neuro Flashcards
What is the immediate management of stroke?
rule out hypoglycaemia
CT scan to rule out haemorrhage
What is immediately given if haemorrhagic stroke is ruled out?
aspirin 300mg stat
and continued for 2 weeks
What other medication can be given post CT scan in stroke?
alteplase if administered <4.5hrs
What is the management of a TIA?
aspirin 300mg daily, secondary prevention of CVD
What is the gold standard imaging tool for stroke?
diffusion-weighted MRI
What medications can be used for the secondary prevention of stroke?
clopidogrel
atorvastatin - not immediately
What surgical intervention can be used to prevent stroke?
carotid endarterectomy or stenting in patients with carotid artery disease
What are the typical presentations of intracranial bleeds?
sudden onset headache
seizures
weakness
vomiting
reduced consciousness
What score is used to assess level of consiousness?
glasgow coma scale (GCS)
What is the score in GCS based on?
eyes, verbal and motor response /15 points
How do subdural haemorrhages present on CT scan?
crescent shape, not limited by cranial sutures
What is the typical patient in which a subdural haemorrhage would occur?
elderly and alcoholic
What veins rupture to cause a subdural haemorrhage?
bridging veins in the outermost meningeal layer
What artery ruptures to cause an extra dural haemorrhage?
middle meningeal artery (in temporo-parietal region)
How does an extradural haemorrhage present on CT scan?
bi-convex shape (cant cross over sutures)
What is the typical patient to have an extradural haemorrhage?
young patient with traumatic brain injury
How does an intracerebral haemorrhage present?
similar to ischaemic stroke
What is the usual cause of a subarachnoid haemorrhage?
ruptured cerebral aneurysm
What are the typical presentations of a subarachnoid haemorrhage?
thunderclap headache (occipital region) during strenuous activity
What are subarachnoid haemorrhages associated with?
cocaine and sickle cell anaemia
What is a common complication of subarachnoid bleeds?
vasospasm
What medication is used to treat vasospasm?
CCB - nimodipine
What are the principles of management for intracranial bleeds?
CT head
FBCs and clotting factors
intubation, ventilation, ICU
correct hypertension but avoid hypotension
What are some of the causes of epilepsy?
idiopathic
cortical scarring
tumours
strokes alzheimers
alcohol withdrawal
when should patients be referred after their first suspected seizure?
within 2 weeks
What are the types of seizure?
tonic-clonic
focal
atonic
myoclonic
absence
What are the typical symptoms of a focal seizure?
halluncinations
deja vu
memory flashbacks
What are the post-ictal symptoms?
confusion, headache, drowsiness, irritability, sore tongue
What is the main diagnostic tool for epilepsy?
EEG
What are the criteria for status epilepticus?
seizure that lasts longer than 5 mins or more than 3 in 1 hour
What medication should be given in status epilepticus in the community?
benzodiazepines - buccal midazolam or rectal diazepam
What should be given for status epilepticus in the hospital?
IV lorazepam 4mg
What is the first line treatment for tonic-clonic seizures, atonic and myoclonic?
sodium valproate
What is the first line treatment for tonic-clonic seizures in women of child-bearing age?
lamotrigine
What is the first line treatment for focal seizures?
lamotrigine
What is the first line management for absence seizures?
ethosuximide
What is the classic triad of features of parkinsons?
resting tremor
rigidity
bradykinesia
Explain the pathophysiology of parkinsons
the substantia nigra progressively fails to produce enough dopamine
What are the features of the parkinsons tremor?
asymmetrical
4-6Hz
worse at rest
improves with intentional movement
no change with alcohol
Which synthetic dopamine medicine is given in parkinsons and is normally first line in patients with motor symptoms that impact QAL?
levodopa
What type of medications are given in parkinsons patients with motor symptoms that do not impede on their life?
dopamine agonists
Give an example of a dopamine agonist
bromocriptine, pergolide, carbergoline
What is levodopa given with to prevent its destruction before reaching the brain?
peripheral decarboxylase inhibitors
Give an example of a peripheral decarboxylase inhibitor
benserazide
carbidopa
What are the two main levodopa combination drugs?
co-benyldopa (beserazide)
co-careldopa (carbidopa)
what are the main side effects of levodopa?
dyskinesias:
dystonia
chorea
athetosis
What are the side effects of dopamine agonists?
pulmonary fibrosis
adverse events: hallucinations, sleepiness, control/impulse disorder
What does monoamine oxidase do?
breaks down dopamine, serotonin and adrenaline
What are the two examples of a monoamine oxidase-B inhibitors?
seregiline
rasagiline
What is the pathophysiology of Huntingtons?
loss of GABA so no inhibition of dopamine, thalamic stimulation, chorea
What genetic abnormality is present in Huntingtons?
expansion of CAG repeats >35 in HTT gene in chromosome 4
What are the typical symptoms of Huntingtons?
chorea
dysarthria
dysphagia
incoordination
dystonia
cognitive decline
when do symptoms typically show in Huntingtons disease?
30-50 yrs
What feature of genetic inheritance can be present in Huntingtons?
anticipation
What medications may be used to manage chorea in Huntingtons?
benzodiazepines
What other medications may be used to manage symptoms of Huntingtons?
antipsychotics (olanzapine)
SSRIs
dopamine depleting agents (tetrabenzamine)
What is the most common cause of death in Huntingtons patients?
pneumonia
What is alzheimers associates with?
B-amyloid plaques (clump between neurones and effect function)
What is the main investigation for dementia?
MRI
What is the onset pattern of alzheimers?
progressive
What medications can be used to manage symptoms of alzheimer?
cholinesterase inhibitor
What is the onset pattern of vascular dementia?
sudden, stepwise deterioration caused by multiple infarcts
What area of the brain does lewy-body dementia effect?
occipito-parietal region
What are the typical presentations of dementia with lewy bodies?
fluctuating cognitive dysfunction, visual hallucinations, parkinsonism
What type of medication can be used in lewy body dementia?
cholinesterase inhibitors
What are of the brain does Pick’s dementia effect?
frontotemporal
what are could be the cause of headache with photophobia, fever or neck pain?
encephalitis, meningitis
what could be the cause of headache that is worse when coughing/straining/standing?
raised ICP
What could be the cause of headache with new neuro symptoms, sudden onset or trauma?
haemorrhage
What could be the cause of headache with visual disturbances?
temporal arteritis, glaucoma
What examination can be used forICP?
fundoscopy - papilloedema
What are the normal features of a tension headache?
gradual onset and offset, no vision changes
What can cause secondary headaches?
infection, obstructive sleep apnoea, pre-eclampsia
alcohol
head injury
CO poisoning
What is the usual cause of sinusitis?
viral infection
What can long term analgesic use cause?
analgesic headache
What causes a hormonal headache?
low oestrogen dues to: menopause, pregnancy, menstrual period
what are the symptoms of cervical spondylosis?
neck pain and headache, more severe with movement
What is trigeminal neuralgia associated with?
multiple sclerosis
What treatment may be used to manage symptoms of trigem neuralgia?
carbemazepine
What are the 4 types of migraine?
with aura
without aura
silent
hemiplegic
what can trigger migraines?
chocolate
hangovers
orgasms
cheese
oral contraceptives
lie ins
alcohol
tumult
exercise
What are the 5 stages of migraines?
prodromal
aura
headache
resolution
postdromal
What medications can be used in the acute management of migraines?
NSAIDs/paracetamol
triptans - sumatriptan
antiemetic
What is the main recommended prophylaxis for migraines?
acupuncture
What medications can be used as prophylaxis for migraines?
propranolol, topiramate, amitriptylin
what supplementation may prevent migraines?
B2 - riboflavin
What are the typical presentations of cluster headaches?
rapid onset
unilateral pain around eye
watery/bloodshot eye
facial flushing
what are the medicinal treatments of cluster headaches?
vaptans - sumatriptan
What are some of the preventative treatments for cluster headaches?
CCB - verapamil
What part of the CNS is demyelinated in MS?
CNS - oligodendrocytes
What is the inflammation mediated by in MS?
T cell mediated (type 4)
What are the potential causes of MS?
multiple genes
EBV
low vit D
smoking
obesity
What are the typical symptoms of MS?
Tingling
Eyes - optic neuritis
Ataxia - cerebellar and sensory
Motor - paraparesis
What are the different disease patterns of MS?
clinically isolated syndrome
relapsing remitting
secondary progression (after relpasing/remitting)
primary progression
how is MS diagnosed?
with clinical presentations
What imaging/invasive investigations can be done for MS?
MRI - identify lesions
lumbar puncture - oligoclonal bands in CSF
What medication can be used to treat relapses in MS?
Methyl prednisolone
What medication can be used to help with neuropathic pain in MS?
amitriptyline
What medication can be used to treat urge incontinence in MS?
tolterodine (anticholinergic)
What medications can be used to treat spasticity in MS?
baclofen/gabapentin
What types of medications can be used to modify disease in MS?
biological therapies - target interleukins/cytokines/inflammation
What is the most common type of MND?
amyotrophic lateral sclerosis (ALS)
What is the second most common type of MND?
progressive bulbar palsy
What are the potential causes/risk factors of MND?
FH
smoking
exposure to heavy metals/pesticides
What are the signs of LMND?
muscle wasting
reduced tone
fasciculations
reduced reflexes
What are the signs of UMND?
increased tone/spasticity
brisk reflexes
upgoing plantar reflexes
How is MND diagnoses?
by exclusion
What is one medicinal treatment that may extend life by a few months in ALS?
riluzole
What may be used at home to support breathing at night in MND?
Non-invasive ventilation (NIV)
What are some of the presentations of progressive bulbar palsy?
LMND + UMND
dysphagia
dysarthria
What autoantibody is responsible for 85% of cases of myasthenia gravis?
acetylcholine receptor antibodies
What are the other two antibodies responsible for myasthenia gravis?
muscle specific kinase (MuSK)
low density lipoprotein receptor related protein (LRP4)
What do the antibodies do in myasthenia gravis?
block ACh receptors or interfere with production of them leading to inadequate ACh receptors
How do symptoms of myasthenia gravis change throughout the day?
worsen as the day goes on
improve with rest
what muscles does myasthenia gravis typically effect?
proximal muscles and small muscles of the face and neck
What are the signs of myasthenia gravis?
diplopia
ptosis
dysphagia
dysarthria
weakness with repetitive movements
What examinations can be done to diagnose myasthenia gravis?
repeated abduction of arm will then show unilateral weakness
What is Myasthenia gravis associated with?
thymoma - look for thymectomy scar
What are the investigations for myasthenia gravis?
antibody testing
MRI thymus gland
edrophonium test
How does the edrophonium test work?
edrophonium chloride given (blocks cholinesterase enzymes) should temporarily relieve weakness
What are the typical medicinal treatments for myasthenia gravis?
reversible acetylcholinesterase inhibitors
immunosuppressives
monoclonal antibodies
Give and example of a reversible acetylcholinesterase inhibitors used for myasthenia gravis
pyridostigmine
neostigmine
What immunosuppressives can be given in myasthenia gravis?
prednisolone/azathioprine
What can trigger a myasthenic crisis?
respiratory tract infection
How is a myasthenic crisis managed?
non-invasive ventilation (BiPAP)
IV immunoglobulins and plasma exchange
What is the most common bacteria to cause meningitis?
Neisseria meningitidis
What type of bacteria is N. meningitidis?
gram-negative diplococcus
What is the other common bacteria to cause meningitis?
streptococcus pneumoniae
What is the most common bacteria to cause meningitis in neonates?
group B strep
what is meningococcal septicaemia?
infection in the blood
what is a sign of meningococcal septicaemia?
non-blancing rash - indicates disseminated intravascular coagulopathy
What is meningococcal meningitis?
infection of the meninges and the CSF
What are the typical symptoms of meningitis?
fever, neck stiffness, vomiting, photophobia
What are the symptoms of meningitis in a neonate?
hypotonia, poor feeding, lethargy, hypothermia, bulging fontanelle
What investigation is recommended in neonates with a fever?
lumbar puncture
What two examinations can be used to diagnose meningitis?
kernig’s and Brudzinski’s tests
what is the initial management of meningitis in the community?
IM/IV benzylpenicillin + immediate hospitilisation
What investigations should be done in the hospital if meningitis is suspected?
lumbar puncture
bloods - meningococcal PCR and glucose
where is a lumbar puncture done?
L3-L4 space
What things are checked for in the CSF in meningitis?
cloudiness, glucose, protein, WCC viral PCR
What is characteristic of CSF in bacterial infection?
cloudy, high protein, low glucose, high neutrophils and positive cultures
What is characteristic of CSF in viral infections?
clear,normal protein, normal glucose, increased lymphocytes
What may cause fungal meningitis?
cryptococcus, candida
what abx are given to patients under 3 months with menigitis?
cefotazime + amoxicillin
What abx are given to patinets over 3 months with meningitis?
cefotaxime
What other antibiotic may be given if there’s a risk of penicillin allergy?
vancomycin
What might be given to reduce the severity of hearing loss or neuro problems in meningitis?
steroids
What is the treatment for viral meningitis with HSV or VZV?
aciclovir
What are some of the complications of meningitis?
hearing loss
cerebral palsy
cognitive impairment
What triggers guillain-barre syndrome?
recent infection
What are the normal pathogens to trigger guillain-barre syndrome?
campylobacter jejuni, EBV, cytomegalovirus
What is the pathophysiology of guillain-barre syndrome?
B cells produce antibodies against the pathogen and they attack the myelin sheath on motor nerve cells
what is the typical presentation of guillain-barre syndrome?
symmetrical ascending weakness
reduced reflexes
peripheral loss of sensation/neuropathic pain
(may progress to facial nerves)
How long do symptoms usually start after infection in guillain-barre syndrome?
4 weeks
What investigations can be done for guillain-barre syndrome?
nerve conduction studies (slow nerve conduction)
lumbar puncture
What would show on lumbar puncture in guillain-barre syndrome?
high protein
What is the management for guillain-barre syndrome?
IV immunoglobulin
plasma exchange
VTE prophylaxis
What is Lamber-Eaton myasthenic syndrome associated with?
small cell lung cancer
How does Lambert-Eaton myasthenic syndrome present?
similar to myasthenia gravis
proximal muscle wasting
ptosis
diplopia
dysphagia
dysarthria
What medication is used to treat Lambert-Eaton myasthenic syndrome?
amifampridine
What is charcot-marie tooth disease?
an autosomal dominant condition that effects motor and sensory nerves
What are the classic features of charcot-marie tooth disease?
high foot arch (pes cavus)
distal muscle wasting
weakness in dorsiflexion
reduced tone/reflexes
What are the causes of peripheral neuropathy? (ABCDE)
alcohol
B12 deficiency
cancer and CKD
diabetes and drugs (azathioprine)
every vasculitis
What is the criteria for neurofibromatosis type 1?
two of CRABBING
cafe-au-lait spots
relative with NF1
axillary or inguinal freckles
bony dysplasia or bowing
iris hamartomas
neurofibromas
glioma of optic nerve
What is a common feature of neurofibromatosis type 2?
bilateral acoustic neuromas
What is tuberous sclerosis?
genetic condition that causes the development of hamartomas (benign neoplastic growths)
what is the classic presentation of tuberous sclerosis?
child with epilepsy and skin feature (cafe-au-lait spots/ash leaf spots etc)
How is tuberous sclerosis managed?
management of complications e.g. epilepsy
What are the typical presentations of brain tumours?
raised ICP and focal neurological symptoms
what are the three main types of glioma?
astrocytoma
oligodendrocytoma
ependymoma
