Acute Neuro Flashcards
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
B. 300mg aspirin, orally
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.Sodium valproate
What are the different types/classifications of collapse?
Syncopal [due to global hypoperfusion of brain]
- Reflex [vasovagal]
- Cardiac
- Cerebrovascular
- Orthostatic
Non syncopal
- Epileptic seizures
- Non epileptic seizures
- Other
Differentials for different types of collapse- fill in table
What are the causes and features in history suggesting these causes of reflex syncope?
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]
What are the causes [and features of each cause] for cardiac syncope
Arrhythmias
Stokes Adam attack
Outlet obstruction
Massive PE
What are the causes [and features of each cause] for orthostatic syncope
Dehydration
Drugs
ANS instability, baroreceptor dysfunction
What are the causes [and features of each cause] for cerebrovascular syncope
Vertrebrobasilar insufficiency
Subclavian steal
Aortic dissection
What are the features of the history for epileptic syncope
Aura or no warning
< three minutes
Tongue biting
Twitching
Incontinence
Slow recovery
Confusion
What are the features of the history for non epileptic syncope
Background history of depression
What are the features of the history for intoxication being a cause of syncope
Alcohol/drugs
Head trauma
Narcolepsy
Hypoglycaemia
Epilepsy
Definition
Aetiology
Triggers
Presentation- symptoms and signs- before, during, after
[see table too]
Classification
Investigations
Management
Complications
-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
Definition of a seizure
Abnormal uncoordinated paroxysmal discharge of cerebral neurons
What are convulsions
Motor signs of electrical discharges
Status epilepticus
Definition
Triggers
Management
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
- Secure airway - and give 100% O2
- IV access and continuous monitoring- sats, BP, ECG, glucose
- IV lorazepam
- Repeat IV lorazepam after 10 mins
- IV phenytoin
- ICU
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
B Spinal cord compression
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
B Campylobacter jejuni
Guillain Barre syndrome
Definition
Pathophysiology
Presentation
Symptoms
Signs
Risk factors/aetiology
Investigations
[Management]
Miller-Fischer syndrome
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
Hydrocephalus
Definition
Epidemiology
Aetiology/Types
Presentation
- Acute
- Gradual
- NPH
Investigations
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]
Spinal cord compression
Definition
Causes
Epidemiology
Presentation- motor, sensory, autonomic
Investigations
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
Cauda equina syndrome
Definition
Causes
Presentation
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
Stroke
Definition
Types/Classifications
Epidemiology
Pathophysiology/aetiology
Scoring systems
Risk factors
Presentation
Investigations
Management
Complications
Prognosis
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
Radiculopathy
Definition
Causes
Presentation
Investigations
Example
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
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 Dissociative seizure
GCS Scoring
Verbal - points? Criteria?
Eye opening- points? Criteria?
Motor- points? Criteria?
GCS
Eyes-4
- No response
- Opens eyes to pain
- Opens eyes to vocal stimulus/speech
- Opens eyes spontaneously
Verbal - 5
- No response
- Incomprehensible sounds
- Inappropriate words
- Confused speech
- Speech indicates orientation to time, person and place
Motor-6
- No response
- Abnormal extension
- Abnormal flexion
- Flexion to withdraw from pain
- Moves to localise painful stimulus
- Obeys verbal command
7.
Dissociative Seizures
Definition
Triggers/Causes
Management
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
Fill in table:- Epilepsy symptoms summary
What is the definition of a TIA?
Sudden onset focal neurological deficit of presumed vascular origin lasting less than 24 hours
What is the ABCD2 score?
Predicts likelihood of someone who has had a TIA having a stroke
Stroke:
Symptoms of PACS
Homonymous hemianopia
Contralateral motor or sensory deficit
Higher cortical dysfunction
Stroke:
Symptoms of POCS
Any of:
Isolated homonymous hemianopia
Brainstem signs
Cerebellar signs
Stroke:
Symptoms of LACS
Pure motor deficit
or
Pure sensory deficit
or
Pure sensorimotor deficit
Stroke:
Symptoms of TACS
- Contralateral motor or
- sensory deficit
- Homonymous hemianopia
- Higher cortical dysfunction
Stroke:
Symptoms of ACA [anterior cerebral artery] stroke
Contralateral hemiparesis lower limb > upper limb
Behavioural changes
Stroke:
Symptoms of PCA {posterior cerebral artery] stroke
Cerebellar signs
Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/Heel-shin test
Brainstem damage:
↓ consciousness
CN pathology
Stroke:
Symptoms of MCA [middle cerebral artery] stroke
- Contralateral hemiparesis upper limb/face > lower limb
- Contralateral hemisensory loss
- Apraxia
- Aphasia
- Quadrantopias
