NEURO Flashcards
Peak incidence in 20-40s, common in pregnancy
acute, unilateral idiopathic facial paralysis
usually have preceding pain/tinging around the post-auricular region
forehead affected
altered taste
dry eyes
hyperacusis (loud sounds)
bell’s palsy
management of bell’s palsy
present with 72hrs = oral prednisolone
can provide eye patch/symptomatic relief
if no improvement in 3 weeks = ENT referral
which cranial nerve is affected in bell’s palsy
facial nerve - CN 7
initial pain in bag or legs
progressive, symmetrical weakness in all of the limbs
classically ascending from (legs upwards)
reduced/absence reflexes
hx of gastroenteritis
CN involvement sometimes or urinary retention
guillian-barre syndrome
what Ix done in guillian barre syndrome?
LP = elevated protein
nerve conduction studies
management of guillian barre syndrome
admit to neuro critical care
IVIG or plasmaphresis
pain control using gabapentin or opiates
motor sensory and optic symptoms seperated by time and space
tingling, paresthesia and numbness
optic neuritis - worse on eye movement
balance difficulties
commonly in females 20-40yrs
Multiple sclerosis
Ix for MS
MRI = multiple areas of focal demyelination in the brain and plaques LP = oligoclonal bands
management of acute MS attack
high dose methylprednisolone for 5 days
management of MS
b-interferon injections
glatiramer acetate, natalizumab and fingolimoid
supportive measures
brisk tendon reflexes and hypertonia
MS spasticity
MS spasticity management
baclofen and gabapentin
more insidious progression of limb weakness, in the symmetrical ascending pattern in all limbs
Chronic inflammatory demyelinating polyneuropathy (CIDP)
management of CIDP
long term immunosuppression
burning feet
tingling and numbness
feet affected first - but all peripheries affected
stocking/glove distribution
diabetic peripheral neuropathy
Ix for diabetic neuropathy
nerve conduction studies
management of diabetic neuropathy
anticonvulsants = gabapentin/pregabalin
antidepressants = SNRI/Tricyclics
tramadol/weak opioid - but addiction risk
lidocaine patches/topical cream
supplements and therapies
exercise, weigth loss and diet
postural tremor - worse outstretched
improved by alcohol and rest
impaired use of spoon/fork
essential tremor
management of essential tremor
propranolol first line
can use primidone
pill-rolling tremor cogwheeling rigidity bradykinesia depression/dementia micrographia shuffling gait - leads to balance difficulties
parkinson’s disease
any Ix for PD?
usually clinical diagnosis
SPECT can be used if hard to distinguish from essential tremor
management of PD
First line = levodopa,
dopamine agonists = bromocriptine and ropinirole
MOA-B inhibitors = selegine
COMT inhibitors = entacapone
cycling meds as can build tolerance
severe cases - surgical = deep brain stimulation
postural instability and falls
impairment of vertical gaze
bradykinesia
cognitive impairment
progressive supranuclear palsy
parkinsonism
autonomic disturbance = erectile dysfunction and postural hypotension
multisystem atrophy
progressive cognitive impairment/fluctuating cognition, visual hallucinations
lewy body dementia
management of lewy body dementia
acetylcholinesterase inhibitors = rivastigmine and donepezil
35 years +
chorea = involuntary movements
dystonia
saccadic eye movements
huntington’s disease
what will HD pts need investigated?
genetic testing for CAG trinucleotide expansion
management of huntingtons
previously incurable, new arising tx
rapid onset of dementia
myoclonus/twitching
all areas of the neurological system affected = gait, sensation, memory, strength, speech and visual losses
in younger pts may have anxiety, withdrawal, dysphonia
Creutzfeldt-jakob disease
Creutzfeldt-jakob disease cause
prion proteins
Creutzfeldt-jakob disease Ix
CSF normal, hyperintense signals in MRI
common in females
unilateral severe throbbing heachache - up to 72hrs
nausea and vomiting
photosensitivity
phonophobia
can be precipitated by aura (usually visual)
can be menstrual related
migraine
what is needed for diagnosis
5 attacks of the symptoms
management for migraines
first line = oral triptan & NSAIDs - nasal triptan in younger patients
metoclopramide + propranolol = preferred in child bearing age / first not tolerated
menstrual migraine = frovatriptan or zolmitriptan
headache = tight-band around the head/pressure
episodic
few other associated symptoms
tension headache
management of tension headaches
first line = aspirin, paracetamol, NSAIDs
prophylaxis = acupuncture/low dose amitriptyline
headache with intense sharp pain around an eye
unilateral redness, lacrimation and lid swelling around affected eye
rhinorrhea
restless patient
same time each day, can feel it coming on
cluster headache
management of cluster headache
acute = 100% oxygen and SC triptan
prophylaxis = verapamil (bridging prednisolone when initiating)
loss of consciousness nausea/vomiting confusion smell of alcohol difficulty walking
may have injured head via high-impact trauma
otherwise may present more insidiously
subdural haemorrhage
investigations for SDH
CT head = crescent shaped feathered fluid, midline shift/mass effect
management of SDH
neurosurgical intervention = decompressive craniotomy or burr holes
caused by trauma to the side of the head - not necessarily high impact trauma LOC focal neurological deficit tympanic tap lucid interval after trauma
epidural haemorrhage
which artery is affected in EDH
middle meningeal artery
investigations for EDH
CT - biconcave collection of blood (suture view)
management for EDH
craniotomy and evacuation haematoma
Headache: typically sudden-onset/thunderclap, severe and occipital
Nausea and vomiting
Meningism (photophobia, neck stiffness)
Coma
Seizures
Sudden death
ECG changes including ST elevation may be seen
subarachnoid haemorrhage
Ix for SAH
CT = hyperdensitiy/brighter in the basal cisterns, sulci
LP within 12hrs = xanthochromia + raised opening pressure
management of SAH
immediate neurosurgery referral - usually treated with coil
nimodipine 21days given to prevent vasospasms
main cause of SAH
intracranial aneurysms/ saccular ‘berry’ aneurysms)
linked to Polycystic kidney and Ehler-Danlos
headaches seizures impaired consciousness/confusion CN lesions = unilateral deafness, diplopia, pulsatile tinnitus focal neuro signs papiloedema
cavernous sinus thrombosis
Ix for cavernous sinus thrombosis
CT/MRI venograms
management cavernous venous thrombosis
heparin/warfarin
headaches - similar to raised ICP seizures impaired consciousness/confusion CN lesions = unilateral deafness, diplopia, pulsatile tinnitus focal neuro signs
venous sinus thrombosis
muscle fatigue after repetition of movements facial weakness proximal arm weakness ptosis diplopia
myasthenia gravis
Ix for MG?
electromyography and serologic testing for Ach antibodies
management for MG?
- long acting acetylcholinesterase inhibitors - pyridostigmine and mestinon
- prednisolone and azathioprine/cyclosporin
sometimes thymectomy (remove thymus)
all-over muscle weakness that may cause double vision or a wobbly walk.
respiratory depression - breathing and talking difficulties- subcostal recession
commonly due to use of B-blocker
MG crisis
MG crisis management
IVIG + plasmapheresis
abnormal tone in early infancy
delayed motor milestones
abnormal gait
feeding difficulties
cerebral palsy
management of cerebral palsy
oral diazepam, baclofen and botulinum toxin A = treat spasticity
anticonvulsants
analgesia
transient loss of consciousness, rapid onset
short duration
spontaneous complete recovery
syncope
investigations needed for syncope
ECG = check, prolonged QT
glucose level
electrolytes, FBC
causes of syncope
reflex/vasovagal = can be triggered from emotion/pain/stress or due to coughing/urinating
orthostatic = volume depletion, autonomic failure, drugs,
cardiac = arrhythmias or MI, PE
management of syncope
treat if underlying cause identified
optimise glucose + hydration
review medications
close follow up
progressive headaches
signs of raised ICP = N/V, headache worse on lying down
aggravated by valsalva
brain/CNS tumour
CNS/brain tumour Ix
MRI scan
management of CNS/brain tumour
usually surgery (reduces ICP even if not fully resectable)
global functional alteration of mental status
changes to memory,
changes to mood
difficulties thinking
acute encephalitis
confusion, memory loss or mood changes
repeated blows to the head/ repeated concussions
chronic encephalitis
management of chronic encephalitis
supportive = helmets, avoid risky activities, allowing time for full recovery from concussion
patients present with weakness in arms or legs usually asymmetric weakness of facial muscles - difficulty speaking, swallowing, chewing or coughing fasiculations/twitching stiffness weight loss muscle atrophy worsening fatigue
Amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis investigations needed?
usually clinical
nerve conduction studies can be done to exclude neuropathy
management of ALS?
riluzole/rilutek
symptomatic tx
PT, OT, speech+language therapy
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief
symptoms classically at night
muscle wasting at thenar eminence
+ve tinels and phalen’s test
carpal tunnel syndrome
investigations for carpal tunnel syndrom
electrophysiology - prolongs APs
management of carpal tunnel syndrome
corticosteroid injection
wrist splints at night
surgical decompression
which nerve is affected in wrist drop
radial nerve
which nerve is affected in foot drop
peroneal nerve (L4, L5, S1, S2) sometimes L5 radiculopathy results in foot drop
a single seizure lasting >5 minutes,
OR
> = 2 seizures within a 5-minute period without the person returning to normal between them
status epilepticus
medical emergency - hypoxic state
management of status epilepticus
ABC = airway adjunct, oxygen, check blood glucose
glucose if BM low and thiamine & Mg2+ if alcoholic
phenytoin or phenoarbital infusion
first line = benzodiazepines = diazepam/lorazepam
can repeat once after 10-20mins
no response in 45mins = general anesthesia
acute treatment of seizures
benzodiazepine first line = lorazepam/diazepam
recurrent seizures
epilepsy
Ix after first seizure
electroencephalogram (EEG) and neuroimaging (usually a MRI).
long term epilepsy management
generalised seizure = sodium valproate
focal seizures = carbamazepine
other tx options include = lamotrigine, levetiracetam
seizure with isolated motor symptoms which may spread across one side of the body
may have some sensory changes
simple partial seizure
seizure where patient has aura (nausea, fear olfactory hallucinations) followed by impaired responsiveness - stereotyped motor movements
complex partial seizure
progressive memory loss despite alertness inability to solve problems language difficulties wandering/inattention personality changes symptoms worse at night/sundowning
alzheimer’s disease
Diagnosis of alzheimer’s
usually clinical
Neuropsychiatric testing useful
widespread cerebral atrophy
neurofibrillary tangles
alzheimer’s disease
management of alzheimer’s
first line = acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine)
second line = memantine (an NMDA receptor antagonist)
other mx options include:
- activities promoting wellbeing
- CBT
- highly structured routines
motor weakness speech problems (dysphasia) swallowing problems visual field defects (homonymous hemianopia) balance problems >24hrs
Stroke
what indicates a haemorrhagic stroke ?
decrease in the level of consciousness:
headache is also much more common
nausea and vomiting is also common
seizures
assessment/Ix of stroke
FAST
ROSIER score - exclude hypoglycaemia first! = A stroke is likely if > 0.
non contrast CT = first line radiological investigation for suspected stroke
management of stroke
Acute ischaemic stroke
Thrombolysis with should only be given if:
it is administered within 4.5 hours of onset of stroke symptoms
make sure haemorrhage has been definitively excluded
secondary prevention
clopidogrel
if contraindicated/not tolerated = aspirin plus MR dipyridamole
Unilateral weakness or sensory loss. Dysphasia. Ataxia, vertigo, or incoordination. Syncope. Sudden transient loss of vision in one eye (amaurosis fugax). Homonymous hemianopia. Cranial nerve defects. <24hrs
TIA
management of TIA
Aspirin 300mg and refer for specialist assessment
further management/ prevention
clopidogrel
if contraindicated/not tolerated = aspirin plus MR dipyridamole
headache vomiting reduced levels of consciousness papilloedema Cushing's triad = widening pulse pressure + bradycardia + irregular breathing
raised ICP/pseudotumor cerebri
investigate raised ICP/pseudotumor cerebri
CT
LP - opening pressure
management of raised ICP/pseudotumor cerebri
head elevation to 30º
IV mannitol may be used as an osmotic diuretic
controlled hyperventilation
removal of CNS - shunting/serial LPs
if due to tumour = Na+ restriction -> Carbonic anhydrase inhibitor (such as acetazolamide) to decrease rate of production of CSF
Diuretics are second line therapy
headache jaw claudication visual disturbances = amaurosis fugax blurring double vision tender palpable temporal artery
temporal arteritis
Ix for temporal arteriris
raised inflammatory marker = CRP/ESR
diagnostic = temporal artery biopsy
CK & EMG normal
management of temporal arteritis
urgent high dose of prednisolone if no visual loss
if visual loss = IV methylprednisolone
urgent ophthalmology review = same-day
(sometimes bisphosphonates & low-dose aspirin given)
fever, headache, psychiatric symptoms, seizures, vomiting
focal features e.g. aphasia
peripheral lesions (e.g. cold sores)
encephalitis
Ix for encephalitis
CSF = lymphocytosis, elevated protein
PCR for HSV
management for encephalitis
IV acyclovir started in all suspected cases
(HSV responsible for 95% of cases
headache fever nausea/vomiting photophobia drowsiness seizures neck stiffness purpuric rash
meningitis
cloudy appearance , low glucose, high protein and high WBCs
bacterial meningitis
clear/slightly cloudy
high glucose
protein normal
raised WBC
viral meningitis
slightly cloudy, fibrin web, low glucose, high protein, elevated WBC
Tuberculous meningitis
management of meningitis
IV antibiotics, usually to include ceftriaxone/cefotaxime + amoxicillin
ampicilin added in >50yrs
IV dexamethasone
prophylaxis offered to patient contacts
HLA-B27 positive
middle aged man
diarrhoea, weight loss
large-joint arthralgia
lymphadenopathy
skin: hyperpigmentation and photosensitivity
whipple’s disease
Ic for whipple’s
jejunal biospy PAS granules
management of Whipple’s
co-trimoxazole for a year
