Neuro Flashcards
What is a focal seizure?
Limited to 1 hemisphere
What symptoms do you get with a temporal focal seizure?
Smell/taste abnormalities, auditory phenomena
Lip smacking
Walking without purpose
Name 3 types of syncope?
Cardiac
Orthostatic
Neurogenic
Causes of orthostatic syncope?
Postural hypotension
Drugs
Diabetes
Parkinsons
What is the definition of epilepsy?
At least 2 unprovoked seizures occurring more than 24 hours apart.
What is a non-epileptic attack?
A manifestation of trauma, usually caused by a psychological cause.
What happens after an episode of syncope?
Usually feels fine after attack, understands where they are and what. No post ictal period.
What is seen before a seizure?
Prodrome, such as abdo rising feeling
Strange smells or tastes
How can you tell the difference between a non-epileptic and epileptic attack/seizure?
NEAD: longer seizure, more frequent (several in a day), may have some awareness of event.
Epilepsy: Shorter, no awareness, a long period of confusion afterwards
What investigations would you do if someone had a seizure?
EEG
CT head (MRI in epilepsy clinic)
What are the driving regulations after having a first seizure?
Must be 6 months seizure free in order to drive
What are the driving regulations around having more than 1 seizures?
Must be 1 year seizure free in order to drive
What are the regulations around sodium valproate in women of childbearing age?
Can only be used in women of childbearing age if they have a pregnancy prevention plan, i.e. they’re on contraception.
Cannot be used first line.
Management of status epilepticus?
4mg of Lorazepam, wait for 10mins and then another 4mg lorazepam.
Load on antiepileptic, levetiracetam
Critical care - intubation/GA
What is the definition of status epilepticus?
Prolonged seizure over 20mins
Or recurrent seizures without recovery
What is meningitis?
Infection of the meninges within the brain
What are the most common organisms that cause meningitis in adults?
Strep pneumonia
Neisseria meningitidis
Haemophilus influenza
What are the risk factors for meningitis?
Advancing age,
Crowds
Exposure to pathogens
Immunocompromising conditions
Key features of meningitis?
Neck stiffness
Photophobia
Fever
Altered mental status
What type of rash is seen in meningitis?
Petechial rash (tiny red flat spots on the skin)
1st line investigations in meningitis?
Blood cultures (do not delay antibiotic treatment until results are back
Gold standard investigations for meningitis?
PCR
LP
What treatment is given for meningitis in primary care?
STAT dose of benzyl penicillin
Which antibiotics should contacts be given in the case of meningitis?
Ciprofloxacin
Which viruses commonly cause encephalitis?
Herpes
Varicella zoster
EBV
What is the difference between meningitis and encephalitis?
Enceph is the inflam of the brain
Meningitis is inflam of the meninges
Which ages are more at risk of encephalitis?
Under 1 over 65
Key features of encephalitis?
Altered mental state
Reduced glasgow coma scale
Fever
headache
Focal neuro signs
Seizures
Investigations for encephalitis?
Blood cultures
Viral PCR
CT or MRI
Management of encephalitis?
IV aciclovir
How long do migraines tend to last?
4-72 hours
What are the characteristic features of a migraine?
Pounding or throbbing
Unilateral
Other features of a migraine, apart from headache?
N&V
Photophobia
Phonophobia
Aura
What happens during a migraine aura?
Blurred vision
Lines across vision
Sparks in vision
What is a hemiplegic migraine?
Mimics the symptoms of a stroke
Unilateral weakness of the limbs
Ataxia
Changes in consciousness
Name 5 triggers for migraines.
Stress
Bright lights
Strong smells
Certain foods (chocolate, cheese and caffeine)
Dehydration
Menstruation
What is the first acute treatment for a migraine?
Paracetamol or ibuprofen in combination with a triptan
When should triptans be taken in migraine?
Early as possible at the start of the headache. If aura, must be started after the aura
When would you consider preventative treatment of migraine?
If attacks are occurring more than once a week
Having significant impact on quality of life
Which medications are typically used for migraine prophylaxis?
Propranolol
Topiramate
Amitriptyline
What class of drugs are triptans?
5HT receptor agonists
What does a tension headache feel like?
Tight band around the forehead
What are tension headaches associated with?
Stress
Depression
Alcohol
Skipping meals
Dehydration
Treatment for tension headaches?
Reassurance
Basic analgesia
Relaxation techniques
Symptoms of cluster headaches?
Red swollen watering eye
Miosis
Ptosis
Nasal discharge
Facial sweating
What is the pattern of cluster headaches?
A patient may experience 2 or 3 attacks a day for 2 months and then none for 2 years
How long does a cluster headache last?
15mins - 3hours
Acute management of cluster headaches?
Triptans
High flow oxygen
Prophylaxis of cluster headaches?
Verapamil
Lithium
Prednisalone
Name 3 symptoms of giant cell arteritis?
Severe unilateral headache
Scalp tenderness
Jaw claudication
Blurred vision
What are the findings on FBC in temporal arteritis?
Raised ESR
What is the gold standard investigation for GCA?
Temporal artery biopsy
Management of GCA?
Steroids to manage acute attack then wean off slowly once resolved
What is a TIA?
Symptoms of a stroke that resolve within 24 hours after onset
Name 5 risk factors for stroke?
CVD
Previous stroke/TIA
AF
Hypertension
Diabetes
Smoking
COCP
Within what time of having a stroke can thrombolysis with alteplase be used?
Within 4.5 hours
When can thrombectomy be used in management of a stroke?
Dependent on location and time since symptoms started. Typically not performed 24 post onset
What is the management of a TIA?
Start 300mg Aspirin daily
What secondary prevention should be offered after a stroke to prevent another?
75mg clopidogrel
Atorvastatin 80mg
Carotid endartectomy
What shape is an epidural haemorrhage on CT?
Lemon
What shape is a subdural haemorrhage on CT?
Banana
What shape is a SAH on CT?
Starfish
Which vessel causes the bleed in an epidural haemorrhage?
Middle meningeal artery
Which vessels cause the bleed in a subdural haemorrhage?
Bridging veins
What is an epidural haemorrage usually caused by?
Trauma or assault to the skull
What is a subdural haemorrhage typically caused by?
Falls and bumps to the head. Usually less severe, sometimes can go unnoticed due to lucid interval
What motor functions will be affected in a ACA stroke?
Motor and sensation to the lower limb
What motor functions will be affected in a MCA stroke?
Region from chin to the hip
What will an ischamic stroke in the PCA affect?
Visual loss
Where are berry aneurysms most common?
Anterior cerebral anterior communicating junction
What are the 4 characteristic symptoms of parkinsons?
Tremor
Rigidity
Bradykinesia
Postural instability
When does parkinsons typically begin?
65
What is the pathophysiology of parkinsons?
Dopamniergic neurone die resulting in reduced amount of dopamine in the basal ganglia.
Excessive inhibitory input in the thalamus
What type of tremor do patients with Parkinson’s have?
Pill rolling tremor (resting tremor)
Presentation of parkinsons?
Resting tremor
Loss of arm swing
Small steps
Shuffling gait
Loss of facial expression
What is the first line treatment for those with mild parkinsons?
Rasagiline
How is Huntington’s inherited?
Autosomal dominant
When does huntingtons start?
35-45
Symptoms of huntingtons?
Chorea
Personality change
Twitching
Restlessness
Loss of coordination
What is bells palsy?
Acute unilateral facial nerve weakness or paralysis.
How quickly does bells palsy come on?
Within 72 hours
What is commonly the causative organism of bells palsy?
HSV and varicella zoster virus
Symptoms of bells palsy?
Facial muscle weakness
Difficulty chewing, dry mouth
Incomplete eye closure
Numbness/tingling
Speech problems/drooling
What are predisposing factors for bells palsy?
Previous stroke/brain tumour
Systemic illness or fever
Skin cancers of head and face
What is the management of bells palsy?
Lubricate eye with drops
Consider pred if presenting within 72 hours of onset
When should you refer a patient to ENT with bells palsy?
No improvement after 3 weeks of treatment
What is trigeminal neuralgia?
Pain in one or more of the branches of the trigeminal nerve, thought to be caused by compression of the nerve.
What type of pain do people with trigeminal neuralgia experience?
Electric shock-like sharp/shooting pain.
Unilateral
Short lived
Episodic
What is the treatment for trigeminal neuralgia if no red flags present?
Carbamazepine
What is the triad seen with Horner syndrome?
Anhidrosis (loss of sweating)
Ptosis
Miosis (constricted pupil)
What is the cause of Horner’s syndrome?
Interference with the sympathetic nervous system that supplies the eye.
What is neurofibromatosis?
A genetic condition causing nerve tumours to develop throughout the nervous system
How do you remember the 7 features of NF1?
CRABBING
What does CRABBING stand for?
Cafe au lait spots
Relative with NF1
Axillary or inguinal freckles
Boney dysplasia, such as Bowing of long bones
Iris hamartomas (yellow/brown spots on the iris)
Neurofibromas
Glioma of optic nerve
What type of tumours arise from NF1?
Neuromas
What types of tumour arise from NF2?
Schwanomas
What type of tumour is most associated with NF2?
Acoustic neuromas
Features of NF2?
Hearing loss
Tinnitus
Balance problems
What is MS?
Demyelination of the myelinated neurones in the CNS due to an autoimmune response.
Which cells produce myelin in the CNS?
Oligodendrocytes
Which cells produce myelin in the PNS?
Schwann cells
How does MS most commonly present?
Optic neuritis (loss of vision in one eye)
Double vision
Ataxia
Numbness and tingling
Focal weakness
Longterm Management of MS
DMARDS and biologic therapies have been introduced to induce long term remission in MS
Management of acute relapses in MS?
Steroids such as methyl pred
What are the different disease patterns of MS?
Relapsing and remitting
Primary progressive
Secondary progressive
What is the characteristic pattern of muscle weakness in myasthenia gravis?
Weakness worse with activity and better with rest
Which antibodies are respinsible for the symptoms of MG in 85% of patients?
Acetylcholine receptor antibodies
What is the most common presentation of MG?
Extraoccular muscle weakness
Diplopia
Ptosis
Jaw fatigue
Difficulty swallowing
Slurred speech
How is MG diagnosed?
Blood tests for the relevant antibodies:
Acetylcholine receptor antibodies
Treatment of MG?
Pyridostigmine to increase the amount of AcH in the NMJ
Rituximab can also be used
What is a myasthenic crisis?
Severe complication
Weakness of the respiratory muscles
Patients require ventilation and IV immunoglobulins
What 3 things are needed to classify a total anterior circulation stroke as per the bamford/oxford classification?
Contralateral hemiplegia or hemiparesis
Contralateral homonymous hemianopia
Higher cerebral dysfunction (Aphasia/neglect)
It also involves both anterior and middle cerebral arteries on the affected side
What is a lacunar infarct?
Either pure motor stroke
Pure sensory stroke
Sensorimotor stroke
NO VISUAL FIELD DEFECTS, HIGHER CEREBRAL DYSFUNCTION OR BRAINSTEM DYSFUNCTION
What do you see in a posterior circulation infarct?
Cerebellar dysfunction
Eye movement disorder
Bilateral motor/sensory deficit
Cranial nerve palsy
Cortical blindness
What medication can be started in SAH to reduce vasospasm (which can cause further brain damage)?
Nimodipine
What is the first line treatment of status epilepticus?
Rectal diazepam
If rectal diazepam fails in status, which other benzo should be givem?
IV lorazepam
What is the second line treatment of status epilepticus?
IV phenyotoin
Name 3 upper motor neurone signs.
Spasticity
Upgoing plantars
Hyperreflexia
Name 4 lower motor neurone signs.
Muscle wasting
Weakness
Hyporeflexia
Fasciculations
Where are upper motor neurones found/
Originate in the cerebral cortex and go down to the brainstem and spinal cord
Where are lower motor neurones found?
Originate in the spinal cord and innervate muscles and glands
Which nerves are affected in bulbar signs?
CN 9,10,12
What are the bulbar signs?
Difficulty swallowing
Speech impairment
Nasal/quiet speech
Fasciculating tongue
What signs are seen in MND?
Upper and lower motor neurone signs
Signs and symptoms of ALS?
Upper and lower motor neurone signs. Makes up 50% of MND cases
Signs and symptoms of primary lateral sclerosis?
Upper motor neurone signs
Signs and symptoms of progressive bulbar palsy?
Bulbar signs such as speech and swallowing impairment
Signs and symptoms of progressive muscular atrophy?
Lower motor neurone signs
What is the only disease modifying treatment for MND?
Riluzole
What supportive treatments are given for MND?
Baclofen for contractures
Anticholinergics for drooling
Pain relief
Botox
What are the symptoms of a cerebellar disorder remebered by?
DANISH
What does DANISH stand for?
Dysdiadokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
If there is a lesion in the cerebellar vermis, what are the characteristic symptoms?
Truncal ataxia (walks like a drunken sailor)
Gait instability
If there is a lesion in the ceribellar hemispheres what are the signs?
Signs are seen in the ipsilateral limb (as fibres haven’t decussated)
What are the 2 most common causes of cerebellar syndrome?
MS and Stroke
What is cataplexy?
Sudden, transient loss of muscle tone caused by strong emotion such as being frightened or laughing
What are the symptoms of narcolepsy?
Excessive daytime sleepiness
Vivid hallucinations
Early REM sleep
What medications are used for daytime stimulation in narcolepsy?
Modinafil
What medications are used for night time in narcolepsy?
Sodium oxybate
What is guillain barre syndrome?
Ascending, demyelinating neuropathy
WHat are the symptoms of GBS?
Ascending symmetrical limb weakness
What monitoring and Ix should be done in GBS?
Regular spirometery to check resp function as risk of resp muscle weakness
LP
What does an LP show in GBS?
Raised protein normal WCC and Normal glucose
What is the treatment for GBS?
IV immunoglobulins in severe cases
Ventilation if required
What are the symptoms of raised ICP?
Headache
Vomitting
Reduced GCS
Papilloedema
What investigations in the case of raised ICP?
Neuro imaging such as CT or MRI to find underlying cause
What is the treatment of hydrocephalus?
Intracranial shunt
Hydrocephalus is a reversible cause of what disease?
Dementia
What is the triad of symptoms of normal pressure hydrocephalus?
Urinary incontinence, gait abnormalities and dementia
What does an MRI head show in normal pressure hydrocephalus?
Ventriculomegaly
Which are the most common cancers to metastasise to the brain?
Lung
Breast
Bowel
Kidney
Skin
What is the most common primary brain cancer?
Glioblastoma
What is the appearance of a glioblastoma on CT?
Solid tumour with central necrosis
What is a meningioma, and where are they found?
From arachnoid cap cells. Usually found near the dura mater
What is a vestibular schwannoma also known as?
Acoustic neuroma
Which condition are vestibular schwannomas associated with?
NF2
How are generalised tonic clonic seizures treated in men?
Sodium valproate
What is the first line treatment of GTCS in women?
Lamotrigine or levitiracetam
What is the treatment of a medication overuse headache?
Stop ibuprofen and paracetamol
Wean off opioids
What are the points in motor for GCS?
Obeys commands
Localises to pain
Withdraws from pain
Flexes to pain
Extends to pain
None
What are the verbal points in GCS?
Orientated
Confused
Words
Sounds
None
What are the eye points in GCS?
Spontaneous
Voice
Pain
None
What is GCS a score out of?
15
What GCS score does a person require intubation?
7
What is a radiculopathy?
Nerve root pain or pinched nerve
Such as sciatica
Symptoms of anterior cerebral artery lesion?
Contralateral hemiparesis and sensory loss. Lower extremity affected more than upper
Symptoms of middle cerebral artery lesion?
Contralateral hemiparaesis and sensory loss. Upper extremity greater than lower extremity. Contralateral homonymous hemianopia
Symptoms of posterior cerebral artery stroke?
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Symptoms of Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)
Ipsilateral CN3 palsy
Contralateral weakness of upper and lower limb
Symptoms of a posterior inferior cerebellar artery lesion?
Numbness on 1 side
Facial droop
Hoarseness
Trouble swallowing
WHat differentiates PICA and AICA lesions?
If it involves hearing it is AICA
Monocular vision loss is caused by what kind of optic lesion?
Optic nerve lesion
Bitemporal hemianopia is a result of what kind of optic lesion?
Optic chiasm, as its the nasal fibres that are impacted.
Remember the images are flipped. So this therefore causes the halves at the side of your eyes to be affected not the nasal fields.
What visual loss would an optic tract lesion cause?
Homonymous hemianopia.
Where is the optic radiation?
Extends from the lateral geniculate body to the ipsilateral visual cortex
What visual loss would occur with a lesion in the optic radiation?
Contralateral homonomyous hemianopia with macular sparing.
The upper half of the visual field is supplied by optic radiation fibres that passes through which lobe?
Temporal lobe
The lower half of the visual field is supplied by optic radiation fibres that pass through which lobe?
Parietal
A lesion in the right temporal lobe would therefore cause what visual field defect?
Contralateral upper quadrantinopia
A lesion in the left parietal lobe would cause what visual field defect?
A contralateral lower quadrantinopia
What is spinal stenosis?
The narrowing of spaces between the vertebrae, causing the pinching of nerves coming out of the spinal cord
Name the cause of 3 peripheral neuropathies that cause predominantly motor loss?
GBS
Charcot marie tooth
Leadpoisoning
Name 3 causes of peripheral neuropathies that cause predominantly sensory loss?
Diabetes
Alcoholism
Vit B12 deficiency
What is anterior cord syndrome?`
Infarction in the anterior spinal artery, causing loss of blood supply to the anterior 2/3 of the spinal cord
What is the most common cause of anterior cord syndrome?
Cross clamping of the aorta in AAA repair
What are the symptoms of anterior cord syndrome?
Bilateral motor weakness below the level of the lesion.
Altered pain and temperature sensation 2/3 dermatomes below the level of the injury
Which antiemetic is associated with extrapyramidal side effects?
Metaclopramide
Which medication is used to treat severe tardive dyskinesia?
Tetrabenazine
Signs of a posterior circulation stroke?
Cerebellar changes
Eye changes
Cranial nerve palsy
What syndrome does a basilar artery stroke cause?
Locked in syndrome
If out of 6 hour window for stroke treatment what is the management?
300mg of aspirin for 2 weeks
What tests would you wan tto run post stroke to look for the cause?
Carotid USS
CT/MRI
ECHO to look for cardioembolic source
Toxicology screen (haemorhagic, as cocaine is common)
What is the most common drug to cause haemorrhagic strole?
Cocaine
What are the symptoms of temporal arteritis?
Jaw claudication
Amaurosis fugax
Scalp tenderness
What is the gold standard investigation for temporal arteritis?
Temporal artery biopsy
What does bulbar palsy affect?
CN9, 10 and 12
How is myasthenia gravis managed?
Prednisalone and pyridostigmine
What is the difference between trigeminal neuralgia and temporal arteritis?
Trigeminal neuralgia is shooting pain which can be triggered by light touch or wind.
Temporal arteritis is scalp tenderness, jaw claudication and eye symptoms
WHich nerve does bells palsy affect?
Facial nerve
What are the symptoms of bells palsy?
Facial muscle weakness
Ear pain
Altered taste and esnesation
What is the treatment of bells palsy?
Steroids for 10 days
What are the causes of horners syndrome?
Stroke
Pancoast tumour
Carotid artery dissection
What are the 5 main symptoms of encephalitis?
Fever
Headache
Psych symptoms
Seizures
Vomiting
Treatment of meningitis ?
IV ceftriaxone
Progressive muscular atrophy has what signs?
Lower motor neurone signs
Primary lateral sclerosis signs?
Upper motor neurone
What is optic neuritis?
Inflammation of the optic nerve
Clinical features of optic neuritis?
Visual loss
Perioccular pain
Dyschromatopsia (loss of colour vision)
Common cause of optic neuritis?
MS
What do you see on LP in MS?
Oligoclonal bands
Acute management of MS?
1g IV methyl pred
What medications to manage chronic MS?
Beta interferon or dimethyl fumerate
What is the triad of normal pressure hydrocephalous?
Incontinence, dementia, gait abnormality
What are the symptoms of raised ICP?
Headach worse on straining
Vomitting
Papilloedema
3rd or 6th nerve palsy
Frontal temporal dementia symptoms?
Personality change and disinhibition
Lewy body dementia symptoms?
Fluctuating cognition, parkinsonism, visual hallucinations
What is the management of a TIA?
300mg aspirin immediately
Refer to specialist to be seen within 24hours
