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Meded Flashcards 2020 > Acute Neuro > Flashcards

Acute Neuro Flashcards

1
Q

SBA

Mrs Smith, an 85-year-old woman is brought to the A & E by her husband. When she woke up this morning her husband noticed that Mrs Smith’s smile looked strange and that she was unable to move her right arm. She seemed fine last night going to bed after watching the news as normal. On examination she had right sided hemiparesis and a positive Babinski sign. A CT-head done at the A & E excluded a hemorrhage. What is the next most appropriate step in her management?

A.Carotid doppler

B.300mg aspirin, orally

C.75 mg clopidogrel, orally

D.ECG

E.IV alteplase

A

B. 300mg aspirin, orally

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2
Q

A 16-year-old boy presents to A & E after collapsing on a cricket game. According to his cricket coach, the boy was unconscious for about one minute during which time, he was moving his arms and legs around. Further review revealed that he had experienced a similar episode a month before.

What is the most appropriate drug for this patient?

A.Sodium valproate

B.Carbamazepine

C.Lamotrigine

D.Lorazepam

E.Phenytoin

A

A.Sodium valproate

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3
Q

What are the different types/classifications of collapse?

A

Syncopal [due to global hypoperfusion of brain]

  • Reflex [vasovagal]
  • Cardiac
  • Cerebrovascular
  • Orthostatic

Non syncopal

  • Epileptic seizures
  • Non epileptic seizures
  • Other
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4
Q

Differentials for different types of collapse- fill in table

A
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5
Q

What are the causes and features in history suggesting these causes of reflex syncope?

A

Vasovagal:

Young

Pale, sweaty

Precipitating factor

Lasts seconds

Twitching of arms and legs, incontinence

Quick recovery

Carotid sinus hypersensitivity

Tight collar

Head turning

Situational syncope

associated with emotions, coughing, micturition [urinating]

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6
Q

What are the causes [and features of each cause] for cardiac syncope

A

Arrhythmias

Stokes Adam attack

Outlet obstruction

Massive PE

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7
Q

What are the causes [and features of each cause] for orthostatic syncope

A

Dehydration

Drugs

ANS instability, baroreceptor dysfunction

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8
Q

What are the causes [and features of each cause] for cerebrovascular syncope

A

Vertrebrobasilar insufficiency

Subclavian steal

Aortic dissection

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9
Q

What are the features of the history for epileptic syncope

A

Aura or no warning

< three minutes

Tongue biting

Twitching

Incontinence

Slow recovery

Confusion

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10
Q

What are the features of the history for non epileptic syncope

A

Background history of depression

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11
Q

What are the features of the history for intoxication being a cause of syncope

A

Alcohol/drugs

Head trauma

Narcolepsy

Hypoglycaemia

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12
Q

Epilepsy

Definition

Aetiology

Triggers

Presentation- symptoms and signs- before, during, after

[see table too]

Classification

Investigations

Management

Complications

A

-Epilepsy

Definition

Recurrent tendency to have unprovoked seizures

Aetiology

  • Primary epileptic syndrome- idiopathic
  • Secondary
  • Infection
  • Inflammation
  • Malignancy
  • Trauma

Triggers

  • Lack of sleep
  • Flashing lights
  • Alcohol
  • Stress

Presentation- symptoms and signs- before, during, after

[see table too]

Aura- before seizures

Vision changes/flashing lights, strange smell, deja vu, strange gut feeling/rising epigastric sensation

During seizures

Tongue biting

Incontinence

Jerking uncoordinated movement

Less than 3 minutes

After seizures

Post ictal phase- confusion, headache, myalgia- slow recovery lasts around 15 mins

Todd’s paresis- after focal seizures, flaccid paresis/paralysis- one limb/half body usually

Classification

Generalised

  • Tonic clonic- LOC, period of stiff paralysis and extension/straightening, followed by whole body uncontrolled jerking
  • Myoclonic- repetitive jerking movements, common in puberty

Atonic- sudden loss of muscle tone, children

Tonic

Clonic

Absence seizure- periods of staring, with behavioural arrest and LOC, brief [five to ten seconds], maintained posture, children

Focal- can have either full or impaired awareness

Temporal lobe- aura, hallucinations, automatisms [eg lip smacking]

Parietal- sensory symptoma

Frontal lobe- motor- Jacksonian march [spasm spreads from distal limb to rest of body], behavioural changes, behavioural disinhibition, Todd’s palsy

Occipital- visual changes

Focal can progress to generalised- Focal with secondary generalisation

Investigations

Clinical diagnosis- >2 unprovoked seizures more than 24 hours apart

Also do:

EEG

Bloods- FBC, U and E, glucose, serum prolactin [transiently elevated in seizures]

CT/MRI- if secondary cause suspected

Management

Generalised seizures:

First line: Sodium Valproate

Second line: Carbamazepine

Focal seizures:

Carbamazepine

Lamotrigine

Other drugs:

Phenytoin, Ethosuximide [absence seizures], Levetiracetam, Topiramate, Vigabatrin, Gabapentin, Clobazam

Aim for one drug/monotherapy- less side effects

Complications

Status epilepticus

SUDEP= sudden death in epilepsy

Behavioural problems

Drug side effects- psychiatric, weight gain

Fractures from seizures

Pregnancy

Some anti epileptic drugs are teratogenic

Avoid sodium valproate

Give lamotrigine instead

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13
Q

Definition of a seizure

A

Abnormal uncoordinated paroxysmal discharge of cerebral neurons

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14
Q

What are convulsions

A

Motor signs of electrical discharges

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15
Q

Status epilepticus

Definition

Triggers

Management

A

Status epilepticus

Definition

Seizure lasting for more than 5 mins or repeated unprovoked seizures with no regaining of consciousness/recovery in between

Triggers

Medication non adherence

Alcohol abuse

OD and drug toxicity

Hypoglycaemia

Management- benzodiazepines

ABCDE

  1. Secure airway - and give 100% O2
  2. IV access and continuous monitoring- sats, BP, ECG, glucose
  3. IV lorazepam
  4. Repeat IV lorazepam after 10 mins
  5. IV phenytoin
  6. ICU
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16
Q

A 62-year-old woman presents back pain and difficulty walking. On examination there is increased tone and hyper-reflexia in both legs. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier. Which is the most likely diagnosis?

A.Guillain-Barré syndrome

B.Spinal cord compression

C.Spondylolesthesis

D.Cauda equina syndrome

E Lumbosacral radiculopathy

A

B Spinal cord compression

17
Q

A 20-year-old woman presents with pins and needles in both legs. Her symptoms rapidly progress over 4 days to include lower extremity weakness to the point that she is unable to mobilise her lower extremities. She reports gastrointestinal symptoms 2 weeks ago. Lumbar puncture reveals mildly elevated protein with no cells and normal glucose. Given the most likely neurological diagnosis which organism is most likely to have caused the gastroenteritis?

A.Salmonella

B.Campylobacter Jejuni

C.E. Coli 0517

D.Rotavirus

E.Entamoeba histolytica

A

B Campylobacter jejuni

18
Q

Guillain Barre syndrome

Definition

Pathophysiology

Presentation

Symptoms

Signs

Risk factors/aetiology

Investigations

[Management]

Miller-Fischer syndrome

A

Guillain Barre syndrome

Definition

Acute autoimmune demyelinating polyneuropathy affecting the PNS, causing symmetrical ascending muscle weakness

Pathophysiology

Autoimmune response attacks myelin in PNS cells

Presentation

  • Occurs 2-3 weeks after an infection - usually URTI or gastroenteritis

[Causative organisms: campylobacter jejuni, CMV, HIV, EBV, Hep B/C]

  • Ascending symmetrical peripheral weakness, parasthesia and pain

Starts distally then moves up, more commonly affects legs first

Hypotonia, Hyporeflexia, Lack of sensation, fasciculations

  • Can affect resp muscles and cause resp problems
  • Autonomic- urinary retention, ileus

Risk factors/aetiology

Cancer - esp lymphoma

Immunisation

Investigations

Nerve conduction studies- decreased nere conduction

Lumbar puncture

  • Albuminocytological dissociation - high protein [due to inflammation], normal glucose, normal cell count

Bloods- Anti ganglioside antibodies in 25% of GBS and all Miller Fischer variant

Spirometry- [bedside, every 6 hours]

[Management]

Resolves spontaneously in a few weeks

IVIg can help improve symptoms

Miller-Fischer syndrome

Opthamoplegia, ataxia, arreflexia

No muscle weakness

Variant of GBS

19
Q

Hydrocephalus

Definition

Epidemiology

Aetiology/Types

Presentation

- Acute

- Gradual

- NPH

Investigations

A

Hydrocephalus

Definition

Excessive accumulation of CSF in ventricles of brain

Epidemiology

Bimodal - affects both young and old

Pathophysiology

Increased CSF= raised ICP

CSF leaks into brain= white matter damage

Aetiology/Types

Non communicating/Obstructive

- something obstructing the ventricles

  • Posterior brain lesion
  • Lesion in 3rd or 4th ventricle
  • Stenosis of cerebral aqueduct/interventricular foramina

Communicating

-Increased production of CSF or reduced reabsorption [blockage of drainage system]

Tumours

Meningitis [TB]

Normal pressure hydrocephalus

Normal pressure hydrocephalus

  • No increased CSF pressure, idiopathic chronic enlargement of ventricles

Hydrocephalus ex vacuo

  • Ventricular enlargement secondary to brain atrophy

Presentation

- Acute

Signs of raised ICP:

Nausea and vomiting

Headache

Papilloedema

Sunset eyes- retracted eye balls, eyes pointing down

In babies- skull enlargement

- Gradual

Cognitive impairment

Impaired gait

Cranial nerve palsy

Double vision

- NPH

Cognitive impairment

Gait apraxia

Hyperreflexia

Investigations

First line: CT/MRI

[ventricular enlargement, may show underlying cause[

Lumbar puncture - CSF analysis

-may show infection

[ONLY do if no raised ICP]

20
Q

Spinal cord compression

Definition

Causes

Epidemiology

Presentation- motor, sensory, autonomic

Investigations

A

Spinal cord compression

Definition

Compression and injury of spinal cord, causing neurological symptoms depending on site and extent of injury

Causes/risk factors

  • Tumours
  • Trauma
  • Intervertebral disease= Disc herniation
  • Corticosteroids
  • Osteoporosis/osteomalacia/osteomyelitis- predispose to spondylolithesis [forward displacement of spine]

If gradual onset= tumour, osteoporosis etc.

If acute onset= trauma, disc herniation

Epidemiology

Young- trauma related

Old- chronic condition related

Presentation

Can be acute or gradual

Motor

  • UMN signs below lesion [this is how you can differentiate from cauda equina/radiculopathy which only have LMN signs]
  • LMN signs at level of lesion- weakness, arreflexia
  • Limb weakness/paralysis

Sensory

  • Sensory loss below certain level
  • Back pain

Autonomic

  • Constipation
  • Urinary retention
    • Erectile dysfunction

Investigations

Emergency

Look for bone cancer/spinal cord cancer

  • Bloods- FBC, U and E, calcium, immunoglobulin electrophoresis [multiple myeloma], ESR
  • Urine- Bence Jones protein [multiple myeloma]
  • Imaging:

MRI gold standard, can also do CT

Lateral X ray/radiographs of spine

21
Q

Cauda equina syndrome

Definition

Causes

Presentation

A

Cauda equina syndrome

Definition

Compression of lumbosacral roots that make up the cauda equina at the end of the spinal cord

Causes

Stenosis of spinal canal

Intervertebral disease- disc herniation/compression

Presentation

LMN signs - lower limb weakness/paralysis

Back pain

Perinanal anaesthesia

Urinary retention

Bowel/bladder incontinence

  • Emergency- if untreated= permanent disability
22
Q

Stroke

Definition

Types/Classifications

Epidemiology

Pathophysiology/aetiology

Scoring systems

Risk factors

Presentation

Investigations

Management

Complications

Prognosis

A

Stroke

Definition

Sudden onset focal neurological deficit of presumed vascular origin lasting more than 24 hours

Types/Classifications- Three ways

Ischaemic-87%

Haemorrhagic-13%

____________________________________________________

Artery affected: [see separate flashcards for presentations of each}

Anterior cerebral artery

Middle cerebral artery

Posterior cerebral artery

Lacunar- lots of small infarcts in multiple vessels

Intracerebral haemorhhage

  • associated with hypertension

____________________________________________________

Oxford classification- general area of brain [see separate flashcards for presentations of each}

PACS- partial anterior circulation stroke

TACS- total anterior circulation

POCS- posterior circulation

LACS- lacunar stroke

Epidemiology

Common

Third leading cause of death

Patholophysiology and aetiology

Ischaemic

  • Atherosclerosis/thrombosis
  • Embolism [due to arrhythmia]

Haemorhhagic

  • Rupture of blood vessel

Scoring systems

CHADS-VASC- likelihood of having ischaemic stroke if have AF- if over 2- start anticoagulation

HAS-BLED- likelihood of having haemorrhagic stroke if start anticoagulation- if over 3, no anticoagulation

Risk factors

Hypertension [esp lacunar strokes]

Obesity

Hyperlipidaemia

FH/PMH of CVD/CVA

Old age

Smoking

Diabetes

Presentation

Sudden onset + depends on area of brain affected

Weakness/numbness in limbs + face

Change in vision

Dizziness, impaired coordination/balance

Speech problems

Symptoms more suggestive of ischaemic stroke: carotid bruit, past AF, past TIA, IHD

Symptoms more suggestive of haemorrhhagic stroke: meningism, severe headache

Investigations

ABC

Urgent non-contrast CT head [in one hour]- rule out haemorhhage

Bloods- FBC, U+E,APTT, PT, glucose,cardiac enzymes[associated MI]

ECG

Vital signs/obs- esp BP, hydration, sats, temperature

Management

Ischaemic

If ischemic and <4.5hrs from onset- first give IV alteplase [thrombolysis]

>4.5hrs - Aspirin 300mg oral

Sometimes thrombectomy

Further investigations after acute phase

CT angio, carotid doppler [leading to potential carotid endarterectomy], MRI/MR angio

+ serum toxicology [in case toxin mimicked stroke]

Long term treatment

Admit to stroke unit

Swallowing assessment, GCS monitoring, VTE prophylaxis, Rehab

Secondary prevention

If AF: Warfarin

If no AF: aspirin for two weeks, then lifelong clopidogrel

Haemorrhagic

ICU/stroke unit

Surgery

Complications

- Aspiration pneumonia

  • Cerebral oedema
  • DVT
  • Immobility
  • Seizures
  • Depression
  • Death

Prognosis

  • 10% mortality in first month
  • 50% dependent on others
  • 10% have recurrence in one year
23
Q

Radiculopathy

Definition

Causes

Presentation

Investigations

Example

A

Radiculopathy

Definition

Compression of nerves at or near nerve root as it exits spinal cors

Causes

Intervertebral disease- disc herniation, degeneration

Tumours

Osteoarthritis

Spondylolisthesis- forward displacement of vertebra

Infection

Presentation

Motor

LMN- weakness of muscles that affected nerves supply

Sensory

Dermatomal distribution of numbeness/parasthesia/pain

Investigations

If doesn’t resolve in 6-8 weeks- MRI/CT

Straight leg raise [for sciatica]- if pain occurs when leg is passivley raised/lifted between 30-70 degrees

Example

Sciatica

Compression of lumbosacral roots

Pain and tingling radiating from lower back down ipsilateral leg

Weakness of calf muscles

24
Q

A 21-year-old woman presents to A & E with acute onset of left-sided body twitching, lasting for 5 minutes, after a minor accident in which she hit her head. She reports 3 similar episodes in the past month, after her boyfriend broke up with her. Past-medical history includes IBS for which she takes laxatives. Physical examination, laboratory investigations and imaging studies are normal.

What is the most likely diagnosis?

A.Dissociative seizure

B.Simple partial seizure

C.Vasovagal episode

D.Todd’s pals

E Myoclonic seizure

A

A Dissociative seizure

25
Q

GCS Scoring

Verbal - points? Criteria?

Eye opening- points? Criteria?

Motor- points? Criteria?

A

GCS

Eyes-4

  1. No response
  2. Opens eyes to pain
  3. Opens eyes to vocal stimulus/speech
  4. Opens eyes spontaneously

Verbal - 5

  1. No response
  2. Incomprehensible sounds
  3. Inappropriate words
  4. Confused speech
  5. Speech indicates orientation to time, person and place

Motor-6

  1. No response
  2. Abnormal extension
  3. Abnormal flexion
  4. Flexion to withdraw from pain
  5. Moves to localise painful stimulus
  6. Obeys verbal command
    7.
26
Q

Dissociative Seizures

Definition

Triggers/Causes

Management

A

Dissociative Seizures

Definition

Seizures that have similar features to epileptic seizures but no biological correlates

Triggers/Causes

Hx of abuse, psychological or emotional stressors

Management

Psychological therapy

27
Q

Fill in table:- Epilepsy symptoms summary

A
28
Q

What is the definition of a TIA?

A

Sudden onset focal neurological deficit of presumed vascular origin lasting less than 24 hours

29
Q

What is the ABCD2 score?

A

Predicts likelihood of someone who has had a TIA having a stroke

30
Q

Stroke:

Symptoms of PACS

A

Homonymous hemianopia

Contralateral motor or sensory deficit

Higher cortical dysfunction

31
Q

Stroke:

Symptoms of POCS

A

Any of:

Isolated homonymous hemianopia

Brainstem signs

Cerebellar signs

32
Q

Stroke:

Symptoms of LACS

A

Pure motor deficit

or

Pure sensory deficit

or

Pure sensorimotor deficit

33
Q

Stroke:

Symptoms of TACS

A
  • Contralateral motor or
  • sensory deficit
  • Homonymous hemianopia
  • Higher cortical dysfunction
34
Q

Stroke:

Symptoms of ACA [anterior cerebral artery] stroke

A

Contralateral hemiparesis lower limb > upper limb

Behavioural changes

35
Q

Stroke:

Symptoms of PCA {posterior cerebral artery] stroke

A

Cerebellar signs

Dysdiadochokinesia

Ataxia (gait and posture)

Nystagmus

Intention tremor

Slurred, staccato speech

Hypotonia/Heel-shin test

Brainstem damage:

↓ consciousness

CN pathology

36
Q

Stroke:

Symptoms of MCA [middle cerebral artery] stroke

A
  • Contralateral hemiparesis upper limb/face > lower limb
  • Contralateral hemisensory loss
  • Apraxia
  • Aphasia
  • Quadrantopias

Meded Flashcards 2020 (36 decks)

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