CNS disease Flashcards
What is Alzheimer’s disease?
A progressive neurodegenerative disease that affects short-term memory and loss of cognition and other brain functions
What will you see in an Alzheimer’s disease brain?
- Cortex shrivels up
- ventricles fill w CSF
- Hippocampus shrinks severely
Clinical features of Alzheimer’s disease
memory loss
aphasia
apraxia
agnosia
disorientation
depression, psychotic symptoms
motor hyperactivity
inability to take care of itself
what would you do when a patient comes in suspect dementia?
- History taking
- physical examination & blood and urine test
- cognitive testing:
the 10-point cognitive screener (10-CS)
the 6-item cognitive impairment test (6CIT)
the 6-item screener
the Memory Impairment Screen (MIS)
the Mini-Cog
Test Your Memory (TYM).
When do you refer the person to a specialist dementia diagnostic service?
- susception of dementia
- reversible causes of cognitive decline
investigation of Alzheimer’s disease
- FDG-PET (fluorodeoxyglucose-positron emission tomography-CT)
- Perfusion SPECT (single‑photon emission CT) if FDG-PET is unavailable
- Cerebrospinal fluid for total tau and phosphorylated-tau 181
what drugs would you give to patient that have Alzheimer’s disease
Acetylcholinesterase (AChE)
- donepezil
- galantamine
- rivastigmine
what medication would be advice to give to patient with moderate-severe Alzheimer’s disease
Memantine
How would you usually assess headaches?
- Subjective data: patient’s report and understanding of the headache
possible causes and precipitating factors
what measure relieve or worse
characteristics - Objective data: behaviours indicating stress, anxiety, or pain; changes ability to carry out activities of daily living, increased body temperature, sinus drainage.
What are the 3 primary headaches?
migraine
tension-type
cluster headaches
What is tension-type headache?
Recurrent episodes of headache lasting from 30 minutes to 7 days
- bilateral location
- band-like pressure and tightening
mild/moderate intensity
- doesn’t aggravate by routine physical activity
treatment for tension headaches
acute - aspirin, paracetamol / NSAID
prophylaxis - acupuncture, drug prophylaxis w amitriptyline 10mg
Migraine
- symptoms
- factors that can triggers it?
- types of migraine
- What is hemiplegic migraine
- treatment
- prophylaxis
- mostly unilateral, moderate-severe intensity, pounding / throbbing, photophobia, phonophobia, osmophobia, aura, nausea & vomiting
- stress, bright lights, smells, certain foods, dehydration, menstruation, disrupted sleep, trauma
- Migraine with aura, migraine without aura, silent migraine, hemiplegic migraine
- migraines with unilateral limb weakness, ataxia (loss of coordination & impaired consciousness; can mimic a stroke / TIA
- NSAIDs (ibuprofen/naproxen), paracetamol, triptans (sumatriptan), antiemetics (metoclopramide, domperidone)
- propranolol, amitriptyline, topiramate
what is aura
list some examples
visual changes that affect vision, sensation / language
Sparks in the vision
Blurred vision
Lines across the vision
Loss of visual fields (e.g., scotoma)
What is cluster headaches?
At least five attacks of severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15–180 minutes
- Conjunctival injection and/or lacrimation.
- Nasal congestion and/or rhinorrhoea.
- Eyelid swelling.
Forehead and facial sweating.
- Forehead and facial flushing.
- Sensation of fullness in the ear.
- Miosis (excessive pupillary constriction) and/or ptosis
How would you manage cluster headaches?
Need to refer to a specialist
triptan for an acute attack
* Sumatriptan SC — initially 6 mg for one dose.
* Sumatriptan intranasal spray (adults aged 18–65 years) — initially 10–20 mg
* Offer short-burst oxygen therapy for acute attacks.
Symptoms of brain tumours that need to be aware of
- headaches
- seizures (fits)
- persistently feeling sick (nausea), being sick (vomiting) and drowsiness
- mental or behavioural changes, such as memory problems or changes in personality
- progressive weakness orparalysison one side of the body
- vision or speech problems
what is a thunderclap headache, and what does this symptom indicate?
Acute onset headache that reaches maximum intensity within 5 min
this can indicate a
- Subarachnoidhaemorrhage (SAH)
- intracranial haemorrhage
- venous sinus thrombosis
- arterial dissection
what would you do if patient have a thunderclap headache?
Urgent CT head within 6 hours of presentation.
if more than 6hours A lumbar puncture will be performed
What is a subarachnoid haemorrhage?
rupture of a cerebral aneurysm that’s caused by trauma
rare condition
What’s an epidural haematoma (EDH)
When blood accumulates between the skull and the dura mater, the thick membrane covering the brain
Where does the subarachnoid haemorrhage occur?
Blood collects between the arachnoid mater and pia mater
the three triads of meningism
photophobia
Neck stiffness
Headache
symptoms of meningism
Fever.
Vomiting/nausea.
Lethargy.
Irritability/unsettled behaviour.
Ill appearance.
Refusing food/drink.
Headache.
Muscle ache/joint pain.
Respiratory symptoms/signs or breathing difficulty
what is meningitis
Inflammation of the two inner meninges (the pia and arachnoid mater) of the brain and spinal cord.
what’s meningitis causes by?
Neisseria meningitidis (most common)
Streptococcus pdneumoniae(pneumococcus)
Haemophilus influenzaetype b
what are the symtoms of meningitis
Fever
neck stiffness
vomiting
headache
photophobia
altered consciousness
seizures
What are the conditions when you assess for meningitis and see non-blanching rashes on the legs?
Septicaemia (basically sepsis) and need sepsis 6
What are the 2 signs that confirm the diagnosis of meningitis? explain them as well
Kerning sign - there’s resistance when you try to extend the leg on 90 degree
and
Brudzinski sign - when till the head on flat position the legs will contract and bend as well
diagnosis of meningitis
Lumbar puncture
blood test and blood cultures
CT head
features of lumbar puncture in viral meningitis
clear and colourless
normal / raised pressure and protein
WBC - 10-300
predominant cell - lymphocytes
glucose - normal
features of lumbar puncture in bacterial meningitis
turbid appearance
raised opening pressure
raised protein
WBC - 100-5000
Predominant cell - neutrophils
glucose - normal / reduced
features of lumbar puncture in fungal meningitis
cloudy appearance
raised opening pressure
raised protein
WBC - 10-200
Predominant cell - lymphocytes
glucose - reduced
features of lumbar puncture in TB meningitis
cloudy appearance
raised opening pressure
raised protein
WBC - 100-500
Predominant cell - lymphocytes
glucose - reduced
Management on meningitis
IM/IV benzylpenicillin (1200mg fo adult; 600mg for child but start of 300mg)
dexamethasone (steriod)
What is encephalitis
Inflammation of the brain parenchyma associated with neurological dysfunction
viruses are the leading cause of encephalitis
herpes virus being the most common group of viruses
symptoms of encephalitis
- an altered state of consciousness
- seizures
- personality changes
- cranial nerve palsies
- speech problems
- motor and sensory deficits
What are the examples of focal neurological signs/symptoms?
- Unilateral weakness or sensory loss.
- Dysphasia.
- Ataxia, vertigo, or loss of balance.
- Syncope.
- Sudden transient loss of vision in one eye (amaurosis fugax), diplopia, or homonymous hemianopia.
- Cranial nerve defects.
What is a stroke?
Sudden focal neurological deficit due to the brain losing blood supply
What are the 2 language areas that supply from the middle cerebral artery?
boca’s
wernicke’s
What cells in the brain will get damaged first after 5 min of hypoxia?
- Pyramidal cells of the hippocampus
- Cells of the neocortex
- The Purkinje cells of the cerebellum
What are the 2 types of stroke?
ischaemic
haemorrhagic
Ischemic stroke can be classified into ________
- thrombotic
- embolic
- hypoxic
What do you do when a patient is diagnosed with haemorrhagic stroke?
Arrange animmediate review by a neurosurgeonto assess whether the patient will benefit from neurosurgery.
How would you manage an ischaemic stroke?
Same-day urgent CT-head
Thrombolysis with alteplase for people with acute ischaemic stroke – to start within 4.5 hours of onset of stroke symptoms.
Thrombectomy can also be considered in combination with thrombolysis.
Do you give anticoagulation or antiplatelet treatment for patients with ischaemic stroke?
YES OR NO??
not until intracerebral haemorrhage has been excluded by brain imaging
what are the secondary prevention for strokes
- Encourage physical exercise
- Smoking cessation
- Eat a healthy and balanced diet
- Reduce alcohol intake
- antiplatelet therapy__clopidogrel 75 mg daily
- High-intensity statin__atorvastatin 20–80 mg daily
- antihypertensive drugs
Symptoms that can indicates head trauma
Loss of consciousness.
Confusion.
Amnesia.
Seizure.
Vomiting (including number of episodes).
Headache.
Neck pain.
Diplopia or other visual disturbance.
How would you investigate a patient with a head injury?
GCS score
16 and lower - CT head within 1 hour
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
post-traumatic seizure
focal neurological deficit
more than 1 episode of vomiting.
Risk factor of serious head injury
- immediate neck pain after event
- Aged 65 years or older.
- Drowning or diving accident.
- Multiple fractures.
- Significant head or facial injury.
- Dangerous mechanism of injury (a fall greater than 1 metre) or a side impact collision.
- Rigid spinal disease (for example, ankylosing spondylitis).
- Unable to walk about or sit following the injury.
When will you need to request a cervical spine radiography?
When patient are not able to rotate their neck45 degrees to the left and to the right
What is Epilepsy?
A disorder that has recurring & unpredictable seizures.
What is a seizure?
A period where cells in the brain (neurons) are synchronously active where they’re not supposed to be
What are the 2 neurotransmitters?
excitatory neurotransmitters
inhibitory neurotransmiters
What’s the primary excitatory neurotransmitter in the brain?
glutamate
how does the inhibitory neurotransmitter in the brain work?
GABA - inhibitory neurotransmitter
binds to GABA receptors and tells the cell to inhibit the signal by opening channels to let in chloride ions which are negative ions that inhibit signals
What are the factors that can alter the neurotransmitters?
tumours
brain injury
infections
What groups of seizures are there?
Partial seizure
&
Generalized seizures
What is a partial seizure?
Where 1 part of the hemisphere/lobe is affected
Subgroup into
simple partial - remains conscious during seizures
and
complex partial-impaired consciousness
What would a simple partial seizure show?
strong sensations
jerking movements
usually knows sm is happening
often remember the event
If a jerking activity starts in one group and spreads to nearby muscle groups, and more neurons are affected, what is the condition called?
Jacksonian March
What is a complex partial seizure?
Where there’s impaired consciousness where the patient:
- lose consciousness
- impaired awareness & responsiveness
- may not remember the event
What is a generalized seizure?
Seizures that affect both sides of the hemispheres and the patient will have a loss of consciousness for a period of time or longer
What are the sub-categories of the generalized seizures?
Tonic - suddenly, muscles become stiff & flexed, which causes the patient to fall backwards
Atonic - muscles become relaxed and cause the patient to fall forward
Tonic-clonic - where patients experience a tonic phase where the muscles suddenly tense up, followed by the clonic phase, where muscles rapidly contract and relax
(*accompanied by tongue bite)
Myoclonic - short muscle twitches
Absence - where the patients lose consciousness and then quickly regain consciousness (blank starting about 10sec)
What are the most common generalised seizures?
Tonic-clonic seizure
Suppose the patient has a seizure that lasts more than 5 minutes or an ongoing seizure that doesn’t go back to normal. What would be your diagnosis of the condition, and what will you do?
A condition called Status epilepticus
Medical emergency
required benzodiazepine that enhances GABA
What would be the initial pharmacologic therapy with patients that have GCSE (Generalized convulsive status epilepticus)?
- Benzodiazepine - potent GABA receptor, increase chloride channel opening
- fosphenytoin - nonbenzodiazepine anti-epileptic drug which prevents seizure recurrence
What are the symptoms after a seizure?
Postical (after seizure )confusion
Todd’s paralysis - paralysis in the arms or legs (1 sided)
-can last 15hrs
Diagnosis and investigation of seizures?
Brain imaging which looks for abnormalities (tumours)
–> MRI & CT
–> EEG (electroencephalogram)
tests & examination of clinical history
management of epilepsy
daily medication
epilepsy surgery
nerve stimulation
ketogenic diet
What could be the cause of the seizure?
Vascular
Infection
Trauma/toxins
Autoimmune
Metabolic
Idiopathic
Neoplasm
Syndromes
What is the first-line treatment for the absence of epilepsy?
Ethosuximide
works by blocking T-type Ca2+ channels in the thalamus
Intravenous magnesium sulfate is the drug used to treat and prevent seizures seen in____________
Eclampsia
What is eclampsia?
Eclampsia is seizures that occur in pregnant people with preeclampsia (hypertension disorder in pregnancy
First-line treatment for partial seizures
Carbamazepine
A confident diagnosis of absence seizure can be made if it is induced by (hypoventilation/hyperventilation)
Hyperventilation
If a patient suffering from an epileptic seizure does not respond to two doses of a benzodiazepine, what would you do?
Administered barbiturates
In patients with a known seizure disorder, the most common cause of status epilepticus is _________
Change in medication
What is often preceded by strange sensations called a seizure aura.
Partial / focal seizure
If seizure activity does not stop in a patient with status epilepticus after aggressive benzodiazepine, fosphenytoin, and/or phenobarbital, what is your management?
Give general anaesthesia
what in the area of the brain is tonic-clonic seizure caused by?
tonic - subcortical, thalamic, brainstem, and spinal cord
clonic - thalamus
What is Multiple Sclerosis?
A demyelinating disease of the central nervous system, which includes the brain and the spinal cord
demyelination happens when the immune system inappropriately attacks and destroys the myelin, which makes communication between neurons break down, ultimately leading to all sorts of sensory, motor, and cognitive problems
What type of reaction is multiple sclerosis?
Type IV hypersensitivity reaction
What’s the cause of multiple sclerosis?
Genetic factors:
- female
- genes encoding for HLA-DR2
environmental factors
- infections
- vitamin D deficiency
What are the types of multiple sclerosis (MS)?
- Relapsing-remitting multiple sclerosis (RRMS)
- Secondary progressive Multiple sclerosis (SPMS)
- Primary progressive multiple sclerosis (PPMS)
- Progressive-relapsing multiple sclerosis (PRMS)
What triad is used for MS, and what are they?
Charcot’s neurologic triad
- Dysarthria__difficult / unclear speech
- Nystagmus__involuntary rapid eye movements
- intention tremor
symptoms of MS
numbness
pins & needles
paresthesias - tinging, itching, burning
Lhermitte’s sign - electric shock runs down back & radiates to limbs when bending neck forward
bowel & bladder symptoms
sexual dysfunction
poor concentration & critical thinking
depression & anxiety
Diagnosis of MS
MRI - white matter plaques
Cerebrospinal fluid - high levels of antibodies
visual evoked potential - measure response to visual stimuli
What is the management for MS?
NO CURE, but medication that helps with less frequent relapse.
corticosteroids
cyclophosphamide
intravenous immunoglobulin
plasmapheresis - plasma is filtered to remove disease-causing autoantibodies
Chronic treatment:
- immunosuppressant –> recombinant beta-IFN
What cells of the central nervous system that are damaged in multiple sclerosis
Oligodendrocytes
What is Bell’s palsy?
inflammation and oedema of the facial nerve secondary to a viral infection or autoimmunity
symptoms of bells palsy
- Unilateral facial weakness
Post-auricular/ear pain (50%)
Difficulty chewing - Incomplete eye closure
- Drooling
Tingling (cheek/mouth)
Hyperacusis (heightened sensitivity to sound)
investigation of Bell’s palsy
base on unilateral facial weakness, of rapid onset without forehead sparing
- blood test
- lumber puncture
- Lyme serology
Treatment of Bell’s palsy
- Prednisolone (50mg) if the patient presents within 72hrs
- lubricating eye drop
What would you do if the patient experiences eye pain along with Bell’s palsy?
Refer to ophthalmology to review for exposure keratopathy
How long does it take for Bell’s palsy to recover?
Generally about 4 months but it can be up to 12 months
