Neuro Flashcards

1
Q

tension headache presentation

A

generalised, bilateral
non-pulsatile
tight band, pressure like
can radiate to neck and shoulders
episodic, chronic

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2
Q

tension headache ix

A

none specific to tension headaches
normal neuro exam
pericranial or neck muscle tenderness possible on examination

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3
Q

is a recent fall a red flag

A

yes for subdural haemorrhage

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4
Q

what do you need to be aware of when prescribing analgesia for headaches

A

medication overuse headaches (aka rebound headaches)

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5
Q

cluster headache presentation

A

unilateral
episodic
sudden onset
excruciating pain
lacrimation, rhinorrhea, partial Horner’s

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6
Q

cluster headache ix

A

no ix specific for cluster headaches.
MRI- exclude anything more sinister
ESR - exclude giant cell arteritis
pituitary function tests - exclude pituitary adenoma

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7
Q

cluster headache mx

A

acute
-subcutaneous sumatriptan
-high dose, high flow O2

prophylaxis
-verapamil (CCB)

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8
Q

migraine presentation

A

unilateral
comes on gradually
pulsating, throbbing
4-72 hrs
exacerbating: activity, stress, phonophobia, photophobia
relieving: quiet, dark room

associated symptoms:
aura. n+v, visual changes, tingling, numbness, migraine interferes with current activities

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9
Q

migraine ix

A

mostly ix of exclusion
- MRI - exclude smth more sinister
- ESR - exclude giant cell arteritis
- LP - haemorrhage, meningitis

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10
Q

migraine mx

A

conservative:
- headache diary
- avoid triggers
- relaxation techniques (CBT, mindfulness)

acute:
- simple analgesia
- triptans
- consider anti-emetic

prophylaxis:
- propanolol
- topimarate
- amitryptiline

DO NOT GIVE OPIATES

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11
Q

trigeminal neuralgia presentation

A

unilateral pain along trigeminal distribution
paroxysmal, lasting seconds, recurrent episodes
stabbing, shooting pain, like electric shock
exacerbated by moving jaw

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12
Q

risk factors for trigeminal neuralgia

A

increased age
female
multiple sclerosis

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13
Q

management of trigeminal neuralgia

A

1st
acute - anticonvulsants (eg carbamazepine)

long term - microvascular decompression or ablation surgery

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14
Q

raised ICP headache presentation

A

bilateral, gradual, throbbing
vomiting
confusion
worse in mornings
severe pain
papilloedema

Cushings triad - increased systolic BP, irregular breathing, bradycardia

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15
Q

raised ICP Ix

A

urgent CT head

never do lumbar puncture, can cause brainstem herniation

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16
Q

raised ICP mx

A

management of risk factors
analgesia
treat underlying cause

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17
Q

what layers of brain does meningitis affect

A

arachnoid and pia

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18
Q

causes of meningitis

A

bacteria - e.coli, h.influenzae, strep pneumoniae, neisseria meningitidis, listeria monocytogenes

virus - enteroviruses, HSV, VZV, HIV

tuberculosis

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19
Q

meningitis signs and symptoms

A

meningism: neck stiffness, photophobia, headache
fever
n+v
seizures
malaise
hypotension
tachycardia

Kernig’s sign
Brudzinski’s sign
petechial non-blanching rash

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20
Q

meningitis Ix

A

obs
VBG

lumbar puncture (most important)
2 sets of blood cultures

CT head before LP

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21
Q

CSF analysis in bacterial meningitis

A

appearance - cloudy
cells - increased neutrophils (polymorphs)
glucose - reduced
protein - increased

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22
Q

CSF analysis in viral meningitis

A

appearance - clear
cells - increased lymphocytes (mononuclear)
glucose - normal
protein - normal/increased

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23
Q

CSF analysis in TB meningitis

A

appearance - fibrin web
cells - increased lymphocytes (mononuclear)
glucose - reduced
protein - increased

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24
Q

meningitis mx

A

at GP: benzylpenicillin IM & urgent referral to hospital

at A&E: broad spec ABs (ceftriaxone IV, benzylpenicillin IM) acyclovir if viral

targeted ABs
consider dexamethasone
manage close contacts

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25
complications of meningitis
hearing loss sepsis impaired mental status
26
encephalitis causes
viral: HSV 1-2, CMV, EBV, HIV, measles non-viral: bacterial meningitis, TB, malaria, listeria, lyme disease, legionella
27
encephalitis presentation
viral prodrome can have signs of meningism headache altered mental state
28
encephalitis Ix
EEG LP Blood (FBC, LFT, culture) CT/MRI
29
encephalitis Mx
give acyclovir to all pts with suspected encephalitis then give appropriate antiviral or antibiotic according to underlying aetiology
30
stroke definition
sudden onset focal neurological deficit of presumed vascular origin lasting more than 24 hrs
31
types of stoke
haemorrhagic ischaemic
32
stroke symptoms
acute onset limb weakness/numbness facial droop dizziness loss of coordination and balance speech difficulties visual changes
33
ACA stroke associated signs
contralateral hemiparesis (legs > arms) behaviour changes
34
MCA stroke associated signs
contralateral hemiparesis (arms > legs) contralateral hemisensory loss apraxia aphasia quadranotopias
35
PCA stroke associated symptoms
contralateral homonymous hemianopia visual agnosia
36
cerebellar dysfunction signs
DANISH Dysdiadochokinesia Ataxia (gait and posture) Nystagmus Intention tremor Slurred, staccato speech Hypotonia/heel-shin test
37
stroke Ix
urgent within 1hr: - non contrast CT head to rule out haemorrhage ROSIER score - risk of stroke in emergency room serum glucose - hypoglycaemia may mimic stroke u&e - exclude hyponatraemia cardiac enzymes to exclude MI FBCs - anaemia or thrombocytopenia prior to initiation of thrombolysis or anticoagulants ECG - monitor vital signs CT angiogram carotid doppler
38
stroke mx
once haemorrhage excluded, initial treatment depends of time from symptom onset <4.5 hrs - thrombolysis (IV alteplase) then give aspirin 300mg oral >4.5 hrs or thrombolysis contraindicated- aspirin 300mg oral all pts should be referred to stroke unit MDT swallowing assessment - aspiration pneumonia, choking
39
secondary prevention of stroke
300mg PO of aspirin for 2 weeks then AF pts: DOAC/warfarin prophylaxis non-AF pts: (1st line) clopidogrel lifelong (2nd) aspirin + dipyrimadole + antihypertensive/glucose control/atorvastatin
40
score used to estimate stroke risk in TIA pts
ABCD2 score score 4+ refer to stroke specialist
41
transient ischaemic stroke mx
300mg aspirin if within 7 days of episode: specialist review within 24 hrs if after 7 days of episode: specialist review within 7 days secondary prevention clopidogrel 75mg o.d + high intensity statin (atorvastatin) + BP control with antihypertensive if necessary
42
vessels affected in extradural haematoma
middle meningeal artery underneath pterion
43
extradural haematoma signs and symptoms
head trauma > loss of consciousness > lucid interval > headache, decreased GCS, symptoms of raised ICP
44
extradural haematoma ix
urgent non-contrast CT head - lemon shape maybe MRI
45
extradural haematoma mx
surgical emergency refer to neurosurgery for burr hole or craniotomy
46
blood vessels affected in subdural haematoma
bridging veins
47
RF for subdural haematoma
head trauma and falls elderly alcoholics anticoagulation
48
classification of subdural haematoma
acute - within 72 hrs (younger pts, trauma) subacute - 3-20 days (worsening headache, elderly) chronic - after 3 weeks (headache, confusion)
49
subdural haematoma signs and symptoms
gradual continuous headache fluctuating consciousness confusion personality changes symptoms of raised ICP
50
subdural haematoma ix
urgent non-contrast CT head - banana shape
51
subdural haematoma mx
depends on size and presenting symptoms A to E approach and neurosurgery referral small (<10mm) + no significant neurological dysfunction - observe large (>10mm) or significant neurological dysfunction - Burr hole or craniotomy
52
subarachnoid haemorrhage risk factors
polycystic kidney disease alcohol smoking hypertension
53
signs and symptoms of subarachnoid haemorrhage
pain in back of head thunderclap headache meningism signs
54
subarachnoid haemorrhage ix
urgent non contrast CT head - look for hyper-attenuation around circle of Willis if CT head normal, lumbar puncture - xanthochromia and oxyhaemoglobin
55
subarachnoid haemorrhage mx
same as haemorrhagic stroke refer for neurosurgical evaluation nimodipine to prevent delayed cerebral ischaemia review anticoagulant medication
56
epilepsy triggers
there may be no triggers lack of sleep alcohol flashing lights stress
57
epilepsy signs and symptoms
before - strange feeling in stomach - strange smells or taste - visual disturbances during - tongue biting - incontinence - jerking movements after - slow recovery - post-ictal headache - post-ictal confusion and drowsiness - post-ictal myalgia
58
frontal lobe epilepsy presentation
motor symptoms jacksonian march post-ictal flaccid weakness involuntary actions
59
temporal lobe epilepsy presentation
aura (epigastric discomfort) automatisms hallucinations
60
parietal lobe epilepsy presentation
sensory disturbances (pain, tingling, numbness)
61
occipital lobe epilepsy presentation
visual phenomena
62
tonic-clonic seizures phases
tonic phase - muscles stiff clonic phase - quick rhythmical jerking of limbs
63
absence seizures presentation
brief staring episodes lasting 5-10 seconds LOC but posture may be maintained common in children may be mistaken for not paying attention
64
epilepsy Ix
EEG bloods to identify cause glucose - hypoglycaemia fbc - infection u+e - electrolyte disturbances serum prolactin - post-ictal transient elevation CT,MRI to identify potential lesion clinical diagnosis made after 2+ unprovoked seizures occurring >24 hrs apart
65
epilepsy mx
focal - carbamazepine - lamotrigine generalised 1st - sodium valproate 2nd - carbamazepine avoid sodium valproate in women of childbearing age lamotrigine preferred
66
side effects of antiepileptics
psychiatric disturbances weight gain carbamazepine - neutropenia and osteoporosis lamotrigine - Stevens-Johnson syndrome
67
what are dissociative seizures
resemble epileptic seizures but no biological correlate suspect if prolonged duration and history of abuse, psychological precipitants mx often involves psychotherapy
68
status epilepticus definition
seizure lasting > 5 mins or repeated seizures without recovery or regain of consciousness in between medical emergency
69
status epilepticus triggers
non adherence to medication alcohol abuse overdose and drug toxicity
70
status epilepticus mx
secure airway - high flow o2 iv access and monitoring IV lorazepam or PR diazepam - repeat after 10 mins if seizure doesn't stop IV phenytoin refer to ICU
71
epilepsy complications
sudden unexpected death in epilepsy (SUDEP) behavioural problems fractures from seizures complications from drugs
72
Guillain-Barre syndrome aetiology
autoimmune process attacking myelin surrounding peripheral nerves 30% cases after gastroenteritis infection caused by Campylobacter jejuni
73
Guillain-Barre syndrome signs and symptoms
gastroenteritis URTI peripheral neuropathy -ascending paraesthesia and pain -symmetrical limb weakness -hypotonia - flaccid paralysis -altered sensation/numbness -fasciculations can cause respiratory paralysis Miller-Fischer syndrome (25% of cases) - opthalmoplegia - areflexia - ataxia
74
Guillain-Barre syndrome Ix
definitive diagnosis - nerve conduction studies spirometry lumbar puncture - increased protein - normal glucose and WCC bloods - anti-ganglioside antibody in Miller-Fisher variant
75
Guillain-Barre syndrome mx
IV immunoglobulin (IVIG)
76
cord compression signs and symptoms
motor - limb weakness -UMN symptoms below level of lesion -LMN symptoms at level of lesion sensory -sensory loss below a specific level -back pain autonomic - constipation - urinary retention - erectile dysfunction
77
cord compression Ix
definitive diagnosis - MRI may use CT bloods- FBCs, u&e, calcium, ESR, immunoglobulin electrophoresis (multiple myeloma) urine- Bence Jones proteins (multiple myeloma)
78
radiculopathy cause
compression of nerve at or near the nerve root as it exits the spinal cord
79
signs and symptoms of radiculopathy
LMN symptoms for muscles innervated by this spinal root dermatomal pattern of pain, numbness eg sciatica
80
management of radiculopathy
physiotherapy and NSAIDs
81
Lasegue's sign
pain in the distribution of the sciatic nerve is reproduced on passive flexion of the straight leg at the hip between 30-70 degrees
82
types of hydrocephalus
obstructive - stenosis of cerebral aqueduct or intraventricular foramina - posterior fossa lesions compressing 4th ventricle communicating - decreased CSF absorption - increased CSF production normal pressure - idiopathic chronic ventricular enlargement without significantly elevated CSF pressure - triad: urinary incontinence, cognitive impairment, gait apraxia (wet, wacky and wobbly) hydrocephalus ex vacuo - ventricular expansion secondary to brain atrophy such as in Alzheinmer's
83
signs and symptoms of hydrocephalus
acute onset - features of raised ICP - n+v - headache - papilloedema chronic onset - cognitive impairment - unsteady gait - double vision - CN palsies in children - sunset eyes - skull enlargement
84
hydrocephalus Ix
1st line - CT/MRI head CSF analysis from ventricular drain
85
management of hydrocephalus
ventriculoperitoneal shunting to drain CSF
86
multiple sclerosis types
relapsing remitting (RR) ms or primary progressive MS both turn into secondary progressive MS
87
multiple sclerosis signs and symptoms
optic neuritis motor weakness sensory disturbance fatigue hemiparesis/hemisensory loss Lhermitte's sign
88
multiple sclerosis diagnosis
1. absence of alternative diagnosis 2. dissemination in time (DIT) 3. dissemination in space (DIS) methods: clinical history and examination MRI CSF electrophysiology (VEPs)
89
antibodies associated with myasthenia gravis
autoantibodies against AChR at NMJ some pts may have anti-MuSK antibodies
90
gland associated with myasthenia gravis
thymus gland ! thymic hyperplasia (70%) thymoma (10%)
91
myasthenia gravis symptoms
muscles fatigue with use: ptosis diplopia dysarthria dysphagia +/- SOB fatigable muscles normal reflexes
92
mysathenia gravis ix
bloods - anti-AChR and anti-MuSK autoantibodies - some patients are seronegative EMG CT/MRI to check for thymomas
93
Lambert Eaton Myasthenic Syndrome pathophysiology
autoantibodies against presynaptic VGCC at NMJ
94
Lambert Eaton Myasthenic Syndrome symptoms
muscle weakness improves with use - difficulty walking - weakness in upper arms and shoulder - similar symptoms to MG - autonomic: dry mouth, constipation, incontinence - hyporeflexia
95
Lambert Eaton Myasthenic Syndrome associations
small cell lung cancer - paraneoplastic autoimmune
96
Lambert Eaton Myasthenic Syndrome Ix
CT/MRI of chest for cancer detection should be performed bloods for autoantibodies EMG CT/MRI to check for thymomas
97
motor neurone disease pathophysiology
build up of ubiquitinated proteins in the cytoplasm death of corticospinal tracts
98
MND symptoms and signs
progressive muscle weakness dysphagia shortness of breath sparing of oculomotor, sensory and autonomic function wasting of thenar muscles wasting of tongue base upper neurone symptoms - spasticity - hyper-reflexia - clonus -positive Babinski's sign lower neurone symptoms - hyporeflexia - hypotonia - muscle atrophy - fasciculations and fibrillations
99
Parkinson's pathophysiology
loss of dopaminergic neurones in substantia nigra misfolded alpha synuclein builds up Lewy bodies and Lewy neurites
100
drugs that cause parkinsonism
drugs that lower dopamine like antipsychotics and antiemetics
101
parkinsonian triad
resting tremor rigidity bradykinesia
102
6 Ms of Parkinsons
Monotonous hypotonic speech Micrographia Marche a petit pas Misery Memory loss hypomiMesis
103
diagnosis of parkinsons
clinical diagnosis
104
Atypical Parkisonisms
Multiple system atrophy - early autonomic and cerebellar features - Papp-Lantos bodies Progressive supranuclear palsy - early postural instability and vertical gaze palsy Corticobasal degeneration - alien limb phenomenon Vascular Parkinsons - legs particularly affected - gait worse than tremor Lewy Body Dementia - early dementia + visual hallucinations
105
Huntington's disease pathophysiology
autosomal dominant inheritance mutation of huntingtin gene (HTT) expansion of CAG trinucleotide atrophy of the striatum (caudate and putamen)
106
Huntington's signs and symptoms
motor - chorea - athetosis - dysphagia - ataxia cognitive - depression - personality changes - lack of concentration - dementia
107
Huntington's Ix
CAG repeat testing MRI
108
Huntington's CAG repeat testing analysis
< 29 repeats: normal range 29-34: pt will not develop disease but next generation is at risk 35-39: some pt may develop disease, next gen at risk 40+: pt will develop disease
109
types of dementia
Alzheimer's Frontotemporal Vascular Lewy body
110
dementia pathophysiology
buildup of abnormal amyloid precursor protein (APP) normally this breaks down into alpha and gamma secretase but in dementia breaks down into beta and gamma secretase which is resistant to degradation this causes: - extracellular amyloid plaques - phosphorylation of tau - intracellular neurofibrillary tangles - leads to build up of abnormal APP - degeneration of ACh neurones
111
5 As of Alzheimers
Amnesia Anomia Apraxia Agnosia Aphasia (+/- depression and paranoid delusions)
112
Alzheimer's ix
clinical diagnosis - CSF: high tau, low beta amyloid - CT, MRI, PET, SPECT - brain tissue required for definitive diagnosis MMSE Addenbrooke's cognitive assessment MOCA
113
frontotemporal dementia (Pick's disease) pathophysiology
tauopathy involves tau. not amyloid beta. frontal and temporal lobes affected pick bodies - hyperphosphorylated tau protein death within 5-10 yrs
114
frontotemporal dementia signs and symptoms
onset 40-60yrs personality change disinhibition overeating- prefer sweet foods emotional blunting relative preservation of memory
115
Vascular dementia pathophysiology
CVS risk factors, female sx similar to Alzheimer's location-specific deficits affects small and medium vessels step-wise progression
116
Wernicke's encephalopathy pathophysiology
thiamine deficiency
117
Wernicke's encephalopathy risk factors
alcoholism malnourishment bariatric surgery dialysis
118
Wernicke's Encephalopathy Ix
bloods (serum albumin, vit B1, LFTs) ECG CT neuropsychology
118
Wernicke's Encephalopathy signs and symptoms
triad: ataxia, eye signs, confusion alcoholism malnourishment
119
Wernicke's Mx
medical emergency likely give Pabrinex (B1)
120
Wernicke's vs Korsakoff's
Wernickes's: - acute - confusion - cerebellar and eye signs - reversible Korsakoff's: - chronic - alert - amnesia and confabulation - irreversible?