Medicine Neurology 2 Flashcards
What is Hydrocephalus
Hydrocephalus describes cerebrospinal fluid (CSF) building up abnormally within the brain and spinal cord. This is a result of either over-production of CSF or a problem with draining or absorbing CSF.
What is Normal CSF Physiology
There are four ventricles in the brain: two lateral ventricles, the third and the fourth ventricles. The ventricles containing CSF. The CSF provides a cushion for the brain tissue. CSF is created in the four **choroid plexuses **(one in each ventricle) and by the walls of the ventricles. CSF is absorbed into the venous system by the arachnoid granulations.
Congenital Causes pof Hydrocephalus
The most common cause of hydrocephalus is aqueductal stenosis, leading to insufficiency drainage of CSF. The cerebral aqueduct that connects the third and fourth ventricle is stenosed (narrowed). This blocks the normal flow of CSF out of the third ventricle, causing CSF to build up in the lateral and third ventricles.
Hydrocephalus
Other causes:
- Arachnoid cysts can block the outflow of CSF if they are large enough
- Arnold-Chiari malformation is where the cerebellum herniates downwards through the foramen magnum**, blocking the outflow of CSF
- Chromosomal abnormalities and congenital malformations can cause obstruction to CSF drainage.
Presentation Hydrocephalus
The cranial bones in babies are not fused at the sutures until around 2 years of age. Therefore, the skull is able to expand to fit the cranial contents. When a baby has hydrocephalus it causes outward pressure on the cranial bones. Therefore, babies with hydrocephalus will have an enlarged and rapidly increasing head circumference** (occipito-frontal circumference)**.
Other signs:
- Bulging anterior fontanelle
- Poor feeding and vomiting
- Poor tone
- Sleepiness
*
What is Ventriculoperitoneal Shunt
Placing a VP shunt that drains CSF from the ventricles into another body cavity is the mainstay of treatment for hydrocephalus. Usually the peritoneal cavity is used to drain CSF, as there is plenty of space and it is easily reabsorbed. The surgeon places a small tube (catheter) through a small hole in the skull at the back of the head and into one of the ventricles. A valve on the end of this tube is placed subcutaneously, and a catheter on the other side of the valve runs under the skin into the peritoneal cavity. The valve helps to regulate the amount of CSF that drains from the ventricles.
VP Shunt Complications
- Infection
- Blockage
- Excessive drainage
- Intraventricular haemorrhage during shunt related surgery
- Outgrowing them (they typically need replacing around every 2 years as the child grows)
Headaches are a very common presentation with a large number of causes. Causes include:
- Tension headaches
- Migraines
- Cluster headaches
- Secondary headaches
- Sinusitis
- Giant cell arteritis
- Glaucoma
- Intracranial haemorrhage
- Venous sinus thrombosis
- Subarachnoid haemorrhage
- Medication overuse
- Hormonal headache
- Cervical spondylosis
- Carbon monoxide poisoning
- Trigeminal neuralgia
- Raised intracranial pressure
- Brain tumours
- Meningitis
- Encephalitis
- Brain abscess
- Pre-eclampsia
Key red flags associated with a headache, indicating a possible serious underly cause, include:
- Fever, photophobia or neck stiffness (meningitis, encephalitis or brain abscess)
- New neurological symptoms (haemorrhage or tumours)
- Visual disturbance (giant cell arteritis, glaucoma or tumours)
- Sudden-onset occipital headache (subarachnoid haemorrhage)
- Worse on coughing or straining (raised intracranial pressure)
- Postural, worse on standing, lying or bending over (raised intracranial pressure)
- Vomiting (raised intracranial pressure or carbon monoxide poisoning)
- History of trauma (intracranial haemorrhage)
- History of cancer (brain metastasis)
- Pregnancy (pre-eclampsia)
What are Tension Headaches
Tension headaches are very common. They typically cause a mild ache or pressure in a** band-like pattern** around the head. They develop and resolve gradually and do not produce visual changes.
Tension headaches may be associated with:
- Stress
- Depression
- Alcohol
- Skipping meals
- Dehydration
Tension headache management
Management is with:
- Reassurance
- Simple analgesia (e.g., ibuprofen or paracetamol)
Amitriptyline is generally first-line for chronic or frequent tension headaches.
Secondary headaches give a similar presentation to a tension headache but with a clear cause, such as:
- Infections (e.g., viral upper respiratory tract infection)
- Obstructive sleep apnoea
- Pre-eclampsia
- Head injury
- Carbon monoxide poisoning
What is Sinusitis
Sinusitis refers to inflammation of the paranasal sinuses in the face. It typically causes pain and pressure following a recent viral upper respiratory tract infection. There may be tenderness and swelling on palpation of the affected areas. Most cases are caused by a viral infection and resolve within 2-3 weeks. Prolonged cases (over 10 days) may be treated with a steroid nasal spray or antibiotics (phenoxymethylpenicillin first-line).
What is Medication-Overuse Headache
Medication-overuse headache (also called analgesic headache) is a headache caused by frequent analgesia use. It gives similar non-specific features to a tension headache. Withdrawal of the analgesia is important in treating the headache, although this can be challenging in patients with long-term pain.
What are Hormonal Headaches
Hormonal headaches are related to low oestrogen. They have similar features to migraines, with a unilateral, pulsatile headache associated with nausea. They are sometimes called menstrual migraines
Hormonal Headache may occur?
- Two days before and the first three days of the menstrual period
- In the perimenopausal period
- Early pregnancy (headaches in the second half of pregnancy should prompt investigations for pre-eclampsia)
Hormonal Headache treatment
Triptans and NSAIDs (e.g., mefenamic acid) are treatment options.
WHat is Cervical Spondylosis
Cervical spondylosis is a common condition caused by degenerative changes in the cervical spine. It causes neck pain, usually made worse by movement. It often presents with headaches.
What is Trigeminal Neuralgia
Trigeminal neuralgia causes intense facial pain in the distribution of the trigeminal nerve, which has three branches:
- Ophthalmic (V1)
- Maxillary (V2)
- Mandibular (V3)
Trigeminal neuralgia can affect any combination of the branches. Over 90% of cases are unilateral. It is more common in patients with __________ ______
Trigeminal neuralgia can affect any combination of the branches. Over 90% of cases are unilateral. It is more common in patients with multiple sclerosis.
What is the pain like in trigeminal neuralgia
The pain comes on suddenly and can last seconds to hours. It may be described as an electricity-like, shooting, stabbing or burning pain. It may be triggered by touch, taking, eating, shaving or cold. Attacks may worsen over time.
Mx of trigeminal neuralgia
NICE CKS (updated 2022) recommend carbamazepine as first-line for trigeminal neuralgia. Various surgical interventions are possible where the symptoms persist.
What is a Migraine
Migraine is a complex neurological condition causing episodes or attacks of headache and associated symptoms. It is very common, tends to affect women more often than men and is most common in teenagers and young adults.
Migraine can be categorised into four main types:
- Migraine without aura
- Migraine with aura
- Silent migraine (migraine with aura but without a headache)
- Hemiplegic migraine
There are five stages of migraine:
- Premonitory or **prodromal stage (can begin several days before the headache)
- Aura (lasting up to 60 minutes)
- Headache stage (lasts 4 to 72 hours)
- Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
- Postdromal or recovery phase
Migraine headaches last between 4 and 72 hours. Typical features are:
- Usually unilateral but can be bilateral
- Moderate-severe intensity
- Pounding or throbbing in nature
- Photophobia (discomfort with lights)
- Phonophobia (discomfort with loud noises)
- Osmophobia (discomfort with strong smells)
- Aura (visual changes)
- Nausea and vomiting
Aura can affect vision, sensation or language. Visual symptoms are the most common. These may be:
- Sparks in the vision
- Blurred vision
- Lines across the vision
- Loss of visual fields (e.g., scotoma)
____________ changes may include tingling or numbness. ____________ symptoms include dysphasia (difficulty speaking).
Sensation changes may include tingling or numbness. Language symptoms include dysphasia (difficulty speaking).
The main feature of hemiplegic migraines is ____________ Other symptoms may include ________ and ________ ___________.
The main feature of hemiplegic migraines is hemiplegia (unilateral limb weakness). Other symptoms may include ataxia (loss of coordination) and impaired consciousness.
How is Familial hemiplegic migraine inherited
autosomal dominant
What can Hemiplegic migraines mimic
stroke or TIA.
Migraine triggers vary between patients and may include:
- Stress
- Bright lights
- Strong smells
- Certain foods (e.g., chocolate, cheese and caffeine)
- Dehydration
- Menstruation
- Disrupted sleep
- Trauma
Mirgraine Acute Management
**Patients may develop strategies for managing symptoms, often retreating to a dark, quiet room and sleeping.
Medical options for an acute attack are:
- NSAIDs (e.g., ibuprofen or naproxen)
- Paracetamol
- Triptans (e.g., sumatriptan)
- Antiemetics if vomiting occurs (e.g., metoclopramide or prochlorperazine)
Opiates are not used to treat migraines and may make the condition worse.
What are Triptans
Triptans are used to abort migraines when they start to develop. They are 5-HT receptor agonists (they bind to and stimulate serotonin receptors), specifically 5-HT1B and 5-HT1D.
When do you take triptans
Triptans (e.g., sumatriptan) are taken as soon as a migraine headache starts. They should halt the attack. If the attack resolves and then reoccurs, another dose can be taken. If it does not work the first time, another second dose should **not **be taken for the same attack
What are the main contraindications for triptans
The main contraindications relate to risks associated with vasoconstriction, for example, hypertension, coronary artery disease or previous stroke, TIA or myocardial infarction.
A headache diary can help identify the triggers and assess the response to treatment. Avoiding triggers can be helpful.
The usual prophylactic medications to reduce the frequency and severity of attacks are:
- Propranolol (a non-selective beta blocker)
- Amitriptyline (a tricyclic antidepressant)
- Topiramate (teratogenic and very effective contraception is needed)
More specialist options for mirgraine include:
- Pizotifen
- Candesartan
- Sodium valproate
- Monoclonal antibodies (e.g., erenumab and fremanezumab)
Migraine Other options mentioned in the NICE clinical knowledge summaries (updated 2022) include:
- Cognitive behavioural therapy
- Mindfulness and meditation
- Acupuncture
- Vitamin B2 (riboflavin)
___________ _______(e.g., frovatriptan or zolmitriptan) are an option for menstrual migraines. Symptoms tend to occur two days before until three days after the start of menstruation. Regular triptans may be taken during this time.
**Prophylactic triptans **(e.g., frovatriptan or zolmitriptan) are an option for menstrual migraines. Symptoms tend to occur two days before until three days after the start of menstruation. Regular triptans may be taken during this time.
Cluster headaches are severe and unbearable ____________ headaches, usually centred around the eye.
Cluster headaches are severe and unbearable unilateral headaches, usually centred around the eye.
What is the normal presentation of cluster headaches
They are called cluster headaches as they come in clusters of attacks and then disappear for extended periods. For example, a patient may suffer 3-4 episodes a day for weeks or months, followed by a pain-free period lasting several years. Attacks last between 15 minutes and 3 hours.
What is a typical exam question patient for cluster headaches?
A typical patient is a 30-50 year old male smoker. They may have triggers, such as alcohol, strong smells or exercise.
Syptoms of cluster headaches?
Cluster headaches cause severe pain. They are sometimes called “suicide headaches” due to their severity.
Associated symptoms are typically unilateral:
- Red, swollen and watering eye
- Pupil constriction (miosis)
- Eyelid drooping (ptosis)
- Nasal discharge
- Facial sweating
Cluster headaches
Treatment options during acute attacks are:
Triptans (e.g., subcutaneous or intranasal sumatriptan)
High-flow 100% oxygen (may be kept at home)
Cluster headaches
____________ is the first line for prophylaxis (to prevent attacks).
Verapamil is the first line for prophylaxis (to prevent attacks).
Other options for cluster headaches prophylaxis are:
- Occipital nerve block
- Prednisolone (e.g., a short course to break the cycle during clusters)
- Lithium
What is Encephalitis
Encephalitis means inflammation of the brain. This can be the result of infective or non-infective causes. Non-infective causes are autoimmune, meaning antibodies are created that target brain tissue.
What is the common causes of encephalitis
viral/bacterial/fungal
Viral
Encephalitis
The most common viral cause is ___________ ________ _______. In children the most common cause is _____ _______ ______ from cold sores. In neonates it is ____________ ______ ______ from genital herpes, contracted during birth.
The most common viral cause is herpes simplex virus (HSV). In children the most common cause is herpes simple type 1 (HSV-1) from cold sores. In neonates it is herpes simplex type 2 (HSV-2) from genital herpes, contracted during birth.
What are the other viral causes of encephalitis?
Other viral causes include varicella zoster virus (VZV) associated with chickenpox, cytomegalovirus associated with immunodeficiency, Epstein-Barr virus associated with infectious mononucleosis, enterovirus, adenovirus and influenza virus. It is important to ask about vaccinations, as the polio, mumps, rubella and measles viruses can cause encephalitis as well.
Presentation of Encephalitis
- Altered consciousness
- Altered cognition
- Unusual behaviour
- Acute onset of focal neurological symptoms
- Acute onset of focal seizures
- Fever
Children with features of encephalitis need some key investigations to establish the diagnosis:
- Lumbar puncture, sending cerebrospinal fluid for viral PCR testing
- CT scan if a lumbar puncture is contraindicated
- MRI scan after the lumbar puncture to visualise the brain in detail
- EEG recording can be helpful in mild or ambiguous symptoms but is not always routinely required
- Swabs of other areas can help establish the causative organism, such as throat and vesicle swabs
-
HIV testing is recommended in all patients with encephalitis
Contraindications to a lumbar puncture include a GCS below 9, haemodynamically unstable, active seizures or post-ictal.
Management for encephalitis
Intravenous antiviral medications are used to treat the suspected or confirmed underlying cause:
- Aciclovir treats herpes simplex virus (HSV) and varicella zoster virus (VZV)
- Ganciclovir treat cytomegalovirus (CMV)
Repeat lumbar puncture is usually performed to ensure successful treatment prior to stopping antivirals
Aciclovir is usually started empirically in suspected encephalitis until results are available. Other viral causes have no effective treatment and management is supportive.
Followup, support and rehabilitation is required after encephalitis, with help managing the complications.
