2 - Neurological Common Presentations and Investigations Flashcards

1
Q

How do you take a history for a blackout/LOC/fall?

A

Patient and Collateral History

Before:

  • Any warning e.g epileptic aura, palpitations, chest pain, SOB, sweating
  • Circumstance e.g watching TV, hit head

During (Collateral)

  • Duration
  • LOC
  • Movements (floppy/stiff/jerking)
  • Incontinence/bite side of tongue
  • Complexion (cyanosis seizure, pale syncope)

After

  • What can patient remember about attack (amnesia)
  • Any muscle ache
  • Any drowsiness/confusion (post-ictal)
  • Injuries from fall

Background: When did attacks start, how frequent, getting more frequent

PMHx: Cardiac

Dx and Allergies: Postural hypotension

FHx

SHx

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2
Q

What are some systems review questions you should ask in a ‘blackout’ history?

A
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3
Q

What are some causes of ‘blackouts’?

A

Syncopal:

  • Cardiac: arrhythmias, aortic stenosis
  • Postural Hypotension: drugs, dehydration, autonomic dysfunction
  • Neurogenic: vasovagal

Seizures

  • Epilepsy
  • Infections
  • Electrolyte disturbances
  • Drugs

Drop Attacks

Hypoglycaemia

Stokes-Adams Attacks

Instability: e.g Parkinson’s, Arthritis can predispose to falls

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4
Q

What is vasovagal syncope?

A

Reflex bradycardia and peripheral vasodilation provoked by emotion, pain or standing too long

Pre-Syncopal Symptoms: nausea, pallor, sweating, narrowing of visual fields

May have brief clonic jerking of limbs due to cerebral hypoperfusion but rapid recovery

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5
Q

How can you tell the difference between a seizure and syncope from a history?

A
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6
Q

What are some precipitants of breakthrough seizures in epilepsy?

A
  • Sleep deprivation
  • Poor medication compliance
  • Alcohol
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7
Q

What is a Stokes-Adams attack?

A

Transient arrhythmias that cause drop in cardiac output so LOC

Patient falls to ground with no warning apart from palpitations. They go pale with a slow or absent pulse and then recover in seconds and flush. Respiration continues the whole time. May jerk

Associated with tacky/brachyarrhythmias and complete heart block

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8
Q

How can anxiety lead to a black out?

A

Hyperventilatin causes hypocapnia so vasoconstriction

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9
Q

What is a drop attack?

A

Sudden fall to the ground without LOC

Causes: hydrocephalus, cataplexy, narcolepsy

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10
Q

What investigations should you consider after a blackout?

A
  • Bloods: CRP, Glucose, FBC, U+Es, CK, PRL
  • ABG
  • Lying/Standing BP
  • ECG and 24h Tape
  • EEG
  • ECHO
  • CT/MRI head

Advise against driving whilst trying to find cause

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11
Q

What examinations/systems review should you do when a patient comes in with a blackout?

A

Cardiac

Neurological

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12
Q

What are some important questions to ask in the history for vertigo/dizziness?

A

Timing
•When started
•Acute/ gradual onset

  • Duration
  • Progression
  • Intermittent or continuous
  • *Background to attacks**
  • E.g had before, frequency, impact on life

Associated Symptoms

  • Difficulty walking or standing
  • Relief on lying or standing still
  • N+V
  • Sweating
  • Hearing loss
  • Tinnitus
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13
Q

What are some causes of vertigo?

A

Peripheral

  • BPPV
  • Meniere’s
  • Labrinthitis

Central

  • Stroke
  • MS
  • Vestibular migraines
  • Ototoxicity e.g amino glycoside abx, loop diuretics (furosemide)
  • Acoustic neuroma
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14
Q

How can you tell the difference between central and peripheral vertigo?

A
  • Dix Hallpike and Epley manoeuvre
  • HINTS examination
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15
Q

Which patients with vertigo should you perform a HINTS examination on?

A

HINTS exam looks for the presence of central vertigo

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16
Q

What is the HINTS examination?

A

Head Impulse Test

  • Exclude H+N trauma and neck OA before doing
  • If corrective saccade suggests issue with ipsilateral vestibulocochlear nerve so peripheral
  • If no corrective saccade central
  • Uses VOR reflex

Nystagmus

  • Unidirectional means peripheral vertigo
  • Bidirectional or Vertical means central vertigo

Test of Skew

  • Cover one eye then rapidly move to the other, observe for any vertical or diagonal corrective movement
  • If movement then central cause
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17
Q

What are some tests you can do when a patient complains of hearing loss?

A
  • Whisper test
  • Tuning fork tests: Webers and Rinne’s with 512 or 256 Hz
  • Audiometry/Tympanometry
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18
Q

What are some causes of conductive hearing loss?

A
  • Wax impaction
  • Otitis media with effusion (glue ear)
  • Eustachian tube dysfunction
  • Ear infections
  • Perforations of the tympanic membrane
  • Chronic supppurative otitis media
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19
Q

What are some causes of chronic sensorineural deafness?

A
  • Presbycusis (high frequency)
  • Noise-induced hearing loss
  • Congenital infections (e.g. rubella, CMV)
  • Neonatal complications (e.g. kernicterus)
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20
Q

What are some causes of sudden sensorineural hearing loss?

A

Needs urgent same day referral to ENT

  • Gentamicin
  • MS
  • Stroke
  • Acoustic neuroma
  • Noise exposure
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21
Q

What investigations should you do if there is sudden sensorineural hearing loss?

A
  • ESR
  • FBC
  • LFT
  • PANCA
  • Viral titres
  • MRI
  • Lymph node and nasopharyngeal biopsy
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22
Q

What are some causes of tinnitus?

A

ANY UNILATERAL TINNITUS NEEDS INVESTIGATING TO EXCLUDE ACOUSTIC NEUROMA

ANY PULSATILE COULD BE CAROTID ARTERY DISSECTION OR STENOSIS OR AV MALFORMATION

  • Inner ear damage and hearing loss
  • Wax
  • Head injury
  • Post stapedectomy
  • Meniere’s
  • Loop diuretics or Aminoglycosides
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23
Q

How is tinnitus managed?

A
  • Exclude serious causes
  • Cognitive therapy
  • Masking e.g white noise, hearing aid
  • Cochlear nerve section (if disabling, last resort as causes deafness)
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24
Q

What questions do you need to ask when a patient presents with bilateral leg weakness?

A

Where is the lesion?

  • Are the legs flaccid (LMN) or spastic (UMN)
  • Is there sensory loss? If there’s a sensory level think spinal cord
  • Is there loss of bowel/bladder control. If yes then likely to be in conus medullar is or caudal equine

What is the lesion?

  • Was the onset sudden or rapidly progressive, if yes this is emergency as may mean cord compression
  • Any signs of infection e.g tender spine, fever, raised WCC, raised ESR, CRP
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25
Q

What are some differentials for bilateral leg weakness?

A
  • Cord compression
  • Cauda equina
  • MND (ALS)
  • MS
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25
Q

What are some differentials for bilateral leg weakness?

A
  • Cord compression
  • Cauda equina
  • MND (ALS)
  • MS
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26
Q

What are some differentials for the following patterns of leg weakness?

  • Unilateral foot drop
  • Weak legs with no sensory loss
  • Chronic spastic paraparesis
A

Unilateral foot drop

  • DM
  • Common perineal nerve palsy
  • Stroke
  • Prolapsed disc
  • MS

Weak legs with no sensory loss

  • MND

Chronic spastic paraparesis

  • MS
  • Cord malignancy/Metastasis
  • MND
  • Syringomyelia
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27
Q

What are some differentials for the following patterns of leg weakness?

A

Chronic Flaccid Paraparesis

  • Peripheral neuropathy
  • Myopathy

Absent Knee Jerks and Extensor Plantars (combine LMN/UMN)

  • MND
  • Conus Medullaris
  • Myeloradiculitis
  • Subacute combined degeneration of the cord
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28
Q

What are some examples of pathologies causing the following gaits?

  • Spastic
  • Apraxic
  • Ataxic
  • Myopathic
  • Psychogenic
A
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29
Q

What are some basic care principals you should consider for paralysed patients?

A
  • Avoid pressure sores: turn, pressure relieving matresses
  • Prevent thrombosis: passive movement of paralysed limbs, pressure stockings, LMWH
  • Bowel evacuation
  • Catheterisation
  • Exercise unaffected limbs to avoid loss of function
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30
Q

What might an ABG show in a seizure?

A

Metabolic (lactic) acidosis

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31
Q

How do you describe a cranial mass on MRI/CT?

A
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32
Q

What are some examples of SOLs?

A
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33
Q

How may a SOL present?

A
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34
Q

LESS THAN 8

A

INTUBATE

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35
Q

What monitoring do you need to do with phenytoin IV in status epilepticus?

A

ECG as risk of arrhythmias

36
Q

What is the first line AED for focal onset and general onset seizures?

A
37
Q

What do you need to do if a patient is having bulbar symptoms with MG?

A

May have slurred speech as a sign

Make them NBM as risk of aspiration!!!

38
Q

What biologics can be used for chronic migraines after botox has been trialled?

A

cGRP antagonists

  • Galcanezumab
  • Erenumab
39
Q

What are triptans CI in?

A
  • Pregnancy
  • Ischaemic heart disease

As causes vasoconstriction

40
Q

How do the following tremors present and what are some causes of each of them?

  • Rest tremor
  • Intention remor
  • Postural tremor
  • Re-emergent tremor
A

Rest:

  • Abolished on voluntary movement
  • Parkinson’s

Intention:

  • Irregular large amplitude worse at the end of purposeful tasks e.g finger pointing
  • Cerebellar Damage e.g MS, Stroke

Postural:

  • Absent at rest, present on maintained posture and can persist on movement
  • Benign Essential tremor, Anxiety, B-Agonists

Re-emergent:

  • Postural tremor developing after a delay of 10s
  • Parkinson’s (don’t mistake for essential)
41
Q

What is chorea and what are some of the causes of this?

A

Non-rhythmic jerky purposeless movements flitting from one place to another

Facial grimacing, raising shoulders, flexing/extending fingers

Made worse by levodopa!!

Causes: Huntington’s, Sydenham’s (Group A Strep Infection)

42
Q

What is hemiballismus and what are some causes of this?

A

Large-amplitude flinging hemichorea (usually proximal muscles)

Lesion in contralateral subthalamic nucleus e.g haemorrhage or diabetic

Recovers spontaneously over few months

43
Q

What is athetosis and what are the causes of this?

A

Slow confluent purposeless movements (especially digits, hands, face, tongue)

Cause: Cerebral palsy

44
Q

What is a tic?

A

Brief repeated stereotyped movements

Need psychological support and clonazepam if they are severe

Causes: Tourette’s, children

45
Q

What is myoclonus and some of the causes?

A

Sudden involuntary jerks

Causes: myoclonic epilepsies, benign essential myoclonus, asterixis (liver or kidney failure, gabapentin)

46
Q

What are tardive syndromes and how are they treated?

A

Delayed onset but potentially irreversible hypo and hyperkinetic movement disorders that occur after exposure to prolonged dopamine antagonists e.g antipsychotics/antiemetics

Mx: Gradually withdraw neuroleptics and wait 3-6 months. Tetrabenazine may help

47
Q

What are the different types of tardive syndromes?

A

Tardive Dyskinesia: orobuccolingual, truncal or choreiform movements e.g vacuous chewing and grimacing movements

Tardive Dystonia: stereotyped muscle spasms of a twisting or turning character e.g retrocollis, back arching

Tardive Akathisia: sense of restlessness or unease and repetitive purposeless movements e.g pacing

Tardive Myoclonus, Tardive Tourettism, Tardive Tremor

48
Q

What is dystonia?

A

Prolonged muscle contractions causes abnormal posture or repetitive movements

49
Q

How do the following dystonia present:

  • Idiopathic Generalised Dystonia
  • Focal Dystonia
  • Acute dystonia
A
50
Q

What type of double vision is a neurological cause?

A

Binocular Diplopia

51
Q

What are some causes of a neurogenic bladder?

A
  • Stroke
  • Parkinson’s disease
  • Multiple sclerosis
  • Spinal cord injuries
  • Spinal surgeries
  • Erectile dysfunction
  • Trauma/accidents
  • Central nervous system tumors
  • Heavy metal poisoning
52
Q

What are some causes of bulbar palsy?

A
53
Q

What are some causes of neuropathic pain?

A
  • Postherpetic neuralgia (shingles)
  • Nerve damage from surgery
  • Multiple sclerosis
  • Diabetic neuralgia typically affects the feet
  • Trigeminal neuralgia
  • Complex Regional Pain Syndrome (CRPS)
54
Q

What are the clinical features of neuropathic pain?

A
  • Burning
  • Tingling
  • Pins and needles
  • Electric shocks
  • Loss of sensation to touch of the affected area
55
Q

What tool can be used to decide if pain is neuropathic?

A

DN4 Questionnaire

Score of 4 or more indicates neuropathic pain

56
Q

What is the management for neuropathic pain?

A

1st Line

Try 1 at a time, if it doesn’t work stop and try another

  • Amitriptyline is a tricyclic antidepressant
  • Duloxetine is an SNRI antidepressant
  • Gabapentin is an anticonvulsant
  • Pregabalin is an anticonvulsant
  • Carbamazepine if trigeminal neuralgia

Other Options

  • Tramadol ONLY as a rescue for short term control of flares
  • Capsaicin cream (chilli pepper cream)
  • Physiotherapy
  • Psychological input
57
Q

What is Complex Regional Pain syndrome?

A

Severe neuropathic pain that tends to only affect 1 limb, usually triggered by injury

Area is very painful and hypersensitive to simple inputs such as wearing clothing.

May intermittently swell, change colour, change temperature, flush with blood and have abnormal sweating

Needs a pain specialist

58
Q

How do you calculate a GCS score?

A
59
Q

What are some neurological circumstances where a LP should be performed?

A
  • Suspected Subarachnoid Haemorrhage
  • Suspected meningitis/encephalitis
  • Immunological disorders e.g MS or GBS
60
Q

What are some contraindications for performing a LP?

A
  • Raised ICP (severe headache, decreased level consciousness with fallen pulse, rising BP, vomiting, focal neurology, papilloedema)
  • Infection at site of needle insertion
  • Bleeding diathesis
  • Cardiorespiratory compromise
61
Q

Why should you no perform a LP in raised ICP or focal neurology?

A

Will cause coning, do CT first

62
Q

What is the method for performing a LP?

A
  • Place patient on left side, full flexed knees to chin, pillow under head and between knees
  • Ink landmark (between PSIS at level L3/L4 as spinal cord ends L1/L2)
  • Aseptic technique
  • Have three plain sterile tubes and one fluoride tube (glucose)
  • Give local anaesthetic
  • Insert spinal needle (stilette in place) perpendicular and slightly up to umbilicus, feel for resistance of spinal ligaments then a give
  • Withdraw stilette, attach manonmeter for opening pressure
  • Catch 10 drops of fluid in each of the three bottles
  • Reinsert stilette then remove needle and apply dressing
  • Document procedure, CSF appearance and opening pressure
  • Send promptly for microscopy, culture, protein, lactate, glucose (do serum glucose too). May also want to send for viral PCR and oligoclonal bands
63
Q

What is the normal CSF composition?

A
  • Lymphocytes <5
  • No polymorphs
  • Protein <0.4
  • Glucose >2.2 or >50% plasma level
  • Pressure <200mm
64
Q

What may cause raised protein in the CSF?

A
  • Meningitis
  • MS
  • GBS
  • Very raised: spinal block, TB, severe bacterial meningitis
65
Q

How will the CSF composition look in the following:

  • Bacterial Meningitis
  • Viral Meningitis
  • TB Meningitis
A
66
Q

How will the CSF composition look in the following:

  • SAH
  • GBS
  • MS
A
67
Q

What are some complications of a LP?

A

Treat any lower body neurology after an LP as caudal equine (haematoma/abscess) until proven otherwise. Obtain urgent MRI spine

  • Post dural puncture headache
  • Infection
  • Bleeding
  • Cerebral herniation (look for raised ICP before)
  • Transient neurological symptoms e.g radiculopathy
68
Q

What type of headache is a post LP headache and how is this prevented?

A

Constant dull ache that is more frontal than occipital. Has positional exacerbation.

Thought to be due to intracranial hypotension from continued CSF leakage from puncture site

Prevention: use smallest spinal needle practical, blunt needles, before withdrawal reinsert stilette

69
Q

What are some indications for an EEG?

70
Q

When might a neurologist request a PET-CT scan?

A
  • Epilepsy
  • Dementia
  • Brain tumour
71
Q

At the start of a neurological examination what do you need to do before topcars?

A

Inspection SWIFT

Scars

Wasting

Involuntary movements

Tremor

Pronator drift

72
Q

What are some indications for an MRI in neurology?

A
73
Q

What is the difference between cytotoxic and vasogenic oedema?

A

Cyotoxic: Infarction, Encephalitis, Hypoxic-Ischaemic Injury

Vasogenic: Tumour, Metastases, Abscess

74
Q

What do you see when neuroimaging the brain with a global hypoxic brain injury?

A
  • Loss of sulci
  • Loss of ventricles
75
Q

What is a Contre-Coup Injury?

A

Also look for secondary injury on opposite side of impact when looking at neuroimaging of head injury

76
Q

How do you switch AEDs?

A

Titrate one up slowly at the same time as slowly titrating down other drug

77
Q

What imaging modality should you use for hearing loss?

A

Conductive (External or Middle ear): CT

Sensorineural (Inner ear): MRI

78
Q

What imaging should you do with a choleasteatoma?

A

CT to check for intracranial extension

79
Q

What imaging should you do when there is an issue with vision?

A

CT: Eye up to optic chiasm

MRI: Optic chiasm back

80
Q

What are the differences between seizures, pseudo seizures and syncope?

A
81
Q

What are the 1st line AEDs for focal and generalised seizures?

A
82
Q

What is the best way after a head injury to lower the ICP to prevent secondary injury?

A
83
Q

What investigations should you do for a suspected SAH?

A

Immediate CT without contrast (90% sensitivity in first 24h, 50% by 72h)

Lumbar Puncture after 12 hours (send for CSF spectrophotometer for bilirubin peak)

84
Q

What is the management for a SAH?

A
  • Cerebral Angiogram urgently with coiling if aneurysm
  • Nimodipine to prevent cerebral vasospasm
  • IV fluids and SBP<150 to allow good cerebral perfusion
  • Close monitoring with neurological observation as hydrocephalus is complication. Urgent CT head if deterioration and then CSF shunt
85
Q

Why do people with SAH die?

A
  • Sudden increase in ICP from rebleed
  • Toxic effects of blood on brain parenchyma and cerebral vessels
86
Q

How many days do you have to be using analgesia for a medication overuse headache?

A

15 days: paracetamol, NSAIDs

10 days: Ergots, Triptans, Opioids

Stop abruptly for 6 weeks (if codeine slowly stop over 2 weeks) then slowly reintroduce making sure not to go over max amount in a month.

Avoid codeine in chronic headaches

87
Q

How many days do you have to be using analgesia for a medication overuse headache?

A

15 days: paracetamol, NSAIDs

10 days: Ergots, Triptans, Opioids

Stop abruptly for 6 weeks (if codeine slowly stop over 2 weeks) then slowly reintroduce making sure not to go over max amount in a month.

Avoid codeine in chronic headaches