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Year 4 - NSS > Neurology common conditions > Flashcards

Neurology common conditions Flashcards

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1
Q

describe

tonic-clonic seizures

A
  • tonic - muscle tensing
  • clonic - muscle jerking
  • typically tonic phase comes before clonic phase
  • may get aura before
  • may have tongue biting, incontience, groaning and irregular breathing
  • post-ictal period where person is confused, tired, and irritable or low
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2
Q

describe

focal seizures

A
  • isolated brain area, often in temporal lobes
  • affect hearing, speech, memory and emotions
  • patients remain awake
  • remain aware during simple partial seizures but lose awareness during complex partial seizures
  • various symptoms depending on location in brain:
    • deja vu
    • strange smells, tastes, sight or sound sensations
    • unusual emotions
    • abnormal behaviours
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3
Q

describe

myoclonic seizure

A
  • sudden brief muscle contractions like an abrupt jump or jolt
  • remain awake
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4
Q

describe

tonic seizure

A
  • sudden onset of increased muscle tone where the entire body stiffens
  • fall if patient is stood
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5
Q

describe

atonic seizures

A
  • causing drop attacks
  • sudden loss of muscle tone often resulting in a fall
  • last briefly
  • patients usually aware
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6
Q

describe

absence seizures

A
  • usually in children but can have in adults
  • patient becomes blank, stares into space and then abruptly returns to normals
  • during the episode they are unaware of surroundings and do not respond
  • typically last 10-20 seconds
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7
Q

DDx

epilepsy

A
  • vasovagal syncope
  • pseudoseizures (dissociative)
  • cadiac syncope
  • hypoglycaemia
  • hemiplegic migraine
  • transient ischaemic attack
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8
Q

Ix

Epilepsy

A
  • EEG - electroencephalogram
    • shows typical patterns and supports the diagnosis
  • MRI brain - used to diagnose structural pathology e.g. tumours
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9
Q

safety precautions

Epilepsy

A
  • inform DVLA, stop driving
  • take showers rather than baths to decrease risk of drowning
  • caution when swimming, heights and dangerous equipment
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10
Q

DVLA

Epilepsy

A

Epilepsy (2 or more unprovoked seizures)
➤ Must be seizure-free for 12 months (with or without medication) to drive.
➤ 10 years for lorry/bus

First provoked/unprovoked seizure / isolated seizure
➤ Must not drive for 6 months (12 months if underlying risk factors exist).
➤ 5 years if lorry or bus

Withdrawal of epilepsy medication
➤ Must not drive during withdrawal and for 6 months after the last dose.
➤ 10 years for lorry/bus

Sleep-only seizures
➤ May drive if seizures have occurred only during sleep for 3 years.

Dissociative seizures
➤ Must be event-free for 3 months and assessed by a specialist if episodes occurred while driving.

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11
Q

medical management

Epilepsy

A

generalised tonic-clonic
- lamotrigine or levetiracetam if <55
- sodium valproate >55

partial (or focal)
- carbamazepine, oxcarbazepine
- lamotrigine or levetiracetam

myoclonic
- valproate (>55), levetiracetam (<55)

tonic or atonic seizures
- valproate (>55), lamotrigine (>55)

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12
Q

sodium valproate SEs

A
  • teratogenic
  • liver damage and hepatitis
  • hair loss
  • tremor
  • reduce fertility
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13
Q

pregnancy considerations

Sodium valproate

A
  • causes neural tube defects and developmental delay
  • pregnancy prevention programme:
    -> effective contraception
    -> anual risk acknowledgement form (2 doctors)
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14
Q

red flags

headache
(SNOOP)

A
  • Systemic symptoms/signs
  • Neurological deficit/symptoms → haemorrhage or tumours
  • Onset - thunderclap
  • Older - new/change in headache >50yo
  • Positional change/papilloedema/prescriptions (clear precipitators)
  • Progressive
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15
Q

primary vs secondary headache

A

primary - primary headache condition e.g. migraine, tension headaches

secondary - headache from something else e.g. hypertension, infection, vasculitis, abscess, carbon monoxide posioning, OSA, head injury

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16
Q

- describe, associations, Mx

tension headache

A
  • mild ache or pressure in a band-like pattern around the head
  • develop and resolve gradually - no visual changes

associations:
- stress
- depression
- alcohol
- skipping meals
- dehydration

Mx:
- reassurance
- simple analgesia
- amitriptyline if chronic or frequent

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17
Q

medication overuse headache

A
  • caused by frequent analgesia use
  • similar non-specific features to a tension headache
  • treatment - withdrawal of analgesia
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18
Q

cervical spondylosis

A

common conditions caused by degenerative changes in the cervical spine

causes neck pain, usually made worse on movement

often presents with headaches

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19
Q

- features

trigeminal neuralgia

A
  • intense facial pain in the distribution of the trigeminal nerve (opthalmic, maxillary, mandibular)
  • 90% unilateral
  • pain comes on suddenly and lasts seconds to hours
  • describes as an electricity-like, shooting, stabbing or burning pain
  • may be triggered by touching, talking, eating, shaving or cold
  • trigger areas - small areas in the nasolabial fold or chin
  • attacks may worsen over time
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20
Q

Mx

trigeminal neuralgia

A
  • carbamazepine - first line
  • surgical options possible where the symptoms persist
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21
Q

definition

cluster headache

A

severe and unbearable unilateral headaches, usually around the eye

  • come in clusters of attacks and disappear for extended periods
  • attacks last 15 minutes to 3 hours
  • may have triggers - alcohol, strong smells, exercise
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22
Q

Sx

cluster headache

A

most severe pain - suicide headaches
associated symptoms - unilateral:
- red, swollen and watering eye
- pupil constriction
- eyelid drooping
- nasal discharge
- facial sweating

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23
Q

Mx

cluster headaches

A

acute attacks:

  • triptans - subcutaneous or intranasal sumatriptan
  • high-flow 100% oxygen

prophylaxis - verapamil first line.

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24
Q

definition

migraine

A

complex neurological conditions causing episodes or attacks of headache and associated symptoms

  • very common
  • women > men
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25
# types migraines
- migraine without aura - migraine with aura - silent migraine (aura but no headache) - hemiplegic migraine
26
# Sx migraine
- usually unilateral - moderate-severe intensity - pounding or throbbing - photophobia - phonophobia - osmophobia - aura - nausea and vomiting
27
# triggers migraine
- stress - bright lights - strong smells - certain foods - chocolate, cheese, caffeine - dehydration - menstruation - disrupted sleep - trauma
28
# acute Mx migraine
- NSAIDs - triptans 5-HT receptor agonists -> cranial vasoconstriction - antiemetics
29
# prophylaxis migraine
- propanolol - amitriptyline - topiramate
30
# definition parkinson's disease
Parkinson's disease is a chronic, progressive neurodegenerative condition resulting from the loss of the dopamine-containing cells of the substantia nigra.
31
# patho Parkinson's disease
loss of dopinergic neurones in: - substantia nigra leading to less dopamine in the basal ganglia causing motor symptoms - eventually involves frontal lobe causing executive dysfunction, apathy, attention deficits.
32
# classic triad - explain Parkinson's disease
- resting tremor worse on one side 4-6Hz pill rolling improves on voluntary movements - rigidity cogwheel resistance to passive movement - bradykinesia micrographia shuffling gait difficulty turning difficulty initiating movements
33
# other features Parkinson's disease
- depression - sleep disturbance and insomnia - anosmia - autonomic dysfunction: postural instability - cognitive impairment and memory problems - mask-like facies
34
# diagnosis Parkinson's disease
- usually clinical - DAT scan -> assesses the level of dopamine transporter proteins in the brain
35
# Mx Parkinson's disease
- Levadopa + carbidopa -> co-careldopa (synthetic dopamine + peripheral decarboxylase inhibitor) - COMT inhibitors (slows breakdown of levadopa) - dopamine agonists (mimic action of dopamine, stimulating receptors e.g. bromocriptine) - monoamine oxidase-B inhibitors (help increase circulating dopamine e.g selagiline)
36
# 3 types motor neurone disease
- amyotrophic lateral sclerosis (ALS) - progressive muscular atrophy - bulbar palsy
37
# general points MND
- progressive - eventually fatal - motor neurones stop functioning (upper and lower) - no effect on sensory neurones
38
# presentation MND
- typically late middle age - insidious, progressive weakness of muscles throughout the body - affects limbs, trunk, face and speech - first noticed in upper limbs → increased fatigue when exercising - clumsiness, dropping things, tripping, slurred speech
39
LMN signs
* muscle wasting * reduced tone * fasiculations * reduced reflexes
40
# Mx MND
- no effective treatments for halting or reversing the disease - riluzole → can slow progression and extend survival by several months (ALS) - NIV → support breathing - support person and family - BBN - MDT - PT - symptoms control - baclofen - muscle spasticity - antimuscarinic - excessive saliva ( glycopyrronium bromide) - benzodiazepine → breathlessness - advanced directives - end of life care
41
# definition Huntington's
autosomal dominant genetic conditions that causes progressive neurological dysfunction - trinucleotide repeat disorder - mutation in the HTT gene on chromosome 4 - codes for the huntingtin protein
42
what is genetic anticipation
- successive generations have more repeats in the gene, resulting in: - earlier age of onset - increased severity of disease
43
# patho Huntington’s disease
the mutant huntingtin protein accumulates within neurones, leading to neuronal degeneration, particularly in the basal ganglia and cerebral cortex
44
# diagnosis Huntington’s disease
made by genetic testing via a specialist genetic centre involves pre and post-test counselling
45
# presentation Huntington’s disease
insidious, progressive worsening of symptoms 1. begins with cognitive, psychiatric or mood problems 2. then movement disorders: - chorea → involuntary, random, irregular and abnormal body movements - dystonia → abnormal muscle tone leading to abnormal posture - rigidity → increased resistance to passive movements of joints - eye movement disorders - dysarthria - dysphagia
46
# Mx Huntington’s disease
- no treatment options for slowing or stopping the progression - management is supportive: - BBN - genetic counselling - MDT - physio - SALT - tetrabenazine - for chorea symptoms - antidepressants - advances directive - EOL care
47
# prognosis Huntington's disease
ife expectancy 10-20 years after onset of symptoms - as it progresses, become more frail and susceptible to illness - death often due to aspiration pneumonia - suicide also a common cause
48
# definition Guillain barre syndrome
- acute paralytic polyneuropathy affecting the peripheral nervous system - autoimmune
49
# patho Guillain barre syndrome
- 1-3 weeks after immune system stimulation: - commonly URTI or GI infection - **campylobacter jejuni**, CMV, EBV - molecular mimicry: - B cells of immune system create antibodies against antigens on the triggering pathogen - these antibodies also match proteins on the peripheral neurones - they may target: - myelin sheath - nerve axon impaired neurotransmission to the periphery
50
# diagnostic criteria Guillain barre syndrome
Brighton criteria required features: - progressive symmetrical weakness - ascending - areflexia (or hyporeflexia)
51
# other symptoms, progression Guillain barre syndrome
- mild sensory signs or symptoms - CN involvement, especially bilateral facial weakness - autonomic dysfunction - absence of fever at onset - progression of symptoms over days to 4 weeks - recovery begins 2-4 weeks after progression ceases
52
# investigations Guillain barre syndrome
- EMG/NCS - reduced signal - CSF - increase protein - serology - cambylobacter if GI upset - CMV, EBv, HSV, HIV, mycoplasma - stool cultures - throat swab
53
# complications Guillain barre syndrome
- autonomic dysfunction - Cardiac arrhythmias – sinus tachy-, brady- - tachyarrhythmias - Postural hypotension - Hypertension - Urinary retention - Ileus - respiratory - need close monitoring as weakness is progressive - pain - DVT/PE - SIADH - renal failure secondary to IV Ig - Hypercalcaemia - immobility
54
# Mx Guillain barre syndrome
- DVT prophylaxis - close observation and support - IV immunoglobulin - plasmapheresis within 2 weeks of onset - I&V if resp failure
55
# prognosis Guillain barre syndrome
- 25% ventilation - 70% complete recovery at 1 year - 25-30% residual deficit - 3% recurrent - 3-5% mortality
56
# definition Myasthenia gravis
autoimmune condition causing muscle weakness that gets progressively worse with activity and improves with rest
57
# epidemiology Myasthenia gravis
- women <40 - man >60 strong link with thymomas
58
# patho Myasthenia gravis
1. acetylcholine receptor antibodies (85%) - bind to acetylcholine receptors - block receptors -> prevent acetylcholine being able to stimulate receptor and trigger muscle contraction - as more receptors used during activity - more become blocked 2. other antibodies (15%) - MuSK - LRP4
59
# presentation Myasthenia gravis
- weakness → worse with use, improves with rest - mostly proximal muscles and small muscles of head and neck - extraocular muscle weakness → diplopia - eyelid muscle weakness → ptosis - facial muscles weakness - difficulty swallowing - fatigue in jaw - slurred speech
60
# examination Myasthenia gravis
elicit fatiguability - repeated blinking - exacerbate ptosis - upward gazing - exacerbate diplopia - repeated abduction - unilateral weakness check for thymectomy scar check forced vital capacity (FVC)
61
# investigations Myasthenia gravis
- AChR antibodies - MuSK antibodies - LRP4 antibodies Tensilon/edrophonium test - if there’s doubt
62
# presentation myasthenic crisis
severe complication, can be life threatening - acute worsening of symptoms - often triggered by respiratory tract infection - slack facial muscles - weak neck - drooling - nasal speech - generally weak - unsafe swallow - can lead to respiratory failure
63
# Mx myasthenic crisis
may require intubation or NIV treatment: - IV immunoglobulins - plasmapheresis
64
cholinergic crisis
- cholinergic crisis - looks similar to myasthenic crisis - excess of acetlycholinesterase inhibitors - repiratory failure - miosis and SSLUDGE syndrome (Salivation, Lacrimation, Urination, Defecation, Gastrointestinal distress, and Emesis)
65
# Mx Myasthenia gravis
- anticholinesterase inhibitors - short term relief of symptoms - increase amount of acetylcholine at neuromuscular junction - pyridostigmine - neostigmine - immunosuppression - corticosteroids - azathioprine - rituximab - if standard treatment isn’t effective
66
# definition, aetiology multiple sclerosis
chronic and progressive autoimmune conditions involving demyelination in the central nervous system - the immune system attacks the myeline sheath of the myelinated neurones - typically presents in <50s and more common in women
67
# patho multiple sclerosis
1. myelin helps impulses travel faster 2. MS affects oligodendrocytes in CNS (provide myelin) 3. inflammation and immune cell infiltration damages the myelin 4. re-myelination occurs in early disease 5. lesions vary in location
68
# causes multiple sclerosis
cause unclear. may be influenced by: - multiple genes - EBV - low vitamin D - smoking - obesity
69
# onset multiple sclerosis
symptoms usually progress over more than 24 hours. Symptoms tend to last days to weeks at the first presentation and then improve.
70
# presentation multiple sclerosis
depends on where the lesion is 1. optic neuritis - most common - central scotoma - pain on eye movmenet - impaired colour vision - RAPD 2. eye movement abnormalities - lesions affective occulomotor, trochlear or abducens - diplopia and nystagmus 3. focal neurological symptoms - UMN more common - sensory - motor 4. ataxia - loss of proprioception - cerebellar lesion
71
# forms multiple sclerosis
- clinically isolated syndrome - relapsing remiting - secondary progressive - primary progressive
72
# diagnosis multiple sclerosis
1. history - onset, weakness, unilateral 2. examination - brisk reflexes, increased tone, decreased sensation 3. MRI - at least 2 lesions, at least 2 places at different times 4. CSF - oligoclonal bands
73
# Mx multiple sclerosis
- disease modifying therapies e.g. natalizumab - relapses -> high dose steroids - symptomatic treatment: 1. exercise -> maintain strength 2. fatigue -> amantadine 3. neuropathic pain -> amitriptyline 4. depression -> SSRI 5. urge incontinence -> antimuscarinic 6. spasticity -> baclofen 7. oscillopsia -> gabapentin/memantine - curative -> autologous stem cell transplant
74
# what is, prognosis, cause Bell's palsy
1. unilateral lower motor neurone facial palsy 2. most fully recover after several weeks 1/3rd left with residual weakness 3. idiopathic
75
# Mx Bell's palsy
- Bell’s palsy within 72 hours of onset → prednisolone: - 50mg for 10 days - 60mg for 5 days → reducing regime - lubricating eye drops → prevent eyes drying out - pain in eye → urgent ophthalmology review → exposure keratopathy - tape eye closed at night
76
# cause, what is, presentation Ramsay-Hunt sundrome
1. caused by varicella zoster virus 2. unilateral lower motor neurone facial nerve palsy 3. painful and tender vesicular rash - ear canal, pinna and around the ear can extend to anterior two thirds of tongue and hard palate
77
# Mx Ramsay-Hunt syndrome
- aciclovir - prednisolone - lubricating eye drops

Year 4 - NSS (10 decks)

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