Neuro Flashcards
ftypes of stroke
ischaemic
haemorrhagic
blood supply can be disrupted to the brain by?
- A thrombus or embolus
- Atherosclerosis
- Shock
- Vasculitis
what is a TIA
- temporary neurological dysfunction (lasting < 24hrs)
- caused by ischaemia but without infarction
- Sx have a rapid onset and often resolve before the patient is seen
- may precede a stroke
What is a crescendo TIA
two or more TIAs within a week and indicate a high risk of stroke
Presentation of stroke
- asymmetrical
- Limb weakness
- Facial weakness
- Dysphasia
- Visual field defects
- Sensory loss
- Ataxia and vertigo (posterior circulation infarction)
RFs for stroke
- Previous stroke or TIA
- Atrial fibrillation
- Carotid artery stenosis
- Hypertension
- Diabetes
- Raised cholesterol
- Family history
- Smoking and obesity
- Vasculitis
- Thrombophilia
- COCP
what is the ROSIER tool
score of stroke likelihood in ED
Mx of TIA
- sx resolved within 24hrs
- aspirin 300mg
- referral within 24hrs (within 7 days if more than 7 days since episode)
- diffusion weighted MRI
- aspirin and clopidogrel to prevent future stroke for 3 weeks then just clopidogrel
Mx of stroke
- exclude hypoglycaemia
- CT brain to exclude haemorrhage
- aspirin 300mg 2weeks
- admission
- thrombolysis when haemorrhage excluded
- thrombectomy if confirmed blockage in proximal anterior circulation or proximal posterior circulation
- only give antihypertensives if an emergency in ischaemic, be aggressive in haemorrhagic
how does alteplase work
tissue plasminogen activator
when can you give alteplase
within 4.5hrs
or within 4.5-9hrs of onset if known to be well prior
when can you do thrombectomy
- within 6hrs
- 6-24hrs if confirmed occlusion of the proximal posterior circulation, potential to salvage brain tissue shown by CT/MRI, or last known to be well up to 24 hours previously
Underlying ix for stroke
- carotid imaging for stenosis (carotid endarterectomy or angioplasty)
- ECG for AF (give anticoag post 2 weeks of asiprin)
Secondary prevention of stroke (post 14 days)
- clopidogrel 75mg OD
- atorvastatin 20-80mg
- BP and diabetes control
MDT for stroke
- stroke physicians, nurses
- SALT
- dieticians
- phyio, OT
- optometry, orthotics
- psychology
- social services
Types of intracranial bleeds
- Extradural (skull and dura)
- Subdural (dura and arachnoid)
- Intracerebral (brain)
- Subarachnoid (subarachnoid)
RFs for intracranial bleed
- anticoagulants
- trauma
- aneurysm
- bleeding disorder
- thrombocytopenia
- stroke
- tumour
Presentation of intracranial bleed
- Sudden-onset headache is a key feature
- Seizures
- Vomiting
- Reduced consciousness
- Focal neurological symptoms (e.g., weakness
GCS
EVM- 4, 5, 6
E: Spon, Voice, Pain, None
V: Orientated, Confused, Odd words, Odd sounds, None
M: Obeys commands, Localise to pain, Normal flexion, Abnormal flexion, Extends, None
Extradural haemorrhage cause
rupture of middle meningeal artery in tempoparietal region
Features of extradural haemorrhage
- can fracture temporal bone
- lens/lemon shape
- limited by cranial sutures
- improve neuro sx then rapid decline
Subdural haemorrhage cause
rupture of bridging veins in outermost meningeal layer
Subdural haemorrhage features
- crescent shape
- not limited by cranial sutures so. can diffuse out hens shape
- elderly, alcoholic pts with more atrophy making vessels more prone to rupture
Intracerebral haemorrhage cause
Spontaneous or secondary to stroke, tumour/aneurysm
can occur anywhere:
- Lobar intracerebral haemorrhage
- Deep intracerebral haemorrhage
- Intraventricular haemorrhage
- Basal ganglia haemorrhage
- Cerebellar haemorrhage
Features of intracerebral haemorrhage
presents similarly to an ischaemic stroke with sudden-onset focal neurological symptoms e.g.
- limb or facial weakness
- dysphasia
- vision loss
Subarachnoid haemorrhage cause
ruptured cerebral aneurysm between pia mater and arachnoid mater
Features of subarachnoid haemorrhage
- thunderclap occipital headache doing strenuous activity
- neck stiffness
- photophobia
- visual changes
- vomiting
Mx of intracranial bleeds
- CT
- FBC and coagulation
- Subdural and extradural: Craniotomy or Burr hole
- Subarachnoid: coiling
RF for subarachnoid haemorrhage
- 45-70
- female
- black
- Hypertension
- Smoking
- Excessive alcohol intake
Conditions associated with subarachnoid haemorrhages
- Family history
- Cocaine use
- Sickle cell anaemia
- Connective tissue disorders (e.g., Marfan syndrome or Ehlers-Danlos syndrome)
- Neurofibromatosis
- AD polycystic kidney disease
Ix for subarachnoid haemorrhage
- CT
- LP if normal CT (wait >12hrs from sx onset) (raiased RCC and xanthochromia)
- CT angio to confirm source
Mx of subarachnoid haemorrhage
- endovascular coiling
- neurosurgical clipping
- nimodipine (CCB) prevents vasospasm
Complication and mx of subarachnoid haemorrhage
Hydrocephalus
- LP
- external ventricular drain
- ventriculoperitoneal shunt
What is multiple sclerosis
- progressive autoimmune condition
- demyelination of CNS
- myelin provided by oligodendrocytes (central) and Schwann cells (peripheral)
- UMN disease
characteristic feature of MS
lesions that are disseminated in time and space
- lesions occur at various sites at different points
- can get remyelination in early stages
Causes of multiple sclerosis
- genes
- EBV
- low vitamin D
- smoking
- obesity
Most common presentation of multiple sclerosis
Optic neuritis
- demyelination of ON = unilateral reduced vision over hours to days
- central scotoma
- pain with eye movement
- impaired colour vision
- RAPD
Other causes of optic neuritis
- sarcoidosis
- SLE
- syphilis
- measles/mumps
- Neuromyelitis optica
- Lyme disease
Mx of optic neuritis
high dose steroids
Eye movement abnormality in MS
lesions in:
- CN 3, 4, 6 = diplopia and nystagmus
- medial longitudinal fasciculus = internuclear ophthalmoplegia, ipsilateral impaired adduction and contralateral nystagmus
- CN6 = conjugate lateral gaze disorder
Focal neurological sx in multiple sclerosis
Focal weakness:
- Incontinence
- Horner syndrome
- Facial nerve palsy
- Limb paralysis
Focal sensory symptoms:
- Trigeminal neuralgia
- Numbness
- Paraesthesia
- Lhermitte’s sign
What is Lhermitte’s sign
- In multiple sclerosis
- electric shock sensation that travels down the spine and into the limbs when flexing the neck.
- Indicates disease in the cervical spinal cord in the dorsal column
what is transverse myelitis
inflammation of spinal cord resulting sneosry and motor sx depending on lesion site
Disease pattern of multiple sclerosis
- relapsing remitting (active, not active, worsening, not worsening)
- clinically isolated syndrome
- secondary progressive (RR + progression and incomplete remission)
- primary progressive (no remission)
How to diagnose multiple sclerosis
- clinical
- MRI with contrast for lesions
- LP for oligoclonal bands in CSF
Mx of multiple sclerosis
- Relapses: steroids oral or IV
- disease modifying therapies to induce remission
- spasticity: baclofen or gabapentin
- Monoclonal antibodies such as natalizumab have the strongest evidence base for reducing relapse in multiple sclerosis
what is motor neurone disease
- progressive eventually fatal condition
- motor neurones stop working
types of motor neurone disease
- Amyotrophic lateral sclerosis (ALS) = most common (stephen hawking)
- Progressive bulbar palsy = second most common. affects muscles of talking and swallowing
- progressive muscular atrophy
- primary lateral sclerosis
cause of MND
- degeneration of upper and lower motor neurones
- unknown cause
- FH important
- smoking
heavy metal and pesticide exposure
presentation of MND
- 60-90 male
- insidious progressive weakness of muscles everywhere
- weakness first in UL
- dysarthria
- fasciculations
- clumsiness
- mixed UMN and LMN sx
- wasting of the small hand muscles/tibialis anterior is common
- eye movements typically spared
UMND and LMND signs
lower
- Muscle wasting
- Reduced tone
- Fasciculations
- Reduced reflexes
upper
- Increased tone or spasticity
- Brisk reflexes
- Upgoing plantar reflex
How to diagnose MND
clinical
diagnosis of exclusion
Mx of MND
- riluzole can slow progression in ALS
- NIV
- baclofen for spasm
- benzos
- percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition and prolongs survival
What is Parkinson’s disease
- reduction in dopamine in substantia nigra in basal ganglia
triad of parkinson’s
- resting tremor (pill rolling): improves with movement
- rigidity (resisting passive): cogwheel
- bradykinesia e.g. handwriting getting smaller, shuffling gait, hypomimia
(one side of body normally affected more)
other features of parkinson’s
- Depression
- Sleep disturbance and insomnia
- Anosmia
- Postural instability
- Cognitive impairment and memory problems
Differences between Parkinson’s tremor and benign essential tremor
Parkinson’s Tremor
- Asymmetrical
- 4-6 hertz
- Worse at rest
- Improves with intentional movement
- Other Parkinson’s features
- No change with alcohol
Benign Essential Tremor
- Symmetrical
- 6-12 hertz
- Improves at rest
- Worse with intentional movement
- No other Parkinson’s features
- Improves with alcohol
Parkinson’s Plus Syndromes
- Dementia with Lewy bodies
- Progressive supranuclear palsy: dysarthria and reduced vertical eye movement
- Corticobasal degeneration
what is progressive supranuclear palsy
- a Parkinson plus syndrome
- postural instability and falls: stiff, broad-based gait
- impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)
- parkinsonism: bradykinesia
- cognitive impairment: frontal lobe dysfunction
What is multiple system atrophy
key differentiator from parkinson’s is unilateral sx and severe autonomic dysfunction
1) MSA-P - Predominant Parkinsonian features
2) MSA-C - Predominant Cerebellar features
Shy-Drager syndrome is a type of multiple system atrophy.
Features
parkinsonism
autonomic disturbance
erectile dysfunction: often an early feature
postural hypotension
atonic bladder
cerebellar signs
Mx of Parkinson’s
- Levodopa (combined with peripheral decarboxylase inhibitors)
- COMT inhibitors: entacapone
- Dopamine agonists: cabergoline, bromocriptine (can cause pulm fibrosis)
- MAOIs: selegiline
- antimuscarinics: procyclidine for tremor
Side effect of levodopa
dyskinesia: can be managed by amantadine
nausea: can give domperidone as an anti-emetic
benign essential tremor features
- fine tremor affecting all voluntary muscle
- MC in hands
- symmetrical
- worse when tired
- absent during sleep
- improved by alcohol
Mx of benign essential tremor
- propanolol
- primidone
types of seizures
- Generalised tonic-clonic seizures
- Partial seizures (or focal seizures)
- Myoclonic seizures
- Tonic seizures
- Atonic seizures
Common seizures in children
- Absence seizures
- Infantile spasms
- Febrile convulsions
Tonic clonic seizure features
- muscle tensing and jerking
- loss of conciousness
- post ictal phase
Partial (focal) seizure feature
- isolated brain area, often temporal
- affect hearing, speech, memory and emotions
- awake
- simple= aware, complex = LOC
- strange smell
- automatisms (lip smacking etc.)
myoclonic seizure features
sudden, brief muscle contractions
juvenile myoclonic epilepsy
tonic seizure features
sudden increase in tone, whole body stiffens
few seconds-minutes
atonic seizure features
- sudden loss of muscle tone–> fall
- brief and aware
- sign of Lennox-Gastaut syndrome
Absence seizure features
- stare blankly
- unaware
- seconds
infantile spasm features
- West Syndrome
- hypsarrhythmia on EEG
- full body spasm
- MX: ACTH and vigabatrin
febrile convulsion features
- tonic clonic
- high fever
- 6month to 5y/os
- 1in3 will have another
Driving with seizures
Only if seizure free for 1 year
Mx of seizures
Generalised tonic-clonic
Sodium valproate*
Lamotrigine/Levetiracetam (P)
Partial (or focal)
Lamotrigine or Levetiracetam (B)
Myoclonic
Sodium valproate*
Levetiracetam (P)
Tonic and atonic
Sodium valproate*
Lamotrigine (P)
Absence
Ethosuximide (B)
Status epilepticus
Seizure >5 mins or multiple seizures without regaining consciousness
Mx of status epilepticus
- O2
- check BM
- Rectal diaz, buccal midaz or IV loraz
- IV keppra, phenytoin or valproate if 2 doses of benzos doens’t work
- 3rd line- phenobarbital or intubation
where does the facial nerve exit
cerebellopontine angle then travels through temporal bone and parotid gland
divisions of facial nerve
- tempora;
- zygomatic
- buccal
- marginal mandibular
- cervical
function of facial nerve
- motor: facial expressions, strapedius in inner ear
- sensory: anterior 2/3 taste
Innervation of forehead
UMN by both sides of the brain
LMN by only one side of the brain
UMN vs LMN facial palsy
UMN- forehead is spared (can move on affected side)
LMN- not spared (cannot move forehead on affected side)
Causes of UMN lesions
- Unilateral: stroke and tumour
Bilateral: pseudobulbar palsies and MND
What is Bell’s palsy
- idiopathic
- unilateral LMN facial nerve palsy
- can have hyperacusis due to FN palsy, affects stapedius muscle in ear which normally dampens loud sound
- recover over weeks can take 1yr
- 1/3 left with weakness
- within 72hrs of sx
- Mx: prednisolone and lubricating eye drops, eye tape
What is Ramsay Hunt syndrome
- VZV
- unilateral LMN facial palsy
- painful vesicular rash in ear canal, pinna, around ear 2/3 tongue
- Mx aciclovir, prednisolone, eye drops
Other causes of LMN facial nerve palsy
- Infection: otitis media and externa, HIV, lyme disease
- Systemic: diabetes, sarcoid, leukaemia, MS, GBS
- Tumour: acoustic neuroma, parotid tumour, cholesteatoma
- Trauma: nerve trauma, surgery, base of skull fracture
Presentation of brain tumours
- asymptomatic
- progressive focal neurological sx
- raised ICP
Causes of raised ICP in intracranial space
- tumour
- haemorrhage
- idiopathic intracranial HTN
- abscess or infection
Signs of intracranial hypertension
- Constant headache
- Nocturnal
- Worse on waking
- Worse on coughing, straining or bending forward
- Vomiting
- Papilloedema
- seizures
- visual field defects
- CN3 and 6 palsies
idiopathic intracranial hypertension
- RF: female, obese, pregnant, COCP, tetracyclines, steroids, retinoids
- headache, blurred vision
- papilloedema (usually present)
- enlarged blind spot
- sixth nerve palsy may be present
- LP can cause low pressure headache
- Mx: weight loss, acetazolamide (carbonic anhydrase inhibitor), topiramate, LP, VP shunt
what is papilloedema
- swelling of optic disc due to raised ICP
- blurred optic disc
- haemorrhages
- Paton’s line
What is a glioma
- tumour in brain or spinal cord
- glial cells include astrocytes, oligodendrocytes and ependymal cells
- graded 1 (benign) to 4
- astrocytoma (gliobastoma most aggressive form)
- Oligodendroglioma
- Ependymoma
What are meningiomas
- tumour from meninges
- benign
- large
- incidence increases with age
- psamomma bodies
Most common cancers that metastasise to the brain
- lung
- brest
- RCC
- melanoma
what are pituitary tumours
- benign
- press on optic chiasm –> bitemporal hemianopia
- can cause hormone deficiencies or excess
- Mx: transphenoidal surgery, radiotherapy, bromocriptine, octreotide
what is an acoustic neuroma
- benign tumour of Schwann cells surrounding audtory nerve
- at cerebellopontine angle
- usually unilateral
- bilateral assoc with neurofibromatosis type 2
Features of acoustic neuroma
- 40-60 year old
- Unilateral sensorineural hearing loss (often the first symptom)
- Unilateral tinnitus
- Dizziness or imbalance
- Sensation of fullness in the ear
- Facial nerve palsy (if the tumour grows large enough to compress the facial nerve)
- KEY: lack of corneal reflex
Ix of acoustic neuroma
audiogram
gadolinium-enhanced MRI head scan
Mx of acoustic neuroma
- conservative
- surgery
- radiotherapy
most common form of brain tumour
metastasis
Features of a Pilocytic
astrocytoma
- grade 1
- 0-20y/o
- BRAF mutation
what is a diffuse glioma
- grade 2 to 3
- 20-40 y/o
what is gliobastoma multiforme
- BAD grade 4
- 50+
- most common aggressive primary tumour
feature of medulloblastoma
2nd MC brain tumour in children after astrocytoma
What is Huntington’s disease
- AD
- progressive neurological dysfunction
- HTT gene Chr4 mutation
- sx begin 30-50 y/o
- earlier onset each generation and increased severity
presentation of huntington’s
- begins with cognitive/psych/mood problems (personality change)
- chorea
- dystonia
- rigidity
- saccadic eye movement
- dysarthria and dysphagia
Mx of Huntington’s
- genetic testing
- nothing to slow or halt progression
- supportive care
- LE 10-20 yrs after sx onset
- death often due to aspiration pneumonia
what is myasthenia gravis
- autoimmune condition affecting NMJ
- causes muscle weakness with activity
- Women <40 and men >60
- strong like with thymoma
Antibodies that can cause myasthenia gravis
- Acetylcholine receptor (AChR) antibodies
- Muscle-specific kinase (MuSK) antibodies
- Low-density lipoprotein receptor-related protein 4 (LRP4) antibodies
Presentation of myasthenia gravis
- sx range from mild to life threatening
- weakness that worsens with muscle use and improves with rest
- sx best in morning
- proximal muscles and small muscles of head and neck effected
- diplopia, ptosis
difficult climbing stairs - dysphagia, fatigue in jaw
- slurred speech
how to elicit muscle fatigablity in myasthenia gravis
- Repeated blinking will exacerbate ptosis
- Prolonged upward gazing will exacerbate diplopia
- Repeated abduction of one arm 20 times will result in unilateral weakness when comparing both sides
Ix for myasthenia gravis
- AChR antibodies (85%)
- MuSK antibodies (<10%)
- LRP4 antibodies (<5%)
- A CT or MRI of the thymus gland to look for a thymoma
- edrophonium test can be helpful if there is doubt on the diagnosis.
What is the Edrophonium test
- IV edrophonium chloride (or neostigmine).
- Blocks cholinesterase enzymes in the NMJ that break down acetylcholine
- level of acetylcholine at the neuromuscular junction rises, relieving the weakness
- +ve result = myasthenia gravis
Mx of myasthenia gravis
- Pyridostigmine: long acting cholinesterase inhibitor
- Immunosuppression (e.g., prednisolone or azathioprine) suppresses the production of antibodies
- Thymectomy can improve symptoms, even in patients without a thymoma
- Rituximab if other mx fails
medication to avoid in mysathenia gravis
beta blocker, lowers FVC
what is a myasthenic crisis
- potentially life threatening complication
- acute worsening of symptoms
- triggered by another illness, such as RTI, BBs, penicillamine, lithium
- Respiratory muscle weakness can lead to respiratory failure.
- May need NIV/mechanical ventilation.
- Mx: IV immunoglobulins and plasmapheresis.
what is Lambert-Eaton myasthenic syndrome
- similar to myasthenia gravis
- sx more insidious and less pronounced
- paraneoplastic syndrome alongisde SCLC, can occur without SCLC
Presentation of Lambert eaton syndrome
- Proximal muscle weakness
- Autonomic dysfunction (dry mouth, blurred vision, impotence and dizziness)
- Reduced or absent tendon reflexes
- Ix: Voltage-gated calcium-channel antibodies
difference between Lambert eaton and myasthenia gravis
- LE improves after periods of muscle contraction, which is the reverse MG
- muscle strength improves after use
Mx of Lambert Eaton syndrome
- exclude underlying malignancy (SCLC)
- amifampridine 1st line
- Pyridostigmine
- Immunosuppressants (e.g., prednisolone or azathioprine)
- IV immunoglobulins
- Plasmapheresis
what is charcot marie tooth disease
- inherited, most AD
- affects peripheral motor and sensory neurones
- usually before 10/yo
Presentation of Charcot Marie tooth disease
- High foot arches (pes cavus)
- Distal muscle wasting causing “inverted champagne bottle legs”
- Lower leg weakness, particularly loss of ankle dorsiflexion (with a high stepping gait due to foot drop)
- Weakness in the hands
- Reduced tendon reflexes
- Reduced muscle tone
- Peripheral sensory loss “glove and stocking”
Causes of peripheral neuropathy
A-E
A- alcohol
B- B12
C- Charcot marie tooth, cancer, CKD
D- diabetes and drugs (amiodarone, isoniazid, cisplatin)
E- every vasculitis
Mx of Charcot Marie tooth disease
No cure or halting mx, supportive
- physio, OT, analgesia, orthopaedic surgeons
What is Guillain-Barre syndrome
- acute paralytic polyneuropathy that affects the peripheral nervous system
- triggered by infection esp. Campylobacter jejuni, CMV and EBV
Presentation of Guillain Barre syndrome
- acute symmetrical ascending weakness
- reduced reflexes
- can also cause peripheral loss or sensation or neuropathic pain
- within 4 weeks of infection
- start in feet
- sx peak within 2-4 weeks
- recovery can last months to years
- can progress to CNs and cause facial weakness
- can have urinary retention, ileus, arrhythmias
How to diagnose Guillain Barre syndrome
- clinically using Brighton criteria
- nerve conduction studies
- LP (raised protein with normal WCC and glucose)
Mx of Guillain Barre syndrome
- supportive
- VTE prophylaxis
- IVIG
- Plasmapheresis
- Ventilation if resp failure
Prognosis of Guillain Barre syndrome
most make full recovery or minor sx
what is neurofibromatosis
- genetic condition that causes benign nerve tumours (neuromas) to develop throughout the nervous system
NF1 MC than NF2
what is neurofibromatosis type 1
- on chr17, AD
CRABBING
C- cafe au lait spots
R- relative with NF1
A- axillary/inguinal freckling
BB- Bony dysplasia, e.g. Bowing of a long bone or sphenoid wing dysplasia
I- Iris hamartomas (lisch nodules): yellow/brown spots on iris
N- neurofibromas
G- glioma of the optic pathway
what is a neurofibroma
- skin-coloured, raised nodules or papules with a smooth, regular surface
- need 2 or more to be significant
- a plexiform neurofibroma is a larger, irregular, complex neurofibroma –>significant
Mx of Neurofibromatosis
monitor and mx sx and treat complications
Complications from neurofibromatosis 1
- Malignant peripheral nerve sheath tumours KEY
- GI stromal tumour (sarcoma) KEY
- Migraines and Epilepsy
- Renal artery stenosis, causing hypertension
- Learning disability
- Behavioural problems (e.g., ADHD)
- Scoliosis
- Vision loss (secondary to optic nerve gliomas)
- Brain tumours
- Spinal cord tumours with associated neurology (e.g., paraplegia)
- Increased risk of cancer (e.g., breast and leukaemia)
what is neurofibromatosis 2
- on chr22, AD
- associated with bilateral acoustic neuromas
- can resect tumour
What is tuberous sclerosis
- AD
- development of hamartomas, benign tissue growths. Commonly affect the skin, brain, heart, lungs, kidneys and eye
- mutations in: TSC1 gene on chr 9, codes for hamartin,
TSC2 gene on ch 16, codes for tuberin
Features of tuberous sclerosis
- Ash leaf spots (depigmented areas of skin shaped like an ash leaf)
- Shagreen patches (thickened, dimpled, pigmented patches of skin)
- Angiofibromas (small skin-coloured or pigmented papules that occur over the nose and cheeks)
- Ungual fibromas (circular painless lumps that slowly grow from the nail bed and displace the nail)
- Cafe-au-lait spots
- Poliosis (isolated patch of white hair on the head, eyebrows, eyelashes or beard)
Neurological features of tuberous sclerosis
- epilepsy
- learning disability
- brain tumour
other features of tuberous sclerosis
- Rhabdomyomas in the heart
- Angiomyolipoma in the kidneys
- Lymphangioleiomyomatosis in the lungs
- Subependymal giant cell astrocytoma in the brain
- Retinal hamartomas
Mx of tuberous sclerosis
- supportive
- mTOR inhibitors ( everolimus or sirolimus) may be used to suppress the growth of brain, lung or kidney tumours
Red flags of headaches
- Fever, photophobia or neck stiffness
- New neurological sx
- Visual disturbance (GCA, glaucoma or tumours)
- Sudden-onset occipital headache
- Worse on coughing or straining (raised ICP)
- Postural, worse on standing, lying or bending over (raised ICP)
- Vomiting (raised ICP or carbon monoxide poisoning)
- History of trauma
- History of cancer
- Pregnancy (pre-eclampsia)
What are tension headaches
- mild band like pattern
- stress, alcohol, dehydration
- Mx: reassure, paracetamol
- Amitriptylline for recurrent headaches
what is sinusitis
inflammation of paranasal sinuses
- pain and pressure post viral URTI
- tenderness and swelling on palpation
- resolve within 2-3 weeks
- >10 days give steroid nasal spray or phenoxymethylpenicillin
what is a hormonal headache
- related to low oestrogen
- similar to migraine: unilateral pulsatile, nausea
- Mx: NSAIDs
what is cervical spondylosis
- degenerative changes in cervical spine made worse on movement
- presents with headaches
what is trigeminal neuralgia
- intense facial pain in distribution
- opthalmic, maxillary, mandibular branches
- 90% cases unilateral branch
- MC in multiple sclerosis
- sudden onset, seconds to hours
- electricity like pain, attacks can worsen over time
- Mx: carbamazepine
types of migraines
- with aura
- without aura
- silent (aura no headache)
- hemiplegic
presentation of migraine
- Premonitory or prodromal stage (can begin several days before the headache)
- Aura (up to 60 minutes)
- Headache stage (4-72 hrs)
- Resolution stage (headache may fade or be relieved abruptly by vomiting or sleeping)
- Postdromal or recovery phase
Presentation of the headache in migraines
- unilateral usually
- mod to severe intensity
- pounding/throbbing
- photophobia
- phonophobia
- osmophobia
- aura
- N+V
what is an aura
- affect vision, sensation or language. Visual is most common
- Sparks
- Blurred vision
- Lines across the vision
- Loss of visual fields (e.g., scotoma)
- tingling/numbness
- dysphasia
what is hemiplegic migraine
- unilateral limb weakness
- ataxia
- impaired consciousness
- can mimic stroke/TIA
triggers for migraine
- stress
- alcohol
- caffeine
- lack of sleep
- bright lights
- strong smells
- food
- menstruation
- trauma
Mx of acute migraines
- dark quiet room, sleep
- NSAID
- paracetamol
- triptans
- antiemetics
contraindications to taking a triptan
risks associated with vasoconstriction:
- hypertension
- coronary artery disease
- previous stroke, MI, TIA
Usual migraine prophylaxis
- propanolol
- amitriptylline
- topiramate (teratogenic- cleft lip)
Specialist migraine propyhlaxis
- Pizotifen
- Candesartan
- Sodium valproate
- Monoclonal antibodies (e.g., erenumab and fremanezumab)
- CBT, acupuncture
why can you not have COCP with migraine + aura
both increase VTE risk
what are cluster headaches
- severe unilateral headache around the eye
- come in cluster of attacks then disappear
- attacks last 15min-3hrs. for 4-12 wks
- triggers: alcohol, smells, exercise
Sx of cluster headache (suicide headache)
- unilateral
- Red, swollen and watering eye
- Pupil constriction (miosis)
- Eyelid drooping (ptosis)
- Nasal discharge
- Facial sweating
Acute mx of cluster headaches
- triptans (subcut or intranasal)
- high flow oxygen
Prophylaxis for cluster headaches
- verapamil 1st line
- occipital nerve block
- prednisolone
- lithium
what are superior homonymous quadrantanopias are caused by
lesions of the inferior optic radiations in the temporal lobe
Nerve palsy associated with seeing double going down the stairs
CN4 trochlear (supplies superior oblique muscle)
what is locked in syndrome
- conscious but unable to move or speak, can move eyes
- basilar artery stroke
- acute decreased GCS and advanced motor symptoms
what is a lacunar stroke
- present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
- strong association with hypertension
- common sites include the basal ganglia, thalamus and internal capsule
what is broca’s dysphasia
- lesion of the inferior frontal gyrus. It is typically supplied by the superior division of the left MCA
- speech is non-fluent, halting and laboured. comprehension normal, repetition impaired
What is Wernicke’s aphasia
- lesion of the superior temporal gyrus. It is typically supplied by the inferior division of the left MCA
- This area ‘forms’ the speech before ‘sending it’ to Broca’s area. Result in sentences that make no sense, word substitution and neologisms but speech remains fluent - ‘word salad’
- Comprehension and repetition is impaired
order of Broca’s and wernicke’s
- Spoken word is heard at the ear.
- This passes to Wernicke’s area in the temporal lobe to comprehend what was said
- Once understood, the signal passes along the arcuate fasciculus, before reaching Broca’s area.
- The Broca’s area in the frontal lobe then generates a signal to coordinate the mouth to speak what is thought (fluent speech).
Features of Wernicke’e encephalopathy
CAN OPEN
- Confusion
- Ataxia
- Nystagmus
- Ophthalmoplegia
- Peripheral
- Neuropathy
What is conduction aphasia
- stroke affecting the arcuate fasiculus - the connection between Wernicke’s and Broca’s area
- Speech is fluent but repetition is poor. Aware of the errors they are making
- Comprehension is normal
what is global aphasia
- Large lesion affecting all 3 of the above areas resulting in severe expressive and receptive aphasia
- May still be able to communicate using gestures
Types of aphasia
- Broca’s
- Wernicke’s
- Conduction
- Global
which vessels supply Broca’s and Wernicke’s
MCA
Pt with aphasia, which side of brain most commonly affected
left because most are right dominant
dorsal column conveys what
fine touch, proprioception and vibration
Degenerative cervical myopathy
- RF smoking
- pain in neck, UL, LL
- loss of motor and sensory function
- hoffman’s sign (flick the middle fingernail to see if the thumb or index finger flexes involuntarily)
- Ix- MRI cervical spine
- Mx- early decompressive surgery
Hoffman’s sign interpretation
sign of upper motor neuron dysfunction –> CNS issue
diabetes insipidus visual field defect
lower bitemporal hemianopia
third nerve palsy
- ipsilateral eye to lesion is deviated ‘down and out’
- ptosis
- pupil may be dilated
- cause: false localizing sign* due to uncal herniation through tentorium if raised ICP
- absent light reflex with intact consensual constriction
HSV encephalitis
- affects temporal lobes
- fever, headache, psychiatric symptoms, seizures, vomiting
- focal features e.g. aphasia
- Mx IV aciclovir
normal pressure hydrocephalus
classical triad of:
1. urinary incontinence
2. dementia and bradyphrenia
3. gait abnormality (may be similar to Parkinson’s disease)
Imaging: ventriculomegaly out of proportion to sulcal enlargement.
Mx- ventriculoperitoneal shunt
homonymous quadrantonopias
PITS
Parietal- inferior
Temporal- superior
Homonymous hemianopia
- incongruous defects: lesion of optic tract
- congruous defects: lesion of optic radiation or occipital cortex
- macula sparing: lesion of occipital cortex
Neuroleptic malignant syndrome
- when on antipsychotics
- pyrexia, muscle rigidity
- autonomic lability: typical features include hypertension, tachycardia and tachypnoea
- agitated delirium with confusion
- CK high and AKI
- Mx: stop antipsychotic and IV fluids, can give bromocriptine
Features of wernicke’s encephalopathy
- oculomotor dysfunction
nystagmus (the most common ocular sign)
ophthalmoplegia: lateral rectus palsy, conjugate gaze palsy - gait ataxia
- encephalopathy: confusion, disorientation, indifference, and inattentiveness
- peripheral sensory neuropathy
Mx- replace thiamine (pabrinex)
common peroneal nerve injury
unable to dorsiflex and evert foot
Syringomyelia
- collection of cerebrospinal fluid within the spinal cord
- cause: tumour, trauma, idiopathic
- cape-like’ (neck, shoulders and arms) loss of sensation to temperature but the preservation of light touch, proprioception and vibration
- due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected
- Ix- MRI spine
Thoracic outlet syndrome
- compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet
- neurogenic (90%) or vascular
- painless muscle wasting of hand muscles, with patients complaining of hand weakness e.g. grasping
- physio, surgical decompression
Oxford stroke classification criteria
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Types of stroke
- Total anterior circulation infarcts (TACI, c. 15%)
- Partial anterior circulation infarcts (25%)
- Lacunar infarcts (LACI, c. 25%)
- Posterior circulation infarcts (25%)
- Lateral medullary syndrome (posterior inferior cerebellar artery)
- Weber’s syndrome
Total anterior circulation infarcts
- involves middle and anterior cerebral arteries
- all 3 of the oxford classification criteria are present
Partial anterior circulation infarcts
- involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
- 2 of the criteria are present
Lacunar infarcts
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Posterior circulation infarcts
- involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
lateral medullary syndrome
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Weber’s syndrome
ipsilateral III palsy
contralateral weakness
ulnar nerve
- Arises from medial cord of brachial plexus (C8, T1)
- Motor to: medial two lumbricals, aDductor pollicis, interossei
hypothenar muscles: abductor digiti minimi, flexor digiti minimi
flexor carpi ulnaris - Sensory to: medial 1 1/2 fingers (palmar and dorsal aspects)
radial nerve
- wrist drop (saturday night palsy)
- supplies extensors of the wrist and fingers
- assoc with mid shaft humeral fracture
- Loss of sensation on the dorsum of the hand over the thumb and index finger
- Sensory: supplying the proximal phalanges on the dorsal aspect of the hand exc little finger and part of ring
- Motor: triceps, bracioradialis, extensors, supinator
ulnar nerve
- formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial (C8 and T1)
- Damage at wrist e.g. carpal tunnel syndrome, Colle’s
Raised ICP mx
- head elevation to 30º
- IV mannitol may be used as an osmotic diuretic
- controlled hyperventilation
- repeated LP, VP shunt
L5 nerve lesion
weakened dorsiflexion, inversion and eversion of the ankle
pituitary apoplexy
- Sudden onset headache, visual field defects + evidence of pituitary insufficiency (e.g. hypotension)
- Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction.
- Mx: urgent steroid replacement due to loss of ACTH, careful fluid balance, surgery
causes of cerebellar injury
PASTRIES
- Posterior fossa tumour
- Alcohol
- Stroke
- Trauma
- Rare causes
- Inherited (e.g. Friedreich’s ataxia)
- Epilepsy treatment
- S Multiple sclerosis
main clinical signs of cerebellar disease
DANISH
- Dysdiadochokinesia
- Ataxia
- Nystagmus multidirectional
- Intention tremor
- Speech
- Hypotonia
cerebellar stroke signs
- vertical nystagmus
- unable to stand without support
- l§esion of the superior cerebellar artery, anterior inferior cerebellar artery or the posterior inferior cerebellar artery (also known as lateral medullary syndrome)
Subacute degeneration of the spinal cord
- due to vitamin B12 deficiency or NO, resulting in impairment of the dorsal columns, lateral corticospinal tracts and spinocerebellar tracts.
- DC: distal tingling/burning/sensory loss is symmetrical, LL>UL
- LC: muscle weakness, hyperreflexia, and spasticity, babinski +ve
- ST: sensory ataxia → gait abnormalities, +ve Romberg’s sign
posterior communicating artery aneurysm
headache and painful third nerve palsy
common reflexes and nerve roots
Ankle S1-S2
Knee L3-L4
Biceps C5-C6
Triceps C7-C8
Autonomic dysreflexia
- occurs in patients who have had a spinal cord injury at, or above T6 spinal level
- triggered by urine infection/faecal impaction
- extreme hypertension
- flushing and sweating above the level of the cord lesion
- associated with haemorrhagic stroke due to hypertension
- agitation
- Mx: remove stimulus
Intracranial venous thrombosis
- headache (may be sudden onset)
- nausea & vomiting
- reduced consciousness
- Ix: MR venogram
- Mx: anticoagulation
pontine haemorrhage
- commonly presents with reduced GCS, paralysis and bilateral pin point pupils
- haemorrhagic stroke
Carpal tunnel syndrome
- PNS disease, compression of median nerve
- Motor: LOAF muscles (lateral lumbricals, opponens pollicis, abductor pollicis brevis and flexor policis brevis)
- tinnel’s, phalen’s, thenar wasting, lack of grip
Cavernous sinus syndrome
- most commonly caused by cavernous sinus tumours
- Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner’s syndrome
what condition are triptans contraindicated
coronary artery disease, can cause coronary vasospasm
Brachial plexus injuries
Erb-Duchenne paralysis
- damage to C5,6 roots
- winged scapula
- may be caused by a breech presentation
Klumpke’s paralysis
- damage to T1
- loss of intrinsic hand muscles
- due to traction
Creutzfeldt-Jakob disease
Rapidly progressive neurological condition caused by prion proteins
- sporadic, acquired, inherited types
- Features: dementia (rapid onset), myoclonus
bitemporal hemianopia visual field defects
- lesion of optic chiasm
- upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
- lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
C8 fact
C8 is the ONLY cervical nerve root that comes out BELOW the vertebra
side effect of lamotrigene
Steven-Johnsons syndrome (seek help if get a rash)
ataxic gait
A wide-based gait with loss of heel to toe walking
restless leg syndrome
- uncontrollable urge to move legs (akathisia)
- movements during sleep may be noted
- causes: FH, diabetes, pregnancy, IDA
- Mx: walking, stretching, dopamine agonist (ropinirole)
combination of lower back pain, pain in the left leg, and tingling in the left big toe, which are consistent with the dermatomal distribution of…
the L5 nerve root
left foot drop nerve effected
L5 nerve root
hypoglossal nerve function
- responsible for motor function of the tongue, including protrusion and side-to-side movements.
- damage = tongue deviate towards affected side
mx of raised ICP
IV mannitol
head lift
VP shunt
mx of cerebral oedema
dexamethasone
what is Brown-Seqard syndrome
- caused by lateral hemisection of the spinal cord
Features
- ipsilateral weakness below lesion
- ipsilateral loss of proprioception and vibration sensation
- contralateral loss of pain and temperature sensation
sensation level of belly button
T10
