Neuro Core Conditions Flashcards
3rd most common cause of death?
Stroke
What % of strokes are ischaemic?
70%
Who has strokes?
> 40
M>F
Asian and Black African populations
Mortality following stroke?
20-25%
Causes of stoke in young patients?
Thrombophilias Vasculitis SAH Venous sinus thrombosis Carotid artery dissection
Causes of stroke in older people?
Thrombus in situ
Athero-thromboembolism (AF, infective endocarditis, MI)
CNS bleed
Sudden BP drop (>40mmHg)
Vasculitis (giant cell arteritis, venous sinus thrombosis)
Risk factors for stroke?
>65 FHx Ethnicity Hx HTN Smoking Obesity DM Heart disease Peripheral vascular disease Polycythaemia vera Carotid artery occlusion Hyperlipidaemia Excess alcohol Clotting disorders COCP
Symptoms of stroke?
FAST
Cerebral hemisphere infarcts –> contralateral hemiplegia, sensory loss, homonymous hemianopia , dysphasia
Brainstem infarct –> quadriplegia, disturbed gaze/vision, locked in syndrome, lateral medullary syndrome
Lacunar infarcts –> pure motor/sensory or mixed signs, ataxia, dysphagia
Differentials for stroke?
CNS tumour Sub/epidural haematoma SAH Todd's palsy Drug OD ACS Bell's palsy BPPV Brain abscess Inner ear labrinthytis MI TIA
Investigations for stroke?
FBC, ESR, BM, lipid profile CXR + ECG for heart disease CTH if GCS<13 Carotid duplex US MRI in some cases
Treatment for stroke?
Restore O2 and get blood glucose between 4-11
If patient has HTN emergency with encephalopathy/nephropathy/HF/MI/aortic dissection/(pre) eclampsia/ICH then give antihypertensives
Aspirin, clopidogrel
Alteplase (thrombolytic)
IC stenting
Surgery for supratentorial haemorrhage with mass effect, posterior fossa or cerebellar haematoma
Who gets TIA?
Rare <60
Uncontrolled HTN
M>F
Asian and black African populations
What % of stroke patients have a TIA first?
15%
Causes of TIA?
Embolic (usually) from carotid bifurcation, heart (AF) Thrombotic Haemorrhagic (rarely) Atherosclerosis Leukaemia Sickle cell Polycythaemia Thrombosysthaemia
Risk factors for TIA?
>65 FHx Hx HTN DM Obese Smoking/alcohol Ethnicity Heart/peripheral vasc disease Polycythemia vera Carotid artery occlusion COCP Hyperlipiaemia Clotting disorders
Symptoms of TIA due to carotid clot?
Unilateral, motor weakness Dysarthria Amaurosis fugax Aphasia Hemiparaesis Hemisensory loss Hemianopic vision B/W dysphasia
Symptoms of a vertibrobasilar TIA?
Diplopia Vertigo Vomiting Choking Dysarthria Ataxia Hemisensory loss Hemianopic vison Tetraparaesis
How long must a TIA take to resolve?
24 hours
Differentials for TIA?
Stroke IC lesion Todd's Syncope due to arrhythmias Temporal arteritis Migraine Retinal or vitreous haemorrhage Focal epileptic seizure Labrynthine disorders Psych disorder Metabolic disturbance
Investigations for TIA?
Urinalysis for glucose FBC, ESR, U+E, fasting lipids and glucose, LFTs, TFTs ECG Cardiac monitoring for paroxysmal AF Carotid/vertebral doppler CT/MRI
Treatment for TIA?
No driving for 1 month Admit to hospital if: On warfarin (CTH) ABCD2 score >4 Uncontrolled AF
Antiplatelet + anticoag
Warfarin for AF
What % of strokes are due to SAH?
5%
Who gets SAH?
Younger patients (50)
50% die
F>M
Rare in children
Causes of SAH?
Saccular berry aneurysm (70%)
AVM (10%)
No arterial lesion found (15%)
Rare associations (5%) - bleeding disorders, mycotic aneurysms from endocarditis, acute bacterial meningitis, tumours
Risk factors for SAH?
Large aneurysms Smoking HTN Alcohol Genetics 10% of AD PCK patients have berry aneurysms
Symptoms of SAH?
Sudden thunderclap headache Vomiting Sentinel bleeds Expansion of aneurysm Dizzy Orbital pain Diplopia Visual loss Sensory/motor disturbances Seizures Ptosis Bruits Dysphasia Neck stiffness Focal neuro signs Complete/partial CNIII palsy (due to PCmmA rupture)
Differentials for SAH?
Meningitis Trauma Cluster headahce Encephalitis First seizure in adulthood IC haemorrhage Ischaemic stroke TIA
Investigations for SAH?
ABG
ECG
CTH and CT angio
-ve CTH = LP (use spectrophotometry to detect xanthochromia)
Treatment for SAH?
Prevent further bleeding Nimodipine Ca antagonists (reduce vascular spasm) Phenytoin (prevent seizure spread) Nitroprusside (vasodilator) Labetolol Clip aneurysm Endovascular embolisation Secondary prevention advice
What % of those with DM for >25 years have peripheral neuropathy?
50%
Who gets peripheral neuropathy?
Older patients
Causes of peripheral neuropathy?
DM B12/folate def Chemo Antiretrovirals Metrodinazole Thalidomide Phenytoin Insecticides Solvents Cancer Alcohol CKD Guillan-Barre syndrome Trauma and nerve compression Shingles HIV Lyme RhA Sjorgens SLE Sarcoidosis Coeliac Charcot Marie Tooth syndrome Freidriech ataxia Idiopathic
Risk factors for periph neuropathy?
Alcohol DM Kidney/liver/thyroid disease Repetitive physical stress Age FHx HTN Peripheral vascular disease Smoking
Symptoms of peripheral neuropathy?
Tingling, numbness Loss of coordination Burning/shooting pains (worse at night) Dificulty walking/picking stuff up Affects hands/feet first Muscle weakness Falling Difficulties with small movements (buttoning shirts) Swallowing problems Cachexia Muscle twitching/cramps/paralysis Dizzy/fainting Reduced sweating Heat intolerance Urinary incontinence Bloating Constipation/diarrhoea Impotence
Differentials for peripheral neuropathy?
Acromegaly Acute inflam demyelinating polyadiculoneuropathy Alcohol related neuropath CMT disease Coagulopathies Drug induced paraneoplastic syndromes Heavy metal toxicity Herpes Labert-Eaton myasthenic syndrome MG Nerve compression Post-surgical vagotomy Vit B6 intox
Investigations for peripheral neuropathy?
BM, vit B12, foalte, U+E creatinine Nerve conduction studies Electromyography Nerve/skin biopsy
Treatment for peripheral neuropathy?
Underlying cause Physio Surgery Anticonvulsants (gabapentin, carbamazepine) Elastic stockings Fludrocortisone Eating small frequent meals Sleeping with head raised Walking aids Occupational therapy
Who has epilepsy/seizures?
Children or >60
Learning difficulties
30% have a 1st degree relative affected
Causes of seizures?
Primarily idiopathic Ischaemia Venous thrombosis Head injury Meningitis/encephalitis Provoked seizures Autoimmune Brain tumour Isoniazid Alcohol (withdrawal) Hypoglycaemia Imbalanced Na or Ca
Risk factors for seizures?
Age M>F FHx Head trauma Stroke Brain infections Prolonged febrile seizures of childhood Congen abnormalities of brain structure Lack of O2 to brain CP Illicit drugs
Symptoms of seizures?
Amnesia Falls Tonic-clonic Blank spells Incontinence Confusion/impaired awareness Visual/auditory/gustatory/olfactory hallucinations
Differentials for seizures?
Syncope Arrhythmias TIA Migraine BPPV Hypoglycaemia Acute encephalopathy Narcolepsy Sleep apnoea Panic attacks
Investigations for seizures?
EEG MRI/CTH BM, U+E, Ca, LFTs, FBC 12 lead ECG Neurophysiological assessment
Treatment for seizures?
Phenytoin
Carbamazepine
Na valproate
Broad spectrum AEDs may work for treatment resistant epilepsy
Drug treatment should be monitored and weaned off
Relaxation and CBT may help
Which is more common, viral or bacterial meningitis?
Viral
Who gets meningitis?
Babies
Young children
Elderly
Can be anyone
Causes of meningitis for neonates?
Group B strep Listeria monocytogenes E coli H Flu B N Meningitis Strep pneumoniae
Causes of meningitis for adults?
S pneumoniae H flu type B N meningitidis Gram -ve bacilla Staph Strep L Monocytogenese
Causes of meningitis for elderly or immunocompromised?
S Pneumoniae
L monocytogenes
TB
Gram -ve
Risk factors for meningitis?
CSF shunts Dural defects Spinal procedures Bacterial endocarditis DM Alcohol Prem birth PROM IVDU Malignancy Thalassaemia, sickle cell, splenectomy CF
Symptoms of meningitis?
Meningitism Fever Headache Altered mental state Shock Septicaemia Kernig's sign Brudzinski's sign PAresis Focal neuro def Seizures Viral may be more mild
Symptoms of meningitis in neonates?
Non-specific Resp distress Fever Apnoea Bradycardia Hypotension Difficulty feeding Irritable
Differentials for meningitis?
Other causes of infection/pyrexia IC abscess Encephalitis SAH Tumours Delirium tremens HSV Paediatric febrile seizures
Investigations for meningitis?
LP (unless at risk of herniation - then CTH)
Gram stain, Ziehl-Neelson, cytology, virology, glucose, protein, culture, rapid antigen testing, PCR, Indian ink (cryptococci)
Blood cultures, FBC, BM, coag, U+E
Urine dip/culture
MRI
General teatment for meningitis?
Fluids
Antipyrexics
Antiemetics
Treatment for viral meningitis?
Analgesia
Aciclovir if due to herpes
Ganciclovir if due to CMV (only if congenital or AIDS related as ganciclovir is v toxic)
Treatment for bacterial meningitis?
Benzylpenicillin STAT if suspicion of meningococcal + non-blanching rash
Blind therapy initially (3rd gen ceph or amoxicillin if listeriosis is suspected)
Meningococcal - benzylpenicillin or cefotaxime for at least 7 days, rifampicin for 2 days to eliminate nasal carraige
Pneumococci - Cefotaxime for 10-14 days
H flu type B - Cefotaxime (10 days) + rif 4 days prior to discharge
Group B strep - Benzylpenicillin + gentamicin or cefotaxime alone for 14 days
Listeriosis - Amoxicillin and gentamicin for 10-24 days
