Neuro Flashcards
what are the types of headaches?
- Primary →
a. migraine,
b. tension-type,
c. cluster,
d. other eg stabbing - Secondary → symptomatic of underlying pathology (↑ ICP, SOL) meningitis, alcohol withdrawal, medication overuse, Acute sinusitis.
- Trigeminal and other cranial neuralgias → eg. nerve root pain from herpes zoster
- Episodic → <15 days per month
- Chronic → 15+ days per month
how do tension headaches present?
This is a symmetrical headache of gradual onset, often
described as tightness, a band or pressure. There are
usually no other symptoms.
how do MIGRAINE WITHOUT AURA present?
- 90% of migraine
- Episodes lasting 1-72 hours, commonly bilateral but can be unilateral
- Pulsatile over temporal or frontal area
- Can be accompanied by GI disturbance eg. nausea, vomiting, abdo pain, photo/phono-phobia
- Aggravated by physical activity
how do MIGRAINE WITH AURA present?
- 10% of migraine
- Preceded by aura (visual, sensory, motor), but can occur without a headache:
migraine aura often begins with positive phenomena such as shimmering lights, zigzags in the vision, or tingling and
then followed in minutes by negative symptoms such as scotoma, numbness, or loss of sensation
- Characteristically: absence of problems between episodes, frequent presence of premonitory symptoms
- Aura symptoms are fully reversible
- Commonly visual
• Episodes last a few hours
what are the risk factors and triggers for migraine?
• Often triggered by disturbance to inherent biorhythms – late nights, stress, winding down (cheese, chocolate, caffeine)
- Genetic predisposition
- Oral Contraceptive Pill and menstruation
what are the postivie and negative phenomena in migraine?
o Negative phenomena
▪ Hemianopia
▪ Scotoma (small areas of visual loss)
numbness, or loss of sensation
o Positive phenomena
▪ Fortification spectra
shimmering lights, zigzags in the vision, or tingling
what are the Uncommon forms of migraine?
caused by;
Benign paroxysmal vertigo of childhood
Abdominal migraine
Cyclical vomiting
In raised ICP, which nerve is most commonly affected?
what signs are seen and why?
VIth (abducens) cranial nerve has a long
intracranial course and is often affected when
there is raised pressure, resulting in a squint with
diplopia and inability to abduct the eye beyond
the midline. It is a false localising sign.
how do cluster headaches present?
- Unilateral (around eye/side of face)
- Severe, sharp/burning/throbbing pain
- ± watery eye, nasal congestion/runny nose, swollen eyelid, facial swelling, constricted pupil/droopy eyelid
- Ranges from 1 every other day to 8 per day
which red flag features should alert on headaches involving raised ICP and SOL ?
- Worse on lying down and morning vomiting
- Can cause night-time waking
- ± change in mood, personality, educational performance
others:
• torticollis (tilting of the head)
• growth failure, e.g. if craniopharyngioma or hypothalamic lesion
• papilloedema – a late feature
• cranial bruits – may be heard in arteriovenous malformations but these lesions are rare
• early or late puberty.
papilloedema - late sign
How do we ivx and mx headaches?
- Detailed explanation and advice
• Ivx / Imaging not needed unless red flag features present
o Medication cannot cure but can help symptoms
Options:
o Analgesia - Paracetamol and NSAIDS (all ages)
o Anti-emetics:
▪ 6+ → cyclizine
▪ 12+ → prochlorperazine and metoclopramide, consider codeine phosphate
2nd line
A o Serotonin 5HT1 agonists → if 12+ → consider sumatriptan, nasal preparation
• Prophylaxis
o If headaches are frequent, obtrusive
1 ▪ Beta blockers → propranolol → contraindicated in asthma
o Refer to Neurology consultant for guidance:
2 ▪ Na channel blockers → sodium valproate, topiramate
3▪ Pizotifen → 5HT agonist
o Psychiatry support
▪ Decrease stressors → anxiety, bullying, relaxation techniques
caveat of Na channel blockers eg topiramate in headache rx?
• Note → fetal malformation link and decreased effectiveness of OCP – fertile young females should be on 2 birth control methods
caveat of 5HT agonist in headache rx?
causes increased weight and sleepiness
How would you manage a migraine?
1o Assess the severity and frequency of attacks, and the impact on the patient’s life:
2o Headache diary - 8 weeks to identify triggers
▪ Identify triggers (menstruation)
▪ Record frequency, duration, severity
Acute Management (in 12-17 year olds) o Step 1: Paracetamol or ibuprofen
o Step 2: Nasal sumatriptan
o Step 3: Nasal triptan + NSAID/paracetamol
§ Consider adding anti-emetic e.g. metoclopramide or prochlorperazine
Follow-up within 1 month -> return sooner if symptoms get worse
§ NOTE: ORAL triptans are not licensed in people < 18 years
Define a seizure.
What are the types of seizures?
Seizure:
An ACUTE & TRANSIENT (<5 mins) neurological events caused by abnormal electrical discharges within the brain.
- Epileptic
- a disease characterised by an persistent predisposition to generate epileptic seizures
- due to excessive electrical activity
- most commonly idiopathic (70-80%)
2. Non-epileptic Triggers iniclude stress No EEG changes in brain Still having jerking/shaking Not made up or being done on purpose Not epilepsy usually outgrown
what is the difference between a seizure and convulsions?
A convulsion is a seizure (epileptic or non-epileptic)
with motor components, particularly stiff (tonic), a
massive jerk (myoclonic), jerking (clonic), trembling
(vibratory), thrashing about (hypermotor);
as opposed to a non-convulsive seizure with motor arrest, e.g. an unresponsive stare (as in generalized epileptic absence
seizures and some focal seizures), or drop
attack (as in an epileptic atonic seizure).
define epilepsy?
Epilepsy is a brain disorder that predisposes the
patient to have RECCURENT UNPROVOKED seizures.
Definition/diagnosis: At least two unprovoked (or reflex) seizures occurring more than 24 hours apart
define febrile seizure?
what are the NICE criteria?
incidence?
Seizure AND fever, in the absence of intracranial infection.
Child has to be between 6 month – 6 years
incidence: 3%
characterise febrile seizures?
prognosis?
Occurs in a viral infection when the temperature is rapidly rising.
- Usually a brief, generalised tonic clonic seizure
- Some genetic predisposition, 30% will have further seizures
Prognosis:
- About 1 in 3 children will have another febrile seizure.
- Simple febrile seizures do not cause brain damage and do not ↑ risk of epilepsy
- Complex febrile seizures → focal, prolonged, repeated in same illness, will lead to an ↑ risk of 4-12% of subsequent epilepsy
how do we ivx febrile seizures?
IX:
• Not routinely needed
Clinical diagnosis
• Lumbar puncture - if meningitis or encephalitis suspicion
• Urine MCS - if UTI suspected
• Check blood glucose
• EEG not recommended as it does not guide treatment or predict recurrence
How do we mx an acute febrile seizures?
DURING THE SEIZURE:
Basic safety protocol; timing, rercording, recovery position etc
If the seizure lasts > 5 mins: (call ambulance)
Simple seizure: nothing needed, can give antipyretics.
- -> Buccal midazolam or Rectal diazepam
1b -> Call an ambulance, if 10 mins after the first dose:
§ Seizure has NOT stopped
§ Child has ongoing twitching
§ Another seizure has started before the child has regained consciousness
1c. Can repeat once after 10 mins if the seizure hasn’t stopped
- Identify and treat cause
- admit if meningitis
- if no foci of infection found - admit n observe
- Immediate hospital assessment by a paediatrician if: conditions met eg lasted >15mins, or <1.5y/o
Can give Ibuprofen/paracetamol BUT they dont help.
Current febrile illness + hx of febrile seizure:
Give prophylactic diazepam (after specialist referral)
—————–
History of 2+ COMPLEX febrile seizures, diazepam uneffective:
- prophylactic anti-epileptic (after specialist referral)
—————–
Status epilepticus:
- Refer to paeds neurologist
- Benzodiazipine
- Start full protocol
when is a paeds review needed after febrile seizure?
§ First febrile seizure or if second seizure in a child who has not been assessed before
§ < 18 months old
§ Diagnostic uncertainty about the cause of the seizure
§ Seizure lasted > 15 mins (complex seizure)
§ Focal features during the seizure
§ Seizure recurred in the same febrile illness (or within 24 hours)
§ Incomplete recovery after 1 hour
§ No serious clinical findings but is currently taking antibiotics
§ Parents are anxious and feel that they cannot cope
§ Suspected cause of the fever (e.g. pneumonia)
what are the causes of non-epileptic seizures?
• Convulsive syncope
– Cardiac syncope e.g. prolonged Q-T syndrome
– Neurally mediated syncope:
(reflex anoxic seizures), (vasovagal syncope)
– Expiratory apnoea syncope (“blue breath holding
spells”)
– Hypovolaemic syncope e.g. with haemorrhage, dehydration or anaphylaxis
• Sudden rise in intracranial pressure e.g.
hydrocephalic attack, haemorrhage
• Sleep disorders e.g. benign neonatal sleep myoclonus, hypnic jerks
• Functional/medically unexplained e.g.
dissociative states
what are the differentials for seizures in kids?
paroxysmal disorders (‘funny turns’} in kids
‘Blue breathholding’ spells
Reflex anoxic seizures (asystolic syncope)
Syncope (transient loss of consciousness) - eg in a hot room or standing for long periods or from fear. ± clonic movements
Benign paroxysmal vertigo
Long QT syndrome / arrhythmia
Benign myoclonus
Pseudo seizure
Panic attacks
Tics
what happens in breath holding attacks?
management?
• Toddlers when upset, child cries, holds their breath, goes blue, may briefly lose consciousness and go limp, rapidly recovers fully
- Attacks resolve spontaneously, drug therapy unhelpful
- Manage with behaviour modification and distraction
what are reflex anoxic seizures?
- Infants and toddlers
- Triggered by - pain, head trauma, cold food (ice cream), fright, fever
- Child becomes pale and falls to floor ± general tonic clonic
- Episodes due to cardiac asystole due to vagal inhibition
- Seizure is brief, and child recovers rapidly
what are the causes, presentation and ivx for Vasovagal syncope?
Causes
• Emotional → fear, pain, shock, sudden sounds or sights
• Orthostatic/ Postural hypotension → prolonged standing, crowds, hot
Clinically:
• Brief LOC, spontaneous recovery, no signs of seizure activity, link to trigger
IX:
• BP measurement standing AND sitting (Postural)
± ECG if indicated
• Need to rule out any cardiac cause
• FBC to rule out bleeding / anaemia
how do we manage vasovagal syncope?
Patient education – teaching how to spot warning symptoms, avoid triggers and learn how to abort attacks
• Physical techniques such as physical counter-pressure manoeuvres and tilt training
• Increase volume – increase dietary salt and electrolyte rich sports drinks
o May give fludrocortisone
what are risk factors for epilepsy?
• Risk factors o Genetic disposition o Perinatal asphyxia o Metabolic disorders o Trauma o Structural CNS abnormalities
How do Absence seizures and Tonic clonic seizures present?
• Absence seizures
o Brief impairment of consciousness, 5-10 seconds
o Behavioural arrest or staring – interrupting normal activity
• Tonic clonic
o Patient falls unconscious ± preceding aura
o Violent muscle contractions and shaking
o Stiffness, jerking
o Ask about symmetry of movements
o Eyes may roll back, tongue biting, incontinence
o Post-ictal phenomena
“tonic” = stiff
Define status epilepticus?
prognosis?
Old definition: a seizure needed to last longer than 20 minutes to be considered status epilepticus
New definition:
1. A single seizure that last more than 5 minutes.
OR
2. Two or more seizures within a 5-30minute period with no recovery in-between.
prognosis: 15-20% mortality within 30 days.
how do we manage status epilepticus?
- ABCDE, secure airway, check blood glucose,
If seizure lasts more than 5 minutes:
Step 2. Then get IV access → IV lorazepam
If no IV access:
-> Buccal midazolam OR Rectal diazepam (repeat after 5 mins if seizure has not stopped)
Step 3. Second dose of Benzo / IV lorazepam (15mins)
- call senior help ; anaesthetics
- prep phenytoin
- note; max 2 doses benzodiazepines regardless iv/buccal/rectal
Step 4. (25mins) Phenytoin 20 mg/kg by intravenous infusion over 20 mins
->Consider rectal paraldehyde 0.8 ml/kg whilst awaiting anaesthetist if seizure aint stopped
if on regular phenytoin:
4b -> Phenobarbital 20 mg/kg intravenously over 5 mins
->Consider rectal paraldehyde 0.8 ml/kg
Step 5: Rapid sequence induction of anaesthesia using thiopental sodium (basically put them to sleep fast) - this is what the anaesthetists would do. its a muscle relaxant
Protect from injury → cushion head, remove harmful objects, make sure environment is safe, do not restrain
which drugs are suited for the different types of seizures?
• Tonic-clonic → Valproate
2nd line Lamotrigine
- Absence → ethosuximide or valproate
- Myoclonic → valproate
- Infantile spasms → vigabatrin
- Partial → carbamazepine or lamotrigine
what are the complications of Anti-epileptic treatment?
• Lamotrigine → Steven Johnson Syndrome (toxic epidermal necrosis, life threatening skin condition)
- Phenytoin → gingival hypertrophy
- Carbamazepine → neutropenia, rickets
How do we ivx seizures?
Depends on what your dfx are for the cause
May need to do:
Septic screen;
Blood cultures, Urine MCS, LP
(want to localise infectious source)
Bloods; FBC - WCC, CRP, ESR (infection) U+Electrolytes - (hypokalaemia/calcaemia) Blood glucose Genetic screening
ECG - electrolyte imbalance
EEG - can do a sleep EEG or use photo stimulation to pick up abnormalities better
CT - if suspecting SOL (much quicker logistically than MRI - can do MRI later for more detialed picture)
What are the types of seizures?
GENERALISED A. Tonic-clonic (stiffness+jerking) B. Myoclonic (shock like) C. Atonic (sudden loss of tone - drop attacks) D. Absence - non motor
FOCAL/PARTIAL
A. Secondary generalised (start focal but spreads to involve both sides)
B. Motor/Sensory (causing either one-sided motor or sensory disturbance - feeling or visual etc)
C. Simple/Complex (s- retained consciousness, c- LOC)
-> note partial seizures can never not be worrying -> must be investigated - head imaging
UNKNOWN
How do Myoclonic seizures present?
what are the subtypes?
o Brief arrhythmic muscular jerking movements o Last a few seconds - sudden jerking or twitching - symmetric - can happen 100s of times a day
note they can have the jerks without a seizure as per say, check the EEG- in such cases, no treatment needed, reassure that it is not epilepsy
o Juvenile myoclonic epilepsy
▪ Usually involving neck, shoulders, upper arms
- most occur after WAKING UP
- There is often a mixture of absence, myoclonic and tonic–clonic seizures, so;
- poor concentration / daydreaming etc
▪ Begin around puberty/TEENS
- reassure as usually outgrown
o Progressive myoclonic epilepsy
▪ Rare syndromes
▪ Combination of myoclonic and tonic-clonic
▪ Patient deteriorates over time
which seizures in kids tends to be photosensitive (flashing or flickering lights)?
Juvenile myoclonic epilepsy
events cluster in the morning
what are the causes of epilepsy?
VITAMIN
Vascular - Stroke
Infection - meningitis, Neurocysticercosis
Truama - CNS injury
Autoimmune - SLE
Metabolic disorders - MELAS, hypoglycaemia or hyponatraemia, calcium changes (in young infants make sure to exclude inborn errors of metabolism)
Idiopathic - most common cause
Neoplasm - Brain tumours/SOLs
Note:
It is only epilepsy if the underlying cause is treated but seizures remain.
What would EEG show in seizures & epilepsy?
Myoclonic seizures eg Juvenile myoclonic epilepsy:
- Polyspikes
- polyspikes and waves
- > atonic presents similarly
Tonic-clonic seizures
- varies in tonic, clonic and postictal phases
