Nervous system 2 Flashcards
What percentage of the popultaion experience migraines?
15%
How does migraine classically present?
Visual or other aura lasting 15–30min followed within 1h by unilateral, throbbing headache.
Partial triggers of migraine
CHOCOLATE
- Chocolate
- Hangovers
- Orgasms
- Cheese/Caffeine
- Oral contraceptives
- Lie-ins
- Alcohol
- Travel
- Exercise
Management of migraine
- Prophylactic
- Propanolol
- Botulinum toxin type A injections are a last resort
- During attack
- Oral triptan with either NSAID or paracetamol
Differential diagnosis for blackouts
- Vasovagal syncope
- Situational syncope
- Carotid sinus syncope
- Epilepsy
- Hypoglycaemia
- Orthostatic hypotension
Causes of stroke
- Small vessel occlusion or thrombosis in situ
- Cardiac emboli
- Atherothromboembolism (eg from carotids)
- CNS bleeds
Cardiac causes of stroke
- AF
- endocarditis
- MI
Modifiable risk factors for stroke
- Hypertension
- Smoking
- Diabetes mellitus
- Heart disease (valvular, ischaemic, AF)
- Combined OCP
- Carotid bruit
- Increased clotting
Signs of cerebral infarcts (50%)
- contralateral sensory loss or hemiplegia
- initially flaccid (floppy limb, falls like a dead weight when lifted)
- becoming spastic (UMN)
- dysphasia
- homonymous hemianopia
- visuospatial deficit
Signs of brainstem infarcts (25%)
- Varied
- Includes quadriplegia
- Locked in syndrome
Acute management of stoke
- Screen swallow - nil by mouth until this is done
- CT/MRI within 1 hour
- Antiplatelet agents - give 300mg of aspirin once haemorrhagic stroke is excluded
- Thrombolysis
- consider this as soon as haemorrhage is ruled out
- provided the onset of symptoms was ≤4.5h ago (best results are within 90 minutes)
- Thrombectomy
Transient ischaemic attack
- This is an ischaemic neurological event with symptoms lasting <24h (often much shorter)
- Without intervention, more than 1 in 12 patients will go on to have a stroke within a week, so prompt management is imperative
TIA treatment
- Control cardiovascular risk factors
- BP, hyperlipidaemia, DM, smoking
- Antiplatelet drugs - as with stroke
- aspirin 300mg for 2 weeks, then switch to clopidogrel 75mg od
- Anticogulation indications
- Cardiac source of emboli
- Carotid endarterectomy
- Perform within 2wks of first presentation if 70–99% stenosis and operative risk is acceptable
What is epilepsy?
Epilepsy is a recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures.
What are the types of generalised seizures?
- Absence seizures: Brief (≤10s) pauses, eg suddenly stops talking in mid-sentence, then carries on where left off. Presents in childhood.
- Tonic–clonic seizures: Loss of consciousness. Limbs stiffen (tonic), then jerk (clonic). May have one without the other. Post-ictal confusion and drowsiness.
- Myoclonic seizures: Sudden jerk of a limb, face, or trunk. The patient may be
thrown suddenly to the ground, or have a violently disobedient limb: one patient described it as ‘my flying-saucer epilepsy ’, as crockery which happened to be in the hand would take off. - Atonic (akinetic) seizures: Sudden loss of muscle tone causing a fall, no LOC.
Epilepsy investigations
- Consider EEG
- MRI (structural lesions)
- drug levels (if on anti-epileptics: is the patient compliant?)
- drugs screen
- LP (eg if infection suspected)
First line antiepileptic drug (AED) for focal seizures
Carbamazepine and lamotrigene
First line AED for generalised tonic clonic seizures
Sodium valproate and lamotrigene
First line AED for absence seizures, myoclonic seizures, tonic or atonic seizures
Sodium valproate
