2 - Neurological Common Presentations and Investigations Flashcards
How do you take a history for a blackout/LOC/fall?
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
What are some systems review questions you should ask in a ‘blackout’ history?
What are some causes of ‘blackouts’?
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
What is vasovagal syncope?
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
How can you tell the difference between a seizure and syncope from a history?
What are some precipitants of breakthrough seizures in epilepsy?
- Sleep deprivation
- Poor medication compliance
- Alcohol
What is a Stokes-Adams attack?
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
How can anxiety lead to a black out?
Hyperventilatin causes hypocapnia so vasoconstriction
What is a drop attack?
Sudden fall to the ground without LOC
Causes: hydrocephalus, cataplexy, narcolepsy
What investigations should you consider after a blackout?
- 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
What examinations/systems review should you do when a patient comes in with a blackout?
Cardiac
Neurological
What are some important questions to ask in the history for vertigo/dizziness?
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
What are some causes of vertigo?
Peripheral
- BPPV
- Meniere’s
- Labrinthitis
Central
- Stroke
- MS
- Vestibular migraines
- Ototoxicity e.g amino glycoside abx, loop diuretics (furosemide)
- Acoustic neuroma
How can you tell the difference between central and peripheral vertigo?
- Dix Hallpike and Epley manoeuvre
- HINTS examination
Which patients with vertigo should you perform a HINTS examination on?
HINTS exam looks for the presence of central vertigo
What is the HINTS examination?
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
What are some tests you can do when a patient complains of hearing loss?
- Whisper test
- Tuning fork tests: Webers and Rinne’s with 512 or 256 Hz
- Audiometry/Tympanometry
What are some causes of conductive hearing loss?
- Wax impaction
- Otitis media with effusion (glue ear)
- Eustachian tube dysfunction
- Ear infections
- Perforations of the tympanic membrane
- Chronic supppurative otitis media
What are some causes of chronic sensorineural deafness?
- Presbycusis (high frequency)
- Noise-induced hearing loss
- Congenital infections (e.g. rubella, CMV)
- Neonatal complications (e.g. kernicterus)
What are some causes of sudden sensorineural hearing loss?
Needs urgent same day referral to ENT
- Gentamicin
- MS
- Stroke
- Acoustic neuroma
- Noise exposure
What investigations should you do if there is sudden sensorineural hearing loss?
- ESR
- FBC
- LFT
- PANCA
- Viral titres
- MRI
- Lymph node and nasopharyngeal biopsy
What are some causes of tinnitus?
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
How is tinnitus managed?
- Exclude serious causes
- Cognitive therapy
- Masking e.g white noise, hearing aid
- Cochlear nerve section (if disabling, last resort as causes deafness)
What questions do you need to ask when a patient presents with bilateral leg weakness?
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
What are some differentials for bilateral leg weakness?
- Cord compression
- Cauda equina
- MND (ALS)
- MS
What are some differentials for the following patterns of leg weakness?
- Unilateral foot drop
- Weak legs with no sensory loss
- Chronic spastic paraparesis
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
What are some differentials for the following patterns of leg weakness?
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
What are some examples of pathologies causing the following gaits?
- Spastic
- Apraxic
- Ataxic
- Myopathic
- Psychogenic
What are some basic care principals you should consider for paralysed patients?
- 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
What might an ABG show in a seizure?
Metabolic (lactic) acidosis
How do you describe a cranial mass on MRI/CT?
What are some examples of SOLs?
How may a SOL present?
LESS THAN 8
INTUBATE
What monitoring do you need to do with phenytoin IV in status epilepticus?
ECG as risk of arrhythmias
What is the first line AED for focal onset and general onset seizures?
What do you need to do if a patient is having bulbar symptoms with MG?
May have slurred speech as a sign
Make them NBM as risk of aspiration!!!
What biologics can be used for chronic migraines after botox has been trialled?
cGRP antagonists
- Galcanezumab
- Erenumab
What are triptans CI in?
- Pregnancy
- Ischaemic heart disease
As causes vasoconstriction
How do the following tremors present and what are some causes of each of them?
- Rest tremor
- Intention remor
- Postural tremor
- Re-emergent tremor
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)
What is chorea and what are some of the causes of this?
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)
What is hemiballismus and what are some causes of this?
Large-amplitude flinging hemichorea (usually proximal muscles)
Lesion in contralateral subthalamic nucleus e.g haemorrhage or diabetic
Recovers spontaneously over few months
What is athetosis and what are the causes of this?
Slow confluent purposeless movements (especially digits, hands, face, tongue)
Cause: Cerebral palsy
What is a tic?
Brief repeated stereotyped movements
Need psychological support and clonazepam if they are severe
Causes: Tourette’s, children
What is myoclonus and some of the causes?
Sudden involuntary jerks
Causes: myoclonic epilepsies, benign essential myoclonus, asterixis (liver or kidney failure, gabapentin)
What are tardive syndromes and how are they treated?
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
What are the different types of tardive syndromes?
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
What is dystonia?
Prolonged muscle contractions causes abnormal posture or repetitive movements
How do the following dystonia present:
- Idiopathic Generalised Dystonia
- Focal Dystonia
- Acute dystonia
What type of double vision is a neurological cause?
Binocular Diplopia
What are some causes of a neurogenic bladder?
- Stroke
- Parkinson’s disease
- Multiple sclerosis
- Spinal cord injuries
- Spinal surgeries
- Erectile dysfunction
- Trauma/accidents
- Central nervous system tumors
- Heavy metal poisoning
What are some causes of bulbar palsy?
What are some causes of neuropathic pain?
- Postherpetic neuralgia (shingles)
- Nerve damage from surgery
- Multiple sclerosis
- Diabetic neuralgia typically affects the feet
- Trigeminal neuralgia
- Complex Regional Pain Syndrome (CRPS)
What are the clinical features of neuropathic pain?
- Burning
- Tingling
- Pins and needles
- Electric shocks
- Loss of sensation to touch of the affected area
What tool can be used to decide if pain is neuropathic?
DN4 Questionnaire
Score of 4 or more indicates neuropathic pain
What is the management for neuropathic pain?
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
What is Complex Regional Pain syndrome?
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
How do you calculate a GCS score?
What are some neurological circumstances where a LP should be performed?
- Suspected Subarachnoid Haemorrhage
- Suspected meningitis/encephalitis
- Immunological disorders e.g MS or GBS
What are some contraindications for performing a LP?
- 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
Why should you no perform a LP in raised ICP or focal neurology?
Will cause coning, do CT first
What is the method for performing a LP?
- 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
What is the normal CSF composition?
- Lymphocytes <5
- No polymorphs
- Protein <0.4
- Glucose >2.2 or >50% plasma level
- Pressure <200mm
What may cause raised protein in the CSF?
- Meningitis
- MS
- GBS
- Very raised: spinal block, TB, severe bacterial meningitis
How will the CSF composition look in the following:
- Bacterial Meningitis
- Viral Meningitis
- TB Meningitis
How will the CSF composition look in the following:
- SAH
- GBS
- MS
What are some complications of a LP?
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
What type of headache is a post LP headache and how is this prevented?
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
What are some indications for an EEG?
- epilepsy
- head injury
- encephalitis
- brain tumor
- encephalopathy
- memory problems
- sleep disorders
- stroke
- dementia
- coma
When might a neurologist request a PET-CT scan?
- Epilepsy
- Dementia
- Brain tumour
At the start of a neurological examination what do you need to do before topcars?
Inspection SWIFT
Scars
Wasting
Involuntary movements
Tremor
Pronator drift
What are some indications for an MRI in neurology?
What is the difference between cytotoxic and vasogenic oedema?
Cyotoxic: Infarction, Encephalitis, Hypoxic-Ischaemic Injury
Vasogenic: Tumour, Metastases, Abscess
What do you see when neuroimaging the brain with a global hypoxic brain injury?
- Loss of sulci
- Loss of ventricles
What is a Contre-Coup Injury?
Also look for secondary injury on opposite side of impact when looking at neuroimaging of head injury
How do you switch AEDs?
Titrate one up slowly at the same time as slowly titrating down other drug
What imaging modality should you use for hearing loss?
Conductive (External or Middle ear): CT
Sensorineural (Inner ear): MRI
What imaging should you do with a choleasteatoma?
CT to check for intracranial extension
What imaging should you do when there is an issue with vision?
CT: Eye up to optic chiasm
MRI: Optic chiasm back
What are the differences between seizures, pseudo seizures and syncope?
What are the 1st line AEDs for focal and generalised seizures?
What is the best way after a head injury to lower the ICP to prevent secondary injury?
What investigations should you do for a suspected SAH?
Immediate CT without contrast (90% sensitivity in first 24h, 50% by 72h)
Lumbar Puncture after 12 hours (send for CSF spectrophotometer for bilirubin peak)
What is the management for a SAH?
- 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
Why do people with SAH die?
- Sudden increase in ICP from rebleed
- Toxic effects of blood on brain parenchyma and cerebral vessels
How many days do you have to be using analgesia for a medication overuse headache?
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
How many days do you have to be using analgesia for a medication overuse headache?
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
What are some differentials for bilateral leg weakness?
- Cord compression
- Cauda equina
- MND (ALS)
- MS
