Neuro Flashcards
When do we prescribe Gabapentin?
Epilepsy. For seizures/ neuropathic pain.
What drug should you prescribe for aggression/ chorea?
Dopamine receptor Antagonist
eg Risperidone
Bacterial Meningitis causes
1 Streptococcus pneumoniae - most common overall
Listeria monocytogenes - pregnant
Neisseria meningitidis
Streptococcus agalactiae - neonates
Migraine Mx:
Prophylactic: Topiramate/ propanolol
1L: NSAID, paracetamol, TRIPTAN
2L:
3L: Amitriptyline
Viral Meningitis causes
= more common than bacterial
Enteroviruses
- Echovirus
- Coxsackievirus
- Poliovirus
Herpes Simplex Virus
Management of viral meningitis
Nowt specific
Supportive.
Acyclovir for HSV
How to tell the difference between bacterial and viral meningitis?
Lumbar puncture:
- Viral: lymphocytosis, normal protein/ glucose
- Bacterial: low glucose, raised protein
Also bacterial: Kernig’s + Brudzinski’s signs
Management of bacterial meningitis
- in primary setting
- secondary setting
- > 3months age
- <3months age
- prophylaxis
GP + non-blanching rash: IM Benzylpenicillin
Hospital:
IV 2g Ceftriaxone
or IV Cefotaxime + amoxicillin/ampicillin if <3months (listeria)
+
IV Dexamethasone if purulent CSF/ >3months with bacteria)
Prophylaxis: Ciprofloxacin or Rifampicin
Strep-resistant -Vancomycin
Define haemorrhagic stroke
Rupture of cerebrospinal artery
Management of an Ischaemic Stroke
ABCDE
IV Alteplase WITHIN 4.5hr onset - Thrombolysis
CT Head - new stroke?
Aspirin 24hr after tx
(Do not lower BP acutely UNLESS malignant; may impair cerebral perfusion)
Contraindications to Thrombolysis for Stroke
> 4.5 hr since onset
Recent head trauma, GI/ intracranial haemorrhage, recent surgery. acceptable BP, platelet count/ INR/BP
When can a Mechanical Thrombectomy be formed in Ischaemic Stroke patients?
Anterior: within 6hr onset
Posterior: within 12hr onset
Stroke prevention/ Chronic stroke management?
HALTSS
Hypertension 2wk AFTER stroke
Antiplatelet: Clopidogrel/ Warfarin (AF)/ rivaroxaban
Lipid-lowering: Atorvastatin
Tobacco: stop smoking
Sugar: Diabetes screening
Surgery: Carotid endarterectomy IF carotid stenosis >50%
How are anterior strokes classified?
Anterior:
a) Contralateral hemiplegia/paresis AND
b) Contralateral homonymous hemianopia AND
c) Higher cerebral dysfunction (aphasia, neglect)
- TACI = ACA + MCA
- PACI = a+b OR c = ACA or MCA
LACI = pure motor/ pure sensory/ sensorimotor/ ataxic hemiparesis. NO higher dysfunction.
How are posterior strokes classified?
Posterior:
a) Cerebellar dysfunction OR
b) Conjugate eye movement disorder OR
c) Bilateral motor/sensory deficit OR
d) Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit OR
e) cortical blindness/ isolated hemianopia
= POCI
Which arteries do POCIs involve?
Vertebrobasilar arteries + associated branches
> cerebellum, brainstem, occipital lobe
Define haemorrhagic stroke
Weakened cerebral vessels lead to rupture and haematoma formation.
What are the two types of haemorrhagic stroke?
Intracerebral haemorrhage - 75%
Subarachnoid haemorrhage - 25%
Strong risk factors for haemorrhagic stroke
Age, male, FHx, haemophilia, anticoagulation therapy, hypertension, vascular malformations.
Cocaine, amphetamines
Acute management of haemorrhagic stroke
Decompressive hemicraniectomy
BP Control <140/80
Pt presents with Lower back pain, saddle parasthesia and are incontinent.
Investigation? Other presentations Cause? Likely diagnosis? Mx?
Cauda Equina Syndrome
- sudden loss of sphincter control
Urgent MRI + Surgical decompression < 48hr
Cause: lumbar disc herniation L4-S1
Young pt presents with sudden severe back pain following a gymnastics competition.
Likely diagnosis?
Vertebral disc degeneration
Pt presents with severe pain and stiffness of their shoulder and neck.
Likely diagnosis? Where else could they be stiff?
Polymyalgia rheumatica
Affected areas: neck, shoulders, hips, lumbar spine
Management of Acute Cord Compression
Steroids - dexamethasone (if malignancy)
Surgical decompression
Cord compression presentations
Acute UMN signs + sensory disturbance below the lesion
Bladder/ bowel incontinence
“weak, hyperreflexive legs + paraesthesia “
Management of all seizures
Lamotrigine, Levetiracetam, Valproate
Mx of Focal Seizures
Carbamazepine, Gabapentin, Phenytoin
Mx of Absence seizures
Ethosuximide
Mx of epilepsy + heart problems
Digoxin (inhibits Na/K/ATPase)
Which epilepsy drug is CI in pregnancy
Valproate = teratogenic
Pt presents with rigidity, bradykinesia and postural instability. Tremor is worse at rest.
Likely diagnosis? Management? Associations?
Parkinson’s
LEVODOPA + Co-careldopa (SE n, hallucinations)
DA agonist - ropinirole
MAO-Bi - Selegline
COMTi - Entacaopone
Assoc with Lewy-Body dementia
Pt presents with sudden painless vision loss and a stiff neck/shoulders.
Likely diagnosis? Management?
Giant Cell Arteritis
(jaw claudication, tender scalp)
Prednisolone + protective bisphosphonate
(lansoprazole, alenronate)
Causes of peripheral neuropathy
Diabetes
HIV
B12 deficiency
MND is associated with which dementia?
Fronto-temporal (Pick’s) Dementia
Most common cause of meningitis
VIRAL - enteroviruses
- echovirus
- Coxsackie
Viral causes of meningitis
Enteroviruses (echo, coxsackie)
Herpes Simplex Virus
Varicella zoster
What are the main causes of Bacterial Meningitis?
Streptococcus pneumoniae
Neisseria meningitidis
Haemophilus influenza b
Listeria monocytogenes (bimodal age)
Immunocompetent Patient under 60 presents in the hospital with bacterial meningitis.
Treatment?
1L IV Ceftriaxone +
Dexamethasone
2L Chloramphenicol +
Dexamethasone
If suspected penicillin-resistant pathogen use 3rd-gen Vancomycin cover
Immunocompetent Patient under 60 presents in the hospital with bacterial meningitis.
After empirical tx, they are found to have Listeria monocytogenes. Tx?
IV amoxicillin
or IV Trimethoprim
Immunocompetent Patient under 60 presents in the hospital with bacterial meningitis.
After empirical tx, they are found to have Staphylococcus aureus. Tx?
IV Flucloxacillin + Rifampicin
2L IV Vancomycin + Rifampicin
Immunocompetent Patient under 60 presents in the COMMUNITY with bacterial meningitis.
Tx IF they have a rash?
IV Benzylpenicillin/ chloramphenicol
Urgent referral
Baby presents in the hospital with bacterial meningitis.
Empirical treatment?
2g IV Ceftriaxone + IV Ampicillin
Most common cause of encephalitis?
HSV-1
Inflammation of brain parenchyma
Encephalitis
Pt presents with fever, headache and altered mental status.
CSF shows normal plasma:glucose ration.
Likely diagnosis? Tx?
Encephalitis
IV Aciclovir
IV Benzylpenicillin
Pt presents with a red, painful rash across her cervical dermatome.
The rash is fluid-filled blisters and is “burning”. She is febrile and fatigued.
Likely diagnosis? Investigations? Tx?
Herpez zoster - Shingles (reactivated varicella zoster)
Inv: PCR, CSF, Blood culture
Tx:
- Acyclovir
- analgesia
- antipyretics
Pt presents with parasthesia of the peripheries and describe a tingling shooting pain in the feet. They show distal weakness and fasciculations on the legs.
They display a + Romberg test (sensory ataxia).
Likely diagnosis? Possible causes? Treament?
Peripheral neuropathy
Diabetes, medicine, alcohol, CKD, injury
infection, connective-tissue disorder, inflammation, malnourishment
Tx:
- underlying
- Pregabalin/ gabapentin (pain)
- supportive
Pt presents with temporal headache and temporary vision loss. Her jaw hurts intermittently and she has double vision.
Likely diagnosis?
Investigations?
Treatment?
Giant Cell Arteritis
American College of Rheumatology:
- ESR>50
- abnormal temporal artery biopsy
- age >50
- New headache
- temporal artery abnormality
minimum 3/5
Tx:
- prednisolone
- aspirin
- Tocilizumab
What is Tocilizumab used for? Outline pharmacology
Giant cell arteritis maintenance
Monoclonal Ab against IL-6 receptor. Helps with GCA remission.
Pt presents with muscle weakness of her hands worse on exertion, and eased with rest. She describes double vision. On examination her eyes are drooping (ptosis).
Likely diagnosis? Investigations?
Treatment?
Complications
Myasthenia Gravis
1L AChR Ab (85%)
MuSK Ab (10%)
Ice pack - ptosis improves
EMG-Single fibre EMG
CT Chest - thymoma?
Tx:
Acute: Prednisolone
Long-term: Acetylcholinesterase inhibitor - Pyridostigmine
+ methotrexate
Complications: Myasthenia Crisis (resp failure), Thymoma
A patient is diagnosed with Myasthenia gravis, What investigation will you also consider?
CT Chest - Thymoma?
37 yr woman from Sweden presents with a 2 day history of blurry vision and pain the right eye. Her visual acuity is 1/60 and there is some loss of colour vision.
Neuro exam is normal, so no CNS involvement
Fundoscopy reveals a swollen right optic disc.
Likely diagnosis?
Investigations?
Treatment?
Multiple Sclerosis
(optic neuritis)
Investigations:
MRI head + SC
- gadolinium-enhanced lesions of ventricles
- myelitis
Lumbar Puncture - Oligoclonal banding (IgG)
Treatment: Empirical Methylprednisolone
If relapse-remitting: injectable beta-interferon (long-term)
Lorazepam use
Acute management of seizures
Pt presents with meningism, fever and nausea, as well as confusion and papilledema.
Likely diagnosis? Investigations?
Suspected Meningitis with raised ICP.
1L CT Head (quicker than MRI)
Then Lumbar Puncture
22yr old M presents to A&E with worsening bilateral headache. He is febrile but otherwise fit and well.
CT Head shows subtle sulcal effacement. LP exudes Frank purulent fluid and a raised opening pressure.
Most likely underlying pathogen?
Neisseria meningitidis
22yr old M presents to A&E with worsening bilateral headache. His PHx shows he is immunocompromised
CT Head shows subtle sulcal effacement. LP exudes Frank purulent fluid and a raised opening pressure.
Most likely underlying pathogen?
Tests? Treatment?
Cryptococcus neoformans
Ag-test + India-Ink stain
Treatment
- 2wk IV Amphotericin B + Flucystosine
- 8wk fluconazole
Describe the LP of a pt with acute bacterial meningitis
Macroscopically purulent, neutrophilic leukocytosis, low glucose, high protein
Describe the LP of a pt with acute viral meningitis
Lymphocytes, slightly raised protein, normal glucose
Pt is suspected to have viral meningitis. There is no signs of encephalitis.
Likely cause? Treatment?
Enterovirus (Coxsackie/ Echovirus)
Self-limiting. Give analgesia, antipyretics, nutrition, fluid.
Pt is suspected to have viral meningitis. She is irritable, febrile and confused.
Likely cause? Treatment?
HSV1/2
IV Acyclovir
1 month old Baby presents with 12hr vomiting, crying, irritability. He is pyrexial and cries when his head is moved.
Treatment?
Probably bacterial meningitis.
IV Cefotaxime (>1month old) AND Ampicillin (listeria cover)
Anti-GD1a
Guillain Barre syndrome
