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Neuro Flashcards

1
Q

Differential of headache

A 
Tension headache
Migraine
Cluster headache 
Giant cell arteries
Raised ICP
Trigeminal Neuralgia
Subarachnoid Haemorrhage
Trauma
Sinusitis
Glaucoma
Iatrogenic
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2
Q

Symptoms of raised ICP

A 
Worse on...
Waking
Lying down
Bending forwards
Coughing

Need to rule out SOL

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3
Q

Symptoms of tension headache

A

Frontal
Gradually worsens
Lasts hours to days

Precipitated by stress/fatigue

Recurrent bilateral, often described as tight band

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4
Q

Symptoms of migraine

A

Lasts hours

Associated with vomiting/photophobia

May be aura/altered sensation

Female

Strong family history

Usually unilateral and throbbing

In women may be associated with menstruation

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5
Q

Symptoms of cluster headache

A

Episodic - 2-10x a day lasting 15mins-2hrs

Peri orbital

Isolated sweating/lacrimation/rhinorrhoea/nasal stuffiness

Alcohol common trigger, typically men and smokers

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6
Q

Symptoms of subarachnoid

A

Thunderclap
Occipital headache

Severe

Drop in GCS

Possible trauma

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7
Q

Symptoms of giant cell arteritis

A

Sub Acute onset (few weeks)

Elderly patient

Tender temporal arteries

Jaw claudication

Raised ESR

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8
Q

Symptoms of trigeminal neuralgia

A

Lasts seconds

Classic - washing or shaving affected area

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9
Q

Red flags for headache

A

Suddenly onset and severe

Altered consciousness level

Fever/neck stiffness

New onset focal neurology

Trauma

Position dependent

Red eye/eye pain/ visual loss/ nausea

Tender temporal regions

Pregnancy

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10
Q

Manage

Tension headache

A

Simple analgesia

Paracetamol + Ibuprofen

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11
Q

Manage

Migraine

A

Acute

  • 1st NSAIDs + Aspirin 900mg
  • 2nd triptans

Prophylaxis

  • 1st propranolol
  • 2nd topiramate or amitriptyline
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12
Q

Manage

Cluster headache

A

Acute = Triptan/100% oxygen

Prophylaxis = Verapamil or Topiramate

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13
Q

Manage

Trigeminal Neuralgia

A

1st Carbemazepine

2nd Lamotrigine

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14
Q

Manage

Giant Cell Arteritis

A

Prompt steroids

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15
Q

Types of strokes and how common

A

Ischaemic = 85%

Haemorrhagic = 15%

Urgent CT head to differentiate and treat

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16
Q

Subtypes of haemorrhagic stroke

A

Intracerebral

  • intra parenchymal
  • intra ventricular

Subarachnoid (between pia mater and arachnoid)

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17
Q

Risk factors for haemorrhagic stroke

A

Elderly

Male

Anticoagulation (warfarin or NOAC)

FH

Chronic liver disease

HTN

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18
Q

Managing haemorrhagic stroke

A

Neurosurgery

May opt for burr hole/craniotomy

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19
Q

Risk factors for ischaemic stroke

A

HTN

Smoking

Carotid artery stenosis

AF

FH

Previous stroke

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20
Q

Management of Ischaemic Stroke

A
  • Within 4.5 hours of onset of symptoms – thrombolyse with ALTEPLASE in the absence of contraindications e.g. recent major surgery
  • If not suitable for thrombolysis – aspirin 300mg
  • Aspirin for 2 weeks then lifelong anti-thrombotic management with clopidogrel 75mg
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21
Q

Secondary Prevention of Ischaemic Stroke

A

Statin, anti-hypertensive, anticoagulate if in context of AF, optimize treatment of co-morbidities e.g. DM

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22
Q

History for head injury

A

Mechanism? High/low energy? Likely part of polytrauma or isolated?
Pain? Where? Head? Neck?
Loss of consciousness, amnesia, persistent vomiting, progressive headache, altered level of consciousness
Intoxication?
More difficult to assess severity
Anticoagulation?
PMH - previous head trauma, seizures

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23
Q

Examination of head injury

A 
C-spine, ABCDE
GCS
13-15 mild, 9-12 mod, <9 severe
Pupils – indicator of ICP
Sluggish response to light
Asymmetrical
Papilloedema
‘down and out’
BOS fracture signs
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24
Q

Head Injury DDx

A 
BOS fracture
CN VII, CN VIII deficit – can complain of facial numbness/vertigo
Subdural haematoma
Extradural haematoma
Intra-cranial haemorrhage
Diffuse axonal injury
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25
Q

Rules for CT1

A

GCS 12 or less
GCS 13-15 and:
BOS/depressed skull fracture and/or penetrating injury
Dropping GCS or new focal neurology
Anticoagulated and LOC, amnesia or any neurological feature
Persistent and severe headache
TWO distinct episodes of vomiting

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26
Q

Rules for CT2 (within 8 hours)

A 
GCS 15 and any of:
Age >65 with LOC or amnesia
Evidence of possible skull fracture but no other features indicative of immediate CT
Retrograde amnesia >30 minutes
Any seizure activity
Significant mechanism of injury
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27
Q

Signs of base of skull fracture

A

Battle’s sign – bruising of the mastoid process of the temporal bone.
Raccoon eyes – bruising around the eyes, i.e. “black eyes”
CSF rhinorrhea
Cranial nerve palsy
Bleeding (sometimes profuse) from the nose and ears
Hemotympanum
Conductive or perceptive deafness, nystagmus, vomitus
In 1–10% of patients, optic nerve entrapment occurs.The optic nerve is compressed by the broken skull bones, causing irregularities in vision.

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28
Q

Subdural Haematoma

A

Bleed between dura and arachnoid mater

Caused by bleeding between damaged bridging veins between cortex and venous sinuses

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29
Q

Subdural Haematoma is associated with…

A

Anticoagulation
alcohol xs
elderly falling and cerebral atrophy

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30
Q

CT of subdural haematoma

A

CT – crescent shaped, bleeding does not cross midline

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31
Q

Management of subdural haematoma

A

Conservative. Reverse coagulopathy, consider antiepileptics prophylactically
Burr hole if GCS <9/neuro signs

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32
Q

Extradural Haematoma

A

Direct impact injury
Lucid interval, then drop GCS
Often focal neurology
CT - ‘lentiform’ appearance

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33
Q

Diffuse Axonal Injury

A

Rapid acceleration/deceleration e.g. RTC
Rapid deterioration in GCS
CT can appear normal in acute phase
Examination findings out of keeping with CT findings

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34
Q

Causes of seizures

A 
Idiopathic – approx 2/3
Structural
Cortical scarring secondary to previous HI
Developmental 
SOL
AVM
Non-epileptic causes of seizures
Trauma
Stroke
Haemorrhage/raised ICP
Alcohol or BDZ withdrawal
Metabolic e.g. hyponatraemia
Iatrogenic e.g. tricyclics, tramadol
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35
Q

Classification of seizures

Generalised

A

Awareness is always impaired

Both hemi-spheres involved

Tonic-clonic
Absence
Myoclonic
atonic

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36
Q

Classification of seizures

Focal

A

Awareness may or may not be impaired

Originates in a single hemisphere

Simple
Complex
Secondary generalisation

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37
Q

Describe tonic clonic seizure

A 
Loss of consciousness
Urinary incontinence
Tongue biting
Stiffened limbs +/- shaking
Post-ictal state
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38
Q

Describe absence seizure

A

Child
Brief pause (under 10s)
Returns to normal
Unaware it’s happened

39
Q

Describe a myoclonic seizure

A

Sudden jerk

Thrown to the ground or throw object out of hand involuntarily

40
Q

Describe an atonic seizure

A

Sudden loss of tone

41
Q

Localising features of focal lesions

Temporal Lobe - most common

A

Automatisms e.g. ‘lip smacking’, fiddling fingers
Dysphasia
Memory phenomena i.e. déjà vu/jamais vu
Hippocampal – emotional disturbance
Hallucinations (auditory, gustatory, olfactory)
Epigastric rising, emotional

42
Q

Localising features of focal lesions

Frontal Lobe

A

Motor features e.g. posturing, peddling of legs, pelvic thrust

Head/leg movements, post-ictal weakness

43
Q

Localising features of focal lesions

Parietal Lobe

A

Sensory disturbance eg tingling, numbness or pain

44
Q

Localising features of focal lesions

Occipital

A

Visual phenomena such as spots, lines and flashes

45
Q

Investigations of seizure

A

Rule out precipitating cause

EEG
NOT diagnostic
Used once clinical diagnosis is made after two seizures
Can help differentiate type of seizures and guide prognosis
Normal EEG does not exclude epilepsy

46
Q

Status Epilepticus - Definition

A

5 or more minutes of continuous seizure activity or repetitive seizures with no intervening period of recovery

47
Q

Status Epilepticus - Treatment

A

IV Lorazepam 4mg

2nd line = Phenytoin

48
Q

Management of Generalised Tonic Clonic Seizure

A

1st Line = Valproate/ Lamotrigine

49
Q

Management of Absence Seizure

A

1st line = Ethosuximide

50
Q

Management of Tonic/Atonic Seizure

A

1st line = Valproate

51
Q

Management of Myoclonic Seizure

A

1st line = Levetiracetam

52
Q

Management of Focal Seizure

A

1st line = Carbemazepine or lamotrigine

Carbemazepine can make generalised epilepsy worse!

53
Q

Side effects of Sodium Valproate

A

Teratogenic
Weight Gain
Hair loss
Fatigue

54
Q

Side effects of Phenytoin

A

Mechanism of action : binds to sodium channels increasing their refractory period

Monitor due to toxicity

Acute - initially dizzy, diplopia, nystagmus, slurred speech, ataxia
Later - confusion, seizures

Chronic - common - gingival hyperplasia, hirsutism, coarsening of facial features drowsiness
- megaloblastic anaemia (altered folate metabolism), peripheral neuropathy, lymphadenopathy, dyskinesia, osteomalacia (enhanced Vit D metabolism)

Idiosyncratic - fever, rashes (including toxic epidermal necrolysis), hepatitis, dupytrens, aplastic anaemia, drug induced lupus

Teratogenic - cleft palate and congenital heart disease

55
Q

Driving and epilepsy

A

1st seizure – car = 6 months, 5 years for HGV/PCV

Epilepsy – car = 1 year or 3years during sleep, 10 years off medication for HGV/PCV

56
Q

Cerebellar Symptoms

A

DANISH

Dysdiadokokinesis, Dysmetria
Ataxia
Nystagmus (horizontal)
Intention Tremor
Slurring speech, scanning dysarthria 
Hypotonia
57
Q

Causes of cerebellar syndrome

A

Unilateral cerebellar lesions cause ipsilateral signs

Friedrichs ataxia, ataxic telangiactasia
Neoplastic: cerebellar haemangioma
Stroke
Alcohol
MS
Hypothyroidism
Drugs - phenytoin, lead poisoning
Paraneoplastic eg. Secondary to lung cancer
58
Q

Symptoms of medication overuse headache

A

Present for 15 days or more per month

Developed or worsened while taking regular symptomatic medication

Patients using opioids and triptans most at risk

May be psychiatric comorbidity

59
Q

Carbamazepine - side effects, mechanism of action, common uses

A

Common uses - partial seizures, neuropathic pain, bipolar disorder

Mechanism - binds to sodium channels and increases their refractory period

Adverse effects - P450 enzyme inducer, dizziness and ataxia, drowsiness, headache, visual disturbances (especially diplopia), SJS, leukopenia and agranulocytosis, SIADH

60
Q

Neuroleptic malignant syndrome

4 features

A

Hyperthermia
Muscle rigidity
Autonomic instability
Altered mental status

61
Q

Painful third nerve palsy

A

Posterior communicating artery aneurysm

62
Q

Amyotrophic lateral sclerosis associated with…

A

Mixed UMN and LMN signs (usually no sensory deficits)

63
Q

Subdural Haemorrhage - what is happening?

A

Damage to bridging veins between cortex and venous sinuses

64
Q

Essential tremor

A

Autosomal Dominant

Worse when arms outstretched

Better with alcohol and propranolol

65
Q

Triptans - what are they, prescribing points, adverse affects and contraindications

A

5HT1 agonists used in acute treatment of migraine

Should be taken after onset of headache, not aura.

Adverse effects - triptans sensations - tingling, heat, tightness in throats and chest, heaviness, pressure

Contraindicated - in patients with a history of, or significant risk factors for, ischaemic heart disease of cerebrovascular disease

66
Q

Most common complication following meningitis

A

Sensorineural hearing loss

67
Q

Features of Wernicke’s Encephalopathy

A

CAN OPEN

Confusion
Ataxia
Nystagmus
Opthalmoplegia
PEripheral
Neuropathy

Caused by B1 - thiamine - deficiency

68
Q

Ptosis + Dilated Pupil

A

Third nerve palsy

69
Q

Ptosis + Constricted Pupil

A

Horner’s syndrome

70
Q

Pseudoseizures..

A

Tend to have a gradual onset

71
Q

Management of restless leg syndrome

A

Dopamine agonists such as ropinirole

72
Q

Sinusitis + focal neurology and fever

A

? Brain Abscess

73
Q

What is pituitary apoplexy?

A

Sudden enlargement of pituitary tumour secondary to haemorrhage or infection

74
Q

Features of pituitary apoplexy

A

Sudden onset headache
Vomiting
Neck stiffness
Visual field defects - classically bitemporal superior quadrantic defect
Extraocular nerve palsied
Features of pituitary insufficiency eg hypotension secondary to hypoadrenalism

75
Q

Management of pituitary apoplexy

A

Urgent steroids

76
Q

Management of mysathenic crisis

A

IV immunoglobulin

Plasma electrophoresis

77
Q

Stroke by anatomy

Anterior cerebral artery

A

Contralateral hemiparesis and sensory loss, lower extremity>upper

78
Q

Stroke by anatomy

Middle Cerebral Artery

A

Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia

79
Q

Stroke by anatomy

Posterior cerebral artery

A

Contralateral homonymous hemianopia with macular sparing

Visual agnosia

80
Q

Stroke by anatomy

Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)

A

Ipsilateral CN III palsy

Contralateral weakness of upper and lower extremity

81
Q

Stroke by anatomy

Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)

A

Ipsilateral: facial pain and temp loss

Contralateral: limb/torso pain and temp loss

Ataxia, nystagmus

82
Q

Stroke by anatomy

Anterior inferior cerebellar artery (lateral pontine syndrome)

A

Similar to Wallenbergs but

Ipsilateral: facial paralysis and deafness

83
Q

Stroke by anatomy

Retinal/ophthalmic artery

A

Amaurosis fugaxy

84
Q

Stroke by anatomy

Basilar artery

A

Locked in syndrome

85
Q

Features of syringimyelia

A

Spinothalamic sensory loss (pain and temp)

Loss of reflexes, bilateral upgoing plantars
Motor wasting and weakness of arms
Slow progression - years
May be asymmetrical initially

Development of cavity in spinal cord (if extends into medulla then syringobulbia)

86
Q

Describe subacute combined degeneration of spinal cord and explain why it happens

A

Happens due to vitamin B12 deficiency

Dorsal and lateral columns affected
Joint position and vibration sense lost first then distal paraesthesia
UMN signs typically develop in legs - classically extensor planters, brisk knee reflexes, absent ankle jerks

If untreated stiffness and weakness persist

87
Q

Multiple system atrophy

A

Suspect if unilateral Parkinsonism and severe autonomic disturbance

Shy Drager syndrome is a type -
Parkinsonism
Autonomic disturbance (atomic bladder, postural hypotension)
Cerebellar signs

88
Q

When a young person (under 55) with no obvious cause of stroke has a stroke what is the blood test work up?

A

Thrombophilia
Autoimmune screening
ANA antinuclear antibodies, APL antiphospholipid antibodies, ACL anticardiolipin, LA lupus anticoagulant, coagulation factors, ESR, homocysteine and syphilis serology

89
Q

TIA immediate antithrombotic therapy

A

Give aspirin 300mg immediately

Unless

  • patient has a bleeding disorder or takes anticoagulant
  • patient is taking low dose aspirin regularly
  • aspirin is contraindicated
90
Q

Antithrombotic therapy for TIA

A

Clopidogrel

91
Q

Types of dysphasia

Wernickes (receptive)

A

Superior temporal gyrus

Fluent speech

Abnormal comprehension

Repetition good

92
Q

Types of dysphasia

Conductive (associative)

A

Actuate fasciculus

Fluent speech

Abnormal comprehension

Poor repetition

93
Q

Types of dysphasia

Broca’s (expressive)

A

Inferior frontal gyrus

Non fluent speech

Normal comprehension

Repetition good

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