Laz Neurology Flashcards
Signs of anterior cerebral artery damage
Affects motor cortex
Lower limb weakness (hemiparesis or a hemiplegia)
Contralateral side
Can get contralateral sensory defects, loss of leg and perineum sensation
Also affects frontal lobe -> disinhibition syndrome
Olfactory lobe -> Amosmia
Signs of middle cerebral artery blockage
Contralateral weakness Hemisensory loss Facial weakness (forehead sparing, can you raise your eyebrows?) Hemineglect Quadrantopia
Which lobes does the anterior cerebral artery supply?
Motor
Sensory
Frontal
Olfactory
Which lobes does the middle cerebral artery supply?
Motor
Sensory
Which lobe is supplied by the posterior cerebral artery?
Occipital lobe
Cerebellum
Signs of posterior cerebral artery infarct
Vertigo
Ipsilateral ataxia
Hoarseness
Contralateral pain/temperature sensation loss
Ix for stroke
ECG because arrhythmia
Echo because thrombi, endocarditis
FBC because thrombocytopenia or polycythaemia
U&E because renal impairment, looking for kidney disease because can cause HTN
Lipid levels, cause of stroke
Should do a vasculitic screen (think of the stroke ward)
Gold standard = CT head to try and detect haemorrhage
Carotid artery Doppler to see if any carotid artery disease
MRI brain = a lot more sensitive
Mx of ischaemic stroke
Timing is crucial
CT head, once haemorrhage is ruled out, can do thrombolysis
If 4.5hr< and excluded haemorrhage, give aspirin 300mg and clopidogrel 75mg
Additional management alongside aspirin, clopidogrel and heparin in stroke
SALT review
Long term prophylaxis post discharge
What’s the cut off for considering hemicraniectomy?
<48hr
Has to be a mass effect to justify
When can you consider hemicraniectomy?
Mass effect
<48hr from onset
Management of haemorrhaged stroke
IV mannitol (lowers ICP) Encourage hyperventilation to lower ICP
Surgical = coiling/clipping (for aneurysms)
Evacuation (for haematoma)
Long term management of stroke
Lifestyle and conservative measures Rehab = MENDOS - MDT - Eating = SALT review - Neurorehab - DVT prohpylaxis - OT management - Sores (avoid pressure sores)
The aim is to reduce disability and handicap
Features of extradural haemorrhage
Trauma
Damages MCA
Big lenticular lesion (looks like a lens)
ACUTE
Features of subdural haemorrhage
Crescent-shaped haemorrhage (along the edge)
Usually in elderly, because its rupture of BRIDGING veins
Slow, insidious onset
Often in patients on blood thinners
Subarachnoid haemorrhage
Thunderclap, SUDDEN
Very old people or 20-30yo
Rupture of an aneurysm, usually berry aneurysm in the circle of Willis
On CT see the SCF filled with blood
Management of subdural haemorrhage
Supportive!
Monitor GCS
Re-scan if deteriorates
If really large with significant impairment, can consider surgical options
Features of meningitis
Photophobia
Headache (because the lining of brain is inflamed which causes increased ICP)
Neck stiffness
Altered mental state (confusion, irritable, drowsy)
Seizures (more common in encephalitis)
Fever
The most common cause of meningitis in adults
Viral
Most common bacterial meningitis cause
Neisseria meningitis
Streptococcus
What is Kernig’s sign?
Meningitis sign
Straightening the leg irritates the meninges
Signs of bactierial meningitis
Normal meningitis stuff
Sepsis
Fever
Non-blanching rash
Mx of meningitis
Start antibiotics immediately in a side room
Bloods (inflammatory signs)
Raised CRP usually indicates bacterial meningitis
Check for raised ICP (contraindicates a LP) = CT head
Signs of raised ICP
Focal neurology
Seizures
Papilloedema
LOC
Why don’t you do an LP on raised ICP?
Risk of coning
Contraindications to LP acryonym
Try LP Unless Contra INdicated Thrombocytopaenia Lateness Pressure Unstable Coagulation disorder Infection Neurological signs
Where do you aim for the LP?
L4/L5
LP viral meningitis
NORMAL glucose High WBC High protein Clear Lymphocytes
LP bacterial menigitis
LOW glucose (being used up)
Much higher protein levels
Turbid
Neutrophils
LP for TB features
Low glucose
High protein levels
Lymphocytes
Fibrin web appearance
LP for fungal infection
Low glucose
High protein
Eosinophils!
Best way to remember LP results
Glucose levels
Cells present
Bacterial = neutrophils, low glucose Viral = lymphocytes, normal glucose TB = lymphocytes with low glucose Fungal = eosinophils with low glucose
Key management of meningitis
Antibiotics + anti-virals
IV cefotaxime
IV acyclovir
What can you give for meningitis if allergic to penicillin?
Chloramphenicol
Complete meningitis management
IV cefotaxime IV acyclovir Fluids Dexamethasone Electrolyte replacement Anticonvulsants if seizure = lorazepam
What is encephalitits
Inflammation of the brain parenchyma (the brain itself)
Most common causes of encephalitis
HSV/VZV
Bacterial = Neisseria meningitides
Ix for encephalitis
Bloods
LP
Blood cultures
CT head for raised ICP
What is Parkinson’s DISEASE
A neurodegenerative disease of dopaminergic neurones in substantia nigra
Parkinsonism is …
Symptoms of Parkinson’s without the Parkinsons
E.g. with antipsychotic medications
Parkinsonian plus syndrome is …
Group of neurodegenerative diseases with parkinsonian features
Motor features of Parkinson’s
Tremor
Rigidity (cog wheel)
Akinesia and BRADYKINESIA
Postural instability
TRAP
At what point of loss do Parkinson’s patients begin to manifest motor symptoms?
70% dopaminergic loss
Prodromal Parkinson disease
Depression, anxiety, fatigue, REM sleep behaviour disorder, memory issues
Late-stage Parkinson’s features
Falls Dysphagia Dementia Psychotic Sx Urinary Sx
Why do Parkinson’s pts have small handwriting?
Struggle to coordinate big movements
Ix of Parkinson’s
Try levodopa and see if it improves Sx (trial) Serum caeruloplasmin (rule out Wilsons) MRI brain to exclude vascular disease/hydrocephalus
Mx of Parkinson’s disease
Parkinson’s disease is because dopaminergic neurones are dying
L-DOPA + carbidopa (which stops peripheral dopamine breakdown, which would cause really bad nausea)
L-DOPA + Carbidopa name of drug
Sinemet
How do MAO B inhibitors work?
Dopamine can be broken down by MAO B
So blocking its breakdown keeps dopamine in the brain
Why does L-DOPA wear off?
The neurones are still dying
Just improving their production for now
Drug for early-onset Parkinsons’
Amantadine
Dopamine agonist
Saves L-DOPA (sinemet) for later on
What is multiple system atrophy and what are its features?
a-synuchleinopathy
Causes autonomic dysfunction -> postural hypotension and urinary retention (remember Hillingdon case)
Cerebral ataxia
Parkinsonian features
It is a Parkinson + syndrome
What is corticobulbar degeneration?
Alien limb movement
Unilateral Parkinson’s
It’s a Parkinson+ syndrome
Can’t move eyes vertically
Parkinsons symptoms
Lots of falls
Progressive supranuclear palsy
Lewy body dementia features
Visual hallucinations
Early dementia
Parkinsonian symptoms
Features of Alzheimer’s
Chronic neurodegenerative disease with insidious onset + progressive slow decline, resulting in memory loss and behavioural changes
Amnesia Aphasia Agnosia (can't recognise objects) Apraxia (using a hair brush upside down, difficulty planning movement) Poor abstract thinking
Cause of Alzheimer’s
Cholindergic loss
Ix for Alzheimer’s
MMSE assesment
Rule out Wilsons
Thyroid disease and B12 can manifest as dementia, so test for these
CT head/MRI to exclude vascular disease
Mainly a clinical Dx
What might the CT show in Alzheimer’s
Cerebral atrophy
Big spaces
Largened ventricles
Mx of Alzheimer’s
Donepezil (help to preserve memory and functional abilities)
Memantine (second line)
+/- antipsychotics = risperidone (reduce behavioural symptoms
Appropriate care and support
Features of vascular dementia
Stepwise decline
Symptoms depend on site
Features of frontotemporal dementia
Disinhibition Personality change Inattention Apathy Language impairment
What is a seizure
Excessive, abnormal, synchronised discharge of neurons -> clinical manifestations
Definition of epilepsy
The tendency to have recurrent, unprovoked seizures
2 seizures, more than 24hr apart
Unprovoked seizure MUST be Ix appropriately because 60% will have another seizure within 10 years
What is a tonic-clonic seizure?
Grand mal
Start with LOC, then tonic (stiff)
Then clonic (repetitive limb movements)
Ix for seizure
Septic screen Electrolyte screen ECG EEG CT head (pick up SOL) BM
Increased WCC could indicate brain infection
Encephalitis can cause them
Drug-induced seizures are very common (you’ve seen one)
Which key initial investigation can indicate they’ve had a seizure?
Lactate
Status epilepticus Mx
A-E High flow O2 Check BM IV access? -> lorazepam 4mg bolus If not -> buccal midazolam Can give 2 doses If that doesn't work, give IV diazepam
Stabilised the status episode, now what do you do?
Monitor ABG Cultures Think about glucose, alcohol, sepsis! WHAT HAS CAUSED IT?
Who should you alert with status?
ITU/anaesthetics
May be considering vasopressors if it doesn’t resolve = ITU stuff
Need to keep airway sufficient!
Epilepsy long term management
Inform DVLA
Got to be seizure free for 12mo
Ketogenic diet (because they get into the brain?!)
Psychological support
Try to keep on very few medications
Carbamazepine
Management of cluster headache
Avoid alcohol and smoking
Acute Mx = oxygen, sumatriptan nasal spray
Prevent = verapamil
Management of migraine
Avoid CHOCOLATE
Med = sumatriptan
Anti-emetics in the acute setting
Propanalol to prevent
Treatment for temporal arteritis
Prednisolone 1mg/kg/day for 4 weeks
PPI cover
Aspirin to reduce risk of vision loss
