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TCD Cases > Headache > Flashcards

Headache Flashcards

1
Q

Define Cushing’s triad

A

Autonomic response to raised ICP characterised by:

  1. Increased BP
  2. Irregular breathing
  3. Bradycardia
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2
Q

The majority of extra-dural haematomas occur where and result from damage to which artery?

A

Temporal region where skull fractures will lead to rupture of the middle meningeal artery

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3
Q

What is the classic history associated with an extradural haemotoma?

A

Headache as a result of an acceleration-deceleration trauma or blow to the side of the head

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4
Q

Where does a subdural haemotoma most commonly occur?

A

Around the frontal and parietal lobes

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5
Q

Give 3 risk factors for the development of a subdural haemotoma

A
  1. Old age
  2. Alcoholism
  3. Anticoagulation
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6
Q

What is the classical position of pain in a subarachnoid haemorrhage?

A

Sudden occipital headache

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7
Q

Recall the ‘shape’ of an extradural and subdural haematoma on CT respectively

A

Extradural - Convex

Subdural - Concave

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8
Q

Outline 5 structures that can be implicated in the pathology of headache.

A
  1. Trigeminalvascular system
  2. Meninges
  3. CSF containing structures
  4. Muscle
  5. Nerves
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9
Q

Give 5 examples of pathological processes that can lead to headache

A
  1. Neurogenic inflammation
  2. Inflammation
  3. Infection
  4. Pressure
  5. Obstruction
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10
Q

What is the most common form of primary headache?

A

Migraine

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11
Q

Give 3 disease mechanisms that can lead to secondary headaches

A
  1. Space occupying lesions
  2. Intracranial hypertension
  3. Vasculitis/ arteritis
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12
Q

Give 2 medications that you should ask about when taking a history relating to headache

A
  1. Oral Contraceptive Pill

2. Codeine

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13
Q

On clinical examination, papilloedema is a sign of what disease mechanism?

A

Raised intracranial pressure

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14
Q

What 2 visual field changes are associated with raised ICP?

A
  1. Peripheral field loss

2. Enlarged blinds spots

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15
Q

What are the 2 potential causes of a 6th nerve palsy in the context of headache?

A
  1. Raised intracranial pressure

2. Giant cell arteritis

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16
Q

The combination of headache and ataxia points towards what disease process?

A

A lesion in the posterior fossa pressing on the cerebellum

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17
Q

What is oral hairy leukoplakia and what organism causes this clinical sign?

A

White patch on the lateral border of the tongue - caused by infection with EBV

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18
Q

What is the clinical significance of oral hairy leukoplakia?

A

It is an indication of immunodeficiency - i.e. patient is susceptible to opportunistic infections.

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19
Q

Define levido reticularis

A

Mottled reticulated vascular patterns that appear on the skin.

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20
Q

Give 3 conditions in which levido reticularis may be seen

A
  1. Antiphospholipid syndrome
  2. Lupus
  3. Vasculitis
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21
Q

Xanthochromic spinal fluid can indicate which condition?

A

Subarachnoid haemorrhage

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22
Q

Which 2 blood results are required for the investigation of potential giant cell arteritis

A
  1. ESR

2. CRP

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23
Q

What is the immediate intervention for giant cell arteritis?

A

60mg prednisolone orally and referral for temporal artery biopsy

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24
Q

What percentage of migraine sufferers experience auras?

A

20-30%

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25
Q

Give 4 neurological conditions in which cortical spreading depression has been observed

A
  1. Cerebrovascular accident
  2. Subarachnoid haemorrhage
  3. Traumatic brain injury
  4. Epilepsy
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26
Q

Name 3 anti-emetics that can be used in the management of headache associated nausea/ emesis

A
  1. Domperidone
  2. Prochlorperazine
  3. Metoclopramide
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27
Q

Why are soluble tablets preferential when prescribing for migraine patients?

A

Migraine is often associated with gastric stasis and poor absorption - hence the feelings of nausea and emesis

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28
Q

What is the mechanism of action of Triptans?

A

Strong agonist action at the 5-HT (serotonin) receptors. Have been shown to induce vasoconstriction in vascular smooth muscle.

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29
Q

Name 2 triptans used in the treatment of migraine

A
  1. Sumatriptan

2. Zolmitriptan

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30
Q

Specifically in the CNS, name two brain structures targeted by triptans

A

Pre and post synaptic receptors in the:

  1. Midbrain
  2. Trigeminal nucleus caudalis
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31
Q

Which brain structure has been particularly implicated in the generation of migraines?

A

Trigeminal nucleus caudalis

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32
Q

Which medical conditions is a contra-indication for the use of triptans?

A

History of ischaemic heart disease or TIA

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33
Q

Recall the 4 criteria that are considered indications for prophylactic migraine treatment

A
  1. Quality of life is severely affected
  2. Two or more attacks per month
  3. Migraine attacks do not respond to acute drug treatments
  4. Frequently, very long and uncomfortable auras occur
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34
Q

Name 2 anti-epileptic medications that can be used as second line prophylactic treatment for migraine

A
  1. Sodium Valproate

2. Topirimate

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35
Q

Name 4 drugs that have an evidence base for migraine prophylaxis by suppressing susceptibility to cortical spreading depression.

A
  1. Sodium Valproate
  2. Topirimate
  3. Propanolol
  4. Amitriptyline
36
Q

What are the differential diagnoses of meningitis? (3)

A
  1. Encephalitis
  2. Non-infectious causes of meningeal irritation e.g. blood, trauma or drugs
  3. Subdural empyema
37
Q

Infective encephalitis is most commonly caused by which organism?

A

Herpes Simplex Virus (HSV)

38
Q

What are the 4 main risk factors for the development of meningitis?

A
  1. Extremes of age
  2. Living in close proximity
  3. Absence of vaccination history
  4. Immune suppression/ deficiency
39
Q

Name 8 countries that have a high incidence of pneumococcal penicillin resistance

A
  1. Canada
  2. Greece
  3. Italy
  4. Mexico
  5. USA
  6. Poland
  7. Spain
  8. Turkey
40
Q

Give 3 important contra-indications to performing a lumbar puncture

A
  1. Papilloedema/ any sign of raised ICP
  2. Coagulation defects
  3. Signs of infection at the site of the needle insertion
41
Q

Name the nerve that is supplied by the spinal nerve roots S2, S3 and S4

A

Pudendal nerve

42
Q

What is the primary sensory function of the pudendal nerve

A

Supply sensory innervation to the external genitalia and anus in both sexes

43
Q

Give 3 examples of a true dry CSF tap (LP)

A
  1. Arachnoiditis
  2. Meningeal infiltration
  3. True low CSF pressure
44
Q

What separate blood test should always be carrie out alongside an LP?

A

BM (blood glucose)

45
Q

An extremely high WBC count in a CSF sample is indicative of what?

A

A bacterial infection

46
Q

Extremely high protein levels in a CSF sample points towards which two infective agents?

A
  1. TB

2. Fungal

47
Q

Give an example of a 3rd generation cephalosporin antibiotic

A

Ceftriaxone

48
Q

If Listeria is suspected in cases of bacterial meningitis, which antibiotic should be added to the administered regime?

A

Ampicillin

49
Q

Which antibiotic should be given to a patient with bacterial meningitis that is allergic to cephalosporins?

A

Choramphenicol

50
Q

What is a hypnic headache?

A

A rare form of headache that only occurs at night and wakes people from sleep

51
Q

A combination of headache, malaise, sweats and proximal muscle weakness in patients aged over 55 could be indicative of what condition?

A

Giant cell arteritis

52
Q

Describe the typical visual symptoms associated with raised ICP

A

Transient visual obscurations

53
Q

Give 3 clinical signs to look for on neurological examination in patients with suspects raised ICP

A
  1. Papilloedema
  2. Restricted visual fields
  3. Enlarged blind spots
54
Q

What is the clinical sign pronator drift indicative of?

A

Subtle pyramidal tract dysfunction

55
Q

Recall the 4 main categories of intracranial space occupying lesions

A
  1. Tumours
  2. Infection
  3. Vascular
  4. Hydrocephalus
56
Q

Name 4 infective condition that can present as an intracranial space occupying lesion

A
  1. Brain abscess
  2. Subdural Empyema
  3. Granulomas (e.g. tuberculosis)
  4. Parasitic
57
Q

Give 3 potential causes of obstructive hydrocephalus

A
  1. Tumours
  2. Cysts
  3. Intra ventricular haemorrhage
58
Q

Give 2 potential causes of communicating hydrocephalus

A
  1. Meningitis

2. Sub arachnoid haemorrhage

59
Q

What is the cause of overproduction hydrocephalus? (Rare)

A

A benign tumour type: Choroid plexus papilloma

60
Q

List 4 symptoms of raised ICP

A
  1. Headache
  2. Vomiting
  3. Blurred vision
  4. Deterioration of conscious level
61
Q

List 3 clinical signs of raised ICP

A
  1. Papilloedema
  2. Bradycardia
  3. Hypertension
62
Q

Give 4 symptoms associated with frontal lobe damage

A
  1. Limb weakness
  2. Dysphasia
  3. Personality changes
  4. Dementia
63
Q

Give 3 symptoms associated with parietal lobe damage

A
  1. Sensory symptoms
  2. Dressing apraxia
  3. Visual field defects
64
Q

Give 2 symptoms associated with temporal lobe damage

A
  1. Dysphasia

2. Visual field defects

65
Q

Suggest 5 potential effects of a space occupying lesion in the posterior fossa

A
  1. Dysmetria
  2. Gait ataxia
  3. Cranial nerve palsy
  4. Tremors
  5. Nystagmus
66
Q

Recall the components of a cerebellar examination referred to through the mnemonic DANISH

A 
D - Dysdiadochokinesis  
A - Ataxia 
N - Nystagmus 
I - Intension tremor 
S - Scanning dysarthria 
H - Heel-shin test positivity
67
Q

What are the two ‘locational’ categories for brain tumours?

A
  1. Supratentorial

2. Infratentorial

68
Q

What is the most common form of benign brain tumour?

A

Meningioma

69
Q

Name 5 clinical syndromes that have been associated with familial brain tumours

A
  1. Neurofibromatosis 1
  2. Neurofibromatosis 2
  3. Von Hippel Lindau syndrome
  4. Tuberous Sclerosis
  5. Li-fraumeni syndrome
70
Q

From what cell type do meningiomas arise from?

A

Arachnoid cap cells

71
Q

Bilateral vestibular schwannoma is associated with which clinical syndrome?

A

Neurofibromatosis

72
Q

Name the 5 most common types of primary brain tumour

A
  1. Meningioma
  2. Pituitary tumour
  3. Metastasis
  4. Glioblastoma
  5. Oligodandroglioma
73
Q

What is a normal ICP?

A

< 15 mmHg in adults

74
Q

Why can ICP be negative on standing up?

A

Venous sinuses are rigid structures

75
Q

Outline the percentage components of the contents of the skull (3)

A
  1. Brain parenchyma 80%
  2. CSF 10%
  3. Blood 10%
76
Q

Recall the average intracranial volume for an adult

A

1400-1700 mls

77
Q

Suggest 3 potential causes of an increased blood volume in the intracranial cavity

A
  1. Raised arterial PCO2
  2. Venous obstruction
  3. Raised temperature
78
Q

Recall the equation for calculating cerebral perfusion pressure

A

CPP = ABP - ICP

79
Q

What is the gold standard for measuring ICP?

A

EVD with strain gauge pressure transducer

80
Q

List the 5 ‘general routine’ measures suggested for the management of ICP in ICU

A
  1. Head up tilt: 3–45 degrees
  2. Keep neck straight
  3. Avoid hypotension
  4. Maintain adequate sedation
  5. Maintain euvolemia and norm-hyper osmolar state
  6. Maintain a normal PCO2
81
Q

Give the 6 potential options for the management of a sustained acute rise in ICP

A
  1. Heavy sedation +/- Paralysis
  2. CSF drainage
  3. Osmotic therapy (mannitol)
  4. Hyperventilation
  5. Barbiturate therapy
  6. Decompressive craniotomy
82
Q

Why can mannitol only be used in the short term as an osmotic diuretic in the treatment of acutely raised ICP?

A

Long term treatment would cause the mannitol to cross the BBB and thus invert the osmotic gradient, leading to retention of fluid within the brain parenchyma and causing ‘rebound’ raised ICP.

83
Q

How can hyperventilation help to elevate a raised ICP in the short term?

A

A reduction in PCO2 causes cerebral vasoconstriction thus reduces intracranial blood volume

84
Q

Give 2 examples of barbiturate drugs

A
  1. Phenobarbitone

2. Thiopentone

85
Q

Give 6 tumour types that commonly can metastasise to the brain

A
  1. Bronchus
  2. Breast
  3. Stomach
  4. Prostate
  5. Thyroid
  6. Kidney
86
Q

Give 4 pathophysiological processes that have been implicated in the aetiology of migraine

A
  1. Cortical spreading depression
  2. Neurogenic inflammation
  3. Vasodilation and vasoconstriction
  4. Patent foramen ovale
87
Q

What is the first line investigation for a suspected subarachnoid haemorrhage?

TCD Cases (25 decks)

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