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Neuro finals KTB > 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
What are the causes of trigeminal neuralgia?
Classified as classic (idiopathic) or symptomatic (2˚) | 2˚: MS, tumours (compression), post-herpetic neuralgia
26
Describe the diagnostic process for suspected trigeminal neuralgia
- History and examination (normal in CTN) - Electrophysiology can distinguish CTN from STN - Imaging eg. MRI for STN
27
Describe the management of trigeminal neuralgia
Medical: -Anticonvulsants (carbamazepine) Surgical: -Decompression
28
Describe the presentation of cluster headache
- 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
Describe the management of cluster headache
Acute: - Parenteral triptans (nasal/SC) - Oxygen ``` Transitional treatment (start with preventative for quicker relief): -Prednisolone ``` Preventative: - Verapamil - Topiramate - > neuromodulation
30
Describe the presentation of GCA
- 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
What are the signs of GCA on examination
- Thickened, hard, tender temporal artery | - Visual field loss
32
Describe the diagnostic process in suspected GCA
- 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
Describe the management of GCA
- 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
What are the 3 types of herniation? Describe.
Tonsillar: cerebellar tonsils -> foramen magnum. BS compression causes cardioresp failure Subfalcine: frontal lobe under the falx cerebri Transtentorial/uncal: temporal lobe under tentorium
35
What are some causes of cerebral oedema?
1. Vasogenic (increased permeability): trauma, infection, neoplasm, etc. 2. Cytotoxic (decreased oncotic pressure -> water into cells) 3. Interstitial: hydrocephalus
36
Define epilepsy
Tendency to recurrent, unprovoked episodes of abnormal electrical activity in the brain that manifests as seizures
37
Name some causes of seizures
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
Describe the presentation of an epileptic seizure
- 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
What are the types of epileptic seizures?
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
A 22 year old man is brought to ED after having a seizure. Describe the management approach.
-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
Name some indications for MRI head in a patient with epilepsy
- New Dx of epilepsy in adulthood - Evidence of focal onset or focal neuro - Seizures continue despite first line treatment
42
Describe the management of epilepsy
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
Describe the side effects of common AEDs
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
Describe the management of status epilepticus
``` 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
Describe the common types of brain tumour
Metastases: commonest of all tumours Benign: Meningioma: Commonest. Astrocytoma Glioblastoma multiforme: grade IV astrocytoma. Poor prognosis.

Neuro finals KTB (8 decks)

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