Neuro Flashcards
Stroke: ACA
Contralateral hemiparesis and sensory loss, lower extremity > upper
Stroke: MCA
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia - difficulty with language or speech
Stroke: PCA
Contralateral homonymous hemianopia with macular sparing (preserves vision in the centre of the visual field)
Visual agnosia ( cannot recognise objects)
Stroke: Basilar artery
Locked in syndrome
Stroke: retinal/ ophthalmic artery
Amaurosis fugax
What is a lacunar stroke?
present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
strong association with hypertension
common sites include the basal ganglia, thalamus and internal capsule
Acute management of a stroke (what are the guidelines)
aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
regards to atrial fibrillation, the RCP state: ‘anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke’
if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation
BM’s, Sats, hydration and temperature should be normal
What are the guidelines regarding thrombolysis for acute ischaemic strokes?
Thrombolysis with alteplase should only be given if:
it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
haemorrhage has been definitively excluded (i.e. Imaging has been performed)
What are the guidelines regarding thrombectomy for acute acute ischaemic strokes?
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA).
Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
What are the secondary prevention guidelines for stroke?
Recommendations from NICE include:
clopidogrel is now recommended by NICE ahead of combination use of aspirin plus modified-release (MR) dipyridamole in people who have had an ischaemic stroke
Aspirin plus MR dipyridamole is now recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated, but treatment is no longer limited to 2 years’ duration
MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated, again with no limit on duration of treatment
What are NICE guidelines regarding the mx of Parkinson’s disease?
What are the nice guidelines for Parkinson’s mx?
For first-line treatment:
if the motor symptoms are affecting the patient’s quality of life: levodopa
if the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
Which parkinsons drug is best for motor symptoms and ADOLS mx?
Levadopa anyday over Dpamine agonists or MAO-B inhibitors
What parkinsons drug can cause the the most motor complications and which one is the one that causes the most adverse events (sleepiness hallucinations etc):
Motor: Levodopa is the worst for side effects
Adverse events: Dopamine agonists
Side effects of levadopa
Dry mouth
Anorexia
Palpitations
Psychosis
Postural HTN
Dyskinesias ( dystonia, chorea and athetosis)
What is a TIA?
The original definition of a TIA was time-based: a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow. However, this has now changed as it is recognised that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ‘tissue-based’ definition is now used: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
What are the features of a TIA
Resolve within1-24hrs however are:
unilateral weakness or sensory loss.
aphasia or dysarthria
ataxia, vertigo, or loss of balance
visual problems:
sudden transient loss of vision in one eye (amaurosis fugax)
diplopia
homonymous hemianopia
What would you do if you came across someone with a sus TIA?
give aspirin 300 mg immediately, unless
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team
Investigations for a TIA!!!!!!
NICE recommend that CT brains should not be done ‘unless there is clinical suspicion of an alternative diagnosis that CT could detect’
MRI (including diffusion-weighted and blood-sensitive sequences) is preferred to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies
Carotid doppler!
How would you treat a confirmed TIA?
Clopidogrel is recommended first line
Aspirin + dipyramidole for those patients who cannot.
Features of a third nerve palsy ?
eye is deviated ‘down and out’
ptosis
pupil may be dilated (sometimes called a ‘surgical’ third nerve palsy)
Causes of a third nerve palsy?
DM , Vasculitis, PCA aneurysm (ASSOCIATED WITH PAIN!!!!!)
MS?
How do we classify seizures?
- Where seizures begin in the brain
- Level of awareness during a seizure (important as can affect safety during seizure)
- Other features of seizures
What is a focal seizure?
these start in a specific area, on one side of the brain
the level of awareness can vary in focal seizures. The terms focal aware (previously termed ‘simple partial’), focal impaired awareness (previously termed ‘complex partial’) and awareness unknown are used to further describe focal seizures
further to this, focal seizures can be classified as being motor (e.g. Jacksonian march), non-motor (e.g. déjà vu, jamais vu; ) or having other features such as aura
Gen seizures what are they ?
these engage or involve networks on both sides of the brain at the onset
consciousness lost immediately. The level of awareness in the above classification is therefore not needed, as all patients lose consciousness
generalised seizures can be further subdivided into motor (e.g. tonic-clonic) and non-motor (e.g. absence)
tonic-clonic (grand mal)
tonic
clonic
typical absence (petit mal)
atonic
What is Bells palsy? What is it caused by and who does it affect?
Bell’s palsy may be defined as an acute, unilateral, idiopathic, facial nerve paralysis. The aetiology is unknown although the role of the herpes simplex virus has been investigated previously. The peak incidence is 20-40 years and the condition is more common in pregnant women.
What are the features of Bell’s palsy?
lower motor neuron facial nerve palsy - forehead affected
in contrast, an upper motor neuron lesion ‘spares’ the upper face
patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis
Mx of bells palsy?
there is consensus that all patients should receive oral prednisolone within 72 hours of onset of Bell’s palsy
Eye care - artificial tears and tape etc
If no improvement in 3 weeks urgent ENT referral
What is a cluster headache and what is its pattern?
The name relates to the pattern of the headaches - they typically occur in clusters lasting several weeks, with the clusters themselves typically once a year.
Men 3:1 and smokers more common
Features of cluster headaches?
Features
pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
clusters typically last 4-12 weeks
intense sharp, stabbing pain around one eye (recurrent attacks ‘always’ affect same side)
patient is restless and agitated during an attack
accompanied by redness, lacrimation, lid swelling
miosis and ptosis in a minority
Acute and prophylaxis treatment of cluster headaches?
acute: 100% oxygen (80% response rate within 15 minutes), subcutaneous triptan (75% response rate within 15 minutes)
prophylaxis: verapamil is the drug of choice. There is also some evidence to support a tapering dose of prednisolone
NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging
What is Myasthenia gravis?
Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. Antibodies to acetylcholine receptors are seen in 85-90% of cases*. Myasthenia is more common in women (2:1)
