Neuro Flashcards
What is the triad of symptoms of Wernicke’s encephalopathy?
Confusion, ataxia and nystagmus
What causes Wernicke’s encephalopathy?
thiamine deficiency (mostly secondary to chronic alcohol consumption)
What is the management of Wernicke’s encephalopathy?
IV pabrinex (B and C vitamins)
What is Korsakoff’s syndrome?
Wernicke’s encephalopathy - if untreated - causes amnesia (antero and retrograde) and confabulation
What medications are used for migraine prophylaxis?
Propranolol or topiramate (in asthmatics but not in women of child-bearing age)
What is the first line treatment for an acute migraine episode?
oral triptan and NSAID/paracetamol
What is the most common presentation of a posterior communicating artery aneurysm?
painful third nerve palsy
What is the management of idiopathic intracranial hypertension?
Acetazolamide (carbonic anhydrase inhibitor)
What are the indications for doing a CT scan within 1 hour of a head injury?
- GCS < 13 initially or <1 after 2 hrs
- skull fracture
- seizure
- focal neurological signs
- more than one episode of vomiting
When would you do a CT scan within 8 hours after a head injury?
- age > 65
- history of bleeding/clotting disorders
- > 30 mins of retrograde amnesia
What imaging do you use to diagnose MS?
MRI brain and orbits with contrast
What are the features of optic neuritis?
- unilateral decrease in visual acuity and colour discrimination
- pain worse on movement
What is the management of optic neuritis?
high dose steroids
What investigations should you do for a TIA?
Carotid artery doppler, CT/MR angiography
What is tardive dyskinesia?
involuntary repetitive movements affecting any part of the body, but mainly face and tongue - s/e of long term anti-psychotic use
What is acute dystonia?
Occurs within days of starting or increasing antipsychotic dose. Sustained muscle contractions leading to abnormal postures
What are the features of temporal arteritis?
patient >60, rapid onset < 1 month, headache, jaw claudication, tender temporal artery, visual changes
What may you see on temporal artery biopsy of someone with temporal arteritis?
skip lesions
What is the management of temporal arteritis?
- urgent high-dose glucocorticoids
- urgent ophthalmology review (if visual symptoms)
What causes visual loss in temporal arteritis?
anterior ischaemic optic neuropathy - swollen pale disc ad blurred margins on fundoscopy
Which ocular cranial nerve palsy is commonly found in patients with raised ICP?
oculomotor - down and out
What is the first line antibiotic used for bacterial meningitis?
IV ceftriaxone or cefotaxime (50yrs + those plus amoxicillin)
IV dexamethasone
What is the management of raised ICP?
- get critical care input
- secure airway, high flow oxygen
- IV access - bloods and cultures
- IV dexamethasone
- IV abx if needed
Which antibiotic is used for listeria meningitidis?
IV amoxicillin + gentamicin
Which antibiotic should be used as prophylaxis for contacts of meningitis?
ciprofloxacin
What is the initial management of an acute ischaemic stroke?
exclude haemorrhagic stroke, then 300mg aspirin.
If within 4.5 hours - thrombolysis (alteplase)
If within 6 hours - thrombectomy if in proximal anterior circulation
What is used for the secondary prevention of strokes?
clopidogrel
If not aspirin plus dipyramidol
What is the first line anti-coagulant for stroke prevention?
DOACs - apixiban/rivaroxiban
How do you manage an aneurysm following a subarachnoid haemorrhage?
Aneurysm coiling
What are the features of an extradural haematoma?
- acceleration-deceleration injury/blow to side of head
- may have a lucid interval
Which blood test can differentiate a seizure and a functional seizure?
Prolactin (10-20 mins after) raised in epileptic seizure
What is the treatment of a brain abcess?
IV ceftriaxone/other cef, plus metronidazole
What is the typical presentation of a pontine haemorrhage?
reduced GCS, paralysis, bilateral pin point pupils
What are the features of Creutzfeldt-Jakob disease?
Rapid onset dementia and myoclonus due to prion proteins
When do you get autonomic dysreflexia?
spinal cord injury above T6
What is the cushing’s triad?
bradycardia, hypertension, bradypnoea
What is the management of tonic-clonic epilepsy?
- levetiracetam or lamotrigine in women of childbearing age
- sodium valproate in everyone else
What is the management of absence seizures (hellooooo)?
1st line: ethosuximide (ethosexymide)
2nds: men: sodium valproate
women: lamotrigine or levetiracetam
What is the management of myoclonic seizures?
men: sodium valproate
women: levetiracetaM
what is the management of tonic/atonic seizures?
Men: sodium valproate
Women: lamoTrigine
What is cataplexy?
sudden, transient loss of muscular tone when experiencing strong emotions
What is weber’s syndrome and how does it present?
Midbrain stroke - ipsilateral CN III palsy with contralateral hemiparesis - may have dilated unresponsive pupils if bad
What is the management of viral meningitis?
supportive - antivirals don’t really help
What medication is typically used for thrombolysis in an ischaemic stroke?
Alteplase
What time frame can you give thrombolysis and thrombectomy?
thrombolysis - within 4.5 hours
thrombectomy - within 6 hours or within 24 hours if chance to salvage brain tissue
Which medication is used to prevent vasospasm in subarachnoid haemorrhage?
CCB - nimodipine
Does a diabetic oculomotor palsy affect the pupil?
Not always - parasympathetic fibres are less affected by ischaemia
What is used for long term prophylaxis of cluster headaches?
CCBs like verapamil
What is the management of raised intracranial pressure?
elevate head to 30 degrees, IV mannitol, controlled hyperventilation (low pCO2 causes vasoconstriction in brain), removal of CSF
What is cushings triad?
widening pulse pressure, bradycardia, irregular breathing
Which antiemetic is used for intracranial causes of nausea and vomiting?
Cyclizine - can also give dexamethasone alongside
What are the features of degenerative cervical myelopathy?
Can have pain/loss of function/loss of sensation/autonomic function - usually progressive
+ve hoffman’s sign - flick finger on one hand, causes reflex twitching of finger on other hand
What is cushings triad?
Hypertension, bradycardia and irregular breathing - raised ICP
When is intraventricular haemorrhage most likely to occur?
Premature babies
What investigation do you do after a subarachnoid haemorrhage seen on a CT scan?
CT angiogram
Which type of weighted MRI is water white?
T2 weighted - H2O is white
Which cerebral event causes torsades de points?
SAH
How can you distinguish a haemorrhagic vs a ischaemic stroke on CT?
haemorrhagic shows hyperdense material surrounded by hypodense (oedema)
ischaemic shows hyperdense artery
What is the management of bacterial meningitis?
Abx (Cefotaxime or ceftriaxone if 3m to 50yrs - add amoxicillin if over 50) plus dexamethasone
What effects can you get when taking levodopa?
wearing off phenomenon - wearing off just before you take the next dose
peak dose dyskinesia - dyskinetic effects shortly after taking
What is the management of malignant spinal cord compression?
high-dose dexamethasone, MRI spine, urgent surgical assessment
How do you diagnose dementia?
Blood screen to exclude reversible causes, neuroimaging - needed for diagnosis
What type of feeding should be initiated in a patient with MND and an unsafe swallow?
PEG
What is the management of a myasthenic crisis?
IV IgG and plasmapheresis
How does an anterior inferior cerebellar infarct differ from a posterior inferior cerebellar infarct?
AICA - facial paralysis and deafness as well as PICA symptoms (pons)
PICA - facial pain and temp loss, contralateral limb pain and temp loss (medulla)
What are the features of Wernickes encephalopathy?
Ataxia, nystagmus and confusion, opthalmoplegia
What is the management of a TIA?
300mg aspirin unless contraindicated. If on anticoagulants - CT to exclude haemorrhage.
If high risk: aspirin + clopidogrel
After 21 days: clopidogrel
What type of facial paralysis is forehead sparing?
UMN problem - due to dual supply
What investigations would you do in a stroke patient under the age of 55 with no known cause?
Thrombophilia panel and autoantibodies
Which opiate can be used for neuropathic pain?
Tramadol - dual action as opiate and SNRI
What types of tumours are more likely to cause bitemporal quandrantanopias?
Pituitary tumour - superior bitemporal quan
Craniopharyngiomas - inferior
What is the investigation of choice for suspected MS?
CT with gadolinium contrast. To diagnose: MRI brain and spine with contrast
What investigation should be done following a TIA?
Carotid doppler ultrasound, CT if other causes need to be ruled out
What is the management of IIH?
Weight loss, carbonic anhydrase inhibitors (acetazolamide), topiramate
repeated lumbar punctures, shunt
What are the features of an uncal (trans tentorial) herniation?
3rd nerve palsy
What are the features of cerebellar tonsil herniation?
asystolic cardiopulmonary arrest
Which scoring system is used to assess likelihood of a stroke?
ROSIER - recognition of stroke in the emergency room
What medication is used for secondary prevention of a stroke/TIA? (1st and 2nd line)
1st - clopidogrel
2nd - aspirin + dipyridamole
3rd - aspirin
How does baclofen work?
It is a GABA-B agonist, which causes relaxation of the skeletal muscles primarily, but can have some effect on smooth muscle
What is the management of an acute relapse of MS?
High dose methylprednisolone (oral or IV)
Which drugs can reduce the incidence of MS relapses?
Nataluzimab, beta-interferon
What is the first line treatment of MS spasticity?
Baclofen and gabapentin
What is the difference in presentation between peripheral neuropathy and mononeuritis multiplex?
peripheral - gradual onset, symmetrical distribution
mononeuritis - focal, isolated nerve damage, asymmetrical
Which sign can be used to differentiate between functional and organic lower limb weakness?
Hoover’s sign (synergistic contraction of other leg and lumbar muscles)
What is the Hoffman’s sign?
flick index finger, see if there is involuntary movement of the index and thumb - UMN lesion
What is the management of status epilepticus?
A-E
pre-hospital PR diazepam or buccal midazolam
hospital - Iv lorazepam (repeat once)
If not working: IV levetiracetam, phenytoin, sodium valproate
after 45 mins: general anaesthesia
What is the acute management of a migraine?
triptan + NSAID/paracetamol
What is the first line management of migraine prophylaxis?
propranolol (not in asthmatics)
topiramate (not in women of childbearing age - can affect hormonal contraceptives)
amitriptyline
Which parkinson’s medication is best for symptom management?
Levodopa
How long must you be seizure-free for to drive?
6 months non-epileptic
12 months epileptic
What is the management of status epilepticus?
IV lorazepam/buccal medazolam
IV lorazepam
IV phenyoin/valproate/levetiracetam
Rapid sequence induction using sodium thiopental
Which anti-epileptics are used in tonic/atonic seizures vs myoclonic seizures?
Males: sodium valproate for both
Tonic females: lamoTrigine
myoclonic females: Levetiracetam
Which antiplatelets are given after a TIA?
within 24hrs, waiting for specialist: Aspirin
first 21 days after specialist review: clopidogrel + aspirin
Long term: clopidogrel
(but if high risk of GI bleeding, give clopidogrel and a PPI)
What is the most common complication of meningitis?
sensorineural hearing loss
What are the CSF findings of bacterial meningitis?
high opening pressure, raised protein, raised neutrophils, low glucose, cloudy
What are the features of a basal ganglia stroke?
slowness, lack of emotion or initiative, hemineglect
What is the management of a TIA?
300mg aspirin, assessed by specialist within 24hours. all patients on anticoagulants should have a CT head to exclude haemorrhage
What investigation is done for trigeminal neuralgia?
MRI head
What is the management of trigeminal neuralgia?
Carbemazepine, IV fluids, trigeminal nerve block
What are the features of secondary hypertension?
Significantly raised BP, occurring at a young age which is resistant to medication
What medications are used in parkinsons?
Levodopa - dopamine precursor
Carbedopa - prevents peripheral breakdown of levodopa
Ropinirole - dopamine agonist
Selegine - MAOB - prevents breakdown of dopamine
When do you give thrombolysis in stroke?
within 4.5 hours of stroke onset, alteplase
When do you give thrombectomy in stroke?
within 6 hours, (can give with thrombolysis in 4.5 hours) and consider if within 24 hours
Which medications do you give for wee wee incontinence?
Duloxetine for stress incontinence
Oxybutinin for urge incontinence
What investigations do you do in Guillan Barre syndrome?
LP and EMG
