Neuro Flashcards
CVA stands for
Cerebrovascular accident - stroke
Types of CVA
Ischaemic, haemorrhagic
TIA management
Aspirin 300 mg daily
Specialist referral
Diffusion-weighted MRI scan
Stroke differentials
TIA, seizure, hypoglycaemia
Stroke management acute
immediate CT brain
Alteplase within 4.5 hrs if no haemorrhage
Thrombectomy cansidered within 24 hrs
Ischaemic stroke - keep high BP
Haemorrhagic - treat high BP
Stroke management long term
Assess for underlying cause e.g. Afib
Anticoagulation after finishing two weeks of aspirin, with Afib.
MDT rehab
Presentation intracranial haemorrhage
Sudden onset headache, seizure, vomiting, reduced LOC, focal neurological symptoms
GCS
Eyes, verbal, motor
Extradural haemorrhage blood vessel
MMA, often temporal bone fracture.
Subdural haemorrhage blood vessel
Bridging veins, elderly & alcoholic
Intracerebral Haemorrhage
Bleeding in the brain tissue, similar presentation to ischaemic stroke.
Aneurysm rupture, secondary to ischaemic stroke, tumours.
Subarachnoid haemorrhage bleed into
Subarachnoid space where CSF is - thunder clap headache
Usually cerebral aneurysm rupture
Intracerebral haemorrhage management
CT head
Bloods - include coagulation screen - correct any clotting abnormality
Correct severe hypertension but avoid hypotension
Presentation subarachnoid haemorrhage
Thunderclap headache - often when strenuous activity.
Neck stiffness, photophobia, vomiting, neurological symptoms
Subarachnoid haemorrhage investigations
CT head (less reliable after 6 hrs from symptoms starting)
Lumbar puncture if normal CT head - red cells in CSF
CT angiography - locate source of bleeding
Subarachnoid haemorrhage management
surgical intervention - endovascular coiling
Intubation & ventilation
MS pathology
Autoimmune demyelination of CNS
MS caused by
Low vit D, ebstein barr virus, smoking, obesity
optic neuritis
most common presentation of MS.
Unilateral reduced vision, developing over hours to days
Most common presentation MS
Optic neuritis
Ataxia can be (2)
Problem with coordinated movement
- Sensory - loss of proprioception
- Cerebellar
MS management
Disease modifying therapy - target immune system
Relapses - steroids
MDT
Motor neurone disease
Progressive disease affecting motor neurons. Eventually fatal. No effect on sensation.
Motor neurone disease presentation
Insidious progressive weakness of muscles throughout body. Often first noticed upper limbs. Dysarthria.
Diagnosis carefully after excluding other conditions - no effective treatments.
Parkinsons pathology
reduction in dopamine in the basal ganglia
Parkinsons presentation
Resting tremor
Rigidity
Bradykinesia
Shuffling gait
Gradual onset symptoms - asymmetrical one side affected more
Dementia associated with parkinsons
Lewy body
Also has visual hallucinations, delusions, REM sleep disorders, fluctuating consciousness
Parkinsons management
Levodopa + carbidopa, Dopamine agonists
Levodopa side effect
Dyskinesia - abnormal movements
- chorea
- athetosis
- dystonia
Benign essential tremor
Fine tremor, mostly in hands but can also head, jaw and vocal. Worse when tired, stressed or caffeine.
Tremor differentials
Parkinson’s
MS
Huntingtons chorea
Hyperthyroid
Fever
Dopamine antagonists (antipsychotics)
Epilepsy types of seizure
Absence
Generalised tonic-clonic
Focal
Prior to seizure patient might experience
aura
Seizure history check
Tongue biting, aura, urinary incontinence, LOC, post-ictal period of confusion, tired, irritable.
Seizure differentials
Vasovagal syncope
Pseudoseizures
Cardiac syncope
Hypoglycaemia
Hemiplegic migraine
TIA
Seizure investigations
EEG
MRI brain - structural pathology
ECG, serum electrolytes, blood glucose, blood cultures if suspect sepsis.
Anti-epileptic
Valproate, levetiracetam, ethosuximide
Carbamazapine, phenytoin
Status epilepticus
Seizure more than 5 minutes
Benzos first line
Opioid reversal
Naloxone
Bell’s palsy presentation and treatment
Bell’s palsy - LMN, unilateral face weakness
Steroids
Lubricating eye drops
most patients fully recover over several weeks
Rule out trauma, tumour, DM, GB, infection
Benign brain tumour
Meningioma
Presentation brain tumour
Progressive focal neurological symptoms
Intracranial hypertension causes
Brain tumours, intracranial haemorrhage, idiopathic, abscesses or infection
Headache concerns for intracranial hypertension
Constant headache, nocturnal, worse on waking, worse on coughing, vomiting, papilloedema on fundoscopy
Worst glioma
Glioblastoma
Pituitary tumour symptoms
Tend to be benign - bitemporal hemianopia
Hormone deficiencies or excesses
Acromegaly, hyperprolactinaemia, cushing’s, thyrotoxicosis
Acoustic neuroma
Benign tumours of schwann cells that surround the auditory nerve
Unilateral sensorineural hearing loss, tinnitus, dizzines, facial nerve palsy
Huntingtons inheritance
Autosomal dominant - huntingtin protein build up
Hungtinton’s presentation
Chorea, dystonia, rigidity, eye movement disorders, dysarthria, dysphagia
Cognitive, psychiatric or mood problems
Huntington’s chorea is a progressive condition
Life expectance 10-20 yrs
Huntington’s treatment and diagnosis
Diagnose via genetic testing, no treatments
Myasthenia gravis pathology
Autoimmune condition - acetylcholine receptor antibodies - neuromuscular junction
Myasthenia gravis presentation
Vary dramatically between patients
Ptosis, diplopia
Difficulty climbing stairs
Weakness in facial movements
Difficulty swallowing
Slurred speech
Investigations myasthenia gravis
AChR antibodies
Edrophonium test?
Treatment options myasthenia gravis
Pyridostigmine - cholinesterase inhibitor - prolongs the action of acetyl choline
Charcot marie tooth disease
Peripheral motor and sensory neurons - heriditary
GB Syndrome presentation
Ascending paralysis autoimmune
Following EBV CMV campylobacter jejuni infection.
Reduced reflexes
GB syndrome diagnosis
Nerve conduction study
GB syndrome management
Supportive care, VTE prophylaxis, Respiratory failure - intubation, ventilation, IV immunoglobulins
Cervical spondylosis
Degenerative changes in cervical spine
Eye afferent
optic nerve pathology
fasciculations upper or lower motor neuron
Lower
Spasticity upper or lower motor neuron
Upper
Chorea seen in
Huntingtons
Myoclonus seen in
MS, dementia, parkinson
Causes of delirium
Chimps phoned
infection, drugs, dehydration
Constipation
Hypoxia
Infection
Metabolic disturbance
Pain
Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic or renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, alcohol and smoking)
Hyperactive delirium symptoms
Clinical features of hyperactive delirium include:
Agitation
Delusions
Hallucinations
Wandering
Aggression
Hypoactive delirium symptoms
Lethargy
Slowness with everyday tasks
Excessive sleeping
Inattention
Delirium management - confusion screen
Blood tests:
FBC (e.g. infection, anaemia, malignancy)
U&Es (e.g. hyponatraemia, hypernatraemia)
LFTs (e.g. liver failure with secondary encephalopathy)
Coagulation/INR (e.g. intracranial bleeding)
TFTs (e.g. hypothyroidism)
Calcium (e.g. hypercalcaemia)
B12 + folate/haematinics (e.g. B12/folate deficiency)
Glucose (e.g. hypoglycaemia/hyperglycaemia)
Blood cultures (e.g. sepsis)
Urinalysis:
UTI is a very common cause of delirium in the elderly.
A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of delirium.2, 3
Look for other evidence supporting the diagnosis (WCC↑/supra-pubic tenderness/dysuria/offensive urine/positive urine culture).
Imaging:
CT head: if there is concern about intracranial pathology (bleeding, ischaemic stroke, abscess)
Chest X-ray: may be performed if there is concern about lung pathology (e.g. pneumonia, pulmonary oedema)
Meds for delirium
Haloperidol
Benzos can worsen - lorazepam if need
Postural hypotension management
Midrodrine, cease antihypertensive, IV fluids
Causes of afferent papillary defect
Optic nerve damage - MS, glaucoma, retinal detachment, trauma
