Neuro Flashcards
describe clasp knife rigidity
assoc with UMN sx increased tone that is velocity dependent ie the faster you move the pts mulsce the greater the resistence until it finally gives way
what will an anterior cerebral artery occlusion result in?
weak, numb contralateral leg +/- similar milder arm sx
face is spared
what will a MCA occlusion result in
lateral part of each hemisphere - contralateral hemiparesis, hemisensory loss, contralateral homonymous hemianopia - dysphagia if dominant side
PCA - occlusion will result in?
supplies occipital lobe = contralateral homonymous hemianopia
when would you suspect subclavian steal syndrome?
brainstem ischaemia can occur typically after use of the arm - suspect if BP differs by >20 mmHg
what is the most common headache
tension
what should you remember to ask in headache hx
analgesia, sex , food photophobia rash weakness focal signs vomiting worse on waking, lying down, coughing or bending forward any head trauma travelled anywhere pregnant change in pattern of usual headaches
investigation and management of trigeminal neuralgia
must do MRI to rule out other cuases
tx with carbemazepine
lamotrigine or gaba
surgery may be necessary
what are possible migraine triggers
chocolate hangovers orgasms cheese/caffeine oral contraceptive lie-ins alcohol travel exercise
wht is the management of migraine
propanolol and topiramate for prophylaxis
attack tx - oral triptan combined with NSAID or paracetamol + anti-emetic
Non-pharm - warm or cold packs on the head, acupuncture NICE recommends or transcutaneous nerve stimulation
what are the causes of blackouts
vasovagal (may have limb jerking) situation syncope carotid sinus syncope epilepsy stokes-adam attacks - transient arrhythmias hypoglycaemia orthostatic hypotension dissociative seizures non-epileptic attack disorder
what are the cuases of conductive hearing loss
wax, otosclerosis, ottitis media, glue ear
what are the cuases of sensioneural hearing loss
Presbyacusis, acoustic neuroma, toxin, MS, stroke, vasculitis
how would you describe a spastic gait
stiff, circumduction of legs +/- scuffing of toe of shoes = UMN lesion
what non-neuro considerations must you take into account in paralysed pts
avoid pressure sores - appropriate pressure relief mattresses
prevent thrombosis in paralysed limbs by freqent movement + pressure stockings + LMWH
bladder care
bowel evacuation
exercise to avoid inappropriate loss of function in partially paralysed limbs
what is the acute management of a stroke?
protect the airway
maintain - consider endotracheal tube homeostasis - blood glucose, BP
screen swallow
supportive O2
CT/MRI within 1 hour
Thrombolysis - after ensuring no CI repeat CT 24 hr after lysis to exclude bleed
thrombectomy
what are the contraindications to thrombolysis
major haemorrhage recent surgery or trauma previous CNS bleed AVM severe liver disease seizures at presentation blood glucose known clotting disorder
what investigations should you do following a stroke
BP 24 hr ECG to look for AF /CXR doppler+/- CT angiography check glucose lipids vasculitis? ANCA Young stroke screen - prothrombotic states, hyperviscosity, thrombocytopena, genetic tests
Re-enablement post stroke
MDT Barthels score - assess functioning rehab early to prevent complications swallow screen - salt input avoid further injury - OT social worker bladder and bowel care positioning monitor progress monitor mood physio involve family/carer advance directives
what is the management of meningitis
Urgent admission to hospital
U/E FBC, LFT, glucose , coag, consider throat swabs - 1 for bacteria, 1 for viral, CXR, consider HIV, TB test
Blood cultures
serum pneumococcal and meningococcal PCR
LP within 1 hour if no signs of riased ICP
A-E approach
rule out sepsis - sepsis 6
IV dexamethasone if features of meningism
antibiotics - based on trust local guidelines - usually ceftrixone or discuss with microbiology
Low threshold for ICU
Isolate pt for 24 hours
If meningococcal infection - prophylaxis needed for close contacts = ciprofloxacin
if pneumococcal no prophylaxis required
what investigations should be performed in suspected encephalitis?
blood cultures, serum for viral PCR, toxoplasma IgM titre, malaria film
Contrast enhanced CT
LP
EEG
hat is the tx of viral encephalitis
start aciclovir within 30 mns of pt arriving IV for 14 days for HSV
Supportive therapy in high dependency unit or ITU
Sx tx e.g. for seizures
what is the initial management of a head injury
A-E
O2 if sats <92% or hypoxic on ABG
Intubate and hyperventilate if needed
immobilise neck until C-spine injury excluded
Stp blood loss and support circulation
treat for shock if required
treat seizures
access GCS if less than 8 involve anaesthetics
assess for anterograde and retrograde amnesia
rapid examination survery
Ix - U/E glcuose, FBC, Blood alcohol, toxicology scree, ABGs and clotting
Neuro exam +hx evaluate wounds check for CSF leak Palpate for any neck tenderness Radiology
what is cushings response
BRADYCARDIA
Hypertension
Cheyne-Stokes respiration
what investigations should you perform in signs of raised ICP
U/E, FBC, LFT, glucose, serum osmolality, clotting, blood culture consider toxicology screen CXR - source of infection e.g. abscess CT head THen consider if LP is safe
what is the emergency management of raised ICP
involve senior A-E Correct hypotension, maintain Mean arterial pressure >90 mmHg and treat seizures Brief exam and hx - any clues e.g. rash elevate bed 30-40 degrees
If intubated hyperventilate the pt to reduce CO2 - this causes cerebral vasoconstriction and reduces ICP
Osmotic agents e.g. mannitol may be useful
If cerebral oedema ?dexameth
restrict fluid monitor pt closely aim to make a diagnosis treat cuase or exacerbting features - hyperglycaemia and hyponatraemia
definitive tx
what is the management of SAH?
Refer to neurosurgery immediately Resusitate this patient in an A-E approach Stop any anticoagulant e.g the DOAC Analgesic Stool softener and anti-emetic
Investigations +
Digital subtraction angiogram - DSA
CT angiogram
Maintain cerebral perfusion but aim for BP to be less than 160
Prescribe Nimodipine
Consetn pt for surgery if applicable
Surgery – endovascular coiling is method of choice or surgical clipping.
Ongoing
- Manage complications e.g. Hydrocephalus, rebleeding, cerebral ischaemia
- Manage cerebral salt wasting syndrome – fluids +/- Na+
- Rehab
- MDT approach
where is the most common dural venous sinus thrombosis?
sagittal sinus
what are common cuases of intracranial venous thrombosis
pregnancy, COCP, head injury, dehydration, tumours and extracranial malignancy, recent LP
Infection, drugs, vasculitis
how will a intracranial venous thrombosis appear on ct head
delta sign after 1 week
management of intracranial venous thrombosis
senior help
anticoagulate
endovascular thrombolysis of anticoag doesnt work
monitor for signs of rasied ICP
what is the management of an extradural haematoma
stabilise and transfer urgentyl to a neurosurgical unit or clot exacuation +/- ligaton of the bleeding
care of the airway and measures to decrease ICP
what is the management of a subdural haematoma
reverse clottign abnormalities urgently. Surgical management depends on the size of clot its chronicity and the clinical picture if large they may require vacuation via craniotomy or burr hole washout
address cause of the truama - e.g. falls and abuse
what are the 2 types of delirium
hypoactive - in whihc pt = slow and withdrawn
hyperactive restlessness, mood liability agitation and aggression
what are the causes of delirium
Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment (PINCH ME)
what is the management of delirium
Identify and tx the underlying cuase
- reorientate the patient - explain where they are and who you are, hunt down hearing aids and glassess, visible clocks and calenders
- encourage family and friends to visit
- monitor fluid balance and encourage oral intake, think of constipation
- mobilise
- practise sleep hygiene
- avoid or remove catheters, IV cannulae, monitoring leads and other devices
- watch out for infection and physical discomfort
- review medication
- provide support
how is dementia diagnosed
hx + collateral cognitive testing - AMTS or similar MSE - depression hallucinations examination - parkinsons medication review - drug induced cognitive impairment
what investigations should you perform in dementia
look for reversible causes - TSH, B12, folate, thiamine, calcium
MSU, FBC, ESR, LFT,UE
?MRI to rule out other pathologies normal-pressure hydrocepahlus
consider EEG if delirum or frontotempora dementia
how do you manage dementia
integrated memory services for further assessment and management
medications - avoid drugs that hinder cognition
Cholinesterase inhibitor therapy with rivastigmine, donepezil, or galantamin
depression
capacity - advanced care directive, lasting power of attourney
how do you investigate Causda equina?
ASIA chart
Urgent MRI spine
FBC, UE, LFT, Ca CRP
what is the management of cauda equina
Analgesia, VTE prophlaxis
neurosurgery for decompression and discectomy
VTE prophlaxis
counselling and advice + physiological support regarding sexual dysfunction
MDT planning
Spinal injury rehab with a pt centred appraoch involving lots of therapists and staff
Important to think about bladder, bowel, skin, PT/OT - alterations to house and long term follow up planning
Bladder management as UTIs are major cuase of morbidity
with aim to presever renal function and contiencne
- pt may get urinary retention and overflow incontinence so risk of autonomic dysreflexia
teach self-catheterisation or indwelling catheter
importnatn to have a bowel regimen - use of laxatives, stook, softeners, digital stimulation and suppositiories
othosis to improve foot drop
how do you investigate Causda equina?
ASIA chart
Urgent MRI spine
FBC, UE, LFT, Ca CRP
what is the management of cauda equina
Analgesia, VTE prophlaxis
neurosurgery for decompression and discectomy
VTE prophlaxis
counselling and advice + physiological support regarding sexual dysfunction
MDT planning
Spinal injury rehab with a pt centred appraoch involving lots of therapists and staff
Important to think about bladder, bowel, skin, PT/OT - alterations to house and long term follow up planning
Bladder management as UTIs are major cuase of morbidity
with aim to presever renal function and contiencne
- pt may get urinary retention and overflow incontinence so risk of autonomic dysreflexia
teach self-catheterisation or indwelling catheter
importnatn to have a bowel regimen - use of laxatives, stook, softeners, digital stimulation and suppositiories
othosis to improve foot drop
describe MSA
may have predom parkinsoniasm or cerebellar features
autonomic dysfucntion - orthostatic hypotension
symmetrical sx, rapid progresson
describe progressive supranuvela palsy
vertical gaze palsy - esp downward
postural instability
fronal lobe abnormaities
describe corticobasal degeneration
asymmetric motor anormlaities usually affects one limb plus cognitive impairment
dx of parkinsons disease
made clinically - dopaminergic trail, could cnsider MRI, serum caeruloplasmin, genetic testing, and dopamine transporter imaging
what ist the mx of parkinsons
physical and occupational therapy, including gait and balance training, stretching and strength exercises and speech therapy
MDT approach - physical and non-pharmacological therapies, progressive resistance exercises, gait training, music and dance therapy
pt education
DVLA advice
manage comorbidities
screening for non motor sx - depression, anxiety and fatigue, cognitive impairment, autonomic dysfunction, and sleep disturbances, cognitive training and vitamin and dietary supplements
medical - dopaminergic medication
1st llne for young or mild pts = MOA-B inhibitor , dopamine agonists and monitor for adverse features, carbidopa/levodopa - explain the up and down sx
+ COMT inhibitors - entracapone may increase the amount of levodopa for therapeutic benefit
DBS for refractory
apomorphine injections as sx worsen
how is multiple sclerosis diagnosed
McDonald criteria, MRI brain/cord, FBC, metabolic panel, TSH, Vit B12, anti-NMO, CSF and evoked potentials
mx of ALS
Currently no cure but aim is to provide symptomatic management and palliative intervention
refer to neuro MDT approach
Riluzole is yhr only drug that modifies disease course
start at time of diagnosis - monitor LFTs and FBCs
MDT clinics - resp therapists, physios and OTs, dietician , SALT conultant and a social worker
immunisations - pneumococcal and influenza and covid
informing pts, cunselling, end of life care, advance directives
manage the ses
excessive saliva - postiiton, oral care and glycopyrranium bromide
dysphagia - blednd tube, percutaneous endoscopic gastrostomy,
mucolytic - carbocysteine
spasticity - exercise and baclofen
consider opoids and NIV in end of care
screen for sx of depression in every clinic
how do you diagnose ALS
El Escoral diagnostic, brain/cord MRI may rule out structural causes, LP to exclude inflam + neurophysiology, EMG
what are the 3 main differentials of a sudden onset headache
brain haemmorhages
meningitis
GCA
what ix do you do in myasthenia gravis
neurophysiology
spirometry
CT thorax
Serum ACh receptor
what is the management of Myasthenia gravis
ach inhibitor - pyridostigmine
physio and OT
psychological support
corticosteroids can cause initial worsening, start at low dose with gradual increase
immunosuppressant and thymectomy
how do you diagnose epilepsy
EEG
MRI
how do you dx GBS?
nerve conduction studies LP LFTs Spirometry Antiganglioside antibody - antiGQ1b antibodies potential stook culture for cause
how do you manage GBS
Plasma exchange - IVIG
serial peak flow
pulse and BP monitored until thye are off venilaor support
DVT prophylaxis
intubation and ventilation esp if bulbar dysfunction
manage the pain - gabapentin or carbamazepine
rehab - - strengthening exercises
hypotension managaed with a fluid bolus
