Neurology Flashcards
1
Q
What is stroke also called?
A
Cerebrovasculat accident (CVA)
2
Q
Label the following:
A
3
Q
What causes CVAs?
A
Ischaemia / infarction = inadequate blood supply
Intracranial haemorrhage
4
Q
What can distrupt blood to the brain?
A
Thrombus formation / embolus e.g. in patients with AF
Atherosclerosis
Shock
Vasculitis
5
Q
What is a TIA?
A
Transient ischaemic attack
Fomerly symptoms of stroke which resolved in 24 hours
Updated definition = transient neurological dysfunction secondary to ischaemia without infarction
6
Q
What does a TIA often precede?
A
Full stroke (crescendo TIA = 2 or more per week)
7
Q
What are the symptoms of a stroke?
A
Sudden:
- Limb weakness
- Facial weakness
- Dysphagia (speech disturbance)
- Visual or sensory loss
8
Q
What are the risk factors of a stroke?
A
CVD e.g. angina, myocardial infarction, PVD
Previous stroke or TIA
Atrial fibrillation
Carotid artery disease
HTN
Diabetes
Smoking
Vasculitis
Thrombophilia
COCP
9
Q
What is the FAST tool for identifying stroke in the community?
A
Face
Arm
Speech
Time (call 999)
10
Q
What is the ROSIER tool?
A
Clinical scoring tool based on clinical features and duration (stroke is likely if anything above 0)
11
Q
What is the management of a patient with a stroke?
A
Admit to specialist stroke centre
Exclude hypoglycaemia
Immediate CT brain to exclude primary intracerebral haemorrhage
Aspirin 300mg stat (after CT) continued for 2 weeks
12
Q
How should thrombolysis be performed (after CT brain has excluded intracranial haemorrhage)
A
Alteplase (a tissue plasminogen activator) that rapidly breaks down clots and can reverse the effect of the stroke (given within a defined window of opportunity e.g. 4.5 hours)
Need monitoring for post thrombolysis complication e.g. intracranial / systemic haemorrhage (repeated CT scans of brain)
Thrombectomy (not used after 24 hours since onset of symptoms)
13
Q
Why should blood pressure not be lowered during a stroke?
A
Risks reducing perfusion to the brain
14
Q
What is the management of TIA?
A
Aspirin 300mg daily
Secondary prevention measures for CVD
Referred and seen within 24 hours by stroke specialist
15
Q
What specialist imaging can be use to find area affected by stroke?
A
Diffusion-weighted MRI - gold standard technique (CT = alternative)
Carotid ultrasound (assess for carotid stenosis)
16
Q
What is the treatment for carotid stenosis?
A
Endarterectomy (to remove plaque or carotid stenting)
17
Q
What treatment is given for secondary prevention of stroke?
A
Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)
Atorvastatin 80mg (started by not immediately)
Carotid endarterectomy or stenting in patients with carotid artery disease
Treat modifiable risk factors e.g. HTN and diabetes
18
Q
Who is involved in stroke rehabilitation?
A
Nurses
Speech and language (SALT)
Nutrition and dietetics
Physiotherapy
Occupational therapy
Social services
Optometry and opthalmology
Psychology
Orthotics
19
Q
What percentage of strokes are caused by intracranial bleeds?
A
10-20%
20
Q
Label the following:
A
21
Q
What are some risk factors for intracranial bleeds?
A
Head injury
Hypertension
Aneurysms
Ischaemic stroke can progress to haemorrhage
Brain tumours
Anticoagulants e.g. warfarin
22
Q
How do intracranial bleeds present?
A
Seizures
Weakness
Vomiting
Reduced consciousness
Other sudden onset neurological symptoms
23
Q
How to calculate the glasgow coma score?
A
Eyes
- Spontaneous = 4
- Speech = 3
- Pain = 2
- None = 1
Verbal response
- Orientated = 5
- Confused conversation = 4
- Inappropriate words = 3
- Incomprehensible sounds = 2
- None = 1
Motor response
- Obeys commands = 6
- Localises pain = 5
- Normal flexion = 4
- Abnormal flexion = 3
- Extends = 2
- None = 1
24
Q
What glasgow score indicates that airways need securing?
A
8/15 or below
25
What is a **subdural haemorrhage** caused by?
**Rupture** of the **bridging veins** in the outermost meningeal layer (in between **dura mater** and **arachnoid mater**)
26
How do **subdural haemorrhages** appear on a **CT scan**?
**Crescent shape** and **not limited by cranial sutures**
27
Who do **subdural haemorrhages** occur more often in?
**Elderly** or **alcoholic patients** (have more atrophy in brains making rupture of vessels more likely)
28
What are **extradural haemorrhages** usually caused by?
Rupture of the **middle meningeal artery** in the **temporo-parietal region** (can be associated with fracture of the **temporal bone**)
29
Where does an **extradural haemorrhage** occur?
Between **skull** and **dura mater**
30
How does an **extradural** haemorrhage appear on a **CT** scan?
**Bi-convex shape** and **limited** by the **cranial sutures**
31
What is the **typical history** of a patient with **extradural haemorrhage**?
Young patient with **traumatic head injury** with ongoing **headache** (period of improvement in symptoms followed by rapid decline as haematoma compresses intracranial contents)
32
Where can **intracerebral haemorrhages** occur?
**Lobar intracerebral** haemorrhage
**Deep intracerebral** haemorrhage
**Intraventricular** haemorrhage
**Basal ganglia** haemorrhage
**Cerebellar** haemorrhage
33
How does an **intracerebral haemorrhage** present?
**Similarly** to a **stroke** (occur spontaneously / bleeding into ischaemic infarct / tumour / rupture of aneurysm)
34
Where is the **bleeding** in **subarachnoid haemorrhage**?
Into **subarachnoid space** where **CSF** is located (between **pia mater** and the **arachnoid membrane**)
35
What normally causes a **subarachnoid haemorrhage**?
**Cerebral aneurysm**
36
What is the **typical history** of a **subarachnoid haemorrhage**?
Occurs during **strenuous activity** e.g. weight lifting / sex (occuring so suddenly it's known as a **thunderclap headache**)
37
What are **subarachnoid haemorrhages** associated with?
**Cocaine** and **sickle cell anaemia**
38
What is the **management** of **intracranial bleeds**?
Immediate **CT** head
Check **FBC** and **clotting**
Admit to **specialist stroke unit**
Discuss **surgery** with neurosurgical centre
Consider intubation and ventilation
**Correct** any **clotting abnormalities**
Correct **severe hypertension** but avoid hypotension
39
What is a **subarachnoid haemorrhage** usually the result of?
Ruptured **cerebral aneurysm**
40
Are **subarachnoid haemorrhages** dangerous?
Very high **mortality** and **morbidity**
41
What are the **features** of a **subarachnoid haemorrhage**?
**Thunderclap headache**
Neck **stiffness**
**Photophobia**
**Vision changes**
**Neuro symptoms** e.g. speech changes, weakness, seizures and loss of consciousness
42
What are some **risk factors** for **subarachnoid haemorrhages**?
**Hypertension**
**Smoking**
Excessive **alcohol consumption**
**Cocaine use**
**FH**
43
Who is **subarachnoid haemorrhage** most common in?
**Black** patients
**Female** patients
Age **45 - 70**
44
What conditions are **subarachnoid haemorrhages** associated with?
**Sickle cell anaemia**
**Connective tissue disorders** (e.g. Marfan or Ehlers-Danlos)
**Neurofibromatosis**
**ADPKD**
45
What is the **first line investigation** for **subarachnoid haemorrhage**?
**CT head** (blood causes **hyperattenuation** in the **subarachnoid space**)
46
What **further** investigations are there for **subarachnoid haemorrhage**?
**Lumbar puncture** to collect sample of **CSF** if CT head is negative:
* **Red cell count** will be raised (if RCC is decreasing in number over samples, could be due to traumatic lumbar puncture)
* **Xanthochromia** (yellow colour of CSF caused by bilirubin)
**Angiography** (CT / MRI) can be used once subarachnoid haemorrhage is confirmed to locate bleeding
47
What is the **managament** of a **subarachnoid haemorrhage**?
**_In a specialist neurosurgical unit_**
* Reduced consciousness = intubation and ventilation
* **Surgical** intervention to treat aneurysms (**coiling** - inserting catheter into arterial system "endovascular approach", alternative is **clipping** - cranial surgery and clipping aneurysm to seal it)
* **Nimodipine** - CCB to prevent vasospasm (common complication that can result in brain ischaemia)
* **Lumbar puncture** or insertion of a **shunt** may be required to treat **hydrocephalus**
* **Antiepileptic** medication can be used for **seizures**
48
What is **multiple sclerosis**?
**Chronic** and **progressive** condition
Involves **_demyelination_** of the **myelinated neurones** in the **central nervous system** caused by **inflammatory process** involving the activation of the **immune cells** against the **myelin**
49
When does MS present?
Younger adults (under 50) - more common in women - **symptoms improve** in **pregnancy** and in **postpartum period**
50
What is **myelin** and where does it come from?
**Myelin** covers **axons** of **neurones** in the **CNS** - helps electrical impulses move **faster** along the **axon**
Myelin is **provided** by cells that wrap around axons:
* **Schwann cells** in **peripheral nervous system**
* **Oligodendrocytes** in **central nervous system**
51
Where does **MS** typically affect?
**Central nervous system** (oligodendrocytes) - affects way electrical signals travel along nerve
52
Why do **symptoms** resolve in **early disease** of **MS**?
**Re-myelination** can occur (in later stages re-myelination is incomplete and symptoms become more permanent)
53
How do **MS lesions** change?
**Disseminated in time and space**
54
What are the **causes** of **MS**?
Multiple genes
EBV
Low vitamin D
Smoking
Obesity
55
What are the **signs** and **symptoms** of **MS**?
**Optic neuritis**
**Eve movement abnormalities**
**Focal weakness**
**Focal sensory symptoms**
**Ataxia**
56
How does **optic neuritis** present?
**Unilateral reduced vision**
Central scotoma (enlarged blind spot)
**Pain** on eye movement
Impaired **colour vision**
**Relative afferent pupullary defect**
57
What are the **causes** other than MS of **optic neuritis**?
**Sarcoidosis**
**SLE**
**Diabetes**
**Syphilis**
**Measles**
**Mumps**
**Lyme disease**
58
What is the management of **patients** presenting with **acute loss of vision**?
Seen by **opthalmologist**
59
What is the **treatment** of **optic neuritis**?
**Steroids** and recovery takes 2-6 weeks (changes on MRI can help predict which patients will go on to develop MS)
60
Why may patients with MS present with **double vision**?
Lesion in **sixth** cranial nerve (**abducens**)
61
What do **unilateral lesions** in the **sixth nerve** cause?
**Internuclear ophthalmoplegia**
Internuclear = never fibres which connect between **cranial nerve nuclei** that controls eye movements (3rd, 4th and 6th cranial nerve nuclei) - these nerve fibres coordinate eye movements
Ophthalmoplegia = problems with muscles around eyes
62
What issues with **gaze** does a lesion in 6th cranial nerve cause?
**Conjugate lateral gaze disorder**
Conjugate = connected
Lateral gaze = both eyes move together to look laterally to left or right
When looking laterally in direction of affected eye, the affected eye will not move
63
What **focal weakness** does **MS** cause?
**Bells palsy**
**Horners** syndrome
**Limb paralysis**
**Incontinence**
64
What **focal sensory symptoms** does **MS** cause?
**Trigeminal neuralgia**
**Numbness**
**Paraesthesia** (pins and needles)
**Lhermitte's sign** - electric shock sensation travels down spine and into limbs when flexing neck - indicates disease in the cervical spinal cord in the dorsal column - caused by **stretching** the **demyelinated dorsal column**
65
What are the different forms of **ataxia** (problems with coordinated movement)?
**Sensory** = loss of **proprioceptive sense** (ability to sense position of the joint - causes **positive Romberg's test** and can cause **pseusoathetosis**)
**Cerebellar** = problems with **cerebellum** coordinating movement (suggests cerebellar lesions)
66
What is the **disease course** of **MS**?
Highly variable, some **relapsing-remitting** for life whereas others are **primary progressive**
67
Can a diagnosis of **MS** be made from a **clinically isolated syndrome**?
Not one one episode - must be **disseminated in time and space** - may never have another episode / develop MS (if lesions are seen then more likely to develop)
68
What is **secondary progressive MS**?
Disease was relapsing-remitting but now **progressive worsening** of symptoms with **incomplete remission**
69
How is a **diagnosis** of **MS** made?
By **neurologist** based on **clinical picture** and symptoms (symptoms have to be **progressive** for a period of **1 year** to **diagnose primary progressive MS**)
70
What **investigations** can **support a diagnosis** of **MS**?
**MRI scans** can demonstrate typical lesions
**Lumbar puncture** can detect "**oligoclonal bands**" in the CSF
71
Who is involved in **MS MDT**?
Neurologists
Specialist nurses
Physiotherapy
Occupational therapy
72
What is the **treatment of MS**?
**Disease modifying drugs** and **biologic therapy** (aim of treatment is to induce long term remission with no evidence of disease activity)
Drugs target **interleukins**, **cytokines** and **various immune cells**
73
How are **relapses** of **MS** treated?
Steroids - **methylprednisolone**
**500mg** orally daily for **5 days** (1g IV for 3-5 days where oral treatment has failed / relapses are severe)
74
How to treat **symptoms** in **MS**?
**Exercise** to maintain activity and strength
**Neuropathic pain** managed with meds e.g. amitriptyline or gabapentin
**Depression** - SSRIs
**Urge incontinence** - anticholinergic medications e.g. tolterodine or oxybutynin (can worsen cognitive impairment)
**Spacsticity** can be managed with **baclofen**, **gabapentin** and **physio**
75
What is **motor neurone disease** (MND)?
Umbrella term for diagnoses of **progressive**, **fatal** condition where **motor neurones stop functioning**
76
Name some **common** MNDs?
**Amylotropic lateral sclerosis** (AML) - stephen hawking had this
**Progressive bulbar palsy** - primarly affects talking and swallowing muscles
**Progressive muscular atrophy**
**Primary lateral sclerosis**
77
What are the **risk factors** for **MND**?
**Genetic component** (take good FH)
**Smoking, exposure to heavy metals** and certain **pesticides** also increase the risk
78
Which **neurones** are affected in **MND**?
Upper and lower motor
**Sensory** neurones are **spared**
79
How does **MND present**?
**Late, middle aged man** possibly with affected relative
**Insidious**, **progressive** weakness of muscles affecting **limbs** (upper first), trunk, face and speech
Increased **fatigue** when exercising
**Clumsiness**, **dropping things**, **falling over**
**Dysarthria** (slurred speech)
80
What are **signs** of **lower motor neurone** **disease**?
**Muscle wasting**
**Reduced tone**
**Fasciculations** (twitching in muscles)
**Reduced reflexes**
81
What are some **signs** of **upper motor neurone disease**?
Increased **tone** or **spasticity**
## Footnote
**Brisk relexes**
**Upgoing plantar responses**
82
How is **MND** diagnosed?
**Clinical presentation** (excluding other conditions)
83
What is the **management** of **MND**?
No effective treatment for halting / reversing disease
**Riluzole** - slows progression of disease and extends survival by a few months in **AML** (licensed in UK and initiated by specialist)
**Edaravone** (used in US but not UK, potential to slow disease)
**Non-invasive ventilation** (NIV) used at home to support breathing at night
84
What else form part of the **management** plan for **MND**?
Effectively **breaking bad news**
Involving **MDT** in supporting and maintaining quality of life
**Advanced directives** to document patients wishes as disease progresses
**End of life care** planning
Patients usually die of **resp failure** or **pneumonia**
85
What is **Parkinson's disease**?
Disease of **progressive reduction** of **dopamine** in the **basal ganglia** of brain leading to disorders of movement (classically asymmetrical)
86
What is the **classic triad** of **features** in **Parkinson's disease**?
**Resting tremor** (not needed for diagnosis)
**Rigidity**
**Bradykinesia**
87
What is the **basal ganglia**?
Group of structures in the **middle of the brain** responsible for **coordinating habitual movements** e.g. walking, looking around, learning movement patterns
88
What part of the **basal ganglia** produces **dopamine** (essential for its functioning)?
**Substantia nigra**
89
At what age do patients with parkinson present?
**Older** (around 70)
90
Describe the **unilateral tremor** in **Parkinsons**?
**Frequency of 4-6 Hz** (occurs 4-6 times a second - **pill rolling tremor**)
More **pronounced when resting** or if distracted (ask pt to mime painting a fence with the other hand)
91
Describe the **cogwheel rigidity** in **Parkinsons**?
**Rigidity** = resistance to passive movement of a joint (flex and extend arm at elbow = tension that gives way in small increments - **cogwheel**)
92
How does **bradykinesia** present in **Parkinson's**?
Handwriting gets smaller
Small steps (**shuffling gait**)
**Difficulty initiating movement** (e.g. from standing still to walking)
Difficulty in turning around when standing (**take lots of little steps**)
Reduced facial movements / expressions (**hypomimia**)
93
What are the **other features** affecting patients with **Parkinsons**?
Depression
Sleep disturbance and insomnia
Loss of sense of smell (**anosmia**)
Postural instability
Cognitive impairment / memory problems
94
How to distinguish a **benign essential tremor** from a **Parkinson's tremor**?
**Parkinson's** = asymmetrical, 4-6 hertz, worse at rest, improves with intentional movement, no change with alcohol
**Benign** = symmetrical 5-8 hertz, improves at rest, worse with intentional movement, improves with alcohol
95
What is **multiple system atrophy**?
Neurones of **multiple systems** in brain degenerate affecting the **basal ganglia** as well as multiple other areas causing **parkinson's presentation** as well as **autonomic dysfunction** (postural hypotension, constipation, abnormal sweating and sexual dysfunction) and **cerebellar dysfunction** (causing ataxia)
96
What is **dementia with lewy bodies**?
Type of demential associated with **features of Parkinsonism** causing progressive cognitive decline (associated symptoms = visual hallucinations, delusions, disorders of REM sleep and fluctuating consciousness)
97
What are the **other parkinson's plus syndromes**?
* **Progressive supranuclear palsy**
* **Corticobasal degeneration**
98
How should **Parkinson's** be **diagnosed**?
Clinically based on **symptoms** and **examination** by specialist
99
When do patients with **Parkinson's** describe themselves as **"****on"**?
**Medications** are acting and moving freely ("off" when medications wear out)
100
What **medications** are **given** for **P****arkinson's**?
Levodopa
COMT inhibitor
Dopamine agonist
Monoamine oxidase-B inhibitor
101
What is **Levodopa**? What is it **usually given with**?
**Synthetic dopamin****e** (given orally)
Drug to stop levodopa being broken down in body before it enters the brain (**peripheral decarboxylase inhibitors** e.g. **carbidopa** and **benserazide**)
Co-benyldopa (levodopa and benserazide)
Co-careldopa (levodopa and carbidopa)
**Levodopa** is most effective treamtnet but becomes less over time - often reserved for when other treatments are not managing symptoms
102
What is the **main side effect** of **dopamin****e**?
Dose is too high = **dyskinesias** (abnormal movements associated with **excessive motor activity**):
* **Dystonia** (excessive contraction = abnormal posture / exaggerated movement)
* **Chorea** (abnormal involuntary movements can be jerking and random)
* **Athetosis** (involuntary twisting / writing usually in fingers, hands or feet)
103
What are **COMT inhibitors**?
Give an example?
How do they work?
Inhibit **catechol-o-methyltransferase** (COMT) - this enzyme metabolises levodopa in both the brain and body
Taken with **levodopa** and **decarboxylase inhibitor** to slow breakdown of levodopa
**Entacapone**
104
How do **dopamine agonist****s** work?
What is a **side effect**?
Give some examples?
**Mimic dopamine** in the basal ganglia and **stimulate** the **dopamine receptors** (less effective than levodopa - used to delay levadopas use, then used in combination)
**Pulmonary fibrosis**
* **Bromocryptine**
* **Pergolide**
* **Carbergoline**
105
How do **monoamine oxidase-B inhibitors** work?
Monoamine oxidase enzymes **break down neurotransmitters** e.g. **dopamine**, **serotonin** and **adrenaline** (monoamine oxidase-B enzyme is **more specific** to **dopamine**)
Used to **delay** the use of **levodopa** and then in combination with **levodopa** to reduce required dose
* **Selegiline**
* **Rasagiline**
106
What is **benign essential tremor**?
Common condition associated with **older age** - characterised by a **fine tremor** affecting **all voluntary muscles** (most noticable in hands, can also affect head, jaw and voice)
107
What are the **features** of a **benign essential tremor**?
**Fine tremor**
**Symmetrical**
More **prominent** on **voluntary** side
Worse when tires, stressed or **after caffeine**
**Improved** by **alcohol**
**Absent** during **sleep**
108
What are the **other causes** of a tremor?
**Parkinson's**
**MS**
**Huntington's Chorea**
**Hyperthyroidism**
**Fever**
**Medications** (e.g. antipsychotics)
109
What **medications** can be **tried** to improve symptoms of **benign essential tremor**?
**Propanolol** (non-selective beta blocker)
**Primidone** (barbiturate anti-epileptic medication)
110
What is **epilepsy**?
**Umbrella** term for condition where **tendency** towards **seizures** (transient episodes of **abnormal electrical acitivity** in the brain)
111
What **investigations** are there for **epilepsy**?
**Electroencephalogram** (EEG) can show typical patterns
**MRI brain** to diagnose structural problems that may be associated with seizures
**ECG** can be used to exclude problems with the heart
112
What are **generalised tonic-clonic seizures**?
Loss of **consciousness** and **tonic** (muscle tensing - typically comes first) and **clonic** (muscle jerking) episodes
Associated with:
* **Tongue biting**
* **Incontinence**
* **Groaning**
* **Irregular breathing**
113
What happens after a tonic-clonic seizure?
**Prolonged** post-ictal phase (**confused**, **drowsy** and **feels irritable** or **depressed**)
114
What is the **management** of **tonic-clonic** seizures?
First line: **sodium valporate**
Second line: **lamotrigine** or **carbamazepine**
115
What are **focal seizures?** How do they present?
Seizure **starts in temporal lobe** affecting **hearing**, **speech**, **memory** and **emotions**
* **Hallucinations**
* **Memory flashbacks**
* **Deja vu**
* **Doing strange things on autopilot**
116
What is the **treatment** of **focal seizures**?
Reverse of tonic-clonic:
* **First line**: carbamazepine or lamotrigine
* **Second line**: sodium valporate or levetiracetam
117
What are **absence seizures**?
What is the **treatment** of **absence seizures**?
Typically happen in **children** - patient becomes **blank**, **stares into space** and then **abruptly returns to normal** (last 10-20 seconds) most patients stop having seizures as get older
First line = **sodium valporate** or **ethosuximide**
118
What are **atonic seizures**?
What may they be suggestive of?
What is the **treatment** of **atonic seizures**?
Aka "**drop attacks**" - brief lapses in muscle tone (lasting no longer than 3 minutes - begin in childhood)
May indicate **Lennox-Gastaut syndrome**
First line = **sodium valporate**
Second line = **lamotrigine**
119
What are **myoclonic seizures**?
What is the treatment?
**Sudden brief muscle contraction** like a "**jump**" - patient usually remains awake - can occur in any epilepsy but typically occur in **juvenile myoclonic epilepsy**
First line = **sodium valporate**
Second line = **lamotrigine, levetiracetam** or **topiramate**
120
What are **infantile spasms**?
What are they **also known as**?
Rare disorder starting at **6 month****s**- characterised by**clusters**of**full body spasms,** poor prognosis:
1/3 die by age 25, 1/3 are seizure free
Also known as **West syndrome**
Treatment = **prednisolone, vigabatrin**
121
How does **sodium valporate** work?
**Increases** activity of **GABA** (has a relaxing effect on the brain) used first line in most epilepsy (except focal seizures)
**Side effects**:
* **Teratogenic** - need contraception (must be avoided in girls / women unless no suitable alternative)
* Liver damage and hepatitis
* Hair loss
* Tremor
122
What **medication** is **first line** for **focal seizures**? What are some **side effects**?
**Carbamazepine**
* Agranulocytosis
* Aplastic anaemia
* Induces the P450 system so many drug interactions
123
What are some **notable side effects** of **phenytoin**?
**Folate and vitamin D** deficiency
**Megaloblastic anaemia** (folate deficiency)
**Osteomalacia** (vitamin D deficiency)
124
What are some **notable side effects** of **ethosuzimide**?
Night **terrors**
## Footnote
**Rashes**
125
What are some **notable side effects** of **lamotrigine**?
**Stevens-Johnson syndrome**
**DRESS syndrome** (life threatening rashes)
**Leukopenia**
126
What is **statis epilepticus**?
Seizure lasting **more than 5 minutes**
**More than 3 seizures** in **one hour**
127
What is the **management** of **status epileptics** in the **hospital**?
ABCDE approach
Secure airway
Give high-concentration oxygen
Assess cardiac and respiratory function
Check blood glucose levels
IV access
IV **lorazepam** 4mg, repeated after 10 minutes if seizure continues
If seizures persist: IV **phenobarbital** or **phenytoin**
128
What are some **medical options** for status epilepticus in the community?
**Buccal midazolam**
**Rectal diazepam**
129
What is **neuropathic pain**?
Abnormal functioning of **sensory nerves** delivering **abnormal painful signals** to the brain
130
What can **cause** **neuropathic pain**?
**Postherpetic neuralgia** from **shingles** is in the distribution of a **dermatome** and usually on the trunk
**Nerve damage** from surgery
Multiple sclerosis
**Diabetic neuralgia** (on feet)
**Trigeminal neuralgia**
**Complex regional pain syndrome** (CRPS)
131
What are the **features** of **neuropathic pain**?
**Burning**
**Tingling**
**Pins and needles**
**Electric shock**
**Loss of sensation** to touch of affected area
132
What questionnaire is used to **assess** neuropathic pain?
**DN4 questionnaire** (scored out of 10 for pain)
**4 or more** indicates **neuropathic pain**
133
What are the **four first line treatments** for **neuropathic pain**?
**Amitriptyline -** TCA
**Duloxetine** - SNRI
**Gabapentin** is an **anticonvulsant**
**Pregabalin** is an **anticonvulsant**
134
What are the **other options** for **neuropathic pain**?
**Tramadol** only as rescue for flares
**Capsaicin cream** (chilli pepper cream) for localised areas of pain
**Physiotherapy** to maintain strength
**Psychological input** to help with understanding and coping
135
What **medication** is used **first line** for **trigeminal neuralgia**?
**Carbamazepine** (if doesnt work then referral to specialist)
136
What is **complex regional pain syndrome**?
Abnormal nerve functioning can cause **neuropathic pain** and **abnormal sensations** - usually isolated to one limb often triggered by **injury** to the area
Area can be become **hypersensitive** even to **wearing clothing** (intermittently swells, changes colour, temperature, flushes with blood and sweat abnormally)
**Treatment** guided by **pain specialist**
137
Where does the **facial nerve** exit the **brainstem**? What does it **pass through**?
Exits at **cerebellopontine angle** passing through **temporal bone** and **parotid gland**
138
What are the **five branches** of the **facial nerve**?
**Temporal**
**Zygomatic**
**Buccal**
**Marginal mandibular**
**Cervical**
139
What are the **motor**, **sensory** and **parasympathetic** functions of the **facial nerve**?
**_Motor_**: muscles of **facial expression**, **stapedius** in middle ear, **posterior digastric, stylohyoid** and **platysma** muscles in the neck
**_Sensory_**: **taste** from **anterior 2/3** of tongue
**_Parasympathetic_**: supplt to **submandibular** and **sublingual salivary glands** and the **lacrimal gland** (stimulating tear production)
140
What is the management of **upper motor neurone facial nerve palsy** vs **lower**?
**Upper** = referred urgently with a suspected stroke
**Lower** = reassured and managed in community
141
How to **distinguish** between **upper motor neurone** lesion and **lower motor neurone** lesion?
Each side of the **forehead** has **upper motor neurone innervation** by **both sides** of the brain but only **lower motor neurone innervation** from **one side** of the brain
* UMNL = forehead spared
* LMNL = forehead not spared
142
How does a **lower motor neurone** facial **palsy** present?
**Forehead affected**
**Drooping of eyelid**, exposing of eye
**Loss of nasolabial fold**
143
What causes a **unilateral upper motor lesion**?
**CVA** (stroke)
## Footnote
**Tumour**
144
What may cause **bilateral motor neurone lesion** (rare)?
**Pseudobulbar palsy**
**MND**
145
What causes **bell's palsy**?
Common **idiopathic condition** causing **unilateral lower motor neurone facial nerve palsy** (majority of patients recover over several weeks but some recovery may take up to **12 months**)
146
What **treatment** is **recommended** for **Bell's palsy**?
**Prednisolone**:
* **50mg** for **10 days**
* **60mg** for **5 days** followed by 5 day regime of reducing 10mg a day
(antiviral PLUS steroid MAY offer small benefit)
147
What **additional managament** is there for **Bell's palsy**?
**Lubricating eye drops** to prevent eye on affected side drying out
If **eye pain** = ophthalmology review for **exposure keratopathy**
Tape can be used to **keep eye shut** at night
148
What is **Ramsay-Hunt syndrome** and **how does it present**?
Caused by **herpes zoster virus** - presents as **unilateral lower motor neurone facial palsy**
* Painful and tender **vesicular rash** in the ear canal, pinna and around the ear
* Rash can extend to **anterior 2/3** of the **tongue** and **hard palate**
149
What is the **treatment** of **Ramsay-Hunt syndrome**?
**Prednisolone**
**Aciclovir**
May also require **lubricating eye drops**
150
What are some **other causes** of **lower motor neurone facial palsy**?
**Infection**: otitis media, malignant otitis externa, HIV, lyme's disease
**Systemic disease**: diabetes, sarcoidosis, leukaemia, MS, Guillain-Barre syndrome
**Tumours**: acoustic neuroma, parotid tumours, cholesteatomas
**Trauma**: direct nerve damage, damage during surgery, base of skull fractures
151
Give an example of a **benign brain tumour** and a **highly malignant**?
**Benign** = meningioma
**Highly malignant** = glioblastoma
152
How do **brain tumours** present?
**Focal neurological symptoms** depending on location of lesion (e.g. frontal lobe personality changes)
**Raised intracranial pressure** symptoms
153
What **causes** **raised intracranial pressure**?
**Brain tumours**
**Intracranial haemorrhage**
**Idiopathic intracranial hypertension**
**Abscesses** or **infection**
154
How does the headache of **raised intracranial pressure** present?
Constant
Nocturnal
Worse on waking
Worse on coughing, straining or bending forwards
Vomiting
155
What are the **other presenting features** of **raised intracranial pressure**?
Altered mental state
Visual field defects
Seizures (particularly focal)
Unilateral ptosis
Third and sixth nerve palsies
Papilloedema (on fundoscopy)
156
What is **papilloedema**?
**Swelling** of the **optic disc** secondary to **raised intracranial pressure** (papill = small rounded raised area)
**Sheath** around optic nerve is connected with **subarachnoid space** - CSF under high pressure can **flow into optic nerve sheath** increasing pressure around optic nerve
Can be seen on **fundoscopy**
157
What are the **fundoscopic** changes in **papilloedema**?
**Blurring** of optic disc **margin**
**Elevated optic disc** (look at way retinal vessels flow across disc)
Loss of **venous pulsation**
**Engorged retinal veins**
**Haemorrhages** around optic disc
**Paton's lines** = creases in retina around optic disc
158
Which **cancers** commonly **metastasis** to the **brain**?
**Lung**
**Breast**
**RCC**
**Melanoma**
159
What are **gliomas**? Give 3 examples (from most - least malignant)
**Tumours** of the **glial cells** in the brain or spinal cord
* **Astrocytoma** (glioblastoma multiforme is most common)
* **Oligodendroglioma**
* **Ependymoma**
160
How are **gliomas** graded?
**1-4** (1 = most benign, 4 = most malignant)
161
What are **meningiomas**?
**Tumours** growing from **cells** of the **meninges** in the brain and spinal cord - **usually benign** (take up space and mass effect leads to **raised intracranial pressure** and **neuro symptoms**)
162
How may a **pituitary tumour** present if it grows large enough?
Presses on **optic chiasm** causing a **bitemporal hemianopia** (loss of outer half of visual fields)
163
How else may **pituitary tumours** present?
**Hypopituitarism** or **excess hormone release**:
* Acromegaly
* Hyperprolactinaemia
* Cushing's disease
* Thyrotoxicosis
164
What are **acoustic neuromas**? AKA vestibular schwannomas?
Tumours of the **Schwann cells** surrounding **auditory nerve** that innervates the inner ear
Occur around the "**cerebellopontine angle**" (aka cerebellopontine angle tumours)
**Slow growing**
Usually **unilateral** (bilateral acoustic neuromas are associated with **neurofibromatosis type 2**
165
What are the **classic symptoms** of an **acoustic neuroma**?
Hearing loss
Tinnitus
Balance problems
(also associated with facial nerve palsy)
166
What are the **management options** for **brain tumours**?
**Palliative care**
**Chemo**
**Radiotherapy**
**Surgery**
167
How are **pituitary tumours** treated?
**Trans-sphenoidal surgery**
**RT**
**Bronocriptine** to block **prolactin-secreting tumours**
**Somatostatin analogues** (e.g. **ocreotide**) to block **growth hormone-secreting** tumours
168
What is **Huntington's chorea**?
**Autosomal dominant** genetic condition which causes a **progressive deterioration** in the nervous system (usually asymptomatic until symptoms begin aged 30-50)
169
What is the **genetic mutation** in Huntington's chorea?
'**trinucleotide repeat disorder** involving a **genetic mutation** in the **HTT gene** on **chromosome 4**
170
Huntington's chorea displays '**anticipation**', what is this?
Feature of **trinucleotide repeat disorder** where successive generations have more **repeats** in the gene causing **earlier age of onset** and **increased severity** of disease
171
How does **Huntington's chorea** present?
Begins with **cognitive, psychiatric** or **mood problems** followed by:
* **Chorea** (involuntary, abnormal movements)
* **Eye movement disorder****s**
* Speech difficulties (**dysarthria**)
* Swallowing difficulties (**dysphagia**)
172
How is **Huntington's chorea** diagnosed?
**Genetic testing** for the **faulty gene** (pre-test and post-test counselling regarding implications for result)
173
What is the **management** of **Huntington's chorea**?
No treatment options for slowing / stopping progression
* Effectively **breaking bad news**
* Involvement of **MDT** in supporting their QoL
* **Speech and language therapy** for speech / swallowing difficulties
* **Genetic counselling** regarding relatives, pregnancy and children
* **Advanced directives** to document patients wishes
* **End of life** care planning
174
Which **medications** can help with **disordered movement?**
**Antipsychotics** (e.g. olanzapine)
**Benzodiazepines** (e.g. diazepam)
**Dopamine-depleting agents** (e.g. tetrabenazine)
175
What is the **prognosis** of **Huntington's chorea**?
Progressive condition - **life expectancy around 15-20 years** after onset of symptoms
As **disease progresses** patient becomes more **susceptible** and less able to fight off illnesses
Death is often due to **respiratory disease** (e.g. pneumonia)
**Suicide** is more common than in gen pop
176
What is **myasthenia gravis**?
**Autoimmune** condition, causing muscle weakness, worse with activity, improves with rest
Affects **women under 40** and **men over 60**
177
Which **disease** is **linked with myasthenia gravis**?
**Thymoma** (tumour of the **thymus glan****d**)
178
What happens across a **normal synapse**?
**Motor nerves** communicate with **muscles** at neuromuscular junctions - **axon****s**of motor nerves are situated across a**synapse**from**post-synaptic membrane**on the**muscle cell**- these axons release**neurotransmitter**(acetylcholine) which leads to**muscle contraction**
179
What **antibody** is produced by patients with **myasthenia gravis?**
**Acetylcholine receptor antibodies** (85%) - bind to **postsynaptic** neuromuscular junction **receptors** - blocking acetylcholine from binding and **activating the complement system** causing damage to cells at **post synaptic membrane**
180
Which **other antibodies** are **produced in myathenia gravis**?
Against **muscle-specific kinase** (MuSK) and antibodies against **low-density lipiprotein receptor-related protein 4** (LRP4)
**MuSK** and **LRP4** are important proteins for creation of **acetylcholine receptors**
181
How does **myasthenia gravis** present?
Weakness worse with muscle use and improves with rest
**Minimal** in **morning** and worse at end of day
Affects **proximal muscles** and those of **head and neck**
* **Diplopia** (extraocular muscle weakness)
* **Ptosis** (eyelid weakness)
* Weakness in **facial muscle**
* Difficulty with **swallowing**
* **Fatigue in jaw** when chewing
* **Slurred speech**
182
How to **examine** for **myasthnia gravis**?
Repeated blinking exacerbates **ptosis**
Prolonged upward gazing exacerbates **diplopia** on further eye movement testing
Repeated **abduction** of arm 20 times will cause **unilateral weakness** when comparing both sides
Check for **thymectomy scar**
Test **forced vital capacity** (FVC)
183
How is **myasthenia gravis** diagnosed?
**Testing for antibodies**:
* Acetylcholine receptor (ACh-R) antibodies
* Muscle-specific kinase (MuSK) antibodies
* LRP4 (low density lipoprotein receptor-related protein 4) antibodies
**CT** or **MRI** of **thymus gland** to look for **thymoma**
**Edrophonium test** can be useful if doubt about diagnosis
184
How is the **edrophonium test** performed?
Given IV dose of **edrophonium chloride** (or neostigmine)
Edrophonium **blocks cholinesterase enzymes** breaking down acetylcholine - providing brief relief from weakness
185
What are the **treatment options** for **myasthenia gravis**?
**Reversible acetylcholinesteras inhibitors** (usually **pyridostigmine** or **neostigmine**) increasing amount of **acetylcholine**
**Immunosuppression** (prednisolone or azathioprine) suppressing production of antibodies
**Thymectomy** can improve symptoms even in patients without a thymoma
**Monoclonal antibodies** (e.g. **rituximab** - targets B cells reducing antibodies OR **eculizumab** - targets **completment protein C5**)
186
What is a **m****yasthenic crisis?**
What is the **treatment**?
**Acute worsening of symptoms** often triggered by another illness e.g. **respiratory tract infection** - patients may require **non-invasive ventilation** with **BiPAP** or full **intubation** and **ventilation**
Treat with:
* IV immunoglobulins
* Plasma exchange
187
What is **Lambert-Eaton myasthenic syndrom****e** similar to?
**Myasthenia gravis** (progressive muscle weakness with increased use)
188
What does **Lambert-Eaton** syndrome usually occur **in conjunction with**? Why?
**Small-cell lung cancer** - antibodies produced by immune system against **voltage-gated calcium channels** in **small cell lung cancer** (SCLC) also attach channels in **presynaptic terminals** of **neuromuscular junction** (so **acetylcholine** cannot be released)
189
How does **Lambert-Eaton syndrome present**?
Slowly - **proximal muscles** are mostly affected
Affects **intraocular muscles** causing **double vision** (diplopia)
**Levator muscles** in eyelids cause **drooping** (ptosis)
**Oropharyngeal muscles** causing slurred speech and swallowing problems (dysphagia)
**Autonomic dysfunction**:
* Dry mouth
* Blurred vision
* Impotence
* Dizziness
190
What is found **on examination** of a patient with **Lambert-Eaton syndrome**?
**Reduced tendon reflexes**
**Post-tetanic potentiation** - reflexes are temporarily normal following strong muscle contraction e.g. after max quadricep contraction
191
What is the **treatment** of **Lambert-Eaton syndrom****e**?
Consider **investigation** for **small cell lung cancer**
**_Amifampridine_** allows **more acetylcholine** to be released in **neuromuscular junction** synapses by **blocking voltage-gated potassium channels** in **presynaptic cells** prolonging depolorisation of cell membrane
Other options:
* Immunosuppressants (e.g. prednisolone or azathioprine)
* IV immunoglobulins
* Plasmapheresis
192
What is **Charcot-Marie-Tooth disease**?
**Inherited disease** affecting **peripheral motor and sensory neurones** causing **dysfunction** in the **myelin** or **axons** (usually **autosomal dominant** inheritance)
Symptoms usually appear **before 10 years old** (can be 40 or later)
193
What are the **classical features** of **Charcot-Marie-Tooth**?
High foot arches (**pes cavus**)
Distal muscle wasting = "**inverted champagne bottle legs**"
Weakness in lower legs - particularly loss of **ankle dorsiflexion**
Weakness in hands
Reduced tendon reflexes
Reduced muscle tone
Peripheral sensory loss
194
What are some **causes** of **peripheral neuropathy**?
**A**lcohol
**B**12 deficiency
**C**ancer and **C**hronic kidney disease
**D**iabetes and **D**rugs (e.g. isoniazid, amiodarone and cisplatin)
**E**very vasculitis
195
What is the **managament** of **Charcot-Marie Tooth**?
_Purely **supportive**_
* **Neurologists** to make diagnosis
* **Physiotherapists** to maintain muscle strength & ROM
* **Occupational therapists** to assist with AoDL
* **Podiatrists**
* **Orthopaedic surgeons** to correct disabling joint deformities
196
What is **Guillain-Barré syndrome**?
**Acute paralytic polyneuropathy** affecting the **peripheral nervous system** causing acute, symmetrical, ascending weakness
Usually triggered by **infection** (campylobacter jejuni, cytomegalovirus, EBV)
197
What is thought to **cause Guillain-Barre syndrome**?
**Molecular mimicry** - **B cells** of the immune system create **antibodies** against the **antigens** on the **pathogen** that causes the preceding infection - antibodies also match proteins on nerve cells (either on **myelin sheath** or on **nerve axon**)
198
How does **Guillain-Barre syndrome present**?
Symmetrical **ascending weakness** (starting at feet)
**Reduced reflexes**
**Peripheral loss of sensation** or **neuropathic pain**
May **progress to cranial nerves** and cause **facial nerve weakness**
199
What is the **course** of **Guillain-Barré** syndrome?
Usually **starts** within **4 weeks** of **preceding infection** - starting at feet and progress upwards
Recovery can take **months to years**
200
How is **Guillain-Barré** diagnosed? What criteria can help with diagnosis?
**Clinically diagnosed** - Brighton criteria
201
What **investigations** can support **diagnosis** of **Guillain-Barré**?
**Nerve conduction studies** (reduced signal through nerves)
**Lumbar puncture** for **CSF** (**raised protein** with a normal cell count and glucose)
202
What is the **management** of **Guillain-Barré** syndrome?
**IV immunoglobulins**
**Plasma exchange** (alternative to IV IG)
**Supportive care**
**VTE prophylaxis** (**pulmonary embolism** is a leading cause of death)
Intubation and ventilation if **respiratory failure**
203
What is the **prognosis** of **Guillain-Barré syndrome**?
80% fully recover
15% left with neuro disability
5% die
204
What is **neurofibromatosis**?
Genetic condtion causing **benign** **nerve tumours** (**neuromas**) to develop throughout the nervous system
Two types:
* Neurofibromatosis type 1 (more common)
* Neurofibromatosis type 2
205
What is the **genetic** mutation is NF1?
Found on **chromosome 17** - codes for a protein called **neurofibromin** - **tumour suppressor protein** (inheritance is **autosomal dominant**)
206
What is the **diagnostic criteria** for **NF1**?
**CRABBING** (must be at least 2)
* **Cafe au lait spots** (6 or more) \>5mm in children or 15mm in adults
* **Relative** with NF1
* **Axillary** or inguinal freckles
* **B**ony dysplasia such as bowing of long bone or sphenoid wing dysplasia
* **Iris hamartomas** (Lisch nodules) (2 or more) - yellow brown spots on the iris
* **Neurofibromas** (2 / more) or 1 plexiform neurofibroma
* **Glioma** of the optic nerve
207
What **investigations** can be performed when there is **diagnostic doubt**?
**Genetic testing**
**X-rays** to investigate bone pain / lesions
CT and MRI to investigate **lesions in brain,** spinal cord and elsewhere
208
What is the **management of NF1**?
**Control symptoms, treat complications**
209
What are the **complications** of **NF1**?
Migraines
Epilepsy
**Renal artery stenosis** causign **hypertension**
Learning and behavioural problems (e.g. ADHD)
**Scoliosis** of the spine
**Vision loss** (secondary to optic nerve gliomas)
**Malignant peripheral nerve sheath tumours**
GI stromal tumour (type of sarcoma)
**Brain tumour**
**Spinal cord tumour** (paraplegia)
Increased risk of **cancer** (e.g. breast)
Leukaemia
210
What is the **genetic mutation** in **NF2**?
Mutation in **chromosome 22** which codes for protein called **merlin** (**tumour suppressor protein** - important for **Schwann cells**)
Causes **schwannomas** - inherited in **autosomal dominant pattern**
211
What is **NF2** mostly associated with?
**Acoustic neuromas** - tumours of the **auditory nerve** innervating inner ear - **symptoms**:
* Hearing loss
* Tinnitus
* Balance problems
212
What do **bilateral acoustic neuromas** indicate?
NF2
213
How do schwannomas present? How can they be treated?
**Symptoms based on location of lesion**
**Surgery** can resect tumours although risk of permanent nerve damage
214
What is **tuberous sclerosis**?
**Genetic condition** - characteristically causing **hamartomas** (benign neoplastic growths of the originating tissue)
215
Where do **hamartomas** typically affect?
Skin
Brain
Lungs
Heart
Kidneys
Eyes
216
What does is the **genetic mutation** in **tuberous sclerosis**?
**TSC1 gene** on **chromosome 9** which codes for **hamartin**
**TSC2 gene** on **chromosome 16** which codes for **tuberin**
217
What do **hamartin** and **tuberin** do?
**Interact** with each other to **control** size and **growth** of cells (abnormalities in one of these causes **abnormal cell size and growth**)
218
What are the **skin signs** of **tuberous sclerosis**?
**Ash leaf spots** - depigmented aread of skin shaped like ash leaf
**Shagreen patches** - thickened, dimpled, pigmented patches of skin
**Angiofibromas** - small skin coloured / pigmented papules occuring over nose and cheeks
**Subungual fibromata** - fibromas under nail bed - usually circular painless lumps that displace the nail
**Cafe-au-lait spots** - light brown coloured flat pigmented lesions on skin
**Poliosis** - isolated patch of which hair on head, eyebrows, eyelashes or beard
219
What are the **neurological features** of **tuberous sclerosis**?
**Epilepsy**
**Learning disability** and developmental delay
220
What are the **other features** of **tuberous sclerosis**?
**Rhabdomyomas** in the heart
**Gliomas** (tumours of the brain and spinal cord)
**Polycystic kidneys**
**Lymphangioleiomyomatosis** (abnormal growth in smooth muscle cells, often affecting lungs)
**Retinal hamartomas**
221
How does **tuberous sclerosis present**?
Child with **epilepsy** and **skin features** of **tuberous sclerosis**
222
What is the **management** of **tuberous sclerosis**?
**Supportive** with **monitoring** and **treating** of **complications** such as epilepsy (no treatment for underlying gene defect)
223
What are the **differential diagnoses** of **headaches**?
**Tension** headaches
**Migraines**
**Cluster** headaches
**Secondary** headaches
**Sinusitis**
**Giant cell** arthritis
**Glaucoma**
**Intracranial** haemorrhage
**Subarachnoid** haemorrhage
**Analgesic** headache
**Hormonal** headache
**Cervical spondylosis**
**Trigeminal** neuralgia
**Raised ICP**
**Meningitis**
**Encephalitis**
224
What are some **red flags** for **headache**?
**Fever, photophobia or neck stiffness** (meningitis or encephalitis)
**New neurological symptoms** (haemorrhage, malignancy or stroke)
**Dizziness** (stroke)
**Visual disturbance** (temporal arteritis or glaucoma)
**Sudden onset occipital headache** (subarachnoid haemorrhage)
**Worse on coughing** or straining (raised intracranial pressure)
**Postural**, **worse on standing, lying or bending over** (raised intracranial pressure)
Severe enough to **wake the patient from sleep**
**Vomiting** (raised **intracranial pressure or carbon monoxide poisoning**)
**History of trauma** (intracranial haemorrhage)
**Pregnancy** (pre-eclampsia)
225
What should be in the **examination** of a patient with a **headache**?
**Fundoscopy** (look for **papilloedema**)
Indicates **raised ICP** (due to **brain tumour, benign intracranial hypertension** and **intracranial bleed**)
226
How do **tension headaches** present?
**Mild ache** across forehead in band like pattern (ache in **frontalis**, **temporalis** or **occipital** muscles)
## Footnote
**No visual changes**
227
What are **tension headaches** associated with?
**Stress**
**Depression**
**Alcohol**
**Skipping meals**
**Dehydration**
228
What is the **treatment** of **tension headaches**?
**Reassurance**
Basic **analgesia**
**Relaxation** techniques
**Hot towels** to local area
229
How do **secondary headaches** present?
Similar to tension headache but clear cause
230
What can **cause** **secondary headaches**?
Underlying medical conditions e.g. **infection**, **obstructive sleep apnoea**, or **pre-eclampsia**
## Footnote
**Alcohol**
**Head injury**
**Carbon monoxide poisoning**
231
What is **sinusitis**?
Headache associated with **inflammation**, in **ethmoidal**, **maxillary**, **frontal** or **sphenoidal** sinuses
Causes **facial pain** behind nose, forehead and eyes
**Tenderness** over affected sinus
232
When does **sinusitus** usually resolve?
Within **2-3 weeks** (mostly viral) nasal irrigation with saline can be helpful
**Prolonged** = steroid nasal spray (abx occasionally required)
233
What is an **analgesic headache**?
Headache caused by **long term analgesia use**
**Withdrawal of analgesia** is important in treating headache
234
What are **hormonal headaches**?
Related to low levels of **oestrogen** (produce **generic, non-specific**, **tension like headache**)
Appear:
* **2 days before and first 3 days** of menstrual period
* **Around menopause**
* **Pregnancy** (worse in first few weeks, improves in last 6 months - if in the 2nd half then investigate for pre-eclampsia)
Oral contraceptive pill can **improve hormonal headaches**
235
What is **cervical spondylosis**?
Condition caused by **degenerative changes** in the **cervical spine** causing **neck pain**, usually worse on movement (can also cause headache)
Must exclude other causes e.g. inflammation, malignancy, infection, spinal cord lesions
236
What are the **branches** of the **trigeminal nerve**?
Opthalmic V1
Maxillary V2
Mandibular V3
237
What causes **trigeminal neuralgia**?
**Unclear** (thought to be compression of nerve)
Most cases are **unilateral**
5-10% of patients with **MS** have **trigeminal neuralgia**
238
How does **trigeminal neuralgia** present?
**Facial pain** comes on spontanously lasting **few seconds** to **few hours** (electricity like shooting pain)
239
What can trigger **pain** in **trigeminal neuralgia**?
**Cold** weather
**Spicy** food
**Caffeine**
**Citrus** fruits
240
What medication is **first line** for **trigeminal** neuralgia?
**Carbamazepine** (surgery to decompress / damage nerve is an option)
241
What are the **different types** of **migraine**?
**Migraine without aura**
**Migraine with aura**
**Silent** migraine
**Hemiplegic** migraine
242
What are the **features** of a **migraine**?
Last between 4 - 72 hours:
* **pounding** / **throbbing** in nature
* **usually unilateral**
* **Photophobia**
* **Phonophobia** (loud noises)
* With / without aura
* N&V
243
What is an **aura**?
Term to describe **visual changes** associated with **migraines**:
* **Sparks** in vision
* **Blurring** vision
* **Lines across vision**
* **Loss** of different **visual fields**
244
How does a **hemiplegic stroke** present?
Mimics **stroke**:
* Typical migraine symptoms
* Sudden / gradual onset
* **Hemiplegia** (unilateral weakness of limbs)
* **Ataxia**
* Changes in consciousness
245
What are some **potential triggers** of a **migraine**?
**Stress**
Bright **lights**
Strong **smells**
Certain foods (e.g. **chocolate**, **cheese**, **caffeine**)
**Dehydration**
**Menstruation**
**Abnormal sleep** patterns
**Trauma**
246
What are the **5 stages** of a **migraine**?
**Premonitory** or **prodromal** stage (begin 3 days before headache e.g. yawning, fatigue or mood changes)
**Aura** (lasting up to 60 mins)
**Headache** (lasting 4-72 hours)
**Resolution** (fades away / relieved by vomiting / sleeping)
**Postdromal** or **recovery** phase
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What are the options for **acute** **medical management** for **migraine**?
**Paracetamol**
**Triptans** (e.g. sumatriptan 50mg as the migraine starts)
**NSAIDs** (e.g. ibuprofen or naproxen)
**Antiemetics** if vomiting occurs (e.g. metoclopramide)
248
What are **triptans**? How are they hypothesised to work?
**5HT receptors agonists** (serotonin receptor agonists)
Act on:
* **Smooth muscles** in arteries to cause **vasoconstriction**
* **Peripheral pain receptors** to inhibit activation of pain receptors
* **Reduce neuronal activity** in the CNS
249
What medications can be used as **migraine prophylaxis**?
**Propranolol**
**Topiramate** (teratogenic and causes cleft lip / palate - DONT GET PREGNANT)
**Amitriptyline**
250
What else can **help with migraines?**
**Acupuncture** (reported to be as effective as prophylactic medication)
Supplementation with **B2** (riboflavin) may reduce frequency and severity
If specifically triggered around **menstruation** then **prophylaxis** with **NSAIDs** (e.g. **mefanamic acid**) or **triptans** (**frovatriptan** or **zolmitriptan**)
251
What is the **prognosis** of **migraines**?
**Better over time** and **go into remission**
252
What are **cluster headaches**?
Who do they typically affect?
What are the triggers?
Severe **headaches** usually around **eye**
**Clusters** = 3-4 attacks a day for weeks / months followed by **pain free** period for 1-2 years (attacks = 15mins - 3 hours)
30-50 year old male smoker
**Triggers** = alcohol, strong smells and exercise
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What are the **symptoms** of **cluster headaches**?
**Suicide headaches**:
* Red, swollen, watering eye
* Pupil contriction (miosis)
* Eyelid drooping (ptosis)
* Nasal discharge
* Facial swelling
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What are the **acute** and **prophylactic** treatment of **cluster headaches**?
**_Acute_** = **triptans** (e.g. sumatriptan 6mg injected subcut) and **high flow** 100% oxygen for 15-20 mins
**_Prophylaxis_** = **verapamil**, **lithium**, **prednisolone** (short course 2-3 weeks to break cycle during clusters)
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How does damage to **median nerve** present?
Motor and sensory to lateral half of hand
256
What does the **sciatic nerve** form?
What can damage to these nerves cause?
Tibial
Common perineal nerves = damage - **foot drop**
257
What are the risk factors for raised ICP?
Female
Obesity
Drugs (tetracycline, steroids, COCP, vitamin A, lithium)
Pregnancy
258
What are the features of idiopathic intracranial hypertension?
Headache
Blurred vision
Papilloedema
Enlarged blind spot
259
What is the management of idiopathic intracranial hypertension?
Weight loss
Diuretics (e.g. acetazolamide)
Repeated LP
260
What is Uhthoff's phenomenon?
Worsening of MS symptoms after a hot shower
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