Neuro Flashcards
Presentation of absence seizures
girls 3-10
provoked by stress or hyperventilation
pt unaware
EEG: bilateral sym 3Hz spike and wave pattern
Management and prognosis of absence seizures
valproate and ethosuximide
90-95% seizure free at adolescence
Classification of epilespy
generalised: motor or non motor
Focal: aware/impaired awareness/awareness unknown: motor/non motor/ other feature
Features of focal temporal seizure
aura: rising epigastric sensation, psychic, hallucinations
automatisms: lip smacking
features of frontal focal seizure
head/leg movements
posturing
post-ictal weakness
features of parietal focal seizure
paraesthesia
features of occipital focal seizure
floaters/flashes
When do you start management of seizures
after 2nd seizure unless
- neurological deficit
- structural abnormality on imaging
- epileptic activity on EEG
- risk of further seizure unacceptable
Management of tonic clonic seizure
m: valproate
f: lamotrigine or keppra
management of tonic or atonic seizure
m: valproate
f: lamotrigine
management of myoclonic seizure
m: valproate
f: keppra
management of focal seizure
1st: lamotrigine or keppra
2nd: carbamazepine
Which anti-epileptics can be used in pregnancy
carbazmazepine, lamotrigine
which anit-epileptics should be avoided in pregnancy
valproate: neural tube defects and neurodevelopment delay
What are the driving rules for epilepsy
inform DVLA
after 1st seizure - no driving 6 months
established - can drive if 1 year seizure free
withdrawing meds - no driving until 6 months after last dose
How does sodium valproate work
increase GABA activity
Valproate SE
p450 inhib
nausea, increased appetite, weight gain
ataxia, tremor
hepatotoxic, pancreatitis
thrombocytopenia, low Na
What causes Bells Palsy
unknown but associated with HSV, EBV
How does Bells Palsy present
Unilateral lower motor neuron facial nerve palsy - forehead affected
pregnant women 20-40
dry eyes
Management Bells Palsy
PO pred within 72h
Debate on anitvirals
artifical tears
tape eye if unable to close
ENT Referral at 3 weeks
Bells Palsy prognosis
most fully recover by 3/4 months
What is BPPV
vertigo triggered by change in head position can be associated with nausea
How is BPPV diagnosied
Dix-Hallpike manoeuvre
Management of BPPV
spontaneous recovery weeks-months
Epley helps with symptoms
betahistine limited valve
Causes of brain abscess
sepsis, trauma, embolic event
Symptoms of brain abscess
headache, fever, focal neurology, nausea, seizures
Investigation and management of brain abscess
CT head
Surgery, Abx and dex
What is Brown-Sequard syndrome
Lateral hemi-section of spinal cord
Features of Brown Sequard syndrome
ipsilateral weakness below lesion
ipsilateral loss of proprioception and vibration sensation
contralateral loss of pain and temperature sensation
Symptoms of cerebellar disease
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremer
Slurred speech
Hypotonia
What is GBS
immune mediated demyelination of peripheral nerve system triggered by infection
Infection associated with GBS
Campylobacter jejuni
Presentation of GBS
leg/back pain
ascending sym limb weakness
reduced/absent reflexes
resp muscle weakness
Investigation of ?GBS
LP (increased protein, normal WCC)
nerve conduction studies
-decreased motor nerve conduction
-increased distal motor latency
-increased F wave latency
Management of GBS
IVIG
plasma exchange (more difficult and equally as effective)
FVC - monitor resp function
Poor prognostic factors of GBS
age > 40 years
poor upper extremity muscle strength
previous history of a diarrhoeal illness (specifically Campylobacter jejuni)
high anti-GM1 antibody titre
need for ventilatory support
Following head injury when does CTH need to be performed in 1 hr
GCS <13 initially
GCS <15 after 2 hrs
Suspected skull # or basal skull #
Seizure
Focal neuro deficit
>1 episode of vomiting
Following a head injury when does a CTH need to be performed in 8 hrs
loss of cons/amnesia +
>65
Hx bleeding/clotting disorder
dangerous mechanism
>30mins retrograde amnesia
What causes herpes simplex encephalitis and where does it affect
HSV1
temporal and inferior frontal lobes
how does HS encephalitis present
fever, headache, seizure, vomiting, psych
focal - aphasia
Investigations of herpes simplex encephalitis
CSF: high WCC high protein
PCR for HSV
CT: petechial haemorrhages temporal/frontal
MRI
EEG: lateral periodic discharges 2Hz
Management and prognosis of herpes simplex encephalitis
IV Aciclovir
10-20% mortality if started early compared to 80% if untreated
What kind of disease is Huntingtons?
autosomal dominant
Genetics of Huntingtons
Chromosome 4, triplet repeat CAG -> glutamine
normal is 10-35
Huntingtons >35
Pathophysiology of Huntingtons
degeneration of cholingeric and GABA neurones in striatum of basal ganglia
Presentation of Huntingtons
35-40 yo
chorea
abnormal eye movements
dementia, personality change
Management of Huntingtons
No treatment to alter prognosis
Tetrabenazine for chorea
Huntingtons prognosis
death 20 years after the initial symptoms develop
What is Lambert Eaton syndrome
antibody directed against presynaptic voltage gated calcium channel in peripheral nervous system
What causes Lambert Eaton syndrome
SCLC (ovarian and breast)
autoimmune
How does Lambert Eaton syndrome present
Muscle weakness that improves with use
prox muscles of lower limbs first
hypo reflexes
autonomic: dry mouth, impotence
Lambert Eaton investigation
EMG: incremental response to repetitive electrical stimulation
Management of Lambert Eaton syndrome
Treat any underlying cancer
Immunosuppression - pred
IVIG
What is myasthenia gravis
autoimmune insufficient functioning of acetylcholine receptors
How does myasthenia gravis present
women<40 or men >60
muscle fatiguability - worse at end of day
prox muscle weakness
diplopia, ptosis, dysphagia
what is myasthenia gravis associated with
thymoma
Myasthenia Gravis examination findings
fatiguing when
- upward gazing
- blinking
- repeated abduction
Investigations for myasthenia gravis
EMG
antibodies - Ach receptor antibodies (85%)
CT thymus
Management of myasthenia gravis
pyridostigmine
immunosuppression
thymectomy
What is a myasthenia crisis
acute worsening of symptoms, triggered by infection, risk of resp failure requiring NIV/intubation and ventilation
Mx: IVIG
What is Menieres disease
excessive pressure and progressive dilation of endolymphatic system - unknown cause
How does Menieres present
vertigo tinnitus, hearing loss
aural fullness/pressure
lasts mins-hours
unilateral->bilateral
How do you manage Menieres
ENT referral
inform DVLA - no driving until symptoms controlled
Acute: prochlorperazine (buc or PO)
prevent: betahistine, vestibular rehab
Menieres prognosis
most resolve within 5-10 years, likely will be left with some hearing loss
Types of MND
1) Amylotrophic lateral sclerosis
2) Primary lateral sclerosis
3) Progressive muscular atrophy
4) Progressive bulbar palsy
Hows does ALS present
LMN signs in arms - drop things, stiffness, wasting
UMN signs in legs - foot drop, difficultly climbing stairs
How does Primary lateral sclerosis present
UMN only, leg weakness
How does progressive muscular atrophy present
LMN only
distal ->proximal, small muscles of hands/feet
How does progressive bulbar palsy present
palsy of tongue, muscles of chewing/swallowing
Which types of MND carry the best and worse prognosis
What is the general prognosis
Best: progressive muscular atrophy
Worst: progressive bulbar palsy
General: 50% died within 3 years
Investigations for MND
clinical diagnosis
NCS: normal
EMG: reduced action potential with increased amplitude
MRI: exclude cervical cord compression
Management of MND
Riluzole - increases life by 3 months
BiPAP at night - increases life by 8 months
PEG
What is MS
chronic cell mediated autoimmune disorder characterised by CNS demyelination
Types of MS
1) Relapsing remitting: most common
2) Secondary progressive: RR with symptoms between, 65% with RR develop this within 15 years
3) Primary progressive: deterioration from onset
Presentation of MS
optic neuritis
optic atrophy
worsening vision following rise in body temp
pins/needles/numbness
spastic weakness
ataxia
urinary incontinence
Investigations of MS
MRI: T2 lesions, periventricular plaques, Dawson fingers (white matter perpendicular to corpus callosum)
CSF: oligoclonal bands
Management of MS relapses
Acute relapse: 5/7 Methypred
Reduce risk of relapse: natalizumab, ocrelizumab
Management of fatigue in MS
amantadine
Management of spasticity in MS
baclofen, gabapentin
Good prognostic features of MS
*common presentation
female
20-30 onset
relapsing remitting
long intervals and complete recovery between relapses
Symptoms of normal pressure hydrocephalus
1) urinary incontinence
2) dementia
3) gait abnormalilty
Imaging findings of normal pressure hydrocephalus
hydrocephalus with ventriculomegaly
Management of normal pressure hydrocephalus
ventriculoperitoneal shunt
What is Parkinsons
progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in substantia nigra
Presentation of Parkinsons
men,65
asym
1) bradykinesia: shuffling gait, reduced arm swelling
2) tremor: resting, pill rolling
3) rigidity: lead pipe, cog wheel
Additional Parkinsons symptoms (Not classic trio)
reduced facial expressions
depression
micrographia
drooling
Management of Parkinsons
Do motor symptoms affect quality of life
yes: levodopa
no: dopamine agonist, levodopa, MAO-B inhib
SE of levodopa
dry mouth, anorexia, palpitations, dyskinesias
Examples of dopmaine receptor agonists + monitoring required
bromocriptine, ropinirole
ECHO, CXR, Cr, ESR
Causes of SAH
berry aneurysm
AVM
Presentation SAH
thunderclap headache
N&V
meningism
Investigtion of SAH
CT head: SAH
Normal CT: <6hrs - no LP
>6hrs: LP after 12hrs - Xanthochromia
Cta for cause
Management of SAH
Supportive
Nimodipine prevents vasospasm
coil
Types of SDH and causes
Acute: trauma
Chronic: rupture of bridging veins (alcoholic /elderly)
CT findings in SDH
crescent shape
acute: hyperdense
chronic: hypodense
Management of SDH
acute: monitor, decompressive craniectomy
Chronic: conservative if incidental, decompression if symptomatic
describe presentation of cluster headache
unilateral sharp pain around eye
lasts 15m-2hr
lid swelling, redness, restlessness
Management of cluster headache
acute: 100% o2, SC triptans
prophylaxis: verapamil ?pred
Describe medication overuse headache
> =15days/month
Which medications can cause medication overuse headache
opioids, triptans
management of medication overuse headache
stop triptans/simple analgesia
slow wean of opioids
What symptoms might a pt experience when analgesia is stopped due to medication overuse headache
vomiting, hypotension, increased HR, restlessness
Migraine triggers
tired, stressed, alcohol, COCP, menstruation
migraine diagnostic criteria
5 attacks
-4-72hrs
-N&V and/or photophobia and phonophobia
-at least 2 of: unilateral,pulsatile, mod/severe, affects routine
- no other cause
Management of migraine
acute: PO triptans and NSAID/PCM *nasal in kids
prophylaxis: propranolol, topiramate, amitriptyline
acupuncture
How to manage migraines in pregnancy
PCM
NSAIDS in 1st and 2nd trimester
Cause of Wernickes
Thiamine def - alcoholics
Presentation of Wernickes
1) opthalmoplegia
2) ataxia
3) encephalopathy
Investigations of Wernickes
Decreased red cell transketolase
MRI: petechial haemorrhages
Management of Wernickes
Thiamine
Complications of untreated Wernickes
Korsakoffs
