Neuro Flashcards
Headache - unilateral, intense, episodic, lacrimation + restless?
cluster
investigation of choice for cluster headache?
MRI with gondalium contrast
acute cluster headache management?
- oxygen
- subcut triptan
chronic cluster headache prophylaxis?
verapamil
facial palsy - LMN vs ULM how to tell?
LMN- affects all facial muscles
ULM - spares the upper face (forehead)
causes of bilateral facial palsy?
sacoidosis
lyme disease
Guillian-barre syndrome
bilateral acoustic neuroma
bell’s palsy
causes of unilateral facial palsy?
Bell’s palsy
Ramsay-Hunt syndrome (due to herpes zoster)
acoustic neuroma
parotid tumours
HIV
multiple sclerosis*
diabetes mellitus
stroke
LMN lesion symptoms + post-auricular pain + hyperacusis + dry eyes + altered taste - what is it?
Bells palsy
management of bells palsy?
prednisolone + lubricating eye care
ear pain + vesicular rash around ear + facial palsy - what is it?
Ramsay Hunt syndrome
management of Ramsay hunt syndrome?
oral aciclovir and corticosteroids
management of suspected encephalitis?
IV aciclovir
investigations for encephalitis?
CSF - elevated lymphocytes + protein
PCR for HSV, VZV + enterovirus
Neuroimagining
EEG
urinary incontinence + dementia + gait instability = ?
normal pressure hydrocephalus
management of normal pressure hydrocephalus?
ventriculoperitoneal shunting
Myasthenia gravis investigations?
- single fibre electromyography
- antibodies to acetylcholine receptors
- Muscle-specific kinase (MuSK) antibodies
- CT or MRI of thymus
- Edrophonium Test - only if doubt about diagnosis
which malignancy is associated with myasthenia gravis?
thymomas
management of myasthenia gravis?
long-acting acetylcholinesterase inhibitors (pyridostigmine - first-line)
immunosuppression (not initially but most patients require it eventually) - prednisolone
thymectomy
monoclonal antibodies e.g. Rituximab
management of myasthenic crisis?
plasmapheresis
IV immunoglobulins
Non invasive ventilation with Bipap or intubation
suspected stroke first line investigation?
non-contrast CT head
which scoring system is used for stroke?
ROSIER
suspected spinal cord compression investigation?
MRI whole spine
What is ‘status epilepticus”?
a single seizure lasting >5 minutes,
OR
>= 2 seizures within a 5-minute period without the person returning to normal between them
first line drugs for status epilepticus?
IV benzodiazepines such as diazepam or lorazepam
2nd line drugs for status epilepticus?
phenytoin or phenobarbital infusion
What is Guillain-Barre syndrome?
immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni).
Investigations for Guillain-Barre syndrome?
- Lumber puncture - protein rise + normal WCC
- nerve conduction studies - (decreased motor nerve conduction velocity (due to demyelination)
prolonged distal motor latency
increased F wave latency)
How does Guillain-Barre syndrome present?
initially - leg/back pain (65%)
Progressive, symmetrical weakness of all the limbs
+ ascending fashion (legs first)
+ reduced/absent reflexes
+ mild sensory symptoms (e.g. distal paraesthesia)
other symptoms -
respiratory muscle weakness
cranial nerve involvement
autonomic involvement (diarrhoea, retention)
papilloedema
Treatment for trigeminal neuralgia?
carbamazepine
Unilateral ‘electric shock’ pain on light touch = ?
trigeminal neuralgia
Management of normal pressure hydrocephalus?
Surgery is ventriculo-peritoneal shunting
If unfit for surgery then conservative treatment and repeated CSF taps.
Investigations in normal pressure hydrocephalus?
MRI or non-contrast CT Head - enlarged ventricles
Walking and cognitive assessment before and after large volume CSF removal - definite investigation.
Investigations for multiple sclerosis?
MRI with contrast - brain and spine
CSF - oligoclonal bands
How does MS present?
- Optic neuritis - most commonly
- Focal weakness (Bells palsy, Horners syndrome, Limb paralysis, Incontinence)
- sensory symptoms (Trigeminal neuralgia, Numbness
,Paraesthesia ) - ataxia
Treatment for acute relapse of MS?
methylprednisolone (500mg oral for 5 days OR 1g IV for 3-5 days)
Head/leg movements, posturing, post-ictal weakness, Jacksonian march seizure = which part of brain affected?
frontal lobe
Paraesthesia seizure = which part of brain affected?
parietal lobe
Floaters / flashes in seizure = which part of brain affected?
occipital lobe
lip smacking/grabbing/plucking + post-ictal dysphasia seizure = which brain part affected?
temporal lobe
seizure with ‘aura’ or deja vu or hallucinations = which part of brain?
temporal
Investigation for neoplastic spinal cord compression?
Whole spine MRI within 24 hours
Treatment for neoplastic spinal cord compression?
high-dose oral dexamethasone
urgent oncological assessment for consideration of radiotherapy or surgery
When would you refer someone with trigeminal neuralgia?
failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology
What is parkinsons disease?
progressive reduction of dopamine in the basal ganglia of the brain, leading to disorders of movement.
Triad of symptoms for parkinsons disease?
Resting tremor
Rigidity
Bradykinesia
Treatment for parkinsons disease with functional impairement?
levodopa (Co-careldopa = levodopa combined with carbidopa)
dopamine agonists e.g. bromocryptine or Monoamine Oxidase-B Inhibitors e.g. Selegiline can be added as adjuvants or to delay use of levodopa
Symptoms of cerebellar syndrome (DANISH)?
D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear ‘Drunk’
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremour
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
What is a seizure?
transient episode of abnormal electrical activity
Investigations for epilepsy?
EEG
MRI brain
What are the different types of seizures?
Generalised tonic-clonic
focal seizure
absence
atonic
myoclonic
Infantile spasms
Management of Generalised tonic-clonic seizures?
MALE:
sodium valproate - 1st line
lamotrigine or levetiracetam - 2nd line
FEMALE:
lamotrigine or levetiracetam - 1st line
Presentation of Generalised tonic-clonic?
loss of consciousness
tonic (muscle tensing) and clonic (muscle jerking) episodes
tongue biting
incontinence
groaning
irregular breathing
prolonged post-ictal period following seizure (confused, drowsy)
Focal seizure - which part of brain typically affected first?
temporal lobes
Presentation of focal seizure?
Affect hearing, speech, memory and emotions:
- hallucination
- memory flashback
- Deja vu
- repetitive behaviour (e.g. lip smacking)
Management of focal seizures?
Levetiracetam or lamotrigine - 1st line
Carbamezapine - 2nd line
Presentation of absence seizure?
- typically in children
- patient becomes blank, stares into space
- unaware of surroundings
- last 10-20 seconds
Management of absence seizure?
Ethosuximide- 1st line
MALES - sodium valproate - 2nd line
FEMALEs - lamotrigine/levetiracetam
Presentation of atonic seizure?
“drop attacks” - lapse in muscle tone
<3mins
Management of atonic seizure?
sodium valproate - 1st line - MALES
lamotrigine - 2nd line - FEMALES
Presentation of myoclonic seizure?
-sudden brief muscle contractions
-patient awake during episode
-typically in children as part of juvenile myoclonic epilepsy
Management of myoclonic seizure?
sodium valproate - 1st line - MALES
levetiracetam - 1st line - FEMALES
lamotrigine or levetiracetam or topiramate - 2nd line
Infantile spasm presentation?
- around 6 months of age
- clusters of full body spasms
Infantile spasms prognosis?
poor - 1/3rd die by age 25, 1/3rd seizure free
Management of infantile spasms?
prednisolone + vigabatrin
Epilepsy in childbearing age woman management?
lamotrigine - first line
What is status epilepticus?
seizure lasting more than 5 mins or more than 3 seizures in 1hr.
Management of status epilepticus?
ABCDE
IV lorazepam 4mg - repeat after 10 mins if needed
if no resolution then IV phenobarbital or phenytoin
Management of status epilepticus in community?
buccal midazolam
rectal diazepam
What are the 3 principles to consider when classifying seizures?
- Where seizures begin in the brain
- Level of awareness during a seizure (important as can affect safety during seizure)
- Other features of seizures
Features which would suggest pseudo-seizure over true seizure?
- pelvic thrusting
- family member with epilepsy
- much more common in females
- crying after seizure
- don’t occur when alone
- gradual onset
Features which suggest true seizure over pseudo-seizure?
rise in prolactin
Criteria for CT head within 1 hour after head injury?
- GCS < 13 on initial assessment
- GCS <15 at 2hrs post injury
- suspected open or depressed skull fracture
- any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, CSF leakage, battle’s sign)
- post-traumatic seizure
- focal neurological deficit
- > 1 episode vomiting
Criteria for CT head within 8 hour after head injury?
loss of consciousness +/- amnesia AND one of the following:
- >65y
- history of bleeding / clotting disorder including anticoagulants
- dangerous mechanism of injury
- >30 mins retrograde amnesia of events immediately before head injury
OR patient on warfarin
Patient post-stroke or TIA + AF = which anticoagulant?
warfarin (or direct thrombin or factor Xa inhibitor - apixiban)
Stroke Classification system + what does it assess?
Oxford (also known as bamford)
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarct - presentation?
involves middle and anterior cerebral arteries
All 3 of:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
Partial anterior circulation infarct - presentation?
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2/3 of:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
Lacunar infarct - presentation?
involves perforating arteries around the internal capsule, thalamus and basal ganglia
Presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Posterior circulation infarct - presentation?
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
Stroke identification screening tool in emergency department?
ROSIER (>0 = likely stroke)
Stroke management?
- admit to stroke unit
- exclude hypoglycaemia
- Immediate CT head
- Aspirin 300mg STAT - continue for 2 weeks
Thrombolysis with alteplase (within <4.5hrs + excluded haemorrhage)
OR
thrombectomy (within 6hrs)
TIA management?
Aspirin 300mg daily. Refer to specialist within 24 hours.
Investigations for TIA/stroke?
CT head - 1st line
Diffusion-weighted MRI - gold standard
carotid USS - check for stenosis
Secondary prevention of stroke?
- Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily + aspirin)
- Atorvastatin 80mg should be started but not immediately
- Carotid endarterectomy or stenting in patients with carotid artery disease
- Treat modifiable risk factors such as hypertension and diabetes
Features of idiopathic raised intracranial pressure?
- headache
- blurred vision
- papilloedema (usually present)
- enlarged blind spot
- sixth nerve palsy may be present
Management of idiopathic raised intracranial pressure?
- weight loss
- Acetazolamide (carbonic anhydrase inhibtor)
- topiramate can be used - headache prophylaxis
- repeated lumbar puncture
- CSF shunting
Which drugs are associated with idiopathic raised intracranial pressure?
Oral contraceptive pill
Steroids
Tetracycline
Vitamin A
Lithium
What do subdural haemorrhages look like on CT?
Crescent shape (suBdural for banana) - not limited by cranial sutures
What causes a subdural haemorrhage?
Rupture of the bridging veins in the outermost meningeal layer. They occur between the dura mater and arachnoid mater.
Which groups of people are more likely to have subdural bleeds?
Elderly and alcoholics
What causes a extradural haemorrhage?
Rupture of the middle meningeal artery in the temporo-parietal region. It can be associated with a fracture of the temporal bone. It occurs between the skull and dura mater.
What does a extradural haemorrhage look like on CT?
Bi-convex shape and are limited by the cranial sutures (they can’t cross over the sutures).
Young patient with a traumatic head injury that has an ongoing headache. They have a period of improved neurological symptoms and consciousness followed by a rapid decline over hours = ?
Extradural haemorrhage
What causes subarachnoid haemorrhages and where are they located?
Ruptured cerebral aneurysm.
Bleeding in to the subarachnoid space (where the cerebrospinal fluid is located) between the pia mater and the arachnoid membrane.
Presentation of subarachnoid haemorrhage?
‘thunder clap headache’
neck stiffness
visual disturbances
photophobia
neuro symptoms
Which conditions is subarachonoid haemorrhage associated with?
cocaine use,
sickle cell anaemia,
connective tissue disorders
Neurofibromatosis
Autosomal dominant polycystic kidney disease
Typical findings on lumbar puncture in subarachnoid haemorrhage?
- raised red cell count
- Xanthochromia (the yellow colour of CSF caused by bilirubin)
Management of subarachnoid haemorrhage?
- managed in specialist neurosurgical unit - supportive management
- surgical intervention of aneurysms - coiling or clipping
- nimodipine - management of vasospasm
What is multiple sclerosis?
Chronic and progressive condition that involves demyelination of the myelinated neurones in the central nervous system. This is caused by an inflammatory process involving the activation of immune cells against the myelin.
MS drugs to induce long term remission?
DMARDS (eg. natalizumab, ocrelizumab)
Spasticity in MS management?
Baclofen and gabapentin - first-line.
Most common type of motor neurone disease?
Amyotrophic lateral sclerosis (ALS)
Presentation of motor neurone disease?
- asymmetric limb weakness
- the mixture of lower motor neuron and upper motor neuron signs
- wasting of the small hand muscles/tibialis anterior
- fasciculations
- the absence of sensory signs/symptoms
Signs of lower motor neurone disease?
- Muscle wasting
- Reduced tone
- Fasciculations (twitches in the muscles)
- Reduced reflexes
Signs of upper motor neurone disease?
- Increased tone or spasticity
- Brisk reflexes
- Upgoing plantar responses
Management of motor neurone disease?
Riluzole - slows progression in ALS
Non-invasive ventilation
PEG for nutrition
Diagnostic criteria for parkinsons disease?
UK Parkinson’s Disease Society Brain Bank Clinical Diagnostic Criteria.
Criteria for assessing neuropathic pain?
DN4 Questionnaire (>4 = neuropathic pain)
Drugs used for neuropathic pain?
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
What is benign essential tremor?
Common condition associated with older age. It is characterised by a fine tremor affecting all the voluntary muscles. It is most notable in the hands but affects many other areas, for example causing a head tremor, jaw tremor and vocal tremor.
Management of benign essential tremor?
Propranolol
Primidone (a barbiturate anti-epileptic medication)
Causes of raised intracranial pressure?
- Brain tumours
- Intracranial haemorrhage
- Idiopathic intracranial hypertension
- Abscesses or infection
Red flags of headache?
Constant
Nocturnal
Worse on waking
Worse on coughing, straining or bending forward
Vomiting
Which tumours typically metastasise to the brain?
Lung
Breast
Renal cell carcinoma
Melanoma
Pituitary tumours presentation?
- Bitemporal hemianopia (as they press on the optic chiasm)
- hormone deficiency (hypopituitarism)
- excessive hormone (e.g. acromegaly, hyperprolactinaemia, cushings, thyrotoxicosis)
Treatment of pituitary tumours?
- Trans-sphenoidal surgery
- Radiotherapy
- Bromocriptine to block prolactin-secreting tumours
- Somatostatin analogues (e.g. ocreotide) to block growth hormone-secreting tumours
What is Myasthenic crisis?
Acute worsening of symptoms, often triggered by another illness such as a respiratory tract infection. This can lead to respiratory failure as a result of weakness in the muscle of respiration
Presentation of myasthenia gravis?
Weakness that gets worse with muscle use and improves with rest.
most often affects proximal muscles + muscles of head and neck
Which condition is lambert-eaton syndrome associated with?
small-cell lung cancer
Features of lambert-eaton syndrome?
- repeated muscle contractions lead to increased muscle strength - can also present with weakness
- limb-girdle weakness (affects lower limbs first)
- hyporeflexia
- autonomic symptoms: dry mouth, impotence, difficulty micturating
Management of lambert eaton syndrome?
Treat underlying cancer
Amifampridine
Immunosuppressants (e.g. prednisolone or azathioprine)
IV immunoglobulins
Plasmapheresis
What is charcot-Marie-Tooth disease?
An inherited (usually autosomal dominant) disease that effects motor and sensory nerves - dysfunction in the myelin or the axons.
Features of charcot-Marie-tooth disease?
- High foot arches (pes cavus)
- Distal muscle wasting causing “inverted champagne bottle legs”
- Weakness in the lower legs, particularly loss of ankle dorsiflexion
- Weakness in the hands
- Reduced tendon reflexes
- Reduced muscle tone
- Peripheral sensory loss
Management of charcot-marie-tooth disease?
MDT approach - neurologists, geneticists, physio, occupational therapy, podiatry, orthopaedic surgeans
What is Guillain barre syndrome?
Acute, symmetrical, ascending weakness and can also cause sensory symptoms - triggered by an infection and is particularly associated with to campylobacter jejuni, cytomegalovirus and Epstein-Barr virus.
Presentation of Guillain barre syndrome?
- Symmetrical ascending weakness (starting at the feet and moving up the body)
- Reduced reflexes
- peripheral loss of sensation or neuropathic pain
- may progress to the cranial nerves and cause facial nerve weakness
- symptoms peak 2-4 weeks of preceding infection - recovery can last months to years.
How can Guillain-barre syndrome be diagnosed?
Brighton criteria
diagnosis can be supported by nerve conduction studies and lumbar puncture.
Management of Guillain-barre syndrome?
- IV immunoglobulins
- Plasma exchange (alternative to IV IG)
- Supportive care
- VTE prophylaxis (pulmonary embolism is a leading cause of death)
- severe respiratory failure - intubation.
Which chromosome does neurofibromatosis type 1 affect + inheritance type?
chromosome 17
autosomal dominant
Diagnostic features of neurofibromatosis?
at least 2/7 of the following:
- C - Cafe-au-lait spots
- R - relative with NF1
- A - axillary or inguinal freckles
- BB - bony dysplasia
- I - iris hamartomas (lisch nodules) - yellow brown spots in iris
N - neurofibromas or plexiform neurofibroma
G - glioma of the optic nerve
bilateral acoustic neuromas associated with what condition?
neurofibromatosis type 2
Which chromosome does neurofibromatosis type 1 affect + inheritance type?
chromosome 22
autosomal dominant
Treatment of tension headache?
- Reassurance
- Basic analgesia
- Relaxation techniques
- Hot towels to local area
Management of sinusitis?
- usually resolves within 2-3 weeks
- nasal irrigation
- prolonged - steroid nasal spray
- antibiotics - rarely.
Presentation of hemiplegic migraine?
- Typical migraine symptoms
- Sudden or gradual onset
- Hemiplegia (unilateral weakness of the limbs)
- Ataxia
- Changes in consciousness
acute management of migraine?
- Paracetamol
- Triptans (e.g. sumatriptan 50mg as the migraine starts)
- NSAIDs (e.g ibuprofen or naproxen)
- Antiemetics if vomiting occurs (e.g. metoclopramide)
Migraine prophylaxis?
- propanolol
- topiramate (teratogenic)
- amitriptyline
- acupuncture
Presentation of brain abscess?
- raised ICP (nausea, papilloedema, seizures)
- headache - persistent
- fever
- focal neurology
Investigation for brain abscess?
CT scan
Management of brain abscess?
- surgery - craniotomy + abscess cavity debried
- IV antibiotics - IV 3rd generation cephalosporin + metronidazole
- intracranial pressure management e.g. dexamethasone.
Triad of symptoms for wernicke’s encephalopathy?
Ophthalmoplegia, fluctuant mental state (confusion) and ataxia
Management of wernicke’s encephalopathy?
Urgent administration of parenteral (not oral) thiamine for a minimum of 5 days.
Management of encephalitis?
2g IV ceftriaxone BD
10 mg/kg aciclovir TDS for two weeks.
Clinical features of encephalitis?
- altered mental state
- fever
- flu like illness
- seizures
Management of spinal cord compression?
urgent WHOLE spine MRI, with an aim (in appropriate cases) to surgically decompress within 48 hours.
dexamethasone if maligancy.
clinical features of spinal cord compression?
back pain
bladder / bowel involvement
acute upper motor neurone signs and sensory disturbance
Common bacterial causes of bacterial meningitis?
- Streptococcus pneumoniae (pneumococcus)
- Neisseria meningitidis (meningococcus)
- Haemophilus influenzae
- Listeria monocytogenes (often in patients at extremes of age)
Clinical features of meningitis?
- headache
- fever
- neck stiffness
- photophobia
- nausea and vomiting
- focal neurology
- seizures
- reduced conscious level
- features of overwhelming sepsis (including the often reported non-blanching petechial rash of impending DIC).
Management of meningitis?
iV cetriaxone
+/- IV amoxicillin
+/- IV aciclovir (if suspicion of encephalitis)
Triad of symptoms for brain stem compression?
Cushing’s triad:
- bradycardia
- hypertension
- irregular/abnormal breathing
What are the 4 main types of space occupying lesions?
tumours
vascular lesions
infective
granulomata
Causes of cerebellar disease?
PASTRIES
P - posterior fossa tumour
A - alcohol
S - multiple sclerosis
T - trauma
R - rarer causes
I - inherited
E - epilepsy treatment
S - stroke
cervical spine fracture investigation?
CT neck
Intrinsic hand muscle wasting + reduced sensation on medial side of arm - indicates which nerve root?
T1
Guillian barre management?
IV immunoglobulins
Which antibiotic should be used as prophylaxis for contacts of patients with meningococcal meningitis?
Oral ciprofloxacin
