Deck 2 - neuro Flashcards
Q. What type of stroke is the most common?
A. 85% are embolic (10% are haemorrhagic, 5% have rarer causes)
Q. In what layer do the a) meningeal vessels, b)bridging veins, c) circle of wilis lie?
A. Meningeal vessels: extradural space
B. Bridging veins: cross the subdural space
C. Circle of wilis: subarachnoid space
D. There are no vessels deep to the pia – the pia forms part of the BBB
- Q. What causes an extradural haemorrhage?
A. Traumatic – fractured skull
B. Causes bleeding from the meningeal arteries
C. There is a lucid period then a rapid rise in inter-cranial pressure – - coning and
death if not treated!
Q. What occurs in a subdural haemorrhage, who is this most likely to occur in?
A. Bleeding from the bridging veins – these are low pressure so bleed soon stops,
days or weeks later the haematoma starts to autolyse. There is a massive
increase in osmotic and oncotic pressure which sucks water into the haematoma
B. Gradual rise in ICP over many weeks
C. Commonly occurs in pts with small brains (alcoholics, elderly with dementia),
also occurs in “shaken babies”
Q. What occurs in a subarachnoid haemorrhage? Name three features of clinical
presentation
A. Rupture of the arteries forming the circle of willis (often due to berry enurysms)
B. Thunderclap headache: sudden onset of severe headache, photophobia and
reduced consciousness, rapidly fatal
Q. Describe the management of a subarachnoid haemorrhage
(CT, LP, angiography), resuscitation, nimodipine, early intervention to prevent re- bleeding, monitor
Q. Where is a traumatic blow to the pterion likely to rupture?
Anterior division of the middle meningeal artery causing an extradural (aka epidural) haematoma. The pterion may also be fractured indirectly by high force blows to the top or back of the head.
Q. Name 3 forms of primary headache and 3 forms of secondary headache
A. Primary: tension, cluster, migraine
B. Secondary: meningitis, subarachnoid haemorrhage, GCA, idiopathic intracranial
HTN, medication overuse headache
Q. Name five features that require urgent investigation due to increased brain tumour risk (red)
A. New headache with Hx cancer, cluster headache, seizure, significantly altered
consciousness, memory, confusion, coordination, papilledema, other abnormal
neuro exam or symptom
Q. Name five features that require monitoring due to mod brain tumour risk
(orange)
New headache where diagnostic pattern not emerged after 8 weeks,
exacerbated by exercise or Valsalva (e.g. coughing, laughing, straining), headache
associated with vomiting, headache increasing in frequency, new headache if
> 50yrs, headache that wakes pt from sleep, confusion
Q. Name four features of headache examination
Any fever? altered consciousness, neck stiffness (Kernigs sign), focal neurological
signs (fundoscopy)
Q. Describe the features of migraine without aura
A. 5 attacks with the following:
B. Attacks last 4-72 hours
C. Two of the following: unilateral, pulsing, mod/severe, aggravation by routine
physical activity
D. During headache at least one of: Nausea/vomiting, photophobia and
phonophobia
E. Not attributed to another disorder
Q. Describe the features of infrequent tension type headache
A. ≥ 10 attacks occurring < 1 day/moth (<12 days/year) and fulfilling B-D
B. Headache lasting from 30 minutes to 7 days
C. Headache has two of the following characteristics:
- Bilateral
- Pressing/tightening (non pulsating) quality
- Mild or moderate intensity
- Not aggravated by routine physical activity (e.g. walking or climbing stairs)
D. Both of the following: 1. No nausea or vomiting (anorexia may occur) 2. No more
than one of photophobia and phonophobia
E. Not attributed to another disorder
- Q. Describe the features of cluster type headache
A. At least five headache attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting
15-180 minutes if untreated
C. Headache is accompanied by ipsilateral cranial autonomic features and/or a sense
of restlessness or agitation
D. Attacks have a frequency from 1 every other day to 8 per day
E. Not attributed to another disorder
- What is the difference between episodic and chronic cluster headache?
A. Episodic ≥ 2 cluster periods lasting 7 days to 1 year separated by pain free periods lasting ≥1 month
Chronic attacks occur for more than 1 year without remission or with remission lasting
Describe the features of Classical Trigeminal Neuralgia
A. At least three attacks unilateral facial pain fulfilling B and C
B. Occurring in one or more distributions of the trigeminal nerve, with no radiation
beyond the trigeminal distribution
C. Pain has at least three of the following four characteristics:
- Reoccuring in paroxysmal attacks from a fraction of a second to 2 minutes
- Severe intensity
- Electric shock like, shooting, stabbing or sharp
- Precipitated by innoculous stimuli to the affected side of the face
D. No clinically evidence of neurological deficit
E. Not better attributed to another diagnosis
Q. Three abortive treatments of migraine
A. Oral triptan and an NSAID, aspirin, paracetamol
B. Anti-emetic as an additional tx for migraine
Q. Three preventative treatments for migraine
A. Topiramate or propranolol, acupuncture, gabapentin
B. Riboflavin, Bot tox A for prophylaxis of chronic migraine
Q. Name 4 possible features of raised intracranial pressure
A. Worse on waking, worse on coughing, sneezing, straining, worse when lying
down, nausea & vomiting, +- papilloedema (+- focal signs)
Q. Name 5 features that could be suggestive of meningitis
A. Headache with: pyraxial, photophobia, neck stiffness, +- Kernig’s sign, pyrexia, rash, reduced GCS, Brudzinski’s sign
Q. Who is at a higher risk of idiopathic intracranial hypertension?
A. Obesity, certain drugs e.g. tetracycline
B. headache of raised intracranial pressure, visual disturbances (acuity, fields),
papilloedema
C. Ix: CT, high LP opening pressure
D. Mx: modify RF, monitor visual fields, drugs (Acetazolamide/topiramate/diuretics)
Q. Name 3 presenting features associated with giant cell arteritis
A. New headache or type of localized pain, tenderness/decreased pulsation of
temporal artery (age>50, elevated ESR, abnormal biopsy)
B. Jaw claudication, visual symptoms, associated with PMR
C. Start high dose steroids – refer for biopsy
Q. What two features would be seen in the eye of a patient with a 3 rd nerve palsy?
Give a medical cause and a surgical cause
A. Depressed and abducted (down and out) – because CN3 damaged so only 2&6
functions left
B. Fixed dilated pupil
Medical: microinfarction (acute onset)
Surgical: brain tumor – longer onset
Q. What may be seen in lateral medullary syndrome?
A. Ipsilateral side: Horner’s syndrome (ptosis, droopy eyelid), hypohydrosis (reduced
sweating), meiosis, limb ataxia, loss of pain and temp sensation on face, reduced
corneal reflex, dysarthria, dysphagia
B. Contralateral: loss of pain and temp sensation
Q. What is a slow nerve conduction study suggestive of? What is a small nerve
conduction study suggestive of?
A. Small – axon loss
B. Slow – demyelination (MS?)
Q. What may slow/big motor units on electromyography be suggestive of?
A. Big motor units = nerve or motor neuron pathology
B. Small motor units = muscle pathology e.g. entrapments, axonal neuropathy etc
Myopathy = NCS normal, EMG shows small waves (multiple nerves show the bigger
picture)
Q. How may Myasthenia Gravis be seen on EMG?
A. Jitters – the time between two muscle fibers contracting varies
Q. What investigation can be used evaluate the spinal cord and optic nerves?
A. Somatosensory evoked potentials
Slow – MS, also used for pt monitoring in spinal cord surgery
B. Visual evoked potentials, transcranial magnetic stimulation
