General Flashcards
What are 5 red flags in headache presentation?
New onset >55 Previous malignancy Immunosuppression Early morning headache Exacerbation by Valsalva
In headache more common in men or women?
Women
What is the criteria for a diagnosis of migraine without aura?
5+ attacks lasting 4-72 hours
2 of: unilateral throbbing pain, worse on movement
1 of: photophobia, phonophobia, autonomic features
What is an “aura”?
Full reversible, visual, sensory , motor or language symptoms lasting 20-60 minutes
What can trigger a migraine?
Sleep, foods, stress, hormones, exercise
How is migraine managed?
Avoid triggers
Relaxation and stress management
Pharmacological
How can migraine triggers be identified?
Use of headache diary
How can headaches be treated pharmacologically?
NSAID, 5HT agonists
What NSAIDs can be used for headache?
Aspirin 900mg
Naproxen 250mg
Ibuprofen 400mg
How are 5HT agonists taken for migraine?
Orally, sublingual or s/c
What 5HT agonist (triptans) can be used for migraine?
Frovatriptan
When would migraine prophylaxis be considered?
3 attacks/month or very severe
What prophylaxis can be used for migraine?
Propanolol 80-240mg
Topiramate (carbonic anhydrase inhibitor) 25-100mg
Amitriptyline 10-75mg
What lifestyle factors affect migraine?
Hydration
Caffeine
Stress
Exercise
What are the 6 types of migraine
Acephalgic Basilar Retinal Ophthalmic Hemiplegic Abdominal
What is an acephalgic migraine?
No headache but aura present
What is a basilar migraine?
Migraine with vertigo/dizziness
Which type of migraine is common in kids?
Abdominal
How are tension type headaches treated?
Relaxation physiotherapy and anti-depressants
What does a tension type headache feel like?
Pressing, tingling, bilateral headache
What is a trigeminal autonomic cephalgia?
Primary headache disorder
Causing unilateral trigeminal distribution pain with cranial autonomic features
What cranial nerve features are present in trigeminal autonomic cephalgia?
Ptosis, miosis, n&v, nasal stiffness, tearing, eye lid oedema
What are the 4 types of trigeminal autonomic cephalgias?
Cluster
Paroxysmal
Hemicrania continua
SUNCT
Who gets a cluster type trigeminal autonomic cephalgia?
Men 30-40s
What is a cluster type trigeminal autonomic cephalgia?
Unilateral, EXTREME, headache lasting 30mins to 2 hours
What is the pattern of cluster type trigeminal autonomic cephalgia?
1-8 per day for months
What is the treatment for a cluster type trigeminal autonomic cephalgia?
High flow oxygen for 20 mins
S/c sumatriptan 6mg
Steroids over 2 weeks
Verapamil for prophylaxis
Who gets paroxysmal hemicrania type trigeminal autonomic cephalgia?
Women 50-60s
How does paroxysmal hemicrania type trigeminal autonomic cephalgia present?
Unilateral with autonomic features
What is the pattern of paroxysmal hemicrania type trigeminal autonomic cephalgia?
Comes and goes
Lasts 10-30 mins
Get 1-40 per day
How is paroxysmal hemicrania type trigeminal autonomic cephalgia treated?
Indomethicin 50mg TDS always works
How does SUNCT type trigeminal autonomic cephalgia present?
Short, unilateral headache with tearing
How are SUNCT type trigeminal autonomic cephalgias treated?
Lamotrigine, gabapentin
What investigations should be done for headaches?
MRI, MR angiogram, CT
Who gets idiopathic cranial hypertension?
Obese females
How does headache from idiopathic cranial hypertension present?
Headache with diurnal variation, worse on lying down
How is headache from idiopathic cranial hypertension investigated?
MRI with sequence
Describe pressure in CSF with idiopathic cranial hypertension?
Elevated >30
How does idiopathic cranial hypertension affect vision?
Visual acuity probably stays normal but there is loss of visual fields
Eventually can go blind
Who gets trigeminal neuralgia?
Old women
How does trigeminal neuralgia present?
Severe stabbing unilateral pain lasting 1-90s
What is the pain in trigeminal neuralgia?
Lasts 1-90s, 10-100x daily
Weeks to months before remission
How is trigeminal neuralgia treated?
Carbamazepine, gabapentin, phenytoin, baclofen, surgical ablation and decompression
What investigation should be done in trigeminal neuralgia?
MRI
Which symptoms would a brain tumour present with?
Headache that wakes you up at night
Progressive neuro symptoms
Motor weakness
Seizures (25%)
What is the most common extra-axial brain tumour?
Meningioma
How likely is it for a meningioma to become malignant?
Not
What is the second most common malignancy in children?
Meningioma
How does increased intercranial pressure present?
Headache, vomiting, mental changes, seizures
What are signs that increased intercranial pressure needs treated immediately?
Blown pupil
Rapidly reducing gcs
What can you give in increased intercranial pressure to reduce pressure in cavity?
Mannitol
Which cell type is mostly likely to be involved in brain tumour?
Oligodendrocytes
Who gets glial tumours?
25-45 year olds
Which tumour is solid, grayish with a “toothpaste” morphology?
Oligodendrocyte tumour
What are the 4 types of astrocytic tumours?
Type I - Pilocytic, pleomorphic xanthoastrocytoma
Type II - Low grade, but becomes malignant
Type III - Anaplastic
Type IV - Glioblastoma multiforme
Who gets type I astrocytic tumours?
Children and young adults
Which type I astrocytic tumour is curable?
Cerebellar
How is a type I astrocytic tumour treated?
Surgery
How does a type II astrocytic tumour present?
Seizure
What are poor prognostic factors for type II astrocytic tumours?
>50 Focal deficit Short duration Raised ICP Altered consciousness Enhancement on contrast
How is a type II astrocytic tumour treated?
Surgery +/- radio or chemo
What is brachytherapy?
Placement of radioactive isotopes directly onto the tumour
What is the mean survival of a type III anaplastic astrocytic tumour?
2 years
What is the life expectancy with type IV astrocytic tumour?
15 months
How likely is a meningioma type III to become malignant?
90% are benign
How does a meningioma appear on a CT?
Homogenous
Oedema
Hyperostosis/skull blistering
How does a meningioma appear on an MRI?
Dural tail
Patent dural sinuses
What is the peak incidence of a germ cell tumour?
10-12 yrs
How does a germ cell tumour appear on CT?
Iso- or hyper-dense
Enhancing
Mixed histology
What is the most common CNS germ cell tumour?
Geminomas
What bloods should be done with any midline brain tumour in a child?
ALP
HCG
LDH
What are the features of POCS stroke?
Cranial nerve deficit Bilateral motor/sensory deficit Eye movement disorders Cortical blindness Cerebellar deficits
What are the features of TACS stroke?
Hemiplegia
Cortical signs incl dysphagia, diploplia, nystagmus and neglect
What are the features of PACS?
2/3 TACS features
Isolated cortical dysfunction
What are the features of LACS?
Occlusion of single deep penetrating artery affecting 2 of: face, leg, arm
Which stroke classification has the best prognosis?
LACS
What is small vessel disease classified into?
Types 1-6
What type of small vessel disease is most common?
Type 1
What is type 1 small vessel disease?
Arteriosclerotic
What is type 2 small vessel disease?
Sporadic and hereditary cerebral amyloid angiopathy
blood vessel in brain problem
What is type 3 small vessel disease?
Genetic
What is type 4 small vessel disease?
Inflammatory and immunologically mediated
What is type 5 small vessel disease?
Venous collagenosis
What is type 6 small vessel disease
Post radiation
What are the two main causes of primary intracerebral haemorrhage?
Hypertension
Amyloid angiopathy
What are causes of secondary intracerebral haemorrhage?
Arteriovenous malformation, aneurysm, tumour
What investigations are done in stroke?
Full lipid profile BP Carotid scan ECG Echo
What is the acute management of stroke?
Thrombolysis Imaging Swallow assessment Anti-platelets Stroke care unit DVT prophylaxis
What is the window of opportunity for TPA treatment in stroke?
4.5 hours
How much CSF is in the body?
150ml
What is the mean pressure of CSF?
14cmH20
Which drug reduces CSF production by 50%
Acetozolamide
When is the max volume of CSF?
Approx 2am
How heavy is the brain?
1.5kg
How does hydrocephalus present at birth?
Large head
Thin/shiny scalp
Bulging/tense fontalles
How can hydrocephalus be picked up prenatally?
USS
How does hydrocephalus present at infancy?
Moving up head centiles Poor feeding Vomiting Sleepiness Muscle stiffness Lack of up gaze Pupils unreactive to light
How is hydrocephalus treated?
Shunt placed posterior to the parietal eminence
What are complications of getting a shunt placed?
Over drainage Underdrainage Infection Haemhorrage Seizures Dissemination of tumour
How does a blocked CSF shunt present?
Headache
Vomiting
Sunsetting in eyes
Blurred vision
How is a blocked shunt treated?
Tap shunt, CT, surgical intervention
What is ETV for hydrocephalus?
Opening created in the floor for the third ventricle to allow CSF to bypass the blockage prevent it from circulating
What major structure is at risk during ETV?
Basilar artery
Who gets normal pressure hydrocephalus?
Elderly
What is normal pressure hydrocephalus?
When the ventricles are enlarged but the pressure is normal
How does normal pressure hydrocephalus present?
Ataxia, memory decline, incontinence
How is normal pressure hydrocephalus investigated?
CT, MRI, LP tap test
What is an LP tap test for normal pressure hydrocephalus?
Measure pressure, drain 30mls CSF
If walking improves or general function is better after, this indicates hydrocephalus
How is normal pressure hydrocephalus managed?
70% success with shunt but only functional for 1 year
What is benign intracranial hypertension?
Normal ventricles but high intracranial pressure
Who gets benign intracranial hypertension?
Young, obese females with hypothyroidism
Abs use
Steroid withdrawal
Sleep apnoea
How does benign intracranial hypertension present?
Headaches
Visual loss
Papilloedema
Loss of VA
How is benign intracranial hypertension managed?
Acetazolamide
Heparin for thrombosis
Diuretics, shunt, decompression
Weight loss
What is the common side effect of acetazolamide?
Tingling in hands and feet
What type of history must be taken in epilepsy?
Collateral
What is epilepsy?
The tendency to have spontaneous/unprovoked seizures
What are the two types of epileptic seizure?
Focal
General
Who is most likely to have epilepsy?
Infancy and >55
What are risk factors for epilepsy?
Pregnancy or delivery problems Developmental delay Seizures in past Head injury Substance misuse FHx Medications
Which medication are risk factors for epilepsy? (8)
Abs Tramadol Anti-emetics Diamorphine Theophylline Lithium Ketamine NSAIDs
What are the features of an epileptic fit?
Rigid muscle Head turned Tongue biting Potentially wet yourself Sweaty Drowsy No memory
Describe focal seizures
Specific jerking movement, somatosensory and memory symptoms
Focal part of the brain had abnormal structure and electrical activity
What makes a focal/partil epileptic seizure complex?
Impaired consciousness level
What are the types of general epileptic seizure?
Absence Myoclonic Atonic Tonic Tonic clonic
Who mostly gets general absent epileptic seizures?
Young kids
What is an atonic general epileptic seizure?
No muscle tone at all
What is a tonic general epileptic seizure?
Stiff rigid muscles
Arms my bend as flexors typically stronger than extensors but this it not clonic
Describe a general tonic clonic seizure
Phase 1 - rigid muscles, tense and tight
Phase 2 - jerky movements, clonic
What examinations should be done with epileptic seizures?
Full neuro and cardio
What investigations should be done with epileptic seizures?
ECG
Imaging
EEG
What is a cardio exam and ECG done with seizures?
To check for arrhythmias
When would imaging be done urgently in seizure?
Suspected skull fracture, lesion, lowering gcs, focal neuropathy, haemorrhage, gcs <15 4 hours later
What is the only situation in which someone who is not a neurologist should do an EEG?
To confirm non-convulsive status
Is an EEG specific to epilepsy?
No - just helps to confirm clinically suspected epilepsy
When can you drive following a seizure?
Car - after 6 months
HGV - after 5 years
When can you drive after a nocturnal seizure?
Car - 6 months
After 1 year of having ONLY nocturnal seizures
When can you drive an HGV after confirmed epilepsy diagnosis?
10 years seizure free
What is SUDEP?
Sudden unexplained death in epilepsy
What are risks of SUDEP?
Drugs
Alcohol
Non-compliance
Sleeping alone
How is partial-seizure epilepsy treated?
Carbamazepine or lamotrigine
What should the patient be made aware of if taking carbamazepine?
Makes other drugs less effective including chemotherapy and OCP
Why is sodium valproate avoided?
Weight gain, hair loss, fatigue and teratogenic
What should NEVER be given to treat generalised epilepsy?
Carbamazepine
How is general epilepsy treated?
Sodium valprotate
Lamotrigine
Why is lamotrigine dose started low?
If too high can cause Steven-Johnsons syndrome
What can lamotrigine make worse?
Myoclonus
How are myoclonic seizures treated?
Sodium valproate
Levetiracetam
Clonazepam
How are absent seizures treated?
Sodium valproate
Ethosuximide
Topiramate
How effective is treatment for epilepsy?
65% seizure free with treatment
Which anti-convulsants should be used with caution when used together?
Sodium valproate and lamotrigine
Why shouldn’t you use sodium valproate and lamotrigine together?
Sodium valproate inhibits the metabolism of lamotrigine
Risk of Steven Johnson syndrome
What is phenytoin used for in epilepsy?
Acute management 6 months - 1 year
Which drug for epilepsy can be used which is well tolerated and causes some mood swings?
Levetiracetam
Which epileptic drug causes sedation, weight loss and isn’t well tolerated?
Topiramate
Which form of contraception should females on anti-convulsants not use?
Progesterone only
What should females on anti-convulsants also be prescribed?
Vit K
Folic acid
What epileptic situation are classed as emergencies?
Continuous seizures >30 mins
Recurrent fits without full recovery of consciousness
Conscious in altered state
Epilepsia partialis continua
What is a tic?
Involuntary stereotyped movement or vocalisation
What is chorea?
Brief irregular purposeless movement which flows from one body part to another
Why is epileptic status dangerous?
Excessive energy use leads to muscle damage, hyperthermia, rhabomyolsis, loss of BBB
What should be given in epileptic emergency?
Patient’s normal medication
Benzo - buccal midazolam, 10mg PR diazepam
Phenytoin
Valproate
When should someone in epileptic status be sent to intensive care?
If there is no improvement with medication after 30 mins
What is sleep?
Normal, recurring, reversible state in which you are not conscious or unconscious
In which type of sleep do you experience non-narrative images?
Non-REM
What are non-narrative images?
Dream without a story which has evoked an emotional response
Which type of sleep occurs at the start of the night?
Non-REM
Which type of sleep is associated with reduced cerebral flow, heart rate and BP?
Non-REM
During which type of sleep does protein synthesis occur?
Non-REM
During which type of sleep is there synchronised, rhythmic EEG activity?
Non-REM
Which type of sleep occurs at the end of the night?
REM
In which type of sleep is there fast EEG activity and increased brain activity?
REM
In which type of sleep is cerebral blow flow increased?
REM
In which type of sleep is there impaired thermal regulation?
REM
Which germ layer is microglia derived from?
Mesoderm
In which injury reaction is there shrinking and angulation of the neuron?
Acute
In which injury mechanism is there a “red neuron” ?
Acute
In which injury mechanism is the visibility of the nucleolus lost?
Acute
Describe axonal damage
Distal degeneration in the axon in response to injury
Increased protein synthesis
Chromatolysis causing loss of Nissl granules
Which response to injury involves reactive gliosis replacing neural tissue?
Simple neuron atrophy
What occurs during simple neuron atrophy?
Neurons shrink, angulate and are lost
Accumulation of lipofuscin pigment
Which type of damage are oligodendrocytes sensitive to?
Oxidative
De-myelination