchronous neuronal discharges in the brain
44
Causes of epilepsy
* 2/3 idiopathic
* Structural – cortical scarring, development, stroke
* Other – autoimmune
45
Defining features of an epileptic seizure
* 30-120 seconds
* ‘Positive’ ictal symptoms
* Postictal symptoms
* May occur from sleep
* Tongue biting, incontinence
46
Common postictal symptoms
Headache, confusion, myalgia, temporary weakness or dysphagia
47
What are the two main types of epileptic seizures?
Focal (partial) seizures, generalised seizures
48
Signs and symptoms of an absence seizure
Brief <10 second pauses, stops talking mid-sentence then carries on where left off
49
Signs and symptoms of a myoclonic seizure
Sudden jerk of limb, face or trunk, violently disobedient limb
50
Signs and symptoms of generalised tonic clonic seizures
Loss of consciousness, limbs stiffen (tonic) then jerk (clonic), post-ictal confusion and drowsiness
51
Investigations for epilepsy
* Look for provoking causes
* EEG if differentials ruled out
* MRI – structural lesions
52
Differentials for epileptic seizures
Syncope, non-epileptic seizures, hypoglycaemia
53
What is syncope?
Paroxysmal event in which changes in behaviour, sensation and cognitive processes are caused by insufficient blood or oxygen supply to the brain
54
Features of syncope
```
o Situational - typically from sitting or standing
o Rarely from sleep
o Presyncopal symptoms
o 5-30 seconds
o Recovery within 30 seconds
```
55
What is a psychogenic non-epileptic seizure?
Paroxysmal event in which changes in behaviour, sensation and cognitive function caused by mental processes associated with psychosocial distress
56
Features of a psychogenic non-epileptic seizure
o Situational
o 1-20 minutes
o Dramatic motor phenomena or prolonged atonia
o Eyes closed ictal crying and speaking
o Surprisingly rapid or slow postictal recovery
o History of psychiatric illness/somatoform illness
57
Pharmocological management of epilepsy
* Focal – 1st line Carbamazepine/Lamotrigine
* Primary generalised– 1st line Valproate/Lamotrigine
* Surgery – if drugs fail
* Vagus nerve stimulation – palliative
58
What advice should be given to someone with suspected epilepsy?
Advice about dangers – swimming, driving, heights
– until diagnosis
o Contact DVLA and avoid driving until seizure-free
for > 1year
59
What are the DVLA guidelines for someone with epilepsy?
Avoid driving until seizure-free for >1 year
60
What is Parkinson's disease?
Progressive nervous system disorder with loss of dopamine producing neurones in the substantia nigra, affects movement
61
Epidemiology of Parkinson's
Adult onset
62
Cause of Parkinson's
Unknown, genetic predisposition
63
Pathology of Parkinson's
Dopamine producing neurones in the substantia nigra (pars compacta) undergo degeneration (darker areas disappear, Lewy bodies in damaged neurones) -> movement affected
64
Investigations for suspected Parkinson's
* Mainly clinical assesment
* MRI and CT - atrophy of the Substantia Nigra
* PET - reduced dopamine supply
65
Signs and symptoms of Parkinson's
Tremour at rest
Ridgidity
Akinesia
Posture stooped
66
Pharmacological management of Parkinson's
• Levodopa - if movement symptoms
• Dopamine agonist (Ropinirole) -
reduced risk of dyskinesias in short-medium term, 1st
line in younger patients (< 60 yr)
• MAO-B inhibitor (Selegiline) – not very powerful,
most likely to be neuroprotective
• Anti-cholingerics - used in drug-induced Parkinsonism
67
SE's of levodopa
Dyskinesia, painful dystonia, N&V, psychosis, hallucinations
68
SE's of dopamine agonists
Drowsiness, compulsive behaviour (gambling), hallucinations
69
SE's of anti-cholinergics
Dry mouth, dry eyes, constipation
70
Complications of late stage PD
* Wearing off – medication doesn’t work as long as before
* On-Dyskinesias – hyperkinetic, choreiform movements whenever drugs work
* Off-Dyskinesias – fixed, painful dystonic posturing, typically of feet, when drugs don’t work
* Freezing – unpredictable loss of mobility
71
Differential diagnosis for Parkinson's
* Normal pressure hydrocephalus
* Essential tremor - no structural pathology
* Cerebellar ataxia – intention tremor
* Huntington’s disease
* Generalised dystonia
72
Cause of cluster headache
Unknown
73
Epidemiology of cluster headache
M>F, smokers
74
Signs and symptoms of cluster headache
o Rapid onset
o Excruciating pain around one eye, watery,
bloodshot, swelling, facial flushing, rhinorrhoea,
miosis ± ptosis
o Pain unilateral, usually same side
o 15-180mins, once or twice per day
o Chronic or episodic with pain-free periods of months
or years
75
Acute management of cluster headache
100% oxygen (CI smoking) and sumatriptan SC
76
Epidemiology of migraines
F>M, associated with FH and obesity
77
Symptoms of migraine
o Aura lasting 15-30min followed by 1hr unilateral
throbbing headache
o Or – isolated aura with no headache
o ‘Common migraine’ – episodic severe headaches without aura, often premenstrual, unilateral, N+V, ± photophobia/phonophobia
78
Give 3 common triggers of migraines
```
Chocolate
Hangovers
Orgasms
Cheese/caffeine
Oral contraceptives
Lie-ins
Alcohol
Travel
Exercise
```
79
Prophylactic treatment of migraines
1st line - Propranolol
2nd line - Topiramate
3rd line - Botox
80
What medications can be taken during a migraine attack?
Oral triptan + NSAID/paracetamol
81
What is a common SE of triptan and in which patient group is it contraindicated?
Arrythmias, do not give if IHD
82
Non-pharmological therapies for migraines
Warm or cold packs, rebreathing into paper bag (↑PaCO2), acupuncture
83
Classification of headaches
o Infrequent episodic – 1day/month
o Frequent episodic – 1-14days/month for 3 months
o Chronic – 15days/month for 3 months
84
Signs and symptoms of a tension headache
o Lasts 30mins to 7days
o Bilateral
o Pressing/tightening quality
o Mild-moderate intensity
o Not aggravated by routine physical activity
o No nausea or vomiting
o No more than one of photophobia or phonophobia
85
Management of tension headaches
Analgesics (aspirin, NSAIDs), tricyclic antidepressants (amitriptyline)
86
What is multiple sclerosis (MS)?
Inflammatory plaques of demyelination in the CNS disseminated in space and time
87
Epidemiology of MS
F>M average age 30yrs
88
Cause of MS
Combination of environment, genetics and chance
89
Pathophysiology of MS
Genetic susceptibility + environmental trigger -> activated autoreactive T-lymphocytes -> inflammatory attack with demyelination -> demyelination heals poorly -> progressive disability
90
Signs and symptoms of MS
• Vision problems - optic neuritis, double vision,
blurred vision, nystagmus
• Spasticity
• Numbness and tingling
• Lhermitte’s sign - electric shock-like sensation on
flexion of neck
• Dizziness and vertigo
• Bladder and sexual dysfunction
• Fatigue
• Pain - worse with heat (hot bath, exercise)
91
Diagnostic criteria for MS
o Two or more CNS lesions disseminated in time and
space
o Exclusion of conditions giving a similar clinical
picture – SLE, AIDs etc.
92
Lifestyle management of MS
Avoid stress, smoking cessation, regular exercise
93
Management of MS relapse
Steroids - methylprednisolone
94
Investigations for suspected MS
```
• MRI
• CSF – electrophoresis
• Delayed visual, auditory and somatosensory evoked
potentials
• Bloods - exclude alternate diagnoses
```
95
Disease modifying drugs for relapse-remitting MS
o Dimethyl fumarate
o Alemtuzumab
o Beta interferons
96
Management of MS symptoms
o Spasticity – baclofen/gabapentin
o Tremor – BB
o Urgency/frequency – teach self-catheterisation
o Fatigue – CBT, exercise
97
What is motor neuron disease?
A group of neurodegenerative disease’s characterised by selective deterioration of motor neurons
98
What 3 areas are motor neurons lost from in motor neuron disease?
Motor cortex, cranial nerve nuclei and anterior horn cells
99
What is the main type of motor neuron disease?
ALS/amyotrophic lateral sclerosis – loss of motor neurons in motor cortex and anterior horn, UMN + LMN symptoms
100
UMN signs
Spasticity, brisk reflexes, ↑plantars (Babinski sign)
101
LMN signs
Wasting, fasciculation of tongue, back, thigh
102
Symptoms of MND
* No sphincter or sensory loss
* Stumbling spastic gait
* Foot-drop ± proximal myopathy
* Weak grip
* Weak shoulder abduction
* Aspiration pneumonia
* Frontotemporal dementia
103
Investigations and diagnosis of MS
• Clinical mainly
• El Escorial diagnostic criteria – more LMN and/or
UMN signs = more likely its MND
• No diagnostic test:
o EMG, NCS – muscle denervation
o LP – exclude inflammatory causes
o MRI of brain/cord – exclude structural causes
104
What drug is used in the management of ALS?
Riluzole – prevents stimulation of glutamate receptors
105
What the most common causes of meningitis?
Meningococcus, pneumococcus
106
Give 3 routes that infection can enter the CSF
o Neurosurgical complications
o Via bloodstream
o Extracranial infection – nasopharynx, ear, sinuses
107
Symptoms of meningitis
o Fever
o Headache
o Neck stiffness – ‘meningism’
108
Hospital management of bacterial meningitis
```
o Assess GCS
o Blood cultures
o Broad spectrum antibiotics – ceftriaxone
o Steroids IV
o Lumbar puncture
o Inform public health
```
109
General practice management of suspected bacterial meningitis
IM benzylpenicillin and admit
110
Differential diagnosis for meningitis
o SAH
o Migraine
o Flu
o Malaria
111
What are the most common causes of encephalitis?
Herpes simplex, Varicella Zoster, bacterial meningitis
112
Signs and symptoms of encephalitis
o Hours to days – preceding ‘flu-like’ illness
o Altered GCS – confusion, drowsiness, coma
o Fever, seizures, memory loss ± meningism
113
Investigations for suspected encephalitis
o MRI head ± EEG
o Contrast CT
o Lumbar puncture – lymphocytic CSF and viral PCR
114
Management of encephalitis
o Mostly supportive
| o Aciclovir if HSV or VZV
115
Cause of Huntington's disease
Genetic - autosomal dominant, expansion of CAG repeat on Chr. 4
116
Pathophysiology of Huntington's disease
• Loss of neurones in caudate nucleus and putamen
• Atrophy and neuronal loss of striatum and cortex
• Loss of GABA and ACh, dopamine spared ->
dopamine imbalance
117
Signs and symptoms of Huntington's disease
• Initially mild – irritability, depression, incoordination
• Progresses to chorea, dementia ± fits and death
(approx. 15 years)
118
Management of Huntington's disease
* No treatment prevents progression
| * Counselling for patient and family
119
Give a cause of acute peripheral neuropathy
Gullian Barré syndrome
120
Give 2 causes of chronic peripheral neuropathy
Alcohol, diabetes
121
Pathphysiology of diabetic neuropathy
Hyperglycaemia damages retinal endothelium, mesangial cells in glomeruli and Schwann cells in peripheral nerves -> can't regulate glucose well -> constant hyperglycaemia -> excessive oxidation -> damage
122
What is Guilian-Barre syndrome?
An acute inflammatory demyelinating poly-neuropathy
123
Pathophysiology of Guillian-Barre syndrome
Infection -> causes antibodies to attack nerves -> paralysis -> recovery
124
Management of Guillian-Barre syndrome
IV immunoglobulin 5 days
125
What is myasthenia gravis?
Autoimmune disease caused by antibodies to ACh receptors -> muscular weakness, fatigability of ocular, bulbar, and proximal limb
126
Pathology of myasthenia gravis
Autoantibodies to nicotinic acetylcholine receptors, anti-AChR antibodies or MuSK, at post synaptic membrane of neuromuscular junction, cause receptor blockade/loss
127
Signs of myasthenia gravis
• Ptosis
• Diplopia
• Myasthenic snarl on smiling
• Orbicularis fatigability – eyelids separate after
manual opposition to sustained closure
• Voice fades when counting to 50
128
Symptoms of myasthenia gravis
Slowly increasing or relapsing muscle fatigue
129
What factors exacerbate myasthenia gravis symptoms?
Pregnancy, hypokalaemia, infection, over-treatment, change of climate, emotion, exercise
130
Epidemiology of myasthenia gravis
Young females, older males, associated with autoimmune conditions
131
Management of myasthenia gravis
* Symptoms – anticholinesterases (pyridostigmine)
* Immunosuppression
* Thymectomy
132
SE's of anticholinesterases
Increased salivation, sweats, vomiting
133
What is a myasthenic crisis?
Life-threatening weakness of respiratory muscles during a relapse
134
Causes of spinal cord compression
Secondary malignancy, infection, cervical disc prolapse, primary cancer
135
Give a cause of inherited cerebellar ataxia
Freidreich’s ataxia (FA)
136
Give 3 causes of acquired cerebellar ataxia
o Toxic – alcohol, phenytoin, lithium
o Immune-mediated
o Neurodegenerative – MSA-C
137
Signs and symptoms of cerebellar dysfunction
• Dysdiadochokinesis and dysmetria (past-pointing)
• Ataxia – limb/truncal – wide-based, cannot walk heel-
to-toe, worse in dark/eyes closed
• Nystagmus (other abnormalities of eye movements)
• Intention tremor
• Slurred speech
• Hypotonia
138
What tool can be used to assess ataxia?
Scale for the Assessment and Rating of Ataxia (SARA)
139
Investigations for suspected cerebellar dysfunction
• MRI – rules out structural causes
• Finger-to-nose test
• Romberg’s test – stand with eyes closed – negative
if cerebellar disease
140
What is carpal tunnel syndrome?
Entrapment of the median nerve against the carpal tunnel
141
Epidemiology of carpal tunnel syndrome
Mainly women
142
Pathophysiology of carpal tunnel syndrome
Inflammation of the carpal tunnel -> median nerve gets trapped -> pain and loss of sensation
143
Symptoms of carpal tunnel syndrome
o Pain and paraesthesia in the hand, worse at night
o Weakening and wasting of the thenar eminence
o Loss of sensation of median nerve innervation
144
Signs of carpal tunnel syndrome
Tinnel’s, Phalen’s test
145
Management of carpal tunnel syndrome
o Surgical decompression
| o Nocturnal splint and steroid injections for pain relief
146
Management of myasthenic crisis
Plasmapheresis
147
What is the first line drug treatment for trigeminal neuralgia?
Carbamazepine
148
What further investigations should you do if a stroke is suspected and a CT head has been done?
Carotid doppler USS, bloods (FBC, ESR, glucose, clotting, lipids), ECG
149
When is a carotid endarterectomy appropriate?
Post TIA/stroke if >70% stenosis
150
In what group is sodium valproate contraindicated?
Women of fertile age
151
Which drug is 1st line in Parkinson's disease if motor symptoms are affecting the patients quality of life?
Levodopa
152
Which form of dementia is associated with Parkinsonism?
Lewy-body
153
Preventative management of cluster headache
Corticosteroids, verapamil, lithium
154
What are the 2 types of hydrocephalus?
Obstructive and communicating
155
Give a cause of obstructive hydrocephalus
- Tumour or cyst
| - Congenital
156
Give a cause of communicating hydrocephalus
- Infective meningitis
- SAH
- Normal pressure hydrocephalus
157
What is the triad of symptoms seen in normal pressure hydrocephalus?
- Parkinsonian gait
- Dementia
- Urinary incontinence
158
Give 3 symptoms of hydrocephalus
- Headache
- Nausea and/or vomiting
- Confusion
- Vision problems
159
Give 3 signs of hydrocephalus
- Reduced GCS
- Papilloedema
- Sunset eyes sign
160
What would be your initial management for acute hydrocephalus?
Extra-ventricular drain (EVD)
161
How would you manage hydrocephalus long-term?
Ventriculoparietal shunt (VPS)
