Neuro Flashcards
What is the most common cause of extradural haemorrhage?
Head injury which results in the fracture of the temporal/parietal bone causing laceration of the middle meningeal artery.
Mainly seen in younger people
S&S of extradural haemorrhage?
Brief initial loss of consiousness, lucid interval where the patient appears well.
Raised ICP = severe headache, nausea/vomiting, confusion, hemiparesis, brisk reflexes and seizures
Brain compression = ipsilateral pupil dilation, bilateral limb weakness and coma
Brain stem compression = decreased GCS and respiratory arrest
How does blood appear in the 3 main brain haemorrhages?
Extradural = rounded Subdural = crescent shaped Subarachnoid = star shaped
Treatment for Extradural haemorrhage?
ABCDE, IV mannitol, intubate and ventilate if unconsiouss, neurosurgery for clot evacuation with/without vessel ligation
What causes a subdural haemorrhage?
Trauma causing rupture of the bridging veins. A haematoma will initially block the bleeding but as the clot is broken down it will enlarge due to osmosis.
Head injury may be quite minor or many months ago.
Most common in alcoholics and the elderly
S&S of a subdural haemorrhage?
Previous trauma, fluctuating levels of consiousness, personality change,
Raised ICP = severe headache, nausea/vomiting, confusion, hemiparesis, brisk reflexes and seizures
Coning = stupour, coma and death
Treatment of subdural haemorrhage?
ABCDE management, IV mannitol, address cause of traum e.g. OT needed, consider neurosurgery
What causes a subarachnoid haemorrhage?
Non-traumatic. Berry aneurysm rupture (often at posterior/anterior communicating artery junctions) or due to encephalitis, vasculitis or tumour
S&S of subarachnoid haemorrhage?
Sudden onset thunderclap headache, vomiting, collapse, seizure, drowsiness/coma, Kernig’s sign, papilloedema = diplopia
Treatment for subarachnoid haemorrhage?
Immediate neurosurgery refferal, IV fluids, CCBs (reduce vasospasm and prevent ischaemia), endovascular coiling/stents/balloons. Give mannitol to reduce ICP
Between which layers do the three types of haemorrhage occur?
Extradural = dura mater and bone Subdural = arachnoid and dura mater Subarachnoid = pia mater and arachnoid
What is a stroke?
Rapid onset of neurological deficit which lasts for >24 hours and can lead to death.
May be ischaemic (thrombosis of small vessels/watershead ischaemia) or haemorrhagic
Ris factors for stroke?
Increasing age, being male, hypertension, past TIA, cocaine use/alcoholism, smoking, DM, oral contraceptive pill, vasculitits
S&S of an ACA stroke?
Leg weakness, leg sensory disturbances, gait apraxia and truncal ataxia, incontinence, drowiness and akientic mutism
S&S of a MCA stroke?
Contralateral arm and leg weakness, contralateral sensory loss, hemianopia, aphasia/dysphasia and facial droop
S&S of a PCA stroke?
Contralateral homonymous hemianopia with macular sparring, cotrical blindness, visual agnosia/prospagnosia, discrimination problems, dyslexia and unilateral headache
S&S of a Posterior circulation stroke?
Locked in sydrome, dysarthria and speech impariment, vertigo, nausea/vomiting, visual disturbances and altered consciousness
S&S of a lucunar stroke?
One of pure motor loss, pure sensory loss or sensorimotor loss
What is a lacunar stroke?
Blockages of the smaller arteries
Treatment of ischaemic stroke?
IV fluids,
<4.5 hours = thrombolysis with tissue plasminogen activator and then antiplatelet therapy (IV alteplase and clopidogrel)
>4.5 hours = aspirin and clopidogrel
Treatment of haemorrhagic stroke
Reverse anticoagulants with vitamin K, mannitol to reduce ICP, control hypertension and consider surgery e.g. stenting
What is a TIA?
Transient Ischaemic Attack. A brief episode (5-10mins) of neurological dysfunction due to temporalry focal cerebral ischaemia without infarction.
Causes of TIA?
Small vessel occlusion with carotid artery atheroembolism, hyperviscosity e.g. polycythemia/myeloma, hypoperfusion e.g. postural hypotension
Causes of stroke?
Small vessel thrombosis = embolism due to AF, MI, infective endocarditis or artery stenosis (atheroembolism)
Watershed stroke = sudden drop in BP due to sepsis
Haemorrhagic = due to trauma, aneurysm, anticoagulation
S&S of TIA?
Sudden loss of function
Anterior circulation = contalateral weakness/numbness, dysphasia and amaurosis fugax
Posterior circulation = diplopia/hemianopia, vertigo, confusion, ataxia, hemisensory loss and dysarthria
What is the ABCD2 score?
Scored 0-7 shows the risk of stroke after TIA
> 6 = v. high risk - refer to specialist immedoatley
> 4 = high risk - refer to specialist within 24hrs
> 0 = medium risk - refer to specialist within 7 days
Treatment for TIA?
Aspirin and dipyridamol for 2 weeks.
Long term = P2Y12 inhibitor e.g. clopidogrel, statins and ACEis/ARBs
What is Giant Cell Arteritis?
GCA is a large vessel vasculitis often exisiting alongside polymyalgia rheumatica. It causes infalmmation fo teh carotid artery
S&S of GCA?
Temporal artery tenderness/swelling/lack of pulsation, abrupt onset unilateral temporal headache, scalp tenderness, jaw claudication on chewing, temporary vision loss
Treatment for GCA?
Oral prednisolone or IV methyprednisolone (if vision loss). Steroid treatment for a max. of 2 years
What are the main priamry headaches?
Migraine, cluster and tension
Causes of migraine?
CHOCOLATE - Chocolate, Hangovers, Orgasm, Cheese, Oral-contraceptive pill, Lie-ins, Alcohol, Tumult, Exercise
S&S of migraine?
Unilateral moderate-severe throbbing pain, motion sesitivity, nausea/vomiting, photophobia/phonophobia, with or without aura (visual changes)
Treatment for migraines?
Acute attacks = triptans e.g. sumatriptan and NSAIDs (avoid ibuprofen and paracetamol)
Preventative if 2+ monthly attacks = Beta-blockers, tricyclic antidepressants and anticonvulsants
S&S of tension headache?
Bilateral pressing/tight non-pulsatile headache of mild-moderate intesity, pressure behind the eyes, no aura and not aggrivated by movement
This is the most common headache and is treated with standard pain killers
S&S of cluster headache?
Rapid onset of excrutiating pain around one eye lasting for 15-20mins once or twice a day, ipsilateral cranial autonomic signs e.g. eye watering, facial flushing and rinorrhoea, may be vomiting
Treatment for cluster headache
Acute attacks = oxygen and triptans e.g. sumatriptan
Prevent = CCBs and avoidance of alcohol
Define epilepsy?
Reccurrent tendency to spontaneous intermittent abnormal/excessive electrical activity in part of the brain manifesting as seizures
How can you identify a non-epileptic seizure?
Last longer, have eyes and mouth closed during tonic-clonic movement, have pelvic thrusting and do not cause inconinence/ tounge biting. They will also NOT occur in sleep
S&S of a generalised tonic-clonic seizure?
No aura, loss of consiousness, tonic = rigid/stiff limbs cause the person to fall, clonic = bilateral rhythmic muscle jerking.
Eyes remain open, there may be tongue biting or incontinence and afterwards = drowsiness and confusion
S&S of an absence sizure?
Usually seen in children
Ceases activity, stares and pales (this is only for a short period of time), patient does not realise they have seized and carries on as normal after
S&S of a myoclonic seizure?
sudden isolated jerk of the limb/face/neck
S&S of a tonic seizure?
sudden sustained intense stiffening of the body not followed by clonic jerking
S&S of an akinetic/atonic seizure?
sudden loss of muscle tone and cessation of movement resulting in a fall
Simple partial vs a complex partial seizure?
Simple = focal symptoms which do not affect memory or consiousness
Complex = focal symptoms which do affect memory and consiousness (may be before, during or immediatley after a seizure)
Exact symtpoms depend on the seizure location
What are the key areas affected by focal seizures in each part of the brain?
Temporal = memory, emotion and speech understanding Frontal = motor and thought processing Parietal = sensation interpretation Occipital = vision
Treatment of seizures?
Tonic clonic = sodium valporate or carbamazepine
Absence = sodium valporate or ethosuximide
Partial = sodium valporate or carbamazapeine
Surgical treatment if a specific cause can be identified
S&S of Parkinson’s disease?
Tremour (asymmetrical, worse at rest and in repetitive hand movements), rigidity (increased tone in limbs/trunk), bradykinesia (reduced repetative actions, narrow gait/shuffling and balance issues)
It is gradual onset
Treatment of Parkinson’s disease?
Dopamine agonists e.g. ropinirole, then MAO-B/COMT inhibitors e.g. selegiline/tolcapone, the L-dopa e.g. levodopa AND decarboxylase inhibitor
What is a common side effect of Parkinson’s and how is it treated?
Neuropsychiatric issues, particularly depression/dementia/psychosis.
Treat with SSRIs e.g. Citalopram or anti-psychotics e.g. quetiapine
What are the 2 diseases of dopamine?
Parkinsons = too little due to mitochondrial dysfunction Huntingtons = too much due to lack of GABA
What causes Huntington’s disease?
Autosomal dominant mutatio leading to the repeated expression of the CAG sequence
S&S of Huntington’s disease?
Mild psychotic symptoms initially, chorea = jerky/rigid/involuntary movements that cease in sleep, dysarthria, dysphagia, abnormal eye movements, dementia, agression and depression
Treatment of Huntington’s disease?
Death will occur within 15 years.
Benzodiazepines/sulpride can help chorea, SSRIs/anti-psychotics/ for mental health, risperidone for aggression
What are the types of MS?
Relapsing and remitiing = periods of good health followed by sudden onset of symptoms. Disability may accumulate
Secondary progressive = progresses from relapsing and remitting, symptoms worsen and remissions become fewer
Primary progressive = diasbility gradually worsens from the start - no remission
S&S of MS?
Unilateral optic neurtitis, leg weakness, numbness/tingling in limbs, ataxia, amnesia, dysarthria, dysphagia, loss of proprioception, intention tremours and spasticity.
Symptoms gradually worsen over time and are worse with heat
Treatment for MS?
General = Badofen (GABA analogue), gabapentin (blocks GABA breakdown), smoking cessation, stress reduction, physiotherapy
Acute relapses = IV methyprednisolone for <3 days
Frequent relapses = S/c interferon IB/IA and monoclonal antibodies e.g. IV alemtuzumab
S&S of brain tumours?
Progressive headache worsened by walking/coughing, drowsiness, nausea/vomiting, papilloedema, lethargy, drowsiness, epilepsy/seizures, progressive neurological deficit (depends on tumour location)
Treatment for brain tumours
Primary = surgical removal, chemotherapy, dexamethosone and carbamazepine Secondary = surgery if <75, chemotherapy and palliative
Where have secondary brain tumours commonly metastasized from?
NSC lung cancer, breast, melanoma, renal and GI cancers
Causes of encephalitis?
EBV, VZV, HIV, CMV, mumps, measles, bacterial meningitis, TB and malaria
S&S of encephalitis?
Fever, headache, personality/behavioural changes - tirad
Myalgia, fatigue, nausea, decreased consiousness, haemiparesis, dysphasia, seizures and coma
Treatment for encephalitis?
Viral = immediate antivirals e.g. acyclovir
Meningitis = emergency benzypenicillin
Anti-seizure meds e.g. primidone
Causes of meningitis?
N.meningitidis, Strep.pneumoiae, H.influenzae
Neonates = E.coli, group B haemolytic strep.
Immunocompromised = CMV, TB, HIV
Pregnany/old = Listeria monocytogenes
S&S of meningitis?
Headache, fever and neck stiffness = triad
Photophobia, vomiting, malaise, decreased GCS, Kernig’s sign, non-blanchign petechial rash
How can you differentiate the cause of meningitis from a lumbar puncture?
Bacteria = increased neutrophils and turbid CSF TB = increased lymphocytes and increased proteins Viral = increased lymphocytes and normal proteins
How do you treat bacterial meningitis?
Immediate IV cefotaxime/ceftriaxone (IV chlorampenicol if penicillin anaphylaxis), oral dexamethosone, IV vacomycin in returning traveller and oral ciprofloxacin for close contacts
What is Meningococcal septicaemia?
Complication of meningitis characterised by non-blanching petechial rash, hearing loss, seizures and developmental issues
Treat with IV benzylpenicillin/cefotaxime. DO NOT perform lumbar punture
S&S of shingles?
Rash which does not extend outside the dermatome - contains papules and vesicles, myalgia, malaise, headache, fever and neuritic pain
Which nerves are commonly affected in immunocompromised shingles patients?
Thoracic and opthalmic divisions of the trigeminal nerve
What is post herpetic neuralgia?
A complication of shingles.
Buring pain > 4months after shinglesm.
Treat with tricyclic antidepressants e.g. amytriptaline, antiepileptics e.g. gabapentin or anticonulsants e.g. carbamazapine.
Treatment of shingles?
Oral antivirals e.g. acyclovir for 5 days and ibuprofen
What may cause spinal compression?
Spondylosis, Disc prolapse, Spinal tumours, Spondyloisthesis, Spinal stenosis and Spinal abscess
S&S of spinal cord compression?
At the level of the compression = sharp shooting burning pain which is well localised
Below the level of compression = UMN signs
S&S of an upper motor neurone lesion?
weakness, hypertonia, hyperreflexia, Babinski sign positive and pronator drift
S&S of a lower motor neurone lesion?
weakness, hypotonia, hyporeflexia, Babinski sign negative and fasiculations
Where does the spinal cord end and where does the corda equina run?
Ends at L1
Runs L2-S2
Causes of cauda equina syndrome?
Disc prolapse, tumour, infection, bleeding and trauma
S&S of cauda equina syndrome?
Loss of anal tone, loss of anal wink reflex, loss of sensation in the saddle region, urinary retention/overflow incontinence, bilateral leg pain/weakness and impotence,
Treatment for cauda equina syndrome?
MEDICAL EMERGENCY
Lumbar decompression
What is motor neurone disease?
A group of degenerative diseases characterised by the selective loss of motor neurones.
UMN/LMN signs but no sensory disturbance, occulomotor issues or sphincter issues
S&S of Amyotrophic Lateral Sclerosis?
MND - loss of MNs in the motor cortex and anterior horn
UMN AND LMN signs, wrist and foot drop and split hand sign
S&S of Progressive Bulbar Palsy?
MND affecting nuclei of CN 9-12
LMN lesions in tongue and muscles of talking/swallowing, flaccid fasiculating tongue (bag of worms) and quiet speech
S&S of Progressive Muscular Atrophy?
MND. Anterior horn cell lesions
LMN signs, affects distal muscles before proximal muscles and often starts in 1 limb
S&S of Primary Lateral Sclerosis?
MND. Loss of beta cells in the motor cortex
UMN signs, Arms = flexors are stronger than extensors, legs = extensors are stronger than flexors. NO cognitive decline
How might you treat MND?
Antiglutamate drugs e.g. riluzole
Oral baclofen for spasm
Oral amitriptyine/propantheline for drool
Analgesia, Non-invasive ventilation, Naso-gastric tube
What is Myasthenia Gravis?
An autoimmune disease agains the nicotinic acetylcholine receptors in the neuromuscular junction. Often due to thymus issues and causing fatigable muscle weakness.
S&S of Myasthenia Gravis?
Increasing muscle fatigue, myasthenic snarl on smiling, voice fades e.g when counting to 50, ptosis, diplopia, respiratory difficulties, muscles get weaker with fatigue. Issues start at the eyes and work downwards (descending)
What is a key test for Myasthenia Gravis?
Increased serum anti-AChR, ptosis improves with ice.
Treatment for Myasthenia Gravis?
Anti-Cholinesterases e.g. pyridostigmine, immunosuppression with prednisolone (add methotrexate if widespread disease), thymectomy if <50
What is Myasthenic Cirisis?
Weakness of the respiratory muscles - can be life threatening. Treat with plasmapheresis (remove Ab) and IV immunoglobulin
What is Guillain-Barre Syndrome?
Acute inflammatory demyelinating disease affecting teh peripheral nerves after a GI/Upper RT infection
Common causative organisms of Guillain-Barre Syndrome?
Campylobacter jejuni - most common, CMV, EBV, HIV, Hepatitis and mycoplasma pneumonia
S&S of Guillain-Barre Syndrome?
Symmetrical ascending muscle weakness (starts at legs then spreads to arms), proxima, muscles are affected the most, pain, parasthesia, loss of reflexes, sweating and arrythmias.
Progresses for 4 weeks and then recovers
Treatment of Guillain-Barre Syndrome?
Ventilation if FVC < 80%, IV immunoglobulin for 5 days, plasma exchange and prophylaxis LMW Heparin
What are the mechanisms that can cause nerve dysfunction?
Demyelination, axonal damge, compression, infarction, infiltration and Wallerian degeneration (cutting)
What are the types of peripheral neuropathy?
Mononeuropathy = affects a single nerve
Mononeuritis multiplex = affects several individual nerves e.g. DM/vasculitis
Polyneuropathy = affects peripheral nerves on both sides of the body - motor/sensory/sensorimotor/autonomic
What are the main cuases of polyneuropathy?
Mostlty motor = Guillain-Barre syndrome, lead poisoning, charcot-marie-tooth syndrome
Mostly sensory = DM, renal failure and leprosy
S&S of polyneuropathies?
Sensory = numbness and paraesthesia with glove and stocking distribution, difficulty with small objects e.g. buttons Motor = Rapidly progressing LMN signs mainly affecting the hands and feet, difficulty walking, weak and clumsy hands and breathing issues
Treatment of polyneuropathies?
Nerve damage is irreversible. Pain relief with amitriptyline/gabapentin/pregablin, quinine for cramps, physiotherapy and walking aids
S&S of Carpal Tunnel Syndrome?
Entrapment neuropathy.
Intermiitent/gradual onset of pain in the hand and arm (worse at night), parasthesia of median nerve distributuion (3 and a half fingers and palm), sensory loss and weakness in the thumb, pain relieved by dangling arm over the bed and shaking
Test for Carpal Tunnel Syndrome?
Phalen’s test adn Tinel’s test
Treatment for Carpal Tunnel Syndrome?
Splint wrist at night, local steroid injections, decompression surgery
S&S of Browns-Sequard Syndrome?
Ipsilateral weakness and loss of fine touch, vibration and proprioception
Contralateral loss of crude touch, pain and temperature
What is paraplegia?
Loss of motor/sensory function in both legs caused by spinal cord damage or genetic issues
What is hemiplegia?
Weakness, spasticity and lack of control of one side of the body due to a brain lesion
