condition 2 Flashcards
defintion in epilepsy/ seizures
recurrent tendency to spontaneous, intermittent, abnormal electrical activity activity in part of the brain manifesting as seizures
epilepsy is not a diagnosis but a symptom with many underlying causes
what are the different types of seizure
generalised - simultaneous onset of electrical discharge throughout cortex with no localising features referable to only one hemisphere, there are other smart subtype within generalised seizures
- absence seizures - brief pauses
- tonic-clonic seizures - loss of consciousness, limbs stiffen (tonic), then jerk (clonic)
- myoclonic - sudden jerk of limb, face or trunk
- atonic - sudden of muscle tone causing fall
partial - focal onset with features referable to a part of one hemisphere, they are other different type within partial
- simple partial seizure - awareness is unimpaired with focal motor, autonomic or psychic symptoms
- awareness is impaired
- partial seizure with secondary generalisation - electrical disturbance which starts focally spreads widely causing a secondary generalised seizures which is typically convulsive
how common is seizure/epilepsy
5-10 cases per 1000 but 5-30% of these are misdiagnosed
causes of seizure or epilepsy
idiopathic (2/3) often familial structural - cortical (cerebrum) scarring eg head injury years before onset - developmental - space-occupying lesion - stroke - hippocampal sclerosis - sarcoidosis -SLE - polyarteritis nodosa
non-epileptic causes of seizures
- trauma
- stroke
- haemorrhage
- raised ICP
- alcohol or benzodiazepine withdrawal
- metabolic disturbance - hypoxia, hyper/hypo-natraemia/gycaaemia, hypocalcaemia, uraemia
- liver disease
- infection
- drugs
symptoms of seizures/epilepsy
prodrome - symptoms preceding the seziure by hours or days such as change in mood or behaviour
aura - part of the seizure of which the patient is aware and may precede its other manifestations eg odd feeling in the gut or flashing lights or strange smells
psot-ictally - heachace, confusion, myalgia, sore tongue, temporary weakness (seizure in the motor cortex)k dysphagia ( seizure in temporal lobe)
what are the specific symptoms for generalised tonic clonic seizures
sudden fall stiff limbs jerking loss of consciousness tongue biting incontinence
differential for seizures
syncope cardiac arrhythmias TIA migraine benign paroxysmal vertigo acute encephalopathy panic attacks aggressive outburst eg related to learning disability
further invest for seizures
EEG - only supportive to diagnosis, should only be performed after the second epileptic seizures, sleep EEG can be more accurate
MRI
bloods - to exclude other causes
ECG
treatment for seizures
drugs are not advised following one fit unless there is a high risk of recurrence. drug treatment should only start after 2nd attack and after discussion with patient
tonic-clonic - sodium valproate or lamotrigine (carbamazepine or topiramate - 2nd line)
absence - sodium valproate, lamotrigine or ethosuximide
tonic, atonic and myoclonic - same as generalised tonic clonic but avoiding carbamazepine and oxcarbazepine, topiramate 2 line
DVLA should be notify when epilepsy
what are some complications for epilepsy
SUDEP - Sudden Unexplained Death in Epilepsy
definition for meningitis
acute inflammation of the meninges and the underlying subarachnoid CSF –> medial emergency
how common is meningitis
2500/year bacterial and 5000/year viral
what are the 2 subtype of meningitis
infective and non-infective
what are some of the pathogens included in infective meningitis
bacterial - neisseria meningitides, strep pneumonia, staph aureus, haemophilius influenze type B (rare in the UK due to vaccine)
viral - enteroviruses, herpes simplex, varicella zoster, Mumps, HIV
fungal - in immunosuppressed
parasitic - eosinophilic meningitis
what are some causes of meningitis in non-infective category
malignant cells
intrathecal drugs (durgs injected in the spinal cord)
blood from SAH
sarcoidosis
SLE
Behcet’s disease (a rare immune-mediated small-vessel systemic vasculitis that often presents with mucous membrane ulceration and ocular problems.)
symptoms of meningitis
headache, leg pains, cold hands and feet
abnormal skin colour
meningism - stiff neck, photophobia seizures focal CNS signs petechial rash - non-bleeding signs of galloping sepsis - slow cap refill, low BP, pyrexia, tachycardia
prognosis of meningitis
viral meningitis usually self-limiting and resolves within 4-10 days might leave headache months after
differential for meningitis
SAH encephalitis other causes of pyrexia/severe infection intracranial abscess septicaemia (blood poisoning)
further investigations for meningitis
bloods - FBC, U&Es, LFT, glucose, coagulation
blood culture
throat swab - one for bacterial and one for viral
stool samples - for viral
LP - measure opening pressure - normally 7-18cm, typically 14-30 in meningitis), send samples for MC+S, gram stain, protein estimation, glucose, virology, only do this when not contraindicated (eg inc ICP, focal signs, papilloedema, truma, middle ear pathology, major coagulaopathy)
CT
what are the appearance of CSF for meningitis
pyogenic (bacterial only) - cloudy, polymorphs mainly with some lymphocytes, glucose half plasma, inc protein
treatment for meningitis
ABCDE assessment, bacterial is fatal if untreated
- if meningitic signs predominate
- dexamethasone IV
- Do LP
- cefotaxime IV post-LP immediately
- adjust Ax following MC&S
- if septicaemic signs predominate then
- cefotaxime IV
- do not do LP
- take to ICU for fluid resuscitation, intubation etc
aciclovir - if herpes simplex meningitis, otherwise, viral meningitis only supportive and analgesia
bacterial meningitis is a notifiable disease
definition for migraine
chronic neurological disorder characterised by recurrent moderate to severe headaches often in association with a number of autonomic nervous system symptoms
what are the different subtype of migraine
migraine without aura (common migraine -70%, aura = migraine without neurology signs)
migraine with aura (classic migraine - 20%)
childhood periodic syndromes
retinal migraine
probable migraine
how common is migraine
6% of men and 18% of women
who is affected the most by migraine
F:N 2:1
in 90%, symptoms begins <40yrs
common around puberty and menopause
causes of migraine
mechanism still unclear
RF for migraine
precipitating factors/partial triggers
CHOCOLATE
Chocolate Hangovers Orgasms Cheese Oral contraceptives Lie-ins Alcohol Tumult (loud noise and commotion of large crowd) Exercise
in 50%, no triggers were found
symptoms of migraine
prodrome (before) - yawnings, craving, modd change, sleep chane
aura (just before and during) (can be visual, somatosensory, motor or speech
- chaotic cascading, distorting, melting and jumbling of dots lines or zigzags
- hemianopia
- parastehsiae spreading from fingers to face
- dysarthria
- ataxia
- opthalmoplegia
- hemiparesis
- dysphasia/paraphasia
symptoms
- unilateral throbbing headache
- nausea and vomiting
- photophobia
- phonophobia (scare of loud noises)
- allodynia - stimuli which normally produce pain cuase pain
differenital for migraine
sudden migraine - SAH or meningitis Hemiplegic, visual and hemisensory symptoms: thromboembolic TIAs (nb in TIA maximum deficit is present immediately = sudden; headaches = gradual) unilateral tingling or numbness - sensory epilepsy cluster or tension headaches cervical spondylosis HTN raised ICP sinusitis/otitis media
management for migraine
explanations
avoidance or dietary triggers
brand change if related to oral contraceptive
treatment for migraine
NSAIDs, triptans, ergot alkaloids
prophylaxis - 1st line - propranolol, amitryptiline, topiramate, 2nd line - sodium valproate, pizitofen, gabapentin
definition of tension-type headache
a primary benign headache that is either episodic or chronic
how common is tension-type headache
most common form of chronic recurring head pain, quite common
who is affected the most by tension-type headache
anyone and everyone
more common in women than man
more common in adult
causes of tension type headache
most are innocent nature
due to neurovascular irritation and referred to scalp muscles and tissues
there many be obvious precipitating factors - worry, noise, concentrated visual effort, depression
symptoms of tension-type heacache
bilateral headache feel like tight band around head pain into or from neck gradual onset mild-moderate intensity pain non-pulsatile not aggravated by routine physical activity pressure behind eye
signs of tension-type headache
tenderness and tension in the neck and scalp muscle
differential for tension-type headache
migraine, raised ICP, cluster headache, sinusitis
management of tension-type headache
stress and trigger management ibuprofen - 1st line diclofenac - GI side effect naproxen - GI side effect paracetamol
definition for parkinson’s diseaese/Parkinsonism
parkinson’s disease - degenerattive disorder of the CNS characterised by resting tremour, rigidity and bradykinesia
parkinsonism - a symptomatic complex whihc shares the symtpoms from Parkinson’s disease but has neumerous underlying causes
what are the different types of Parkinson’s Disease
primary or idiopathic parkinsonism
different types of parkinsonism
secondary and atypical parkonsonism or parkinson’s syndrome
what is Parkinson’s-plus syndrome
neurodegenerative disease featuring the classical features of parkinson’s disease with additional features that distinguish them from primary Parkinson’s disease eg multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration
how common is parkinson’s disease or Parkinsonism
incidence 0.6% at 60-64 yrs and incidence rises steeply with age
pathology of Parkinson;s Disease
- mitochondrial DNA dysfunction
- causes cell death in substantia nigra pars compacta (thought to be associated with Lewy body)
- leads to reduced activity of producing cells
- reduced dopamine in the striatum
- leads to difficulty initing movement leading to hypokinesia, rigidity and tremor
what are the causes of parkinssonism
parkinson’s disease - most common cause
drugs - that block dopamine receptors or reduced storage of dopamine
toxins chemicals, Wilson’s disease
encephalopathy
trauma/boxing
HIV
Parkinson’s Plus syndromes
RF for parkinsons’s disease
Inc age
pesticide exposure
symptoms of parkinson’s disease
resting tremor oillin-rolling thumb over fingers rigidity/dec tone cogwheel rigidity felt on rapid pronation and supination Bradykinesia/hypokinesia postural instability festinate/shuffling gait decreased arm swing freezing at obstacles or doors expressionless face
differential for Parkinson’s disease
benign essential tremor
durg-induced tremor
hungington’s disease -FH
Parkinson’s Plus syndrome
cerebellar tremor - intension tremor
psychogenic tremor - inc on direct observation
investigation for Parkinson’s Disease
Diagnosis
Bradykinesia plus at least one of the following:
• Muscular rigidity
• Resting tremor (4-6Hz)
• Postural instability not caused by primary visual, vestibular, cerebellar or proprioceptive dysfunction
Supportive prospective positive criteria 3 or more are required for diagnosis of definitie PD: • Unilateral onset • Rest tremor present • Progressive disorder • Persistent asymmetry affecting the side of onset most • Excellent response (70-100%) to L-dopa • Severe L-dopa-induced chorea • L-dopa response for five years or more • Clinical course of ten years or more • Hyposmia • Visual hallucinations
treatment for Parknson’s Disease
Levodopa - key decision is when to start L-dopa as its efficacy decreases over time and requiring larger doses and greater frequency
