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Neuro finals > Headache + Intracranial Pathology > Flashcards

Headache + Intracranial Pathology Flashcards

1
Q

How are headaches classified? Give examples

A

Primary vs secondary
1˚: migraine, tension, cluster
2˚: SAH, meningitis, IIH, GCA

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2
Q

What are the important features in a headache history?

A 
SOCRATES 
-Onset eg thunderclap (SAH)
-Character eg pulsating (migraine)
-Timing eg discrete episodes (cluster)
-Exacerbating eg lying flat (IIH, SOL)
Red flags 
-Systemic: weight loss, fever
-Focal neurology- weakness, visual changes
-Trauma-related
-Hx of cancer or immunosuppression
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3
Q

How does SOL present?

A

Insidious onset:

  • Headache: worse on lying/bending, improved on standing. Waking from sleep.
  • Vomiting
  • Seizures
  • Papilloedema
  • Focal neurology
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4
Q

What are some specific features that would make you worry about SOL?

A

Adult onset seizures esp. post-ictal weakness eg. Todd’s paralysis
Focal neurology evolving over time

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5
Q

Name some causes of SOL

A

Vascular: AVM
Infection/inflamm: TB granuloma, sarcoid granuloma, toxoplasmosis, abscess
Neoplasm: benign or malignant, 1˚ or 2˚

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6
Q

Which cancers commonly metastasize to the brain?

A 
Melanoma
Breast
Lung
Thyroid
Colorectal
Renal
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7
Q

What is the best imaging modality for SOL?

A

MRI

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8
Q

Describe the classic presentation of IIH

A

Overweight/obese woman, recent weight gain
Raised ICP signs:
-Headache worse on lying/bending
-Pulse-synchronous tinnitus
-Blurry vision, diplopia, visual loss (blind spot large)
-Papilloedema

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9
Q

Describe the approach to diagnosis in someone presenting with features of raised ICP

A
  • History suggestive
  • Examination: focal neurology, vision, fundoscopy
  • Imaging: CT head if worrying features eg rapid onset. MRI is best
  • Visual fields
  • LP for opening pressure (above 30 is abnormally high)
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10
Q

Describe the management of IIH

A 
Conservative: 
-Weight loss is definitive 
-Analgesia PRN
Medical:
-Acetazolamide 
Surgical:
-Shunting
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11
Q

Describe the presentation of intracranial haemorrhage

A

EDH: headache with rapidly progressive decline in cognitive function and altered consciousness after traumatic event
SDH: slowly progressive decline in cognitive function and altered consciousness. Usually elderly, alcoholics, anticoagulated. Possible Hx of trauma
SAH: thunderclap headache, possible Hx of hypertension

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12
Q

Describe the diagnostic process in suspected SDH

A
  • History suggestive
  • Examination: focal neurology, GCS, obs
  • Imaging: CT head (hyperdensity, midline shift)
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13
Q

What are the indications for CT head?

A

CT within 1 hour if:

  • GCS <15 2 hours after incident or <13 at any time
  • Suspected open skull fracture or basal skull fracture
  • 1+ episodes of vomiting after incident
  • Focal neuro or seizures

Ct within 8 hours if amnesia/loss of consciousness and:

  • Age >65
  • Dangerous mechanism of injury
  • Current anticoagulation
  • > 30 mins retrograde amnesia
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14
Q

Describe the management of SDH/EDH

A
  • Generally: reversal of anticoagulation, prophylactic antiepileptics
  • Consider severity-> conservative vs surgical Mx, ITU or ward
  • Conservative: Prevent raised ICP
  • Nurse flat
  • Analgesia and sedation PRN
  • > Hypertonic saline, osmotic diuretics (mannitol)
  • > intubation and ventilation
  • Surgical: craniotomy (large, GCS <9)
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15
Q

Describe the aetiology of intracranial haemorrhage

A

SDH: tear of the bridging veins
EDH: laceration of MMA
SAH: bleeding/ruptured aneurysm, AVM

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16
Q

What are the types of intracranial venous thrombosis? What is the imaging of choice?

A

Dural venous sinus thrombosis eg. cavernous sinus, sagittal sinus, etc.
Cortical vein thrombosis
Imaging with CT/MR venography

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17
Q

Describe the presentation of migraine

A

Migraine causes an episodic, unilateral headache often describes as ‘pulsating’ in nature. Lasts 4-72 hours

  • Assoc w photophobia, phonophobia, N+V
  • Relieved by rest + quiet
  • Can be triggered: wine, cheese, stress, menstruation
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18
Q

What are the types of migraine?

A

Migraine w aura
Migraine wo aura
Ancephalgic migraine
Chronic migraine: 15+ days/month over 3 months

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19
Q

What are some types of migraine aura?

A
  • Most commonly visual: visual fortification
  • Sensory disturbance
  • Weakness (hemiplegic migraine)
  • Vestibular
20
Q

What are the criteria for migraine diagnosis?

A

ICHD-3 criteria

1) Migraine wo aura: 5+ attacks, 4-72 hours, has migraine qualities
2) Migraine w aura: 2+ attacks, with classic description of aura

21
Q

What are the red flags for headache?

A 
SNOOP4
Systemic symptoms 
Neurological S/Ss: altered MS, focal neuro 
Onset 
Older age
Pattern change
Papilloedema
Precipitating factors
Positional aggravation
22
Q

Describe the diagnostic process for suspected migraines

A
  • History suggestive
  • Examination for any focal neuro
  • > If suggestive Hx, no red flags and normal exam: no further tests needed
  • > If any atypical features/red flags -> MRI w contrast. Consider CT or CTA/MRA if urgent
23
Q

Describe the management of migraine

A

Acute:

  • NSAIDs, aspirin/paracetamol/caffeine, anti-emetics (metoclopramide, prochlorperazine), hydration
  • Triptans: sumatriptan 1st line. Take first dose -> second after 2+ hours if the first was not effective or migraine returns

Prophylaxis (if >3 per month):

  • Trigger avoidance
  • Mg, riboflavin
  • Betablockers (propranolol), amitriptyline, anticonvulsants (topiramate), CCBs
24
Q

Describe the presentation of trigeminal neuralgia

A

Paroxysms of sharp stabbing pain the distribution of the branches of the trigeminal nerve
<2 minutes
May be triggered by eating, brushing teeth, shaving

25
Q

What are the causes of trigeminal neuralgia?

A

Classified as classic (idiopathic) or symptomatic (2˚)

2˚: MS, tumours (compression), post-herpetic neuralgia

26
Q

Describe the diagnostic process for suspected trigeminal neuralgia

A
  • History and examination (normal in CTN)
  • Electrophysiology can distinguish CTN from STN
  • Imaging eg. MRI for STN
27
Q

Describe the management of trigeminal neuralgia

A

Medical:
-Anticonvulsants (carbamazepine)
Surgical:
-Decompression

28
Q

Describe the presentation of cluster headache

A
  • Attacks of rapid onset unilateral headache occurring in clusters (8x/day-every other day) over weeks-mos
  • Last 15 mins-3 hours
  • Occur with ipsilateral autonomic signs (red and teary eye, runny nose, sweating, ptosis)
  • Often restless and agitated patient
  • Triggered by different stimuli
29
Q

Describe the management of cluster headache

A

Acute:

  • Parenteral triptans (nasal/SC)
  • Oxygen
Transitional treatment (start with preventative for quicker relief):
-Prednisolone

Preventative:

  • Verapamil
  • Topiramate
  • > neuromodulation
30
Q

Describe the presentation of GCA

A
  • Medium vessel vasculitis affecting branches of external carotid
  • Temporal headache in >50s
  • Worse w chewing, brushing hair
  • Can have visual loss
  • Assoc w PMR in 1/3
31
Q

What are the signs of GCA on examination

A
  • Thickened, hard, tender temporal artery

- Visual field loss

32
Q

Describe the diagnostic process in suspected GCA

A
  • History and examination- vital to know if any visual loss
  • Bloods: routine bloods + ESR and CRP
  • Imaging: USS
  • Extra tests: temporal artery biopsy (can be done within 2 weeks of diagnosis, do not delay treatment)
33
Q

Describe the management of GCA

A
  • Medical emergency! Same day rheum review. Ophthal if any visual loss
  • High dose prednisolone (40-60mg) ASAP
  • Taper slowly, usually treatment over 1-2 years
34
Q

What are the 3 types of herniation? Describe.

A

Tonsillar: cerebellar tonsils -> foramen magnum. BS compression causes cardioresp failure
Subfalcine: frontal lobe under the falx cerebri
Transtentorial/uncal: temporal lobe under tentorium

35
Q

What are some causes of cerebral oedema?

A
  1. Vasogenic (increased permeability): trauma, infection, neoplasm, etc.
  2. Cytotoxic (decreased oncotic pressure -> water into cells)
  3. Interstitial: hydrocephalus
36
Q

Define epilepsy

A

Tendency to recurrent, unprovoked episodes of abnormal electrical activity in the brain that manifests as seizures

37
Q

Name some causes of seizures

A

Non-epileptic:

  • Vascular: ischaemic stroke, haemorrhage
  • Infection/inflamm: viral encephalitis, TB, syphilis, HIV, sarcoidosis
  • Trauma
  • Autoimmune: encephalitis
  • Metabolic: hypoxia, hypoglycaemia, electrolyte disturbance, hyperbilirubinaemia (kernicterus), hypothermia
  • Iatrogenic
  • Neoplastic
  • Functional seizures

Epileptic seizures

38
Q

Describe the presentation of an epileptic seizure

A
  • May have a prodrome for hours/days. May have aura
  • Seizure activity, during may have incontinence, tongue-biting
  • Followed by post-ictal period of drowsiness, focal neuro etc
39
Q

What are the types of epileptic seizures?

A

Simple vs complex: loss of consciousness or not
Focal vs generalised: confined to one area of the brain or more widespread
Focal can be subdivided into location eg
-Frontal lobe: motor eg. Jacksonian march, Todd’s paralysis
-Temporal lobe: automatisms, sensory, deja vu
-Parietal lobe: tingling/numbness
-Occipital lobe: visual phenomena

Generalised can be divided into types:

  • Tonic-clonic: tonic phase and clonic phase. Classic.
  • Tonic: stiffness
  • Myoclonic: jerks
  • Atonic: no tone
  • Absence
40
Q

A 22 year old man is brought to ED after having a seizure. Describe the management approach.

A

-History: elicit if epileptic seizure, head trauma/precipitating factors, PMH, etc. Collateral Hx.
-Examination: look for any focal neuro, listen to heart
-Obs
-Urine drug screen
-ECG
-Bloods: FBC, CRP, U+Es, LFTs, TFTs, glucose
-Imaging if indicated eg. CT head, MRI
Mx:
-First episode: educate on seizure recognition, first aid, reporting further seizures, when to call 999

41
Q

Name some indications for MRI head in a patient with epilepsy

A
  • New Dx of epilepsy in adulthood
  • Evidence of focal onset or focal neuro
  • Seizures continue despite first line treatment
42
Q

Describe the management of epilepsy

A

MDT approach
Conservative:
-Education
Medical:
-Antiepileptic drugs (AEDs) usually after 2nd seizure or 1st if structural lesion
eg. valproate (men only), lamotrigine (usually 1st line. Worsens myoclonic seizures), levetiracetam (Kepra), carbamazepine
Surgical: refractory cases

43
Q

Describe the side effects of common AEDs

A

Valproate: N+V, alopecia, weight gain, abnormal LFTs, enzyme inhibition, teratogenicity
Lamotrigine: rash, SJS, sedation, diplopia
Levetiracetam: psych- irritability, depression, anxiety
Carbamazepine: SIADH, N+V

44
Q

Describe the management of status epilepticus

A 
Start timer
A to E approach:
-Airway: consider need for airway Mx
-Breathing: high flow O2
-C: IV access and bloods. ECG
-D: GCS, pupils
-E: check BM, exposure
5 minutes: 
-Buccal midazolam 10mg 
-IV/IM lorazepam 4mg
-Consider IV glucose (50ml 50%) or Pabrinex (250mg)
15 minutes: repeat loraz
25 minutes: 
-Phenytoin 18mg/kg at rate of 50mg/min 
-Phenobarbital
Refractory status (60-90 mins): GA eg. propofol, thiopental
45
Q

Describe the common types of brain tumour

A

Metastases: commonest of all tumours

Benign:
Meningioma: Commonest.
Astrocytoma

Glioblastoma multiforme: grade IV astrocytoma. Poor prognosis.

Neuro finals (8 decks)

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