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Phase 3a > Neuro 1 - Stroke, Headache, Seizures > Flashcards

Neuro 1 - Stroke, Headache, Seizures Flashcards

1
Q

Define TIA

A

Sudden onset neurological dysfunction caused by ischaemia, without acute infarction (previous definition of <24h, but even short periods of ischaemic can cause tissue damage)

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2
Q

What is the commonest cause of TIA?

A

Arterial embolism or thrombosis in the carotid, vertebral or cerebral arteries

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3
Q

What is the most common location for TIA?

A

Anterior circulation (carotid territory) 90%

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4
Q

What are the symptoms of anterior circulation TIA?

A

Hemiparesis
Hemi-sensory disturbance
Dysphasia
Amaurosis fugax

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5
Q

What are the symptoms of a posterior circulation TIA?

A

Loss of consciousness (brainstem)
Bilateral motor or sensory dysfunction
Binocular blindness
Vertigo/diplopia/dysarthria

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6
Q

What is the pathophysiology of amaurosis fugax?

A

Temporary reduction in the retinal, ophthalmic, or ciliary artery blood flow, leading to retinal hypoxia

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7
Q

What are the causes of amaurosis fugax?

A

Giant cell arteritis

TIA - internal carotid or ophthalmic atherosclerosis

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8
Q

What is transient global amnesia?

A

Episodes of confusion/amnesia lasting several hours, followed by complete recovery

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9
Q

What is Todd’s paralysis?

A

Focal weakness of the body following a seizure

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10
Q

What are the differentials for TIA?

A 
Migraine with aura
Hypoglycaemia
Focal epilepsy
Todd's paralysis
Subdural haematoma
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11
Q

Give three investigations in the diagnosis of TIA

A

ECG - AF
Echo - cardiac cause
Carotid Doppler - stenosis

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12
Q

What are the features of the ABCD2 score?

A

Age >60 = 1 point
BP>140/90 = 1 point
C = clinical features (unilateral weakness 2 points, dysarthria w/o weakness 1 point)
D = duration >60m 2 points, 10-59m 1 point
Diabetes 1 point

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13
Q

An ABCD2 score of what indicates a high risk of stroke after TIA?

A

4 or more

OR AF, multiple TIA in one week, or TIA on anticoags

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14
Q

What is the management of TIA?

A

Lifestyle
Control HTN, DM, AF
2 weeks aspirin/300mg aspirin/300mg clopidogrel loading dose
Long term antiplatelets - clopidogrel 75mg OD
Statin

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15
Q

What is the management of high-risk TIA patients?

A

Refer within 24h (low risk refer within 7d)

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16
Q

How long can you not drive for following a TIA?

A

4 weeks

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17
Q

Give three causes of stroke

A

Cardiac emboli
Atherosclerosis
Vasculitis

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18
Q

Give three risk factors for stroke

A 
Smoking
Hypertension
Diabetes mellitus
Age
Heart disease/AF
Previous TIA
Alcohol
Polycythaemia
Thrombophilia
COCP
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19
Q

What are the three symptoms required for total anterior circulation stroke?

A 
Unilateral weakness (and/or sensory deficit) or face, arm, and leg
Homonymous hemianopia
Higher cerebral dysfunction (dysphasia etc)
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20
Q

What is the criteria for a partial anterior circulation stroke?

A

2 of the 3 symptoms for Total

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21
Q

What does the anterior circulation comprise?

A

ACA, MCA

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22
Q

What is the criteria for posterior circulation syndrome?

A

One of: cerebellar or brainstem syndrome, loss of consciousness, and isolated homonymous hemianopia

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23
Q

Where is the location of a subcortical/lacunar stroke?

A

Midbrain

Internal capsule

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24
Q

What is the criteria for lacunar syndrome

A

One of: unilateral weakness (and/or sensory deficit) of face and arm, arm and leg, or all 3; pure sensory loss, ataxic hemiparesis

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25
What is required before thrombolysis is initiated and why?
Urgent CT head | Rule out haemorrhagic stroke
26
What is the treatment of ischaemic stroke?
``` IV alteplase (tissue plasminogen activator) within 4.5 hours of symptom onset Clopidogrel 24 hours after thrombolysis ```
27
What is the treatment of ischaemic stroke after 4.5 hours has passed after onset?
300mg aspirin OD for two weeks, then lifelong clopidogrel
28
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space
29
What are the risk factors for SAH?
Hypertension Aneurysm (and predisposing conditions e.g. PKD) Family history
30
What is the most common cause of SAH?
Rupture of berry aneurysm
31
What are the symptoms of SAH?
``` Thunder clap headache Vomiting Nuchial rigidity Decreases consciousness Papilloedema Seizures CNS deficits e.g. cranial nerve signs ```
32
What is the name of the prodrome in SAH caused by a small leak of the aneurysm?
Sentinel headache
33
What is seen on CT in SAH?
Star shaped lesion (blood filling gyral patterns)
34
When should a lumbar puncture be performed in SAH?
CT head negative but high clinical suspicion AND | No raised ICP
35
What is seen on lumbar puncture in SAH if performed?
Xanthochromic CSF
36
What is the treatment of SAH?
Dexamethasone Neurosurgery Nimodipine reduces risk of vasospasm
37
What is the cause of a subdural haematoma?
Tearing of bridging veins between venous sinuses and cortex | Usually deceleration injury during violent head movement
38
What type of blood is seen on SDH?
Clotting
39
What are the signs and symptoms of acute SDH?
Interval between injury and symptoms can be days-weeks-months Signs and symptoms of raised ICP Confusion and seizures
40
What is seen on CT in acute SDH?
Hyper dense crescent shaped mass
41
What is the most common condition affecting elderly patients with a change in personality and decreased GCS?
Chronic subdural haematoma
42
What is an extradural haematoma?
Collection of blood between the dura mater and the bone
43
What causes an EDH?
Fracture of the temporal or parietal bone causing laceration of the middle meningeal artery
44
What age group usually gets EDH?
Young adults
45
What are the symptoms of EDH?
Brief post-traumatic LOC Lucid interval for hours or days Followed by altered consciousness Then headache, n+v, confusion, seizures
46
Rapid increase in ICP equals
Ipsilateral pupillary dilatation, signs of brain stem compression, death
47
What is seen on CT in EDH?
Hyperdense biconvex (lemon) shape adjacent to the skull
48
What is the treatment of EDH?
Craniotomy and clot evacuation
49
What is the commonest primary headache?
Tension
50
What are the characteristics of tension headaches?
Bilateral, non-pulsatile, chronic daily headache Tight band Pressure behind the eyes Mild-moderate pain
51
What is the treatment of tension headaches?
Lifestyle advice | Symptomatic treatment - paracetamol, NSAIDs, NOT OPIOIDS
52
What is the only prophylactic treatment for tension headaches recommended by NICE?
Acupuncture
53
What is a medication overuse headache?
Headache worsens whilst on regular analgesia, especially opioids
54
What is a theory behind the pathophysiology of migraine?
Neuronal hyperexcitability | Cortical spreading depolarisation
55
What are the risk factors for migraine?
Female | Genetics
56
What are the characteristics of a migraine headache?
Moderate to severe, lasts 4-72h Unilateral, pulsatile, throbbing, aggravated by movement N+v, photo/phonophobia
57
What is an aura?
Evolving and reversible focal deficit
58
What is the treatment of migraine?
Avoid triggers | Sumatriptan + NSAID/para + anti-emetic if needed
59
What is the treatment of migraine in children aged 12-17?
Nasal triptan
60
When is migraine prophylaxis indicated?
2+ attacks a month | Acute treatment needed more than twice a week
61
What medication is used for migraine prophylaxis?
Propanolol | Topiramate
62
What are the characteristics of cluster headaches?
Rapid onset Excruciating crescendo unilateral pain around one eye Wakes patient from sleep Occurs in clusters of 1-2x/day, 5-12 weeks
63
What are the risk factors for cluster headaches?
Male | Smoking
64
What are the facial symptoms of cluster headaches?
``` Watery and bloodshot eye Lid swelling Lacrimation Facial flushing Rhinorrhoea Miosis and ptosis ```
65
What is the treatment of cluster headaches?
100% 15L oxygen 10-20 minutes Sumatriptan Avoid alcohol
66
What is first line prophylaxis for cluster headaches?
80mg verapamil TDS
67
What is trigeminal neuralgia?
Paroxysms of intense, debilitating pain in the distribution of the trigeminal nerve
68
What is the peak age of onset of trigeminal neuralgia?
50 years
69
What causes the pain in trigeminal neuralgia?
Compression of the trigeminal nerve causing demyelination and excitation of the nerve
70
What is a risk factor for trigeminal neuralgia?
Hypertension
71
What are the characteristics of trigeminal neuralgia?
Sudden, unilateral paroxysms of knife-like/electric shock pain Mandibular --> maxillary and ophthalmic Lasts seconds to minutes Triggers- eating, shaving, talking
72
How is trigeminal neuralgia diagnosed?
MRI to exclude secondary causes or other pathologies
73
What is the treatment of trigeminal neuralgia?
Carbamazepine | Neurovascular decompression
74
What is temporal arteritis?
Inflammatory granulomatous vasculitis of large cerebral arteries
75
What are the symptoms of GCA?
``` Temporal pulsating headache Scalp tenderness Jaw claudication Amaurosis fugax Systemic: fatigue, fever, myalgia ```
76
How is GCA investigated?
Pulseless temporal artery Raised ESR and CRP Biopsy within 1 week (skip lesions)
77
What is the treatment of GCA?
Prednisolone 12 months Visual symptoms - IV methylprednisolone 3 days PPIs and bisphosphonates from long term steroid use
78
What condition presents in 50% GCA patients?
Polymyalgia rheumatica
79
What is the most common cause of encephalitis?
Herpes simplex virus 1 and 2
80
Which lobes of the brain are most affected in encephalitis?
Frontal and temporal
81
What are the main symptoms of encephalitis?
``` Features of a viral infection Decreased consciousness Behavioural change Focal neuro deficit Seizures and coma ```
82
How is encephalitis diagnosed?
LP: culture CSF: increased protein and lymphocytes, decreased glucose FBC and blood film, cultures CT/MRI, EEG
83
What is seen on EEG in encephalitis?
Diffuse abnormal slow wave changes
84
What is the treatment of viral encephalitis?
Urgent acyclovir
85
What are the symptoms of meningitis?
``` Fever Headache Meningism Altered GCS Seizures Non-blanching petechial rash ```
86
What are the CSF findings in bacterial meningitis?
Neutrophils Raised protein Low glucose
87
What are the CSF findings in viral meningitis?
Lymphocytes Normal protein Normal glucose
88
What is the treatment of bacterial meningitis in adults?
IV ceftriaxone | GP - IM benzylpenicillin
89
What antibiotic is used to treat listeria in pregnant/older patients?
Ampicillin
90
What is the prophylaxis of meningitis?
Rifampicin
91
What is the organism usually responsible for triggering GBS?
Campylobacter jejuni
92
What is seen on nerve conduction studies in GBS?
Slow nerve conduction Prolonged distal motor latency Conduction block
93
What is the pathophysiology of GBS?
Molecular mimicry --> demyelination
94
What other investigations are used in the diagnosis of GBS?
LP: increased proteins Spirometry: decreased FVC = ITU
95
What is the treatment of GBS?
IVIG 5 days
96
What is epilepsy?
A recurrent tendency to spontaneous, intermittent, abnormal electrical activity in the brain
97
What is a seizure?
The clinical manifestation of dyssynchronous neuronal discharge
98
What is a primary generalized seizure?
Bilaterally symmetrical discharge involving both hemispheres | Consciousness lost from the start
99
What is a partial seizure?
One hemisphere is involved at onset
100
Give four types of primary generalised seizures
``` Generalised tonic-clonic Clonic or tonic Absence Atonic Myoclonic ```
101
What are the tonic and clonic phases of a grand mal seizure?
Tonic - rigid stiff limbs | Clonic - generalised, bilateral, rhythmic jerking
102
What are three types of partial seizure?
Simple partial Complex partial Partial seizure with secondary generalization
103
What are the characteristics of a simple partial seizure?
Awareness unimpaired Focal motor/sensory/autonomic symptoms No post-ictal symptoms
104
What are the characteristics of frontal lobe seizures?
``` Motor features Jacksonian March (up and down the motor homunculus) ```
105
What is required for a diagnosis of epilepsy?
2 unprovoked seizures >24 hours apart EEG normal between seizures MRI to identify structural abnormalities
106
What is the treatment of primary generalised seizures?
Valproate or lamotrigine
107
What is the treatment of absence seizures?
Valproate or ethosuximide
108
What is the treatment of partial seizures?
Carbamazepine or lamotrigine
109
When can a patient drive with epilepsy?
Free of daytime seizures for at least one year
110
What is the management of status epilepticus (seizures lasting >30m)?
IV lorazepam/rectal diazepam or buccal midazolam (home) (repeat x2) Phenytoin loading Rapid sequence induction with sodium thiopental (status epilepticus only) Ventilation
111
What is SUDEP?
Sudden unexpected death in epilepsy
112
What is the pathophysiology of Parkinson's disease?
Loss of dopaminergic neurons In the substantia nigra pars compacta Of the basal ganglia
113
What is the common presentation of Parkinson's disease?
Impaired dexterity Unilateral foot drop Assymetrical
114
What is the triad of Parkinson's disease?
Rigidity Bradykinesia Resting tremor
115
Describe the tremor seen in Parkinson's
Pill-rolling 4-6Hz Seen at rest, improves with activity Induced by concentration
116
Describe the Parkinsonian gait
``` Stooped posture Small shuffling steps Festinant Reduced arm swing Difficulty initiating movement and turning ```
117
What are three other symptoms of Parkinson's disease?
Micrographia Serpentine stare, mask Monotonous speech Brisk reflexes
118
Give three non-motor symptoms of Parkinson's disease
Depression Anosmia Constipation/urinary frequency and urgency
119
What is the gold standard of treatment for Parkinson's disease?
Levodopa combined with a decarboxylase inhibitor, e.g. carbidopa (co-careldopa)
120
What is the function of the decarboxylase inhibitor in Parkinson's treatment?
Prevents peripheral conversaion of L-dopa to dopamine so reduces peripheral side effects of N+V, arrhythmias, alopecia, hypotension
121
What medications are used to delay starting L-dopa (because of its reduced efficacy over time and dyskinetic side effects)?
Dopamine agonists - ropinirole Monoamine oxidase B inhibitors - selegiline COMT inhibitors - entacapone
122
What are three Parkinson-plus syndromes?
Progressive supranuclear palsy Multiple system atrophy Corticobasal degeneration Lewy Body dementia
123
How does PSP differ from Parkinson's disease?
Early postural instability and falls Vertical gaze palsy (difficulty going downstairs) No tremor
124
How does multiple system atrophy differ from Parkinson's disease?
``` Early autonomic features (postural hypotension, bladder dysfunction) Cerebellar signs (ataxic gait) ```
125
How does Lewy Body dementia differ from Parkinson's disease?
Dementia occurs prior to or at the same time as motor symptoms in Lewy body
126
What are the symptoms of a cerebral venous sinus thrombosis?
Severe but insidious headache | Subtle and non-specific neurology
127
What is the gold standard investigation for cerebral venous sinus thrombosis?
MR venogram
128
What is Weber's syndrome?
Midbrain stroke syndrome Ipsilateral cranial nerve findings, contralateral motor/sensory findings Posterior inferior cerebellar artery
129
What is the 2nd line prevention of stroke if clopidogrel is contraindicated?
Lifelong aspirin and dipyridamole
130
What is the treatment of delirium in normal patients and patients with a history of Parkinson's disease?
Anti-psychotics | Parkinson's - avoid anti-psychotics and give lorazepam
131
What is a side effect of the dopamine agonist ropinirole?
Drowsiness | Pathological gambling
132
Which neurotransmitter is affected in Parkinson's disease?
Dopamine D1 and D2

Phase 3a (18 decks)

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