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Y3 NEUROLOGY > Headache and Intracranial Bleeds > Flashcards

Headache and Intracranial Bleeds Flashcards

1
Q

List red flag symptoms/signs related to headache

A 
New onset in over 55 yr old
Known/previous cancer
Immunosuppressed
Early morning onset
Exacerbated by valsalva (coughing, sneezing, straining)
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2
Q

What is a migraine?

A

Severe throbbing pain on one side of the head

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3
Q

Migraine affects males more than females. True/False?

A

False

Females more than males, especially if young

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4
Q

What is the difference between migraine with and without aura? Which is more common?

A

Migraine with aura: warning signs before migraine begins, e.g. flashing lights
Migraine without aura (80%) is more common

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5
Q

What is the criteria for diagnosing migraine without aura?

A

At least 5 attacks in 4-72 hours
2 of: Moderate/severe unilateral throbbing pain, worse on movement
1 of: Autonomic features or photophobia/phonophobia

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6
Q

What is the pathophysiology of migraine?

A 
Vascular and neural influence
Stress triggers serotonin release
Trigeminovascular system activation
Blood vessel constriction-dilation
Substance P irritates nerves and vessels, causing pain
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7
Q

How long do auras typically last in migraine?

A

20-60 mins

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8
Q

List some visual auras

A 
Central scotoma (grey, black or blind spot in middle of vision)
Central fortification (disruption in middle of vision that expands outwards, typically a flickering light)
Hemianopia
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9
Q

List triggers of migraine

A 
Sleep
Diet
Stress
Physical exertion
Hormones
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10
Q

List non-pharmacological treatment for migraine

A

Trigger diary
Education (avoidance of triggers, diet, hydration (min, 2l/day and avoid caffeine))
Stress management
Relaxation techniques e.g. acupuncture

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11
Q

List pharmacological management of migraine

A

NSAID (aspirin, naproxen, ibuprofen) + anti-emetic if vomiting
Triptans (5HT agonist/ rizatriptan)
TAKE AS EARLY AS POSSIBLE INTO HEADACHE

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12
Q

When should prophylaxis be considered for migraine?

A

More than 3 attacks in a month or very severe

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13
Q

List prophylactic therapy for migraine

A 
Propranolol
Topiramate
Amitryptilline
Gabapentin
Sodium valproate
Botulinum toxin
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14
Q

What type of drug is topiramate and what are its adverse effects?

A

Carbonic anhydrase inhibitors

Weight loss, paraesthesia, impaired concentration

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15
Q

What are trigeminal autonomic cephalgias?

A

Headache disorders characterised by unilateral pain in a trigeminal distribution with ipsilateral cranial AUTONOMIC features

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16
Q

List some ipsilateral cranial autonomic features

A 
Ptosis
Miosis
Nasal stuffiness
Nausea, vomiting
Tearing
Eyelid oedema
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17
Q

List the 4 main types of trigeminal cephalgias

A

Cluster headache
Paroxysmal hemicranias continua
Hemicrania continua
SUNCT

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18
Q

Who gets cluster headaches more - men or women?

A

Men

Typically 30-40 yr olds

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19
Q

When do cluster headaches typically come on?

A

Around sleep time (stricing circadian rhythm)

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20
Q

Describe a cluster headache

A

Severe unilateral headache lasting 20mins-3hrs + AUTONOMIC FEATURES
1 to 8 episodes a day

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21
Q

Outline management of cluster headache

A

High flow oxygen
Sumatripan
Steroids
Verapamil for prophylaxis

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22
Q

Who gets paroxysmal hemicranias continua more - men or women?

A

Women

Typically 50-60 yr olds

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23
Q

How would you distinguish paroxysmal hemicranias continua from cluster headache?

A

Shorter duration (10-30 minutes typically), more frequent (1-40 a day)

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24
Q

Which drug provides absolute response to paroxysmal hemicranias continua?

A

Indomethicin

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25
Q

What is a SUNCT trigeminal cephalgia?

A 
Short
Unilateral
Neuralgiform headache
Conjunctival injections
Tearing
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26
Q

What is the treatment for SUNCT?

A

Lamotrigine

Gabapentin

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27
Q

Who gets trigeminal neuralgia more - men or women?

A

Women

Typically elderly

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28
Q

What typically triggers trigeminal neuralgia and how is it described?

A

Touch in V2/V3 region e.g. shaving, eating

Severe stabbing unilateral pain

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29
Q

How long does an episode of trigeminal neuralgia usually last?

A

1-90 seconds

10-100 episodes a day

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30
Q

List the main investigation and treatments for trigeminal neuralgia

A

MRI brain

Carbamazepine
Gabapentin
Phenytoin
Baclofen
Surgical abltation/decompression
31
Q

List the 3 main spontaneous intracranial haemorrhage disorders

A

Subarachnoid haemorrhage
Intracerebral haemorrhage
Intraventricular haemorrhage

32
Q

Where does bleeding occur in a subarachnoid haemorrhage?

A

Into subarachnoid space that encloses CSF

33
Q

What is the most common underlying pathology in a subarachnoid haemorrhage?

A 
Berry aneurysm (typically at the junctions in the Circle of Willis)
Otherwise arteriovenous malformation or no identifiable cause
34
Q

List typical clinical features of a subarachnoid haemorrhage

A

Sudden onset “thunderclap” headache
Collapse
Meningism - vomiting, photophobia, neck pain/stiffness
Focal neuro deficit (dysphasia, hemiparesis)
Reduced conscious level

35
Q

Subarachnoid haemorrhage can occur whilst having sex. True/False?

A

True

36
Q

Which cranial nerve can be particularly affected in subarachnoid haemorrhage?

A

CN III

37
Q

What may be seen on fundoscopy in someone who has had a subarachnoid haemorrhage?

A

Retinal or vitreous haemorrhage

38
Q

CT scan of a brain may be normal in subarachnoid haemorrhage. True/False? What is the typical appearance on CT?

A

True
Depends on delay - once blood spills out bleeding may stop
White blood in SAS (‘spidery’)

39
Q

If a CT scan of a person with suspected subarachnoid haemorrhage is normal, what is the next best investigation?

A

Lumbar puncture

40
Q

Describe CSF appearance on lumbar puncture in subarachnoid haemorrhage. What must you consider?

A

Xanthochromatic or bloodstained (ensure not traumatic tap - do three samples)

41
Q

What investigation is gold-standard for identifying bleeding location of a subarachnoid haemorrhage? How does a Berry’s aneurysm appear?

A

Cerebral angiography with/without CT/MR

‘Mushroom-like’

42
Q

List some complications of subarachnoid haemorrhage

A 
Re-bleeding
Hydrocephalus
Hyponatraemia
Seizure
Delayed ischaemia
43
Q

How is re-bleeding in the brain addressed?

A 
Endovascular repair (mainstay)
Surgical clipping
44
Q

When might delayed ischaemic neurological deficit occur post- subarachnoid haemorrhage? What are the signs? What is the drug of choice to treat?

A

3-12 days
Altered conscious level or focal deficit
Nimodipine

45
Q

What is the H triple therapy used for delayed ischaemic neurological deficit?

A

Hypervolaemia
Haemodilution
Hypertension

46
Q

How does hydrocephalus arise? What are the main signs?

A

Increase in intracranial CSF pressure

Transient worsening headache or altered conscious level

47
Q

How is hydrocephalus treated?

A

CSF drainage - lumbar puncture, ventricular drain, shunt

48
Q

What should you not do to someone with hyponatraemia as a complication of subarachnoid haemorrhage? Why? What is the management?

A

Fluid restrict - Will cause hypovolaemia, predisposing to vasospasm and cerebral ischaemia
Supplement sodium intake and give fludrocortisone

49
Q

What is the most common aetiology/risk factor for intracerebral haemorrhage?

A

Hypertension leading to microaneurysms on small perforating arteries (Charcot-Bouchard)

50
Q

Typically where does a hypertensive intracerebral haemorrhage affect anatomically? What are the presenting signs?

A

Basal ganglia (haematoma or AV malformation)
Headache
Focal neuro deficit
Reduced conscious level

51
Q

List the main investigations for intracerebral haemorrhage

A 
CT scan (urgent if decreased consciousness)
Angiography (suspicious of vascular anomaly)
52
Q

What is an aura?

A

Fully reversible, visual, sensory, motor or language symptom, typically with a headache following less than 1 hour later

53
Q

What is the first line management for uncomplicated headache?

A

Symptomatic OTC medications

54
Q

What type of drug is propranalol and when should it be avoided?

A

B blocker

In asthma, HF, PVD

55
Q

What type of drug is amitryptiline and what are its adverse effects?

A

Try-cyclic antidepressant

Dry mouth, postural hypotension, sedation

56
Q

What are the two types of tension type headache?

A

Episodic or chronic

57
Q

Which symptoms are present, and which are not in tension type headache?

A

Mild - moderate blateral pressing tingling quality

No N+V, photophobia, phonophobia

58
Q

What are the management options for tension type headache?

A

Relaxation physiotherapy
Antidepressant - diothiepin or amitriptyline for 3M
Reassurance

59
Q

What investigations must be carried out in new onset unilateral cranial autonomic features?

A

Imaging

MRI brain and MR angiogram

60
Q

Idiopathic intracranial hypertension is more common in…

A

Obese females

61
Q

What are the features of idiopathic intracranial hypertension?

A

Headache
Diurnal variation
Morning N+V
Loss of vision

62
Q

What investigations should be carried out in idiopathic intracranial hypertension?

A

MRI brain with MRV sequence (should be normal)
CSF (increased pressure with normal constituents)
Visual fields

63
Q

What are the management options for idiopathic intracranial hypertension?

A

Weight loss
Acetazolamide
Ventricular atrial/ lumbar peritoneal shunt
Monitor visual fields and CSF pressure

64
Q

List differential diagnoses of sudden onset headache

A

SAH
Migraine
Bening coital cephalgia (occurs whilst having sex, before orgasm)

65
Q

Why does hyponatraemia occur as a complication of SAH?

A

SIADH

Cerebral salt wasting

66
Q

Outline the management options for SAH

A 
Bed rest
Analgesia
Anti-emetic
IV fluids
Refer to neurosurgeons
67
Q

Outline the management options for intracerebral haemorrhage

A

Surgical evacuation of haematoma +/- treatment of underlying abnormality
Non-surgical management

68
Q

How does an intraventricular haemorrhage arise? How does it appear on CT?

A

Rupture of subarachnoid or intracerebral bleed into ventricle
White pockets in ventricle

69
Q

What are the presenting signs of AV malformation?

A

Seizure
Haemorrhage
Headache
Steal syndrome

70
Q

Outline the management options for AV malformation

A

Surgery
EV embolisation
Stereotactic radiotherapy
Conservative

71
Q

List atypical causes of haemorrhage, not vascular pathology

A

Bleeding diathesis
Anticoagulants (warfarin, heparin)
Tumour

72
Q

What is the diagnostic technique used for AV malfromation? What is the characteristic sign?

A

Catheter angiography

Tangle of vessels with large feeding artery and draining vein

73
Q

What is the gold standard imaging used in suspected SAH?

A

CT scan

74
Q

Triptans are contraindicated in…

A

Heart disease

Y3 NEUROLOGY (22 decks)

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