Medicine - Neurology Flashcards
What are siezures?
. Seizures are transient episodes of abnormal electrical activity in the brain.
What are the types of seizures generally seen in adults?
Generalised tonic-clonic seizures
Partial seizures (or focal seizures)
Myoclonic seizures
Tonic seizures
Atonic seizures
What are the common types of seizures seen in children?
Absence seizures
Infantile spasms
Febrile convulsions
What are generalised tonic-clonic seizures?
Generalised tonic-clonic seizures involve tonic (muscle tensing) and clonic (muscle jerking) movements associated with a complete loss of consciousness. Typically, the tonic phase comes before the clonic phase. There may be tongue biting, incontinence, groaning and irregular breathing
What are tonic clonic seizures also called?
grand mal seizures
What might patient experience before a tonic clonic seizure?
Before the seizure, patients might experience aura, an abnormal sensation that gives a warning that a seizure will occur
What is a post ictal period
After the tonic clonic seizure, there is a prolonged post-ictal period, where the person is confused, tired, and irritable or low.
What are Partial seizures (or focal seizures)
Partial seizures (or focal seizures) occur in an isolated brain area, often in the temporal lobes. They affect hearing, speech, memory and emotions.
TRUE or FALSE
Patients remain awake during partial seizures
TRUE
In which seizures do you see loss of awareness and in which seizures do they have awareness?
They remain aware during simple partial seizures but lose awareness during complex partial seizures
There are various symptoms associated with partial seizures, depending on the location of the abnormal electrical activity:
- Déjà vu
- Strange smells, tastes, sight or sound sensations
- Unusual emotions
- Abnormal behaviours
What are myoclonic seizures?
Myoclonic seizures present with sudden, brief muscle contractions, like an abrupt jump or jolt. They remain awake. Myoclonic seizures can occur as part of juvenile myoclonic epilepsy in children.
What are tonic seizures?
Tonic seizures involve a sudden onset of increased muscle tone, where the entire body stiffens. This results in a fall if the patient is standing, usually backwards. They last only a few seconds, or at most a few minutes.
What are Atonic seizures
Atonic seizures (causing “drop attacks”) involve a** sudden loss of muscle tone,** often resulting in a fall. They last only briefly, and patients are usually aware during the episodes. They often begin in childhood. They may be indicative of Lennox-Gastaut syndrome.
What are Absence seizures
Absence seizures are usually seen in children. The patient becomes blank, stares into space, and then abruptly returns to normal. During the episode, they are unaware of their surroundings and do not respond. These typically last 10 to 20 seconds. Most patients stop having absence seizures as they get older.
Infantile spasms are also known as
West syndrome
What is Infantile spasms
It is a rare (1 in 4,000) disorder starting at around six months of age. It presents with clusters of full-body spasms. Hypsarrhythmia is the characteristic EEG finding. It is associated with developmental regression and has a poor prognosis.
Tx for Infantile spasms
Treatment is with ACTH and vigabatrin.
What are Febrile convulsions
Febrile convulsions are tonic-clonic seizures that occur in children during a high fever. They are not caused by epilepsy or other pathology (e.g., meningitis or tumours). Febrile convulsions occur in children aged between 6 months and 5 years. Febrile convulsions do not usually cause any lasting damage. One in three will have another febrile convulsion. They slightly increase the risk of developing epilepsy.
It is essential to differentiate seizures from other conditions with a similar presentation, such as:
- Vasovagal syncope (fainting)
- Pseudoseizures (non-epileptic attacks)
- Cardiac syncope (e.g., arrhythmias or structural heart disease)
- Hypoglycaemia
- Hemiplegic migraine
- Transient ischaemic attack
What Ix are done is epilepsy and what do they show?
Electroencephalogram (EEG) shows typical patterns in different forms of epilepsy and supports the diagnosis.
MRI brain is used to diagnose structural pathology (e.g., tumours).
Additional investigations can be considered to exclude associated pathology:
- ECG
- Serum electrolytes, including sodium, potassium, calcium and magnesium
- Blood glucose for hypoglycaemia and diabetes
- Blood cultures, urine cultures and lumbar puncture where sepsis, encephalitis or meningitis is suspected
Patients and families presenting with seizures are advised about safety precautions and recognising, managing and reporting further seizures. Safety precautions include:
The DVLA will remove their driving licence until specific criteria are met (e.g., being seizure-free for one year)
Taking showers rather than baths (drowning is a major risk in epilepsy)
Particular caution with swimming, heights, traffic and dangerous equipment
Mx
Mx
How does sodium valproate work?
Sodium valproate works by increasing the activity of gamma-aminobutyric acid (GABA), which has a calming effect on the brain.
What are notable side effects of sodium Valproate?
Teratogenic (harmful in pregnancy)
Liver damage and hepatitis
Hair loss
Tremor
Reduce fertility
Sodium valproate in pregnancy can cause ________ _______ _______ and ________________ _____
Sodium valproate in pregnancy can cause neural tube defects and developmental delay
There are strict rules for avoiding sodium valproate in females with childbearing potential unless there are no suitable alternatives and strict criteria are met. The __________ __________ __________ __________ is in place to ensure this happens, which involves ensuring effective contraception and an annual risk acknowledgement form.
There are strict rules for avoiding sodium valproate in females with childbearing potential unless there are no suitable alternatives and strict criteria are met. The Valproate Pregnancy Prevention Programme is in place to ensure this happens, which involves ensuring effective contraception and an annual risk acknowledgement form.
What is Status Epilepticus
Status epilepticus is a medical emergency defined as either:
- A seizure lasting more than 5 minutes
- Multiple seizures without regaining consciousness in the interim
Management for Status Epilepticus
Management of status epilepticus involves an ABCDE approach, including:
- Securing the airway
- Giving high-concentration oxygen
- Checking blood glucose levels
- Gaining intravenous access (inserting a cannula)
Medical treatment involves:
- A benzodiazepine first-line, repeated after 5-10 minutes if the seizure continues
- Second-line options (after two doses of benzodiazepine) are IV levetiracetam, phenytoin or sodium valproate
- Third-line options are phenobarbital or general anaesthesia
Status Epilepticus
Options for benzodiazepines?
- Buccal midazolam (10mg)
- Rectal diazepam (10mg)
- Intravenous lorazepam (4mg)
What is Guillain-Barre syndrome?
Guillain-Barré syndrome is an acute paralytic polyneuropathy that affects the peripheral nervous system. It causes acute, symmetrical, ascending weakness and can also cause sensory symptoms. It is usually triggered by an infection
Guillain-Barré is particularly associated with?
Campylobacter jejuni, cytomegalovirus (CMV) and Epstein-Barr virus (EBV)
What is the patho of Guillain-Barré
Guillain-Barré is thought to occur due to a process called molecular mimicry. The B cells of the immune system create antibodies against the antigens on the triggering pathogen. These antibodies also match proteins on the peripheral neurones. They may target proteins on the myelin sheath or the nerve axon itself.
What is the presentation of Guillain-Barré
Symptoms usually start within four weeks of the triggering infection. They begin in the feet and progress upward. Symptoms peak within 2-4 weeks. Then, there is a recovery period that can last months to years.
The characteristic features are:
- Symmetrical ascending weakness
- Reduced reflexes
There may be peripheral loss of sensation or neuropathic pain. It may progress to the cranial nerves and cause facial weakness. Autonomic dysfunction can lead to urinary retention, ileus or heart arrhythmias.
Diagnosis of Guillain-Barré
The diagnosis of Guillain-Barré syndrome is made clinically (using the Brighton criteria), supported by investigations:
- Nerve conduction studies (showing reduced signal through the nerves)
- Lumbar puncture for cerebrospinal fluid (showing raised protein with a normal cell count and glucose)
Management of Guillain-Barré
Management involves:
- Supportive care
- VTE prophylaxis (pulmonary embolism is a leading cause of death)
- IV immunoglobulins (IVIG) first-line
- Plasmapheresis is an alternative to IVIG
Severe cases with respiratory failure may require intubation, ventilation and admission to the intensive care unit.
Prognosis of Guillain-Barré
Recovery can take months to years. Patients can continue regaining function five years after the acute illness. Most patients eventually make either a full recovery or are left with minor symptoms. Some are left with significant disability. Mortality is around 5%, mainly due to respiratory or cardiovascular complications.
Intracranial haemorrhage refers to bleeding within the skull. There are four types: What are they?
- Extradural haemorrhage (bleeding between the skull and dura mater)
- Subdural haemorrhage (bleeding between the dura mater and arachnoid mater)
- Intracerebral haemorrhage (bleeding into brain tissue)
- Subarachnoid haemorrhage (bleeding in the subarachnoid space)
____________ haemorrhage and ____________ haemorrhage account for 10-20% of strokes.
Intracerebral haemorrhage and subarachnoid haemorrhage account for 10-20% of strokes.
Risk factors for Intracranial Bleeds
- Head injuries
- Hypertension
- Aneurysms
- Ischaemic strokes (progressing to bleeding)
- Brain tumours
- Thrombocytopenia (low platelets)
- Bleeding disorders (e.g., haemophilia)
- Anticoagulants (e.g., DOACs or warfarin)
Presentation of Intracranial Bleeds
Sudden-onset headache is a key feature. They can also present with:
- Seizures
- Vomiting
- Reduced consciousness
- Focal neurological symptoms (e.g., weakness)
What is the Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a universal assessment tool for the level of consciousness. It is scored based on eyes, verbal response and motor response. The maximum score is 15/15, and the minimum is 3/15. A score of 8/15 needs airway support, as there is a risk of airway obstruction or aspiration, leading to hypoxia and brain injury
Extradural haemorrhage occurs between the ____ and ____ mater and is usually caused by a rupture of the ________ ________ ________ in the ____________ region
Extradural haemorrhage occurs between the skull and dura mater and is usually caused by a rupture of the middle meningeal artery in the temporoparietal region
What fracture is associated with Extradural Haemorrhage
fracture of the temporal bone
What would you see in CT for extradural haemorrhage
On a CT scan, they have a bi-convex shape and are limited by the cranial sutures (they do not cross the sutures, which are the points where the skull bones join together).
What is a typical history of extradural haemorrhage?
A typical history is a young patient with a traumatic head injury and an ongoing headache. They have a period of improved neurological symptoms and consciousness, followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.
Subdural haemorrhage occurs between the _____ _____ and __________ ______ and is caused by a rupture of the ________ ____ in the outermost meningeal layer.
Subdural haemorrhage occurs between the dura mater and arachnoid mater and is caused by a rupture of the bridging veins in the outermost meningeal layer.
What does a subdural harmorrhage show on CT scan
On a CT scan, they have a crescent shape and are not limited by the cranial sutures (they can cross over the sutures).
Typical history of subdural haemorrhage?
Subdural haemorrhages may occur in elderly and alcoholic patients, who have more atrophy in their brains, making the vessels more prone to rupture.
What is Intracerebral Haemorrhage
Intracerebral haemorrhage involves bleeding in the brain tissue. It presents similarly to an ischaemic stroke with sudden-onset focal neurological symptoms, such as limb or facial weakness, dysphasia or vision loss.
Intracerebral Haemorrhage can occur spontaneously or secondary to __________ ______, ________ or ___________ _______.
They can occur spontaneously or secondary to **ischaemic stroke, tumours or aneurysm rupture.
What is Subarachnoid Haemorrhage
Subarachnoid haemorrhage involves bleeding in the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of a ruptured **cerebral aneurysm. **
What is the typical history of Subarachnoid Haemorrhage
The typical history is a sudden-onset occipital headache during strenuous activity, such as heavy lifting or sex. The sudden and severe onset leads to the “thunderclap headache” description.
Diagnosis of Intracranial Bleeds
Immediate imaging (e.g., CT head) is required to establish the diagnosis. Bloods should include a full blood count (for platelets) and a **coagulation screen. **
What is initial management of Intracranial Bleeds
- Admission to a specialist stroke centre
- Discuss with a specialist neurosurgical centre to consider surgical treatment
- Consider intubation, ventilation and intensive care if they have reduced consciousness
- Correct any **clotting abnormality **(e.g., platelet transfusions or vitamin K for warfarin)
- Correct severe hypertension but avoid hypotension
Intracranial Bleeds
Smaller bleeds may be managed conservatively with close monitoring and ______ ______
Smaller bleeds may be managed conservatively with close monitoring and repeat imaging.
Surgical options for treating an extradural or subdural haematoma are:
- Craniotomy (open surgery by removing a section of the skull)
-
Burr holes (small holes drilled in the skull to drain the blood)
*
Brain tumours range from benign (e.g., ____________) to highly malignant (e.g., ____________).
Brain tumours range from benign (e.g., meningiomas) to highly malignant (e.g., glioblastomas).
Brain tumours may be asymptomatic, particularly when they are small. As they grow, they present with ____________ ______ __________ symptoms depending on the location of the lesion.
Brain tumours may be asymptomatic, particularly when they are small. As they grow, they present with **progressive focal neurological **symptoms depending on the location of the lesion.
Brain tumours often present with symptoms and signs of …
Brain tumours often present with symptoms and signs of raised intracranial pressure (intracranial hypertension).
What is a common presentation for frontal lobe tumour?
A common exam scenario is an unusual change in personality and behaviour, which indicates a frontal lobe tumour. The frontal lobe is responsible for personality and higher-level decision-making.
The causes of increased pressure in the intracranial space include:
- Brain tumours
- Intracranial haemorrhage
- Idiopathic intracranial hypertension
- Abscesses or infection
In patients presenting with headaches, the concerning features that may indicate intracranial hypertension include:
- Constant headache
- Nocturnal (occurring at night)
- Worse on waking
- Worse on coughing, straining or bending forward
- Vomiting
- Papilloedema on fundoscopy
Other presenting features of raised intracranial hypertension may include:
- Altered mental state
- Visual field defects
- Seizures (particularly partial seizures)
- Unilateral ptosis (drooping upper eyelid)
- Third and sixth nerve palsies
What is papiloedema?
Papilloedema is a crucial fundoscopy finding in patients with increased intracranial pressure. Papilloedema describes swelling of the optic disc secondary to raised intracranial pressure. Papill- refers to a small, rounded, raised area (the optic disc) and -oedema refers to the swelling.
Patho of papilloedema?
The sheath around the optic nerve is connected with the subarachnoid space. The raised cerebrospinal fluid (CSF) pressure flows into the optic nerve sheath, increasing the pressure around the optic nerve behind the optic disc causing the optic disc to bulge forward.
Papilloedema can be seen on fundoscopy as:
- Blurring of the optic disc margin
- Elevated optic disc (look for the way the retinal vessels flow across the disc to see the elevation)
- Loss of venous pulsation
- Engorged retinal veins
- Haemorrhages around the optic disc
- Paton’s lines, which are creases or folds in the retina around the optic disc
What are the differences between Parkinson’s Diseas and Benign Essential Tremor
