Neuro core conditions Flashcards
What is a TIA?
An acute loss of cerebral or ocular function
symptoms last less than 24 hours
caused by an inadequate cerebral or ocular blood supply due to ischaemia or embolism
How long do the symptoms of a TIA usually last?
minutes
may last a few hours
What are the 2 main types of ischaemic stroke?
Thrombotic ischaemic stroke
embolic stroke
What is a thrombotic ischaemic stroke?
blood clot spontaneously forms in the brain
common complication of atherosclerosis
What is an embolic stroke?
part of the fatty material from an atherosclerotic plaque or a clot in larger artery or the heart breaks off and travels to the brain
What are embolic strokes common complications of?
AF
Atherosclerosis of the carotid arteries
What % of strokes are ischaemic?
85
What are the 2 types of hemorrhagic stroke?
Intracerebral and subarachnoid
What is a intracerebral haemorrhagic stroke and what causes them?
Bleeding from a blood vessel within in the brain
High blood pressure
What is a subarachnoid haemorrhagic stroke?
bleeding from a blood vessel between the surface of the brain and the arachnoid tissue
What are the risk factors for strokes?5
high BP age DM smoking alcohol
What are the FAST symptoms and signs of a stroke? And how do you elicit them?
FACIAL WEAKNESS
- ask person to smile or show their teeth
will be facial asymmetry
ARM WEAKNESS
Lift arm to 90 or 45 (if lying)
will fall or drift down
SPEECH PROBLEMS
slurred
struggles to find the name of commonplace objects
What are the features of a sudden onset focal neurological deficit (found in strokes)? 8
usually unilateral
facial weakness
unilateral weakness and sensory loss of upper and/or lower limb
speech problems
visual defects
disorders of perception
disorders of balance
coordination disorders
What investigations do you do in suspected stroke?
CT scan
How do you calculate the risk of stroke following a TIA?
ABCD2 score:
A- age >60 -1 point
B- BP 140/90 -1 point
C- clinical features:
- unilateral weakness- 2 point
- speech disturbances without weakness- 1 point
D-duration of symptoms
- =/>60mins - 2points
- 10-59 mins - 1 point
D- Diabetes - 1 point
People are at high risk of a stroke if they have a score of 4 or more
AF
more than 1 TIA a week
TIA whilst on anticoagulants
How do you manage people at high risk of a stroke post TIA?
refer within 24 hours
Give statin- e.g. simvastatin
If they aren’t currently on any blood thinners immediately give clopidogrel or aspirin
DON’T start anti-platelet treatment until haemorrhagic stroke has been ruled out
How do you manage a haemorrhagic stroke?
Control bleeding
anticonvulsants to control bleeding e.g. diazepam
antihypertensives- to stem the growth of the haematoma
osmotic diuretics- to decrease intracranial pressure in the subarachnoid space
What is the management for secondary prevention of strokes?
Manage: AF, diabetes, hypertension
Antiplatelet drug
statin
What are the neurological complications of strokes? 9
Neurological problems: balance movement tone sensation
Disturbances of spatial awareness- neglect
Visual agnosia- disturbance of perception
aphasia, dysarthria, apraxia of speech
Where is pain felt as a complication of stroke?
Pain:
Neuropathic
shoulder pain and subluxation
MSK pain
What are the mental health complications of stroke?6
Depression anxiety emotionalism disturbed social interaction attention and concentration problems memory problems
What are the causes of a subarachnoid haemorrhage? (SAH)
aneurysmal rupture
traumatic brain injury- most common
What causes a spontaneous SAH? 5
Bleeding from a berry aneurysm - 85%
Non-aneurysmal peri-mesencephalic haemorrhage-10%
vascular abnormalities- 5%:
arteriovenous malformation
vasculitis
abnormal blood vessels associated with a tumour
What is the mean age for SAH?
50
Is SAH more common in F or M
F
Which ethnic group is SAH more common in?
Afro-Caribbean
What are the risk factors for a spontaneous SAH? 8
1-HTN 2-smoking 3-cocaine 4-excess alcohol 5-Family history - get at younger age and more likely to have larger and multiple ones 6- autosomal dominant adult polycystic disease 7-Ehler's Danlos syndrome type IV 8- Neurofibromatosis type 1
What are the features of a SAH headache? 3
Sudden explosive headache - thunder clap
May lasts seconds or even fraction of a second
Typically pulsates towards occiput
What are the other symptoms of SAH? 4
seizure
confusional state
Vomiting
Neck stiffness and other signs of meningism- usually around 6 hours post onset of SAH
What are the warning symptoms of an SAH and what are they due to? 10
Sentinel bleeds= small leaks or expansion of the aneurysm
May be up to 3 weeks prior to SAH
Symptoms: Headache like an SAH but usually resolves itself dizziness orbital pain diplopia visual loss sensory or motor disturbances seizures ptosis bruits dysphasia
What may be seen on fundoscopy in a patient with SAH? 2
Intraocular haemorrhages:
- 15%
- especially if they’ve got depressed level of consciousness
- occurs due to raised pressure
Isolated pupillary dilation with loss of light reflex
-may indicate brain herniation due to rising ICP
What is the main focal neurological sign that may be present in SAH? And what does it suggest?
suggest stroke and bleeding from posterior communicating artery
1- complete or partial palsy of the oculomotor nerve
What causes the associated cardiac arrhythmias in SAH?
Marked rise in BP due to a sympathetic response and surges of adrenaline
What does SAH in a person with known seizures suggest?
Arteriovenous malformation
What do new-onset seizures and SAH suggest?
Berry Aneurysm
What should be done immediately in patients that present with severe sudden headache?
CT scan
CT scan without contrast is the first line
Once acute SAH has been confirmed what further investigation should follow?
Angiography
either cerebral angiography or CT angiography
When do you do a lumbar puncture in suspected SAH?
If the CT scan is negative but the history is suggestive
How long after the onset of SAH do you do a lumbar puncture?
12 hours
To allow time for red blood cells in the CSF to undergo sufficient lysis for oxyhaemoglobin and bilirubin to have formed
What investigation do you carry out on the CSF in SAH?
spectrophotometry
to detect small amounts of xanthochromia= yellow discolouration of spinal fluid
What ECG changes occur in SAH? Why should caution be taken?
CT prolongation, Q waves, dysrhythmias and ST elevation
May be interpreted incorrectly as an MI –> thrombolysis being given = DISASTROUS in SAH
what are the surgical options to occlude an aneurysm in SAH?
Endovascular obliteration by means of platinum spirals- preferred
-through femoral catheterisation it obliterates the artery by causing a blood clot to form
Direct neurosurgical approach-clipping
How do you manage delayed cerebral ischaemia due to vasospams in SAH?
Oral nimodipine (Ca channel blocker) and maintaining circulatory volume
Hydrocephalus can be a side effect of SAH in the first hours or days, how do you treat this?
Lumbar puncture or ventricular drainage
Hypertension as a response to SAH is a common complication, how do you manage this?
Nitroprusside- a potent vasodilator and labetolol (b-blocker)
Need BP to be low enough to prevent re-bleeding whilst high enough to maintain cerebral perfusion
What preventative measures can be taken to stop re-bleeding?
Clipping or coiling aneurysm
Antifibrinolytic drugs
What are the complications of an SAH?
1- overall death rate= 50% 2- cardiac arrest 3- cerebral ischaemia 4- hydrocephalus 5-can develop epilepsy 6- re-bleeding 7-intra-parenchymal haematomas
What are the differential diagnoses for SAH? 8
Other causes of stroke
Meningitis-rarely features thunderclap headache
For the headache: Primary sexual headache cerebral venous sinus thrombosis Cervical artery dissection Carotid artery dissection hypertensive emergency Pituitary apoplexy= infarction or haemorrhage of the pituitary gland
How does peripheral neuropathy happen?
Axonal degeneration- nerves becomes electrically inert within a week
Demyelination
What are the health conditions that causes peripheral neuropathy?
1-DM 2- surgery 3-shingles 4-alcohol 5-low vit B12 6-hypothyroidism 7-CKD 8-chronic liver disease 9-vasculitis 10- MGUS (monoclonal gammopathy of undetermined significance = presence of abnormal protein in the blood) 11- myeloma 12-lymphoma 13- Charcot-Marie-Tooth disease 14- lead, arsenic or mercury 15- Guilain Barre syndrome 16- Amyloidosis 17 rheumatoid 18- lupus 19-sjorgen's syndrome
What medications can cause peripheral neuropathy?
chemotherapy Metronidazole or nitrofurantoin if taken for months Phenytoin (epilepsy) amiodarone thalidomide
What factors increase your risks of developing peripheral neuropathy if you have DM? 3
Smoke
alcohol
>40
What are the signs and symptoms of peripheral neuropathy? 6
Paraesthesia burning pain numbness loss of vibration and position sense muscle wasting ataxia due to loss of sense of posture
Where is usually first affected in peripheral neuropathy?
feet
How do you relieve neuropathic pain? 7
Amitryptyline Duolextine Pregabalin Gabapentin Capsaicin cream Lidocain plaster Tramadol- when other treatments haven't worked
How do you treat hyperhydrosis?
Botulin injection
What are the complications of peripheral neuropathy?
Foot ulcers –> sepsis and and gangrene
May affect nerves controlling autonomic functions of the heart and circulatory system= cardiovascular neuropathy
- may need treatment for hypotension: fludrocortisone or midodrine
- or in rare cases a pacemaker
what is an epileptic seizure?
A transient occurs of signs/ symptoms due to abnormal electrical activity in the brain
When can you declare seziure epilepsy?
Once they’ve had at least 2 unprovoked seizures occurring more than 24 hours apart
Who gets provoked seizures that are not of primary cerebral origin?
People exposed to trainsient noxious stimulus People with: alcohol or drug withdrawal Fever hypoxia hypoglycaemia
What is status epilepticus?
A continuous seizure of 30mins or longer or recurrent seizures without regaining consciousness lasting 30mins or longer
What causes epilepsy?8
2/3rds do not have anatomically identifiable cause
1/3rd have symptomatic epilepsy= epilepsy due to underlying disease or condition:
- most common cause of epilepsy in older people
- cerebrovascular disease
- cerebral tumour
- post traumatic epilepsy
- foetal hypoxia or trauma
- cortical or vascular malformation
- cerebral abscess or tuberculoma
- surgery to brain
When does epilepsy most commonly start?
Children
or over 60s
What are the risk factors for epilepsy? 11
1-learning disabilities 2-childhood epilepsy syndromes- genetic 3-tuberous sclerosis- genetic 4-neurofibromatosis- genetic 5- FH 6- Previous febrile seizures in childhood 7- Previous intracranial infections 8- Brain trauma or surgery 10- cerebrovascular disease 11-cerebral tumours
What are examples of seizure triggers?
walking
sleep deprivation
flashing lights
What are auras?
simple partial seizures with no loss of consciousness
What are the symptoms of temporal lobe auras?
Unexpected tastes and smells
paraesthesia
rising abdominal sensation
What happens in tonic seizures?
impairment of consciousness
stiffening
Trunk may be either straight or flexed at waist
What happens in clonic seizures?
Impairment of consciousness
jerking
What happens in Tonic-clonic seziures?
Impairment of consciousness
stiffening and jerking
What happens in absence seizures? And when do they begin? And how long do they last?
Begin in childhood
sharp onset and offset with no residual symptoms
child stares for a few seconds
eyelids may twitch
small jerking movements of the fingers may occur- usually not noticed
Last 5-10 seconds, and less than 30 seconds
What happens in myoclonic seizures?
Brief shock like contraction of the limbs without apparent impairment of consciousness
What happens in focal motor seizures?
Jerking movement
typically beginning at the face or one hand
spreading to involve limbs
What happens in focal sensory seizures?
Typically involves the temporal lobe
may causes sensory, autonomic, emotional, cognitive or other changes
what happens in the post-ictal period (residual symtpoms) after a seizure?
Drowsiness amnesia Injury- biting the tongue aching limbs headaches Focal neurological deficit that slowly recovers
What are the differential diagnoses in epilepsy?
syncope
cardiac arrhythmias
Panic attacks with hyperventilation
Non-epileptic attack disorders- F>M, provoked by stressful situations
Children- night terrors, breath holding attacks
How do you treat people having a tonic-clonic seizure for more than 5 mins or who have more than 3 seizures?
Buccal midazolam
Rectal diazepam- if buccal midazolam isn’t available
IV lorazepam if IV access already establishes
What are the long-term management options for epilepsy?
Carbamazepine phenytoin primidone sodium valoprate may increase risk of osteoperosis--> give vit D supplements
what are the viral causes of meningitis? 3
Enteroviruses:
Coxsackie A &B
Echovirus
Herpes simples 2 (genital herpes complication)
Usually self limiting
What are the fungal causes of meningitis? 2
LIFE THREATENING, but rare
cryptococcus- most common
tuberculos meningitis
What are the bacterial causes of meningitis is in children >3months and adults? 3
Neisseria meningitides (--> meningococcal disease) Strep pmeumoniae H. influenzae type b
What are the bacterial causes of meningitis in neonates (<1month)?4
Streptococcus agalactiae
E.coli
S.pneumoniae
Listeria monocytogenes
What are the autoimmune causes of meningitis?2
SLE
Behcet’s syndrome
What are the risk factors for meningitis?7
Young age winter season >65 immuno-compromised organ dysfunction smoking overcrowded housing
What are the non-specific symptoms of meningitis? (common signs are often missing in infants) 9
fever vomiting/ nausea lethargy irritabillity/ unsettled ill appearance refusing food/drink headache muscle ache/ joint pain respiratory symptoms
What are the specific symptoms of meningitis? 14
Non-blanching rash stiff neck cap refill time >2secs unusual skin colour shock and hypotension leg pain back rigidity bulging fontanelle photophobia paresis seziures Focal neurological deficit Kernig's sign brudzinksi's sign
What is Kernig’s sign?
Person is unable to fully extend at knee when hip is flexed
What is Brudzinksi’s sign?
Person’s hips and knees flex when neck is flexed
What are the features of the rash?
Scanty petechial rash- purple or red non-blanching macules <2mm
Pupuric (haemorrhagic) rash- spots >2mm. May be absent in early phase of illness, may intially be blanching or macular
What are the indications that meningococcal disease is likely to develop, in children? 4
The petechiae start to spread
The rash become pupuric
There are signs of bacterial meningitis
There are signs of meningococcal septicaemia
What investigations do you do in meningitis?
Lumbar puncture
How do you manage a patient with meningitis?
If they have a rash: single dose of parenteral benzylpenicillin asap- ideally IV but can do IM
Antibiotics + corticosteroids
Benzylpenicillin
if allergic: cefotaxime or chloramphenicol
Give prophylaxis of close contacts
What are the complications of meningitis? 8
death neurological damage hearing loss seizures motor deficit cognitive impairment hydrocephalus visual disturbances
What is a common migraine?
Migraine without aura
What are classic migraines?
Migraines with aura
What is contraindicated in migraines with aura?
the contraceptive pill
What are the risk factors for migraines? 7
FH stress depression anxiety menstruation menopause head or neck trauma
What are the common internal triggers for migraines? 4
Menstrual cycle
altered sleep pattern
stress
relaxation after stress- weekend migraine
What are the external triggers for migraines?
Specific foods- only suspect as trigger if migraine occurs within 6 hours of eating it
strenuous exercise- for those not used to it (however regular exercise helps migraines)
strong smells
bright light
dehydration
missed meals
jet lag
Are migraines more common in M or F?
F
When is the mean onset of migraines for F?
18
When is the mean onset of migraines for M?
14
What are the diagnostic criteria for migraine without aura?
Recurrent episodes of headaches
lasting between 4-72hours
associated with either nausea/ vomiting or photophobia and phonophobia or both
usually unilateral
Pulsating in character
aggravated by routine physical activity
What are the diagnostic criteria for migraine with aura?
Symptoms of a migraine are preceded by the onset of an aura of visual or sensory symptoms or dysphasia
Visual symptoms- zig-zag or flickering lights, spots, lines or loss of vision
Sensory symptoms- pins and needles or numbness
What are episodic migraines?
headache which occurs on <15 days/ month
chronic = >15
When do menstrually related migraines occur?
2 days before and 3 days after the start of menstruation
What are the acute treatment options for migraines?
Oral combination therapy of oral triptan and an NSAID or paracetamol
consider an antiemetic- metoclopermaide, domperidone or prochloerperazine
What oral triptans can be used?
sumatriptan
zolmitriptan, naratriptan, rizatriptan, eletriptan, almotriptan and frovatriptan
What are the prevantative treatment options for migraines?
topiramate or propanolol first line
If after 2 months these aren’t working then offer 10 sessions of acupuncture over 5-8weeks
What are the risks with topiramate?
can impair effectiveness of oral contraceptives
can cause foetal malformations
Who can’t take propanolol?4
People with asthma COPD PVD or uncontrolled heart failure
What are the complications of migraines? 6
Medication overuse
status migrainosus- migraine .72hours
increased risk of ischaemic stoke
migraine with aura might increase risk of haemorrhagic stroke
depression, bipolar, anxiety and panic disorder are all associated with migraine
migraine triggered seizure
What classifies as an infrequent tension headache?
At least 10 episodes of TTH
On less than 1 day/month
What classifies as a frequent episode of tension headaches?
At least 10 episodea
On 1 day or more each month
On less than 15 days per month for at least 3 months
What classifies as a chronic tension headache?
Occurs on 15 days or more per month
lasts for more than 3 month at a time
or for more than 180 days in a year
Are tension headaches more common in F or M?
F
How long do tension headaches last?
30 mins to 7 days
To be diagnosed as a tension headache they have to have two of what criteria? 5And have both of what features?
Bilateral pressing or tightening (non-puslating) mild to moderate intensity not aggravated by exercise Radiate to or arise from the neck
Not associated with nausea or vomiting
Photophobia or phonophobia may be present, but NOT both
How do you manage an acute tension headache?
Paracetamol
aspirin (not for under 16s)
NSAIDs
Who gets preventative treatment of tension headaches?
People requiring analgesia 2 or more days each week
What are the preventative options for a tension headache?
Acupuncture Amitryptiline (or if not tolerated nortriptyline)
How long are people on the upper does of amitryptilne for in tension headaches?
2 months
Then decrease dose by 10mg to 25mg each week
What causes Parkinson’s disease?
Loss of dopamine containing cells in the substantia nigra
What is Parkinsonism?
Umbrella term for clinical syndrome involving bradykinesia plus at least one of:
tremor
rigidity
postural insatbility
What are the causes of Parkinsonism? 6
Parkinson's disease= most common drug incuded cerebrovascular disease Lewy body dementia multiple system atrophy progressive supranuclear palsy
What are the risk factors for Parkinson’s? 2
Age
FH
Is it more common in M or F?
M
What are the motor symptoms of Parkinson’s? 6
Bradykinesia Hypokinesia = poverty of movement stiffness or rigidity resting tremor postural instabillity Frezing gait
How does bradykinesia in Parkinson’s present?
slowness in initiation of voluntary movements
with progressive reduction in speed and amplitude of repetitive actions such as finger or foot tapping
How does hypokinesia in Parkinson’s present?
Reduced facial expression, arm swing or blinlinh
difficulty with fine movements- buttons, opening jars,
small cramped handwriting= micrographia
What are the two types of rigidity in Parkinson’s?
Lead pipe-
constant resistance when a limb is passively flexed in the presence of increased tone without tremor
Cogwheel rigidity
regular intermittent relaxation of tension when a limb is passively flexed in the presence of tremor and increased tone
What are the features of the resting tremor in Parkinson’s?
Usually improves with moving, mental concentration and during sleep
May affect thumb and index finger= pill rolling
wrist, leg, lips, chin or jaw
absent in 30% of people at disease onset
Are the features of parkinson’s unilateral or bilateral?
Early disease they are usually unilateral, become bilateral as the disease progresses
What are the non-motor symptoms of parkinson’s? 7
depression anxiety fatigue reduced sense of smell cognitive impairment sleep disturbance constipation
What are the differential diagnoses of parkinson’s disease? 7
drug induced Parkinsonism cerebrovascular disease Non-Parkinson's dementia progressive supranuclear palsy multiple system atrophy corticobasal degeneration Wilson's disease
What are the medication options for managing motor symptoms in Parkinson’s? 6
Levodopa
COMT inhibitors- entacapone
Dopamine agonists- pramipexole, ropinirole
Amantadine
Anticholinergic drugs
MAO-B inhibitors- selegiline or rasagiline
Where does deep brain stimulation stimulate in Parkinson’s treatment? And who gets it?
subthalamic nucleus People with motor symptoms who are: Fit enough Levodopa responsive have no co-morbid health problems
What anti-emitcs can’t you use in Parkinson’s and which one can you use?
NOT: metoclopramide or prochlorperazine
Low dose domperidone is ok
What causes fluctuations in motor symptoms in Parkinson’s? 2
End to end dose failing
On-off phenomenon
What are the mental health complications of parkinson’s? 7
depression anxiety apathy dementia cognitive impairment impusle control disorders psychosis
What are the autonomic complications of parkinson’s? 8
constipation postural hypotension dysphagia weight loss excessive salivation hyperhidrosis bladder problems sexual problems
What are the most common type of proximal myopathies?
Muscular dystrophies e.g. Duchene
What are the inherited causes of peripheral myopathies? 2
Myopathies- e.g. Duchene, Becker’s
Inherited biochemical defects e.g myochondrial myopathy or lipid storage disease
What are the aquired causes of myopathies? 4
Immunologically mediated- SLE, RA
Non-inflammatory myopathies- Hyper/hypothyroidism. DM, Cushing’s
Toxic and cachetic myopathies- alochol, protein malnutrition, statins, steroids
Infection-HIV, cosackie
What are the signs and symptoms of myopathies? 5
weakness
myalgia- may occur in inflammatory myopathy
fluctuating muscle power- suggests metaboluc myopathy
Malaise/ fatigue
Atrophy of muscles with reduced reflexes - occurs late with myopathies (early with neuropathies
What are the features of weakness associated with myopathy? 5
Predominately affects proximal muscle groups- limb girdle and shoulders
–> decreased foteal movements in utero
floppy infant neonatally
reduced muscle strength and power
symmetrical proximal muscle weaknes with paraesthesia
What are the complications of peripheral myopathies? 4
respiratory failure
aspiration pneumonia
Joint contractures
chest and spinal deformities
What is MS?
an autoimmune condition characterised by repeated episodes of inflammation of nervous tissue in the brain and spinal cord –> loss of myelin sheath –> slows or blocks signals
What are the causes of MS?
Genetic
Environmental
Is MS more common in M or F?
F
When is the peak incidence for MS?
40-50
What are the eye signs and symptoms of MS? 3
Optic neuritis- painful reduction of vision in 1 eye
symmetrical jerking nystagmus –> double vision
Lateral rectus weakness
What are the other (aside from eye) symptoms of MS?) 8
Bell's Palsy Deafness and feeling unsteady progressive loss of memory and language skills no-specific pain loss of sensation in legs ascending to the trunk incontinence impotence loss of thermoregulation
What will a MRI show in MS?
Periventricular lesions and discrete white matter abnormalities
What can electrophysiology detect in MS?
demyelination
What will be found in CSF in MS?
Rise in total protein
Increase in immunoglobulin concentration with presence of oligoclonal cases
What do you give for symptom exacerbations in MS?
Steroids
usually methylprednisolone for 5 days
What are the medication options to stop remitting and relapsing in MS> 7
Azathioprine Interferon-beta Glatiramer- designed to mimic the main protein in myelin Dimethyl fumarate teriflunomide aletuzumab
