Neuro Flashcards
1
Q
imaging used in strokes
A
non contrast CT, carotid dopplers
2
Q
scoring systems used in stroke
A
NIHSS
ROSIER - both used acutely to assess severity and guide tx
3
Q
On non contrast CT, difference in appearance of ischaemic vs haemorrhage
A
ischaemia - patch of darker grey
haemorrhage - bright white
4
Q
Mx haemorrhagic stroke (SAH)
A
nimodipine - 60mg every 4h for 21d
1st - coiling
2nd - surgical clipping - need craniotomy
5
Q
Mx ischaemic stroke
A
CT- exclude haemorrhage
Aspirin 300mg OD/PR 2 weeks.
No AF - clopidogrel 75mg OD life + statin
AF - apixaban + statin
<4.5h - thrombolysis (alteplase)
<4.5h and occluded proximal anterior circulation - thrombolysis and thrombectomy
<6h - thrombectomy
6
Q
Parkinsons core symptoms
A
Bradykinesia
Hypertonia
Tremor
7
Q
(Parkinson plus syndromes)
Multiple Systems Atrophy (MSA) / Shy-Drager Syndrome
S+S
A
Autonomic dysfunction (postural hypotension, bladder dysfunction)
Cerebellar ataxia
Rigidity > tremor
8
Q
(Parkinson plus syndromes)
Progressive Supranuclear Palsy (PSP)
S+S
A
Vertical gaze palsy
Postural instability – falls
Speech disturbance, dementia
9
Q
(Parkinson plus syndromes)
Corticobasilar Degeneration (CBD)
S+S
A
Unilateral parkinsonism
Aphasia
Astereognosis (cortical sensory loss) – alien limb phenomenon
10
Q
(Parkinson plus syndromes)
Dementia with Lewy Bodies (DLB)
S+S
A
Visual hallucinations
Fluctuating cognition
Dementia – parkinsonism
11
Q
Difference between Parkinsonism and Parkinson’s disease
DPR - distribution, progression, response
A
Parkinsonism is a general term that refers to
a group of neuro disorders that cause movement problems similar Parkinson’s disease e.g. tremors, slow movement and stiffness
Distribution - symmetrical
Progression - rapid
Response - poor response to levodopa
Parkinson’s disease is a neurodegenerative brain disorder that progresses slowly
Distribution - asymmetrical
Progression - slower
Response - good response to levodopa
12
Q
PD Mx
A
MDT, physio, depression screen
1st
- levodopa
- SINEMET/ co-careldopa = Levodopa + Carbidopa . (Combined with dopa decarboxylase inhibiters)
- MADOPAR = levodopa + benserazide
- MAO-B inhibitors (i.e. selegiline)
- DA agonists (i.e. pramipexole, ropinirole)
2nd adjuncts
- COMT inhibitors e.g. entacapone (peripheral) tolcapone (central and peripheral)
- give with Levodopa to improve compliance but may increase SE
- Amantadine (PO; nicotinic antagonist, DA agonist, non-competitive NMDA antagonist)
- Apomorphine (SC; DA agonist)
- Deep brain stimulation (of subthalamic nucleus)
13
Q
PD ix
A
CT MRI - rule out vascular
DaTScan = Dopamine Transporter scan - Can exclude other causes of tremor
14
Q
Causes of Parkinsonism
A
drug induced
e.g. antipsychotics, some CCB, cocaine, amphetamines
Other neurodegenerative disorders e.g.multiple system atrophy, Lewy body dementia and progressive supranuclear palsy
Vascular Parkinsonism
Depression - Severe psychomotor retardation can give a parkinsonian appearance, with slow movements and loss of facial expression.
Tumour
Repeated head trauma
15
Q
What medications to avoid in PD
A
metoclopramide, haloperidol
dopamine antagonists
16
Q
Side effects of levodopa
A
DOPAMINE
Dyskinesia On/off phenomena Psychosis Arterial BP down Mouth dryness Insomnia N&V Excessive daytime sleepiness
17
Q
What does the Dopa decarboxylase inhibitor help do with levodopa?
Indications?
A
Prevents levodopa being broken down peripherally, but doesn’t cross the BBB allowing levodopa to be broken down releasing dopamine in the brain.
Predominant motor symptoms, less side effects
18
Q
Criteria for epilepsy
A
2 or more epileptic seizures or
1 seizure with epileptogenic markers (EEG or brain malformation)
19
Q
you do not treat the first episode of seizure unless
A
abnormal brain architecture (i.e. MRI) or EEG findings
20
Q
S+S/ stages of tonic clonic seizure
A
1st - behavioural arrest (i.e. stop writing, stop talking)
2nd - head and eyes turn to one side (it looks painful) – the side they turn is the opposite side to the lesion
3rd - Stiffening
4th - Shaking
21
Q
What increases chances of seizure
A
[STRESS]
– ETOH, insomnia,
medications, recreational drugs, trauma, infection, etc.
22
Q
Epilepsy Ix
A
A-E - including glucose, consider pabrinex
- ECG - cardiac causes
- MRI - structural causes
- prolactin - distinguishes dissociative seizure from true CNS seizure (raised in central seizures)
23
Q
Epilepsy Mx
Tonic clonic (during seizure)
A
Tonic-clonic seizure:
- 1 = Buccal midazolam, PR diazepam / IV lorazepam if IV access
- 2 = IV lorazepam
- 3 = IV phenytoin (phenobarbital if already on regular phenytoin)
- Rapid sequence induction of anaesthesia using thiopental sodium
24
Q
When to admit a patient with a seizure
A
- Poor initial response
- First seizure
- Status epilepticus
- high risk of recurrence (hx of recurrent)
25
Epilepsy Mx
Focal seizure (during seizure)
Focal seizure:
• Conservative measures
• Admission if first seizure or lasts longer than 5 minutes
• Review patients once a year
26
Definition of status epilepticus
STATUS EPILEPTICUS
| - ≥5 minutes OR >3 seizures in an hour (no recovery in between)
27
LT Mx of tonic clonic seizure
1st line = valproate
2nd = lamotrigine
28
LT Mx of absence seizure
1st line = valproate, ethosuximide
2nd = lamotrigine
29
LT Mx of tonic, atonic or myoclonic seizure
1st line = valproate
2nd = levetiracetam
30
LT Mx of focal seizure
1st line = lamotrigine
2nd = CBZ
31
SE carbamazepine
Hyponatraemia
| Rash
32
SE Valproate
VALPROATE
```
V = Vomiting, nausea
A = Anorexia
L = Liver toxicity
P = Pancreatitis
R = Retain weight
O = Oedema
A = Alopecia
T = Teratogen, tremors
E = Enzyme inhibitor
```
33
SE levetiracetam
mood changes
34
SE Lamotrigine
SJS
| Dizzy
35
SE phenytoin
Enzyme inducer
| gum hypertrophy
36
Which part of brain is affected first in Alzheimers
hippocampus
37
3 theories for AD
Amyloid - beta amyloid protein forms toxic aggregates
Tau - tau tangles cause damage to neurones
Inflammation - microbial cells increased phagocytosis and decrease levels of neuroprotective proteins
38
RF for AD
Biological:
- Age
- Genetics (92% sporadic though) - Presenilin 1 and 2, Downs, APEN, APP, ApoE
- Head injury
- Vascular RF e.g. HTN
Psychosocial
- Low IQ
- Poor educational level
39
S+S are due to which 4 elements of pathophysiology
- Atrophy (neurone loss)
- Plaque formation
- Neurofibrillaty tangle formation
- Cholinergic loss§
40
S+S presentation of AD
4As
Amnesia
- recent memories first, disorientation
Aphasia
- difficulty finding correct words, speech muddled
Agnosia
- visual e.g prosopagnosia
Apraxia
- dressing, skilled tasks
BPSD = mood change, abnormal behaviour, hallucination/ delusion
Psychiatric presentations - delusions, depression, GAD
Behavioural disturbances - aggression, wandering, sexual disinhibition, explosive temper
41
Dementia Ix
- GPCOG
- AMTS (<8/10)
- MMSE (20-24 = mild dementia, 13-20 = moderate dementia, and <12 = severe dementia.
Bloods
- LFT, TFT, U+E, HbA1c, B12 and folate
MRI CT
42
Prognostic factors in AD
Good - female
Bad - male, depression, behavioural problems, severe focal cognitive defect
43
AD Mx
Biological - start low, go slow
1st = anticholinesterases (mild-moderate)
- Donepezil (reversible)
- Galantamine (reversible)
- Rivastigmine (pseudo-reversible)
2nd = NMDA glutamate partial receptor agonist (moderate, 1st line in severe)
- Memantine
Psych
1st = structural group cognitive stimulation sessions (mild-mod)
- exclude GAD/ depression
- multisensory therapy
- group reminiscence therapy
- validation therapy
Social
- explain diagnosis
- optimising health e.g. hearing, vision
- identify future wishes e.g. AD, LPA
- carers
- social support
- FU every 6m with yourself and a dingle care managed
- DVLA, insurers
General
- wear ID
- dossed boxes
- change gas to electricity
44
Anticholinesterases - must check
ECG
45
Anticholinesterases SE
GI - NV, diarrhoea, anorexia
fatigue, dizziness, headache
46
Anticholinesterases absolute CI
anticholinergics (block ACh from binding)
BB
NSAIDs
muscle relaxants
47
Migraine S+S, Mx
unilateral, throbbing, severe, 4-72h
48
Migraine Mx
acute, prophylaxis
Acute
- oral triptan + NSAID/ paracetamol
Prophylaxis
- topiramate/ propanolol (only if >2 attacks a month)
49
Cluster headache S+S,
Intense pain around eye, watering; last 15m-2hrs
50
Cluster headache Mx
acute, prophylaxis
Acute: 100% O2, SC triptan
Prophylaxis: verapamil
51
Temporal arteritis S+S
Headache, jaw claudication, tender scalp
52
Temporal arteritis Mx
Oral prednisolone
53
Medication-overuse headache S+S and Mx
≥15 days / month, worsened with medication
stop meds
54
Define MS
an autoimmune demyelinating disorder of the CNS characterised by multiple plaques of separate in time and space
55
Classification of MS
Relapsing remitting
Primary progressive
Secondary progressive
Progressive relapsing
56
S+S of MS
TEAM
Tingling
Eye / optic neuritis
Ataxia (and other cerebellar signs DANISH)
Motor (spastic paraparesis)
INO
57
What is Lhermitte's sign
Neck flexion --> electric shocks in trunk or limb
58
What is Uhthoff's sign
temporary worsening of MS symptoms with increased temperature – i.e. a hot bath, exercise
59
What is INO
lesion in the medial longitudinal fasciculus (MLF) connecting CN6 to CN3 (and CN 4) which has S/S of weak adduction of ipsilateral eye and nystagmus of the contralateral eye
60
Criteria for MS
McDonald criteria - demonstrating lestions disseminated in time and space
61
MS Ix
o Contrast MRI (gadolinium-enhanced, T2-weighted)
o LP (IgG oligoclonal bands)
o Blood antibodies:
- Anti-MBP (myelin basic protein)
- NMO-IgG (neuromyelitis optica) Devic’s syndrome (S/S: MS + transverse myelitis + optic atrophy)
o Evoked potentials
62
MS differentials
```
stroke
tumour
CNS sarcoidosis
SLE
Devic's syndrome
```
63
MS Management
ACute
chronic
Sx Mx
Acute
- methyprednisolone 1g IV/PO OD for 3d
Chronic
- DMARDs - IFN beta
- Biologics - natalizumab
64
MS symptom management
Drug for
Fatigue
modafinil
65
MS symptom management
Drug for
Depression
SSRI
66
MS symptom management
Drug for pain
amitryptiline, gabapentin
67
MS symptom management
Drug for spasticity
baclofen + gabapentin
68
MS symptom management
Drug for urgency/ frequency
oxybutynin, tolterodine
69
MS symptom management
Drug for
tremor
clonazepam
70
MS good and bad prognostic factors
Good
- female
- <25yo
- sensory signs at onset
- long interval in relapses
- few MRI lesions
Bad
- male
- older
- motor signs at onset
- short interval in relapses
- many MRI lesions
- axonal loss
71
Myasthenia gravis definition
Autoimmue disorder characterised by insufficient functioning NACh receptors
72
Myasthenia gravis antibody
Anti-ACh-R in 85-90% cases
Anti muscle specific receptor TK AB 40%
73
Myasthenia gravis associations
15% thymoma
50-70% thyme hyperplasia
AI disease e.g. RA, SLE, AI thyroid
74
MG S+S
Muscle fatiguability
Extraocular (diplopia, ptosis), bulbar, face and neck muscles affected
Proximal myopathy - face neck, limb girdle
Dysphagia
Reflexes normal
75
MG Exacerbating drugs
```
Penicillamine
BB
Quinidine, procainamide
Lithium
Phenytoin
Abx - gentamicin, macrolides, quinolones, tetracyclines
```
76
Causes of myasthenia crisis
emotion, exercise, hypokalaemia, drugs e.g. opiates, BB, abx
77
What happens in myasthenia crisis
S+S
RESP FAILURE
risk of sudden apnoea: FVC ≤1L, negative inspiratory force ≤20cmH2O, need ventilation
S+S
- decreased RR
- accessory muscle use
weak cough
78
myasthenia crisis Ix
ABG (hypercapnia before hypoxia)
| FVC
79
myasthenia crisis Mx
Plasmapheresis
IVIG
intubation
80
MG Ix
- single fibre EMG >92% sensitivity
- Repetitive nerve stimulation (test fatiguability)
- Serial pulmonary function testing (test fatiguability)
- Ice pack test - ice pack on affected eyelid - temporary resolution = positive (80% positive rate)
TFTs
81
MG Mx
Crisis - IVIG and plasmapheresis
1st line symptomatic - long acting AChE inhibitor
- pyridostigmine, neostigmine
1st line LT control -
- prednisolone
2nd - azathioprine, cyclosporine, mycophenolate mofetil
surgery
- thymectomy
82
Lambert eaton myasthenic syndrome seen in associated with
SCLC and breast and ovarian cancer
83
Lambert eaton myasthenic syndrome S+S
- repeated muscle contractions lead to increased muscle strength (in 50% pt)
- limb girdle weakness (lower limbs first)
- hyporeflexia
- ANS symptoms (dry mouth, impotence, difficulty micturating)
- eye signs rare
84
Lambert eaton myasthenic syndrome Ix
EMG
| Incremetnal response to repetitive electrical stimulation
85
Lambert eaton myasthenic syndrome Mx
Treat cancer
| immunosuppression (pred ± azathioprine)
86
MND definition
motor neurone loss from cortex, brainstem, spinal cord and ant. horn cells of spinal cord
87
MND classification
50% amyotrophic lateral sclerosis
30% primary lateral sclerosis
10% progressive muscular atrophy
10% progressive bulbar palsy
88
MND amyotrophic lateral sclerosis
where is affected?
S+S UMN or LMN?
Corticospinal tracts
Mixed UMN LMN
89
MND primary lateral sclerosis
where is affected?
S+S UMN or LMN?
Loss of Betz cells in the motor cortex
UMN mainly -- spastic leg weakness and pseudo bulbar palsy (CN5, 7, 9-12), no cognitive decline
90
MND Progressive Muscular Atrophy
where is affected?
S+S UMN or LMN?
Anterior horn cell lesions
LMN mainly - distal to proximal signs
91
MND progressive bulbar palsy
where is affected?
S+S UMN or LMN?
Cranial nerves 9-12
Bulbar palsy
92
MND type with best prognosis
Progressive muscular atrophy
93
MND type with worst prognosis
Progressive bulbar palsy
94
Difference between bulbar and pseudo bulbar palsy
Bulbar = LMN signs
CN 9-12
Pseudobulbar = UMN signs
CN 5, 7
CN 9-12
95
MND S+S
S+S
Mixed UMN and LMN
```
Neuro exam
Inspection (wasting & fasciculations – esp. tongue)
Tone (spastic)
Power (weak)
Reflexes (absent, extensor plantars)
Sensation (NORMAL)
```
Cranial nerves:
Speech (bulbar = nasal; pseudobulbar = hot potato)
Jaw-jerk (bulbar = absent; pseudobulbar = brisk)
Eye movements (NORMAL; preserved until very late)
96
Differentials for mixed UMN LMN signs
MAST
- MND
- Ataxia (Friedrich's)
- SCDC (subacute degeneration of the spinal cord)
- Taboparesis
97
MND Ix/ criteria
Diagnostic criteria = revised el Escorial criteria
- MRI brain/ spinal cord - exclude structural causes
- EMG (fasciculations)
- LP - exclude inflammatory conditions
98
MND Mx
MDT - neurologist, physio, OT, dietician, GP, specialist nurse
- Riluzole - extends life by ~3 months
- Supportive
Drooling - amitriptyline
Resp failure - NIV
Dysphagia - NG/PEG
Spasticity - Baclofen, botulinum
Pain - analgesic ladder
99
Guillan Barre S defintion
immune-mediated demyelination of the peripheral nervous system often triggered by an infection (often C. jejuni
100
GBS Initial Sx
Characteristic features
65% initially get back/leg pain
o Progressive symmetrical weakness of all limbs
o Ascending weakness (legs affected first)
o Reflexes reduced or absent
o Sensory sx mild e.g. digital paraesthesia with very few sensory signs
• Other features – Hx gastroenteritis, resp muscle weakness, CN involvement diplopia, bilateral facial nerve palsy, oropharyngeal weakness, autonomic involvement e.g. urinary retention and diarrhoea
101
GBS Ix
LP = 66% have rise in protein, normal WCC
o Nerve conduction studies – decreased motor nerve conduction velocity (demyelination
102
GBS Mx
IVIG
Plasmapheresis
103
Causes of UMN lesion in cortex
```
functinal
abscess
CVA
tumour
demyelination
```
104
Causes of UMN lesion in spine
```
MS
compression
trauma
MND (some LMN)
Syringomelia (some LMN)
```
105
Causes of UMN lesion - anterior horn cell disease
spinal muscular atrophy
polio
MND (ALS)
106
UMN bilateral (spastic paresis) causes
MS
cord compression
cord trauma
cerebral palsy
107
UMN unilateral hemicord causes
MS
| cord compression
108
UMN unilateral hemisphere causes
MS
stroke
SOL
cerebral palsy
109
Mixed UMN LMN cause
```
MAST
MND
Ataxia (Friedrich's)
Subacute demyelination of the spinal cord (low b12)
Taboparesis
```
110
LMN peripheral neuropathy
Predominantly motor
causes
Infection e.g. GBS, Polio
Metabolic e.g. porphyria, lead poisoning
congenital (Charcot marie tooth)
Autoimmune./ infection = hepatitis, SLE
111
LMN peripheral neuropathy
Predominantly sensory
causes
Infection - leprosy
Metabolic - DM, ETOH, amyloid, uraemia
congenital - Charcot marie tooth
Autoimmune/ metabolic / iatrogenic - vitamin B12 deficiency. isoniazid
112
LMN peripheral neuropathy sensory and motor
causes
Alcoholic neuropathy - toxic effects and reduced B vitamin absorption
Sensory --> motor
V B12 deficiency - SCDC - dorsal columns affected first -- decreased joint position, vibration sense -- later get distal paraesthesia
113
LMN
| Proximal myopathy causes
Autoimmune - MS, polymyositis
Iatrogenic/ drugs - ETOH, statins, steroids
Neoplastic - paraneoplasm (detmaomyositis, LEMS)
congenital - muscular dystrophy
Endo - cushings, hyperthyroid, acromegaly, osteomalacia, diabetic amyotrophy
114
LMN
Hand wasting causes
Anterior horn cell - syringomyelia, MND, polio
Roots (C8, T1) - spondylosis
Brachial plexus - compression by cervical rib, avulsion e.g. Klumpke's palsy
Neuropathy - hereditary sensory motor neuropathy, mononeuritis multiplex, DM
Muscle - disuse RA, myopathy - myotonic dystrophy
115
Charcot marie tooth types
hereditary sensory motor neuropathy 1 and 2
116
Charcot marie tooth types S+S
inspection
- pes cavus
- distal muscle wasting
- thickened nerves esp common perineal
- BL symmetrical distal LMN features -- foot drop, high stepping gait, absent ankle jerks
- stocking distribution loss of sensation
117
Charcot marie tooth Ix
nerve conduction studies
* HSMN1 = demyelination-- ↓ conduction velocity
* HSMN2 = axonal degeneration -- ↓ conduction amplitude
Genetic testing (HSMN1 PMP22 gene)
118
Cerebellar syndrome S+S
| DANISH
Dysdiadochokiensia, dysmetria, dysarthria
Ataxia
Nystagmus
Intention tremor
Speech - scanning, staccato
Hypotonia
119
Cerebellar syndrome
causes
VITAMIN CD
Vascular = (vertebrobasilar) stroke
Infection = encephalitis, abscess
Trauma ---- raised ICP
Autoimmune - MS, paraneoplasic cerebellar degeneration
Metabolic - ethanol, poisons e.g. phenytoin
Neoplastic - posterior fossa tumour
Degeneration - spinocerebellar ataxia
120
Nystagmus
cerebellar cause/ vestibular cause
- Fast phase to or away from lesion?
- Maximal looking toward or away from lesion?
Cerebellar = Close
fast phase towards lesion
maximal looking towards lesion
Vestibular = V far
fast phase away from lesion
maximal looking away from lesion
121
Cerebellar syndrome Ix
o Bloods
- ETOH
- FBC, UE, LFT
- clotting (thrombophilia)
- Wilsons (low ceruloplasmin)
o ECG (arrhythmia)
o CSF (oligoclonal bands)
o MRI (posterior cranial fossa)
o Pure tone audiometry (CPA lesion)
122
Spinocerebellum
where are the lesions
midline cerebellar lesions
123
Neocerebellum
where are the lesions
Lateral cerebellar lesions
124
Spinocerebellum
controls
S+S
movement sand posture
truncal ataxia
125
Neocerebellum
controls
S+S
motor planning
limb coordination
dysmetria, intention tremor, dysdiadochokiensia
126
Vestibulocerebellum
controls
S+S
balance and vision
diplopia, nystagmus, vertigo
127
Lateral medullary syndrome occurs after
occlusion of the posterior inferior cerebellar artery
128
Lateral medullary syndrome S+S
o Cerebellar:
- Ataxia
- Nystagmus
o Brainstem:
- Ipsilateral: dysphagia, facial numbness, cranial nerve palsy (HORNERS – miosis, anhidrosis, ptosis)
- Contralateral: limb sensory loss
129
Marcus-Gunn (RAPD)
what is it
causes
The afferent pathway of the eye is disrupted which leads to a non-responsive direct stimulation and a responsive indirect stimulation (light in opposite eye)
MS, glaucoma, retinal disease
130
Argyll Robertson pupil
what is it
causes
Small, irregular pupils
ARP -- Accommodation Reflex Present
PRA-- Pupillary Reflex Absent
Diabetes, neurosyphilis
131
Holmes-Adie Pupil
| Adie Tonic Pupil
- Dilated pupil (Holmes has a dilated ego)
- Poorly reactive (accommodation and light)
Idiopathic
132
3rd nerve palsy S+S
o 'Down and out'
o Ptosis
o Dilated pupil (aka: surgical 3rd nerve palsy – due to compression on peripheral PNS fibres)
133
3rd nerve palsy causes
DM
Vasculitis (GCA, SLE)
Uncal herniation through tentorium (raised ICP)
Posterior communicating artery aneurysm
Cavernous sinus thrombosis
Amyloid, MS
Weber's syndrome:
134
What is weber's syndrome
ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
135
Clostridium botulinum infection
RF
S+S
Mx
o RF: IVDU
o S/S: descending paralysis, diplopia, bulbar palsy
o Mx: botox antitoxin
136
Normal pressure hydrocephalus
Onset
S+S
quick
"wet, wobbly, wacky” (incontinent, falls, dementia
137
Syringomyelia
causes
chiari malformation, trauma, tumours, idiopathic
138
Syringomyelia
S+S
- ‘cape-like’ (neck and arms) loss of sensation to pain & temperature
(preserved light touch, proprioception, vibration)
139
Paroxysmal hemicrania
S+S
Cluster headache presentation
140
Paroxysmal hemicrania
Mx
Indomethacin (completely resolves)
141
Horner's syndrome S+S
Ptosis, mitosis, anhidrosis, enopthalmos
142
Horner's syndrome Ix
differentiating causes
- heterochromia (congential horners)
- anhidrosis presence
143
Degenerative cervical myelopathy aetiology
cervical spondylosis
144
Degenerative cervical myelopathy S+S
- Pain neck and limbs
- Loss of ANS function (incontinence, impotence)
- Loss of motor function (loss of digital dexterity)
- Loss of sensory function (numbness)
- Hoffmans +ve (flick nail of middle finger and there's flexion of index/ thumb)
145
what is cervical spondylosis
age related wear and tear to spinal discs in neck - discs shrink, OA Sx
146
Degenerative cervical myelopathy Ix
cervical spine MRI - disc degeneration and ligament hypertrophy, with accompanying cord signal change
147
Degenerative cervical myelopathy Mx
Urgent referral (neurosurgery or orthopaedic spinal surgery)
-- early <6m decompression surgery
148
Acute meningitis S+S
fever
neck pain
confusion
149
Acute meningitis causes
Neonates
Children
Adults
Bacterial is most common
Neonates
- GBS
- Listeria
- E coli
Children
- H influenzae
- S pneumoniae
- N meningitidis
Adults
- S pneumonia
- N meningitides
Older - Listeria monocytogenes
150
Acute meningitis Mx
- S pneumoniae, N meningitidis --> IV ceftriazone + IM benzylpenicillin (in community)
Elderly (listeria)
- IV amoxicillin/ ampicililn
Neonate (listeria, E coli)
- IV cefotaxime + IV amoxicillin
151
Chronic meningitis causes
TB, syphillis, cryptococcus (immunosuppressed)
152
Chronic meningitis Mx
Tx cryptococcus neoformans with Ambisome ± flucytosine
153
Viral meningitis causes
Enterovirus (Coxsackie A and B, echovirus)
154
Viral meningitis Mx
children - self limiting 1-2 weeks
155
Encephalitis S+S
Meningitis Sx: Meningism - headache stiff neck, photophobia
Confusion
Fever
+
Focal neuro deficit
Altered mental state
156
Encephalitis causes
UK
Worldwide
UK - HSV2
Worldwide - arboviruses, West Nile virus
157
Encephalitis Tx
often treat as ‘meningoencephalitis’ as you cannot differentiate them
o IV aciclovir (10mg/kg, TDS) + IV ceftriaxone (2g, BD) ± IV amoxicillin (immunocompromised or >50yo)
158
Cerebral abscess S+S
- fever
| - raised ICP (seizures, papilloedema, localising signs)
159
Where are bacterial abscesses
peripheral
160
where are Toxoplasma abscesses
deeper; basal ganglia
161
Cerebral abscess Ix
ESR
WCC
CT MRI- ring enhancing lesion
162
Cerebral abscess mx
urent neurosurgical referral
163
Status epilepticus definiton
= a seizure that lasts for ≥30 minutes (or multiple seizures in <30 minutes)
164
Status epilepticus
Early status
Established status
Refractory status timeframe and drugs
o Early status = 5-30 minutes
--> lorazepam, usual AED medication
o Established status = 30-60 minutes
-->phenytoin
o Refractory status = ≥60 minutes
-->anaesthesia
165
Status epilepticus IX
o Initial: CBG, pulse oximetry, cardiac monitor
o Once treatment started: lab glucose, ABG, U&Es, Ca2+, FBC, ECG
o Consider: anticonvulsant levels, toxicology, LP, CT/MRI, urine/blood culture, EEG, CO levels
166
Status epilepticus Mx
0 minutes
- buccal midazolam OR
- PR diazepam OR
- IV lorazepam (0.1mg/kg; preferable if IV access)
10-20 minutes
- IV lorazepam (0.1mg/kg; bolus)
- anaesthetic help if ≥20 minutes
30 minutes
- IV phenytoin (15-18mg/kg at 50mg/minute)
- OR IV phenobarbitone
60 minutes
- Rapid induction anaesthesia (i.e. propofol + ventilation)
167
Head injury + pupils unequal ... what do you do
diagnose high ICP (i.e. extradural haemorrhage)
neurosurgical emergency
168
Head injury Ix / Mx
o ABCDE (if GCS ≤8, intubate)
o Assess events (retrograde + anterograde amnesia)
o Examine CNS
o Early involvement of anaesthetics and ITU
169
Head injury
| - when to do CT Head immediately
- GCS (<13 on initial assessment; <15 at 2 hours post-injury)
- Fracture (suspected open or depressed skull fracture or basal skull fracture)
- Hemotympanum, 'panda' eyes, CSF leakage from ear/nose, Battle sign
- Seizure (post-traumatic)
- Focal neurological deficit
- Vomit >1
170
Head injury
| - when to do CT Head soon <8h (if some LOC or amnesia since injury) AND ....
ABCD
- Age ≥65
- Bleeding or clotting disorders (incl. current anticoagulation medication)
- (Re-)Collection of events before (>30 minutes' retrograde amnesia of events before the head injury)
- Dangerous mechanism of injury:
• Pedestrian or cyclist struck by a motor vehicle
• An occupant ejected from a motor vehicle
• Fall from a height >1m or 5 stairs
o CT spine immediately (<1 hour):
171
Head injury
| - when to do CT Spine immediately <1h
- GCS <13 on initial assessment
- Patient intubated
- Ruling out needed (i.e. for surgery)
- Clinical suspicion and…
• Age ≥65yo • High-impact injury
• Focal neurological deficit • Paraesthesia in limbs
172
Head injury Cx
Early:
- Extradural / Subdural haemorrhages
- Seizures
Late:
- Subdural haemorrhage
- Seizures
- Diabetes insipidus
- Parkinsonism
- Dementia
173
Normal ICP
<15mmHg
174
Raised ICP causes
o Tumours (primary, metastatic)
o Head injury
o Haemorrhage (subdural, extradural, subarachnoid, intracerebral, intraventricular)
o Infection (meningitis, encephalitis, brain abscess)
o Hydrocephalus
o Cerebral oedema
o Status epilepticus
175
Raised ICP S+S
o Headache (worst on leaning forward) / vomiting
o Altered GCS, focal neurological deficit
o Trauma history
o Cushing’s response (high BP, low HR), Cheyne-Stokes respiration (period of gradual hyperpnoea then gradual hypopnea then period of apnoea)
o Eye changes:
- Pupil constriction early --> dilation late
- Reduced visual acuity, peripheral field loss
- Papilloedema ± visible venous pulsation LOSS (absent in 50% normally, but LOSS is a useful sign)
176
Raised ICP Ix
o U&E, FBC, LFT, glucose, serum osmolality, clotting, BC
o Toxicology screen
o Consider… CXR, CT head --> LP
177
Raised ICP Mx
o Urgent neurosurgery referral
o Holding measures:
-Sit up 40 degrees
- If intubated --> hyperventilate them (reduce PaCO2 --> cerebral vasoconstriction --> reduce ICP)
- Osmotic agents (mannitol) – n.b. can lead to rebound raised ICP with prolonged use (12-24hrs)
- Steroids (only useful for oedema surrounding tumours)
o Fluid restriction
178
Cauda Equina Syndrome definiton
= a constellation of symptoms due to compression of the Cauda Equina
179
where is then cauda equina
L2 and below and film terminale form it
180
Cauda Equina responsible for....
- Lower limb sensation/power
| - S2-4 (bladder control, EAS, external genitalia, perianal sensation)
181
Cauda Equina causes
```
V
I abscess
T trauma, haematoma
A
M
I iatrogenic spinal surgery
N tumour
C congenital spinal abnormalities
D spinal cord disc prolapse (L4/5, L5/S1)
```
182
Cauda Equina S+S
- Back pain, unilateral/bilateral sciatica (50%)
- Saddle anaesthesia
- Urinary retention, urinary/faecal incontinence
- ---- Urinary retention (bladder distension as sensation of fullness lost)
- ----- Urinary incontinence (by loss of sensation when passing urine)
- ---- Faecal incontinence (due to loss of sensation of rectal fullness)
- Reduced sexual function, lower limb weakness
183
Red flags for Cauda Equina
Bilateral sciatica
Saddle anaesthesia
Lower limb weakness
184
White flag for Cauda Equina (too late)
Urinary retention or incontinence
185
Cauda Equina Ix
Exam
- lower limb near exam
- saddle anaesthesia
- DRE (anal tone, sensation)
Bladder scan (urinary retention)
MRI
186
Cauda Equina Mx
PO dexamethasone (if metastatic whilst waiting MRI results)
Decompressive laminectomy (<48h from bladder dysfunction)
187
Spinal cord compression - definition
oncological emergency - extradural compression from vertebral body mets - lung, breast and prostate cancer
188
Spinal cord compression S+S
o Back pain (earliest, most common, worse on lying down and coughing)
o Above L1 --> UMN signs + sensory level
o Below L1 (as spinal cord ends around L1/2) --> LMN signs + peripheral numbness
o Tendon reflexes = increased below the level of the lesion and absent at the level of the lesion
189
Spinal cord compression Ix
Urgent <24h whole spine MRI
190
Spinal cord compression Mx
High dose PO/IV dexamethasone ± radiotherapy (frail, multiple lesions) or surgery (non-frail, single/few lesions)
