control term two (1) Flashcards
how many vertebrae are there?
7 cervical 12 thoracic 5 lumbar 5 sacral (fused) 1 coccygeal (made of 4 fused segments)
30 total
(33 if include different segments of coccyx)
how many spinal cord segments are there?
31 (one more than no. vertebrae
8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal
what doe each spinal cord segment give rise to?
a PAIR of spinal nerves
how are the spinal nerves named?
cervical region: spinal nerve goes ABOVE vertebrae (ie C1 is above c1 vertebrae)
below cervical region: spinal nerve goes BELOW vertebrae (ie T1 is below T1 vertebrae)
what spinal nerve comes out above T1 vertebrae
C8
where are the 2 enlargements of the spinal cord?
cervical enlargement
lumbosacral enlargement
what is the most inferior tip of the spinal cord called? and at what vertebral level does it occur?
conus medullaris (medullary cone)
vertebrae L2
what is the structure that connects the end of the spinal cord to the coccyx?
filum terminale
extension of pia matter
what are the 2 differences between the meninges that surround the spinal cord and the ones that surround the brain?
surrounding spinal cord: only ONE layer of dura matter (brain has 2)
- spinal dura is a continuation of the meningeal layer (layer closest to brain/spinal cord)
spinal cord has denticulate ligaments (brain doesn’t)
what are denticulate ligaments?
little extensions of PIA matter which extend laterally, anchoring spinal cord to vertebral column
- prevent spinal cord rotating within vertebral column
- have about 21/22 of them down length of cord
how does the CSF from the brain enter the subarachnoid space surrounding the spinal cord?
by leaving the ventricular system via the lateral and median apetures
what are the 2 layers of dura matter that surround the brain? which is closest to the brain? where do they go when the brain –> spinal cord?
meningeal layer
- closest to brain
- surrounds spinal cord
periosteal layer
- closest to skull
- fold around onto superficial surface of skull
nb also have periosteal dura surrounding vertebrae
what is the potential space between the arachnoid matter and the dura matter?
subdural space
where is the epidural space?
outside (superficial to) the dura
aka extradural space
where is anaesthetic injected into for a spinal block?
subarachnoid space
what are the nerves which fill the vertebral column called inferior to the end of the spinal cord? at what levels of vertebrae do these arise?
cauda equine
“horses tail”
L2-S2
what is the area in the vertebral column called inferior to the spinal cord (from L2 down)?
what 3 things are found in this space?
lumbar cistern
- CSF
- Filum terminale
- cauda equina
what is a lumbar puncture? and where is it performed?
collection of CSF (via a needle) for testing
lumbar cisterne
so no risk of puncturing spinal cord
why does the spinal cord not terminate at the coccyx?
itdid, in the foetus, but then the foetal vertebral column grows faster than the spinal cord and so it looks like spinal cord has shrunk
describe the blood supply of the spinal cord
the 2 vertebral arteries each give off a branch anteriorly which combine to form ONE ANTERIOR SPINAL ARTERY, they both also give of a branch posteriorly, TWO POSTERIOR SPINAL ARTERIES
these arteries are supported by SEGMENTAL MEDULARY and RADICULAR arteries along length of cord
what 4 sections of white matter are in the spinal cord?
- dorsal white column
- lateral white column
- ventral white column
- ventral white commissure
what 4 sections of grey matter are in the spinal cord?
- dorsal grey horn
- lateral grey horn (only sometimes!!)
- ventral grey horn
- dorsal grey commissure
what type of fibres do dorsal + ventral roots tend to carry?
dorsal - sensory
ventral - motor
where do you get lateral grey horns? why here?
T1-L2
S2-S4
the lateral grey horn is full of AUTONOMIC cell bodies so you get them where there is a lot of autonomic viscera (ie in thorax and pelvis)
what are the 3 types of nerve in a mixed spinal nerve? and where are their cell bodies? and where do they synapse?
somatic and visceral sensory
- cell bodies: dorsal root ganglion
- synapse: dorsal grey horn
somatic motor
- cell bodies and synapse: ventral grey horn
visceral motor
- cell bodies and synapse: lateral grey horn
as each mixed spinal nerve leaves the vertebral canal it takes with it the meningeal layers, what structure do these meningeal layers go on to form?
epineurium
“Epineurium, ie on top of neurons”
a protective outer sheath of connective tissue
what specific part of the spinal cord enlarges are the cervical and lumbosacral enlargements?
ventral grey horms
- as lots of motor fibres to limbs needed
does white matter increase or decrease as cord descends?
white matter INCREASES as cord descends
what are the 2 dorsal white matter columns on each side of the midline called? and what happens to them as you go down the spinal cord?
gracile fascicle (medially) - starts small but grows until it takes up the entire dorsal white matter column INFERIOR TO T6
cuneate fascicle (laterally) - starts large but shrinks as you go down, disappears at level of T6 vertebrae
what are the 4 main fibre tracts in the spinal cord? and which are ipsilateral and which are contralateral?
dorsal column (ipsilateral)
lateral corticospinal tract (ipsilateral)
ventral corticospinal tract(contralateral)
spinothalamic tract (contralateral)
“tracts on DORSal part of cord are IPSIlateral, ones on ventral side are contralateral - remember DORSI = IPSI”
what’s the difference between a stroke and a TIA?
symptoms last MORE than 24hours = stroke
symptoms last LESS than 24 hours = TIA
how can you differentiate between a ischaemic and haemmorhagic stroke on a CT scan?
infarction = dark (area of low density oedema)
bleed = white (area of high density ‘fresh’ blood)
nb after a while post-stroke a bleed will go darker and look like a infarct. Also you may see small strip of white in infarct (which is the actual clot)
during a stroke, what is the penumbra?
an area of brain tissue (outside the core, where there is irreversible cell damage) where electrical function is impaired, due to low/no perfusion, but the cells have not yet died and may restore function if repurfusion occurs
what compensatory processes occur when there is an infarct in the brain?
smaller (high resistance) vessels dilate to allow for greater perfusion
when these can dilate no more: body increases oxygen extraction from blood
only when these 2 methods have been exhausted will patients get stroke symptoms
suggest some immediate treatments which can be given to patients who’ve suffered an ischaemic stroke
- aspirin (and/or clopidogrel)
- BP lowering
- statins
- thrombolytic drugs (but see guidlines as lots of exclusions)
- warfarin (only if caused by AF)
consider surgery (removing clot by open surgery or using a stent), depending on location of clot
what is carotid endarterectomy`
surgery to unblock a carotid artery
what does aphasia mean?
inability (or impaired ability) to understand or produce speech
what does aphagia mean?
inability (or refusal) to swallow
describe the process of clot removal, using stents
go through artery in leg to affected arterty
place stent across occlusion: leave in position for 10 mins
repurfuse brain
‘relax’ and plan stratergy
most clots will lyse naturally or improves efficacy of IV tPA (IV thrombolytics)
withdraw stent (carefully to avoid bit breaking off and embolysing) with smaller clot ‘core’
are TIAs normally ischaemic or haemorhagic?
almost always ischaemic
name 5 conditions which may be mistaken for a TIA
- seizures
- syncope
- hypoglycaemia
- migraine
- acute confusional states (eg delerium)
what is todd’s paresis?
todd’s paresis is a focal weakness in a part of the body after a seizure (normally epileptic). This weakness typically affects appendages and is localized to either the left or right side of the body. It usually subsides completely within 48 hours. Todd’s paresis may also affect speech, eye position (gaze), or vision.
what signs/symptoms are typically seen in patients with clots in their anterior circulation (ie internal carotid arteries)?
- dysphasia/receptive aphasia
- amarausis fugax
= temporary painful loss of vision in one, or both, eyes
(patients describe like a shutter going down over eyes)
what are the two types of dysphasia? damage to which brain areas causes which? what is the difference between them?
expressive aphasia - broca’s area (trouble finding words to say!)
- reading/writing/comprehension relatively intact
receptive aphasia - wernicke’s area (get words out but is all gobblydeygoop, they don’t realise they don’t make sense!)
- reading/writing/comprehension impaired
what signs/symptoms are typically seen in patients with clots in their posterior circulation (ie vertebral arteries)?
ataxia (poor coordination)
diplopia (double vision)
vertigo
bilateral symptoms
what signs/symptoms can be seen in patients with clots in either their anterior or posterior circulation?
- visual field disturbances
- hemiparesis
- hemisensory loss
what is hemianopia?
blindness over half field of vision
nb NOT blind in one eye!!
what is the ABCD2 score used to assess? and what does it stand for?
assess someone’s likelihood of getting a stroke after having a TIA (NOT used for diagnosis of stroke or TIA)
A = age B = BP C = clinical features D = duration symptoms D = diabetes
on a CT scan, what is a wedged shape area of hypodensity on the right lateral side of the brain indicative of?
an infarct in the right middle cerebral artery
“remember the MCA does NOT supply the ‘middle’ (medial aspects) of the cerebrum, the ACA does that”
what is dysarthria?
Dysarthria often is characterized by slurred or slow speech that can be difficult to understand
due to weakness + incoordination of oropharyngeal muscles
- NOT aphasia!!
where is wernickes area?
posterior section of the superior temporal gyrus
“on the V shaped junction where the temporal lobe is separated from rest of brain by the lateral fissure”
nb this is in the LEFT hemisphere for 95% of right handed people, but only 60% of left-handed people (so in 40% of lefties, it’s on right)
where is broca’s area?
infero-lateral frontal lobe
nb on LEFT side for majority of right handed people but can be on right side for left handed people
blood pressure rises acutely after a stroke (may settle within a few days), however antihypertensive treatment is NOT recommended, unless… (4)
- intracerebral haemorrhage with systolic BP>200
- hypertensive encephalopathy/neuropathycardiomyopathy
- aortic dissection
- eclampsia/preeclampsia (in pregnancy)
what should goals for rehabilitation be?
SMART
Specific Measurable Achievable Relevant Time-limited
when should stroke rehabilitation begin?
in hospital, basically ASAP!
what type of pneumonia do stroke patients normally get? why?
right basal pneumonia
because they aspirate on food (due to lack/poor swallowing ability)
due to layout/angle of bronci, aspiration food norm goes to right lower lobe
(nb NG tube is not completely protective against aspiration and families occasionally feed patients against advice!)
how do you assess the swallowing ability of a patient?
- position patient correctly
- ensure they are alert
1) give single teaspoon of water
2) give 2 further teaspoons of water
3) give 50ml of water
do they do any of these things: - drooling from mouth? - coughing or choking? - wet voice or cough? if YES, don't progress to next stage, keep NIL BY MOUTH + refer to speech and language therapist
nb if still unsafe after 6 weeks: consider gastrostomy tube
what are the risk factors for pressure ulcers? 6
- immobility
- malnutrition
- diabetes
- smoking
- terminal illness
- sensory impairment (as less able to feel pain of growing sore)
what 3 factors result in pressure sores developing?
- sustained pressure (often over bony priominence)
- friction (+ shear forces when moving patient)
- moisture (dt incontinence, sweating)
what’s the difference between shoulder subluxation and dislocation?
dislocation is when the head of the humerus comes fully out of the glenoid fossa, subluxation is when it shifts out of it’s proper position (normally due to damage/weakness of rotator cuff muscles) but is still in the glenoid fossa
why are stroke patients susceptible to shoulder subluxation? 2
how is it treated?
- weakness of rotator cuff muscles on stroke side
- neglect of affected limb (in right-sided stroke only)
management: optimise positioning, support shoulder
what are other possible causes of shoulder pain in stroke patients (apart from shoulder subluxation)? 3
how do you rule these out?
- tear of rotator cuff muscles
- capsulitis
- tendonitis
exclude by ultrasound scan
what musculoskeletal problems may be unmasked or exacerbated when someone has a stroke? 3
why is this?
- chronic back pain
- osteoarthritis
- RA
because patients may compensate for weakness on affected side by increased use of unaffected side, putting excess pressure on bones/joints
what are the negative (1) and positive (2) phenomena which can be part of post stroke pain?
why does this occur?
negative:
- decreased sensation (numbness)
positive:
- paraesthesia, burning, shooting pains
- dysaesthesia: altered perception (eg soft touch felts as prickly pain)
because of damage to contralateral primary sensory cortex (during the stroke) leads to sensory disturbances
post-stroke pain doesn’t normally respond to normal analgesics (paracetamol, NSAIDs, opiates), what drugs may be used instead? 3
pregabalin or gabapentin (anti-epileptic agents)
amitriptyline (type of antidepressant)
give 3 examples of medical problems which can cause incontinence when a patient is also disabled by a stroke
diabetes mellitus (polyuria)
UTIs
prostatic hypertrophy
what % of people who have had a stroke experience depression?
50%
name 5 reasons why patients may develop depression after a stroke?
- changing relationship with partner/family
- medical condition (concern for future)
- COMMUNICATION (unable to express self)
- worry about financial problems (how pay for care)
- adjustment to disability (+ being dependent on others)
what 2 things is rehabilitation a balance between?
- restoration of function
- adaption to disability
what are the 2 things that the brain naturally does in the first few days post stroke which aid recovery?
- resolution of oedema
- repurfusion of ischaemic penumbra
what part of the visual field does the left cerebral hemisphere process?
RIGHT HALF of visual field
nb NOT all info from right EYE
what is neglect?
a stroke in which area of the brain leads to neglect?
problem of ATTENTION: failure to attend to/monitor LEFT side
may be visual and/or somatosensory
(NOT explainable by visual field defect or loss of sensation - may be confused with visual field defect!)
caused by stroke in RIGHT PARIETAL LOBE
what is agnosia?
o Modality-specific inability to access sematic knowledge of an object (or other stimulus)
- (ie inability to process sensory info)
Can apply to any sensory modality
Not attributable to sensory impairment alone
Eg visual agnosia
= Unable to recognise common object by sight alone. May be able to do so when allowed to use other modalities, eg touch
what is it called when someone is unable to recognise specific human faces?
prosopoAGNOSIA
a type of visual agnosia
after a stroke, what are the 4 symptoms which would mean someone would be absolutely barred from driving (unless they resolve)?
- seizure within past year
- visual neglect
- visual field defect
- cognitive impairment
nb absolute 1 month driving ban post stroke
whose responsibility is it to report to the DVLA if a person cannot drive for medical reasons?
the patients
but if they refuse to, dr may breach confidentiality and inform DVLA without patient’s consent
what is dyspraxia?
what anatomical lesions may cause this?
loss of ability to conceptialise, plan + execute complex sequence of motor actions
(not explainable by weakness or lack of comprehension of the task)
caused by loss of cortical pathways for initiating + performing skilled actions
anatomical lesions may include:
- left inferior parietal lobe
- supplementary motor area
describe a spastic hemiparetic gait
stiff legged
- spasticity of ankle plantar flexors and knee flexors
short, slow steps
unsteady, risk of falls
- ankle weak, unable to dorsiflex: even on uneven surfaces
- loss of ‘righting reflexes’
how do you manage a spastic hemiparetic gait? 4
splints to correct foot drop
physiotherapy
manage spasticity
walking aides
what is the management of spasticity more generally?
physiotherapy + splinting of joint to maintain range of movement
drugs:
- botulinum toxin injections (local)
- baclofen (systemic)
what differences can you see between T1 and T2 MRI scans?
T1
- fluid = dark
- fat = white
(therefore white matter (high in myelin fat) is white + grey matter is grey)
T2
- fluid = white
- fat = dark
(white matter = grey, grey matter = white)
what orientation are transverse/horizontal head CTs/MRIs viewed from?
as if looking up from patients feet
what are the main differences between CTs and MRIs? 4
CT
- xray
- short time
- medium cost
- best for bone
MRI
- no xray
- long time
- high cost
- best for soft tissue
when can MRIs not be used?
if they have any metal implants (incl pacemakers etc)
if patient has severe claustrophobia
when can CTs not be used?
pregnant patients
what differences are seen between a haemmorhagic and ischaemic stroke on a CT scan?
bleed
- white
- mass effect (pushes other structures)
clot
- dark grey/black (due to oedema)
- no mass effect
nb if bleed is old it will appear grey/black as body digests blood
nb clot may be visible (will be a white strip)
nb in ischaemic stroke, if CT is done quickly, damage may not yet show on scan
nb in both strokes can also see a loss of definition between white and grey matter (loose sulci)
what parts of the brain do the three cerebral arteries supply?
ANTERIOR cerebral artery (ACA):
- anteromedial part of the cerebrum
MIDDLE cerebral artery (MCA):
- anterolateral part of cerebrum
POSTERIOR cerebral artery (PCA):
- posterior part of cerebrum (also lower part of temporal lobe)
what colour is contrast on a CT scan?
white
what do TACI and PACI stand for? what are the common symptoms?
total anterior circulation infarct
partial anterior circulation infarct
loss of movement/sensation in upper
and/or lower limbs and may include thinking (cognitive), speech
and language or visual difficulties.
what does POCI stand for? what are the common symptoms?
POsterior Circulation Infarct
visual and balance difficulties.
is the cerebellum contralateral or ipsilateral?
ipsilateral
how can you tell is a stroke on a CT is old or new?
- new looks like a presence of different tissue (with or without mass effect)
- old looks like an absence of brain tissue
what is the layer of dura matter that goes down the longitudinal fissure called?
falx cerebri
what are the common symptoms of a stroke in the cerebellum?
- incoordination
- inattention (important in sensory info)
on IPSILATERAL side
what arteries do the internal carotid arteries (ICAs) predominately supply?
what arteries do the vertebral arteries predominately supply?
Internal carotid:
- Anterior cerebral arteries
- Middle cerebral arteries
- opthalmic arteries
Vertebral: - Posterior cerebral arteries - superior cerebellar arteries - anterior inferior cerebellar arteries - posterior inferior cerebellar arteries - pontine arteries - anterior spinal arterY (all via basillar artery, except anterior spinal)
what is a haemorrhagic transformation? what does it look like on a CT?
where, after an ischaemic stroke, there is then a haemorrhage (normally due to thrombolytic drugs or blood disorders)
a large oedematous dark patch (from ischaemic stroke) with a smaller white patch on top (the bleed)
what is the difference between intra axial and extra axial lesions?
intra axial - inside brain tissue
extra axial - between layers of meninges
what are the 3 types of extra axial haemorrhage? where do they occur?
subarachnoid haemorrhage:
- between arachnoid and pia
subdural haemorrhage:
- between dura and arachnoid
extradural haemorrhage:
- between dura and skull
what are the symptoms of a subarachnoid haemorrhage? 7
a sudden agonising (thunderclap) headache
a stiff neck
feeling and being sick
sensitivity to light (photophobia)
blurred or double vision
stroke-like symptoms – such as slurred speech and weakness on one side of the body
loss of consciousness or convulsions (uncontrollable shaking)
what normally causes a subarachnoid haemorrhage?
what does it look like on a CT scan?
80% are caused by a ruptured (‘berry’) aneurysm
white areas in sulci (ie where CSF normally goes)
what are the symptoms of a subdural haemorrhage (aka haematoma)? 6
a headache that keeps getting worse
feeling and being sick
confusion
personality changes, such as being unusually aggressive or having rapid mood swings
feeling drowsy
loss of consciousness
what is the common cause of a subdural haemorrhage (aka haematoma)?
what does it look like on a CT scan?
head trauma
more likely in:
- alcoholics
- elderly
- people on ‘blood thinning’ drugs
often caused by venous damage
on CT: typically CRESENTIC (crescent moon-shaped) and more extensive than EDH, with the internal margin paralleling the margin of the adjacent brain
what is a contre-coup injury?
an injury that occurs on the side opposite the area that was hit.
what are the symptoms of an extradural haemorrhage?
may or may not lose consciousness transiently. Following the injury they regain a normal level of consciousness (lucid interval), but usually have an ongoing and often severe headache. Over the next few hours they gradually lose consciousness.
what is the most common cause of an extradural haemorrhage?
what does this look like on a CT?
head trauma
- normally to lateral side of skull
- – bursts middle meningeal artery
Typically LENTIFORM (lens-shaped, biconvex)
what is the treatment for a subdural haemorrhage/haematoma?
various management strategies depending on the size, location and extent of mass effect and is either conservative (monitor with serial CT) or surgical (drainage with burr holes).
what is the treatment for a extradural haemorrhage?
urgent drainage via a craniotomy
if there is damage in the pons on an MRI, what could this indicate?
locked- in syndrome
what are the two different types of general anaesthetic?
where are they excreted?
inhalational agents
(excreted via lungs)
intravenous agents (excreted via kidneys)
what are 3 different types of inhalational anaesthetic agents?
halogenated ethers (sevoFLURANE, isoFLURANE, desFLURANE)
nitrous oxide (NOS) - weak
xenon
what are 4 types of intravenous anaesthetic agents?
propofol
etomidate
barbiturates
ketamine
what are the three properties of balanced anaesthesia?
unconciousness (hypnosis)
analgesia (amnesia)
muscle relaxation (immobility)
why is balanced anaesthesia better/used more than single drugs?
- safer than larger dose single agent
- maximises benefit of individual agent
- minimises adverse effects
how is the potency of inhalational anaesthetic agents measured?
MAC (minimum alveolar concentration)
- concentration of drug which is effective in 50% of patients
how is the potency of intravenous anaesthetic agents measured?
Cp50
- concentration which is effective in 50% of patients
with inhalational anaesthetic agents, what properties will an agent have if it has a LOW solubility?
fast onset and quick recovery
what are inhalational anaesthetic agents most commonly used for?
exceptions? 2
maintenance
used for induction:
- paediatrics
- needle phobic adults
what effect does anaesthetic have on overweight/obese people?
due to high fat content, it takes a longer time for anaesthetics to get into fatty tissue, but also a long time to get out!
so ‘hangover’ effect after a general anaesthetic is longer
what are the properties of intravenous anaesthetic agents?
when are they used?
- quick onset
- short duration
most commonly: induction
(increasingly used for maintenance as well, by continuous infusion)
why do general anaesthetics lead to a drop in blood pressure? 2
- vasodilation
- decrease cardiac contractility
nb can reduce organ perfusion (esp in elderly or hypovloemic patients)
what are the 2 main adverse effects of INHALATIONAL anaesthetics?
- malignant hyperthermia
(genetic) - hepatotoxicity
both very RARE!
what are the 2 main adverse effects of INTRAVENOUS anaesthetics?
- allergy
- pain on injection
what is the most commonly used anaesthetic?
pros? 2
cons? 3
propofol (IV)
pros
- excellent suppression of airway reflexes
- decreases incidence of post operative nausea and vomiting (PONV)
cons
- marked drop in HR + BP
- pain on injection
- can cause involuntary movements (dt spinal reflex)
What is a common barbiturate anaesthetic that is given IV?
pros? 3
cons? 4
Thiopentone
pros:
- faster than propofol
- antiepileptic properties
- protects brain
cons:
- drops BP but RAISES HR
- rash / bronchospasm
- if given intra-arterially: thrombosis + gangrene
- contraindicated in porphyria
when is Ketamine used?
what are the properties of ketamine? 6
nb it is used IV
- short procedures
- at roadside RTAs
- in battle
properties:
- anterograde amnesia
- profound analgesia
- slow onset (90 mins)
- rise in HR/BP
- nausea + vomiting
- emergence phenomenon (get odd dreams)
what is anterograde amnesia?
loss of the ability to create new memories after the event that caused the amnesia, leading to a partial or complete inability to recall the recent past, while long-term memories from before the event remain intact.
what are the 5 methods of assessing unconciousness after giving a general anaesthetic?
- clinical signs
- measure level MAC (with inhaled agents)
- BIS monitor (brainwaves)
- isolated forearm
- evoked potential (complicated brainwaves)
what are 2 reasons why you might use a muscle relaxant during surgery?
- if have to cut through a lot of muscle (as harder to cut through tensed muscle)
- if doing very fiddly operation (eg neuro) so patient can’t move
what type of headache could each of these onset times typically be suggestive of?
- acute (seconds to minutes) 3
- evolving (hours to days) 3
- chronic (weeks to months) 2
acute (seconds to minutes)
- subarachnoid haemorrhage (thunderclap, very severe pain)
- coital (norm caused by sexual orgasm)
- intra-cerebral haemorrhage
evolving (hours to days)
- infection
- inflammatory
- raised ICP (intercranial pressure)
chronic (weeks to months)
- chronic daily headache
- raised ICP
what type of headache could each of these periodicity typically be suggestive of?
- episodic (at least a few days between attacks) 2
- chronic (headache most days) 3
episodic (at least a few days between attacks)
- migraine
- cluster headache
chronic (headache most days)
- medication overuse
- chronic migraine
- hemicrania continua (chronic unilateral headache)
fill the gap:
any headache that is acute is …………. until proven otherwise
any headache that is acute is VASCULAR until proven otherwise
what are 4 possible associated features of headaches? what could they indicate?
diurnal variation/postural element
- raised ICP?
nausea + vomitting
- migraines?
- lots of other causes!
photophobia/phonophobia (aversion to loud noise)
- meningeal irritation (eg meningtitis, SAH, ecephalitis)
- migraine
autonomic features (lacrimation, horners, red eye)
what are the red flag questions to ask about for a patient with a headache? 6
- cognitive effects (eg memory)
- seizures (?encephalitis)
- fever (?infection)
- visual disturbance (?cranial nerves ?raised ICP)
- vomiting
- weight loss (?malignancy)
what behaviours, to deal with the headaches, to patients typically have in:
- migraine?
- cluster headaches?
migraine:
- lie down in dark room
cluster headache:
- agitation/pacing around
why should you ask about family history for headaches?
- migraines are often familial (2/3 have family member with it)
on examination, what signs should you look for in someone who has headaches? 9
- fever
- rash
- neck stiffness
- ^BP (can mean ^ICP)
- organomegaly
- paplioedema (optic disc swelling caused by ^ICP)
- cranial nerve signs
- horners syndrome
- systemic neuro signs
name 8 primary headache syndromes
- migraine
- tension headache
- cluster headache
- cluster headache
- paroxysmal hemicrania (similar to cluster)
- exertional headache (similar to migraine)
- ice-pick headache (brain freeze)
- coital headache (sexual orgasm)
- hypnic headache (wake from sleep)
name 8 secondary headache syndromes
- subarachnoid haemorrhage (SAH)
- intra-cerebral haemorrhage/stroke
- meningoencephalitis
- intracranial venous thrombosis
- giant cell arteritis
- tumour with raised ICP
- cervicogenic headache (from neck)
- benign (aka idiopathic) intracranial hypertension
what are the clinical signs and symptoms of someone having a subarachnoid haemorrhage? 8
- sudden agonising headache (blinding pain) - stiff neck
- nausea/vomitting
- photophobia
- blurred or double vision
- stroke-like symptoms (such as slurred speech and weakness on one side of the body)
- loss of consciousness
- convulsions
what are the signs + symptoms of occulomotor (CN3) palsy? 4
- fixed dilated pupil (doesn’t constrict with light)
- droopy eyelid (ptosis)
- pupil looks ‘down and out’ (inferiorly and laterally)
- diplopia (double vision)
what’s the difference between ptosis and proptosis?
ptosis = droopy eyelid
proptosis (aka exophalmos) = bulging eye
what is the management for someone who’s had a subarachnoid haemorrhage?
resus
pain relief
CT scan (95% picked up via this) - if not then do lumbar puncture AFTER 12 hours
refer to neuro surgeons
(they coil/clip the berry aneurysm)
in using a lumbar puncture to diagnose a subarachnoid haemorrhage, what are you looking for?
xanthochromia in the csf
ie bilirubin realeased from lysing RBCs
what are the symptoms of an infective brain abcess? 8
what group of patients are more likely to get these?
- sub-acute worsening headache (often severe, located in a single section of the head and can’t be relieved with painkillers)
- changes in mental state (confusion or irritability)
- problems with nerve function (muscle weakness, slurred speech or paralysis on one side of the body)
- fever
- seizures
- nausea and vomiting
- stiff neck
- changes in vision
diabetics!
nb patients often present after having an acute ear/nose/eye infection
what changes are seen with fundoscopy in patients with raised intracranial pressure?
Fundoscopy shows blurring of the disc margins, loss of venous pulsations, disc hyperaemia and flame-shaped haemorrhages. In later stages, obscured disc margins and retinal haemorrhages may be seen.
called Papilloedema
what signs/symptoms (other than papilloedema) are seen in patients with raised intracranial pressure? 5
- headache (worse on lying + awakening = postural + diurnal)
- vomiting
- seizures
- lateralising signs
- high blood pressure (as body desperately tries to get blood to brain)
what are 5 potential causes of raised intracranial pressure?
- mass effect (tumour/abscess)
- brain swelling (hypertensive encephalopathy)
- increased venous pressure
- CSF outflow obstruction (hydrocephalus)
- increased CSF production (meningitis/SAH)
what is the immediate (and long term treatment) for an infective brain abscess?
- resus
- broad spectrum IV antibiotics (cefotaxime)
- possibly steroids (dampening down swelling)
- refer to neurosurgeons (craniotomy + drainage of abscess)
long term:
- cognitive/psychological sequelae
- ENT for assessment of hearing loss
what are the signs/symptoms of temporal arteritis? 6
- weight loss
- myalgia
- transient loss of vision
- jaw claudication (cramping pain)
- tender NON-pulsatile temporal artery (it’s normally pulsatile)
- raised ESR (inflammatory marker) + CRP
what is temporal arteritis?
what is it also called?
arteries in head and neck get inflammed (so there is reduced flow)
giant cell arteritis
what people are more likely to get temporal arteritis?
- elderly people (>60)
- females more than men
- people with polymyalgia rhematica (PMR)
what is the treatment for people with suspected temporal arteritis?
- immediate high dose steroids (predisolone)
SLOWLY taper off
patients symptoms should start to resolve within 48 hours! (if they don’t, question diagnosis!)
to confirm diagnosis can dotemporal artery biopsy!
what are the symptoms of a migraine? 6
- intense throbbing headache on one side of the head (episodic, lasts between 4 hours + 3 days)
- nausea
- vomitting
- photophobia
- aura
- can get stroke like peripheral symptoms
what is aura?
1/3 of people with migraines have temporary warning symptoms (known as aura) before a migraine.
- visual problems (eg seeing flashing lights, zig-zag patterns or blind spots)
- numbness or a tingling sensation (pins and needles–which usually starts in one hand and moves up your arm before affecting your face, lips and tongue)
- feeling dizzy or off balance
- difficulty speaking
- loss of consciousness ( although this is unusual)
what medication should patients who get migraines with aura not take? why?
combined oral contraceptive pills (ones with oestrogen + progesterone)
slight increased risk of stroke
what are the 4 main triggers of migraines?
- sleep deprivation
- hunger
- stress
- oestrogens
what is scintillating scotoma?
the most common type of visual aura
scintillating scotoma usually begins as a spot of flickering light near or in the center of the visual field, which prevents vision within the scotoma area. The affected area flickers but is not dark. It then gradually expands outward from the initial spot. Vision remains normal beyond the borders of the expanding scotoma(s)
what are the two warning signs of a focal migraine?
- cranial neuropathies/cerebellar signs
- hemiplegic
what is the pathophysiology of a typical migraine?
cortical spreading depression
- depression spreads from the back of the cortex forwards
- releasing chemically active irritants
- that trigger sensory fibres in the meninges
- which can be felt as pain
when would you use brain imaging on a patient who has a migraine?
- if this is the first migraine they’ve ever had
- if there are focal signs/symptoms lasting >24hrs
what conservative measures should migraine sufferers take to reduce frequency + severity of migraines? 5
- drink more water
- avoid caffeine
- avoid tyramine foods (cheese/chocolate/red wine)
- get a good sleep routine
- eat regular meals
what analgesia should patients suffering with migraines avoid?
codeine-based
what preventative treatment can be offered for patients suffering with migraines (if they are having more than 2 a month)? 6
- propranolol
- pizotifen (migraine preventer)
- topiramate (anti-epilepsy)
- valproate (anti-epilepsy)
- amitriptiline (antidepressant)
- botox
what is a trigeminal autonomic cephalgia?
what are the characteristics of these?
what are the three types? (what differentiates them)
over activation of trigeminal + parasympathetic systems
- short lasting headaches
- variable autonomic features
types:
- cluster headaches (attacks last 30-180min, 1 per 24hrs)
- paroxysmal hemicrania (2-30 mins, over 5 per 24hrs)
- SUNCT (seconds, up to 200 attacks per 24hrs, V. RARE!)
what risk factors are there for getting cluster headaches?
- male
- onset norm early 20s
- smoking
- family history
what sort of pain is felt during a cluster headache?
what are the associated symptoms? 6
- sudden onset
- severe pain (sharp, burning or piercing sensation)
- on one side of the head.
- pain is typically felt around the eye, temple and sometimes face
- typically recurs on the same side for each attack
associated symptoms:
- red and watering eye
- drooping and swelling of one eyelid
- smaller pupil in one eye
- sweaty face
- blocked or runny nostril
- red ear
what treatment is given for cluster headaches? 2
what preventative treatment is given? 3 (to take at beginning of cluster)
pain relief:
- sumatriptan
- high flow 100% oxygen
prevention:
- prednisolone (steroid)
- verapamil (calcium channel blocker)
- indomethacin (NSAID)
how do patients describe the type of pain associated with a tension headache?
- BILATERAL
- like a tight band constricting around head
what treatment is suggested for management of frequent tension headaches?
- relaxation + massage
- if frequent, small dose of amitriptyline
- acupuncture
- optician check (checking for eye strain)
LOW intracranial pressure can cause headaches, as well as high ICP.
what are 2 potential causes of low ICP?
- spontaneous intracranial hypotension
- post lumbar puncture headache (if too much fluid is drained)
what is idiopathic intracranial hypertension?
who does it tend to affect?
what are the symptoms? 5
idiopathic increase in volume of CSF produced, thus causing intracranial hypertension
- overweight fertile women
symptoms:
- constant throbbing headache (may be worse in the morning, or when coughing or straining; it may improve when standing up)
- blurred or double vision
- temporary loss of vision – your vision may become dark or “greyed out” for a few seconds at a time; this can be triggered by coughing, sneezing or bending down
- nausea + vomiting
- drowsiness and irritability
what is the definition of a chronic daily headache?
headache lasting:
>4 hours on >15 days per month for >3 months
what are the 4 commonest causes of a chronic daily headache?
de novo:
- new daily persistent headache
previous episodic headache:
- transformed migraine (usually due to overuse of analgesics)
- chronic tension-type headache
- hemicrania continua
what types of brain tumours are most common in:
- children? 2
- adults? 3
children:
- cerebellum (“they are still learning to get their balance”)
- PNET (medulloblastoma)
adults:
- cerebrum (“they think more than kids”)
- glioma
- meningioma
what type of brain tumours are most common in:
- men? 1
- women? 1
men:
- gliomas (“a penis GLIdes into a vagina”)
women:
- meningioma
what are the 4 types of glia cells in the brain? what are their functions?
astrocytes
- support + protect
oligodendrocytes
- produce myelin
ependymal cells + choroid plexus cells
- produce CSF
microglia
- defense, type of macrophage
what are the 5 broad types of primary neural tissue tumours?
- gliomas (glia cells)
- meningioma (meninges)
- neurocytoma (neurons)
- PNET
- schwannoma (nerve sheath)
what does PNET stand for?
what is the commonest type?
Primitive neuroectodermal tumours
(tumours of childhood/adolescence)
medulloblastoma
what are the three main types of glioma?
- astrocytoma
- oligodendroglioma
- ependyoma
what is the most aggressive type of brain tumour?
gliomas (they also infiltrate a lot due to lack of barriers within the brain)
which two cranial nerves are most commonly affected by schwannomas?
cranial nerve 5 and/or 8
what are the 4 histological criteria for MALIGNANCY in brain tumours?
- cellular density + atypia
- mitotic activity
- necrosis
- vascular proliferation
what is a familial cancer syndrome which leads to higher than normal rates of certain types of brain tumours?
neurofibromatosis
3 types
what is a known cause of meningioma?
radiotherapy
what is a known cause of lymphoma?
immunosuppression
what are the four genetic markers which are most relevant for molecular diagnostics of gliomas?
MGMT promoter methylation
- predictive of response of glioblastomas to chemo
1p/19q deletion:
- better prognosis in oligodedroglial tumours
IDH1/IDH2 mutation
- better prognosis of certain types of gliomas
BRAF duplication/fusion:
- help distinguish between 2 different type of astrocytoma
what 4 main ‘symptom groups’ may present due to a brain tumour?
- raised intracranial pressure
- epilepsy
- neurological deficit
- endocrine dysfunction
what are symptoms of raised intracranial pressure (ICP)? 3
- headaches (in early morning)
- vomiting (that’s unrelated to eating)
- blurred vision (due to papiloedema + direct compression of tumours)
what 3 ways can brain tumours result in raised ICP?
- tumour mass
- surrounding oedema
- obstructive hydrocephalus
nb small tumours with a lot of surrounding oedema are more often very aggressive primary brain tumours or secondary from other tumours
- whereas large brain tumours are often very slow growing (eg meningiomas)
- brain has time to compensate until can do no longer
which type of brain tumours are more likely to cause seizures?
tumours in cerebral hemispheres
a lot less likely in cerebellar or brain stem tumours
what types of neurological deficit can brain tumours present as? 5
- cognitive (memory/personality etc)
- visual
- cranial nerve
- motor
- sensory
what are the two types of brain tumours which are often picked up incidentally (ie during a brain scan done for another reason)?
meningiomas
pituatory tumour
nb especially in older people
what are the three types of brain scan done in patients with brain tumours?
- CT scan (often done first)
- MRI scan
- cerebral angiography
nb CT is better for bone detail and MRI is better for soft tissue detail
why might a patient with a brain tumour have a angiography?
to tell if the tumour is highly vascularised, ie whether it is likely to bleed a lot during surgery
what is a fMRI?
why are they done in patients with brain tumours?
functional MRI
to see how close tumour is to important functional structures and so which way to surgically approach tumour
what is the treatment for brain tumours? 5
- steroids
- anti-epileptic drugs
- surgery
- radiotherapy
- chemotherapy
A 40 year old right handed plumber presents to A & E after a fit and has a 2 week history of gradually increasing numbness and weakness of right side.
Where is the lesion?
Left fronto-parietal region (ie both sides of central sulcus)
A 30 year old mother can’t make her children understand what she is trying to say. She seems to understand what is said to her. She is right handed.
Where is the lesion?
Left temporo-frontal region
A 50 year old company director becomes withdrawn, apathetic and bad-tempered - then develops headaches and vomiting.
Where is the lesion?
frontal regions
A 55 year old window dresser can’t dress herself properly, has numbness down one side and develops headaches
Which lobe of the brain is likely to be affected?
Parietal lobe: sensory loss, dyspraxia, inattention
what are the ACUTE side effects of cranial radiotherapy (few weeks post-RT)? 3
- cerebral oedema (causing raised ICP + exacerbation of pre-RT neurological symptoms)
- hair loss
- scalp/ear erythema
what are the INTERMEDIATE effects of cranial radiotherapy (within a few weeks/months of RT)?
somnolence syndrome (severe tiredness) + exacerbation of existing neurological symptoms
what are the LATE effects of cranial radiotherapy (several months to years after)? 3
damage to sensitive structures (try to shield them as much as possible):
- lens (cataracts)
- pituatory (hypopituitarism)
- cerebral hemispheres (memory loss)
