Neuro Dr Vidhya Flashcards
Headache: Cluster or Migrainous Neuralgia CLINICAL FEATURES
TRIAD:
* Retroorbital Headache
* Rhinorrhoea
* Lacrimation
Unilateral headache
Occurs nightly or in the early hours of
the morning
No visual disturbances or vomiting
Hallmark : Cyclical nature of the attacks and at least 5 attacks. Occurs typically in males; Rare in childhood.
Headache: Cluster or Migrainous Neuralgia ACUTE Management
1st line: 100% O2 15 L/min for 15 minutes
2nd line: Sumatriptan sc injection or intranasally
Headache: Cluster or Migrainous Neuralgia PROPHYLAXIS (once a cluster starts TO PREVENT FURTHER ATTACKS)
- For control of attack – Naratriptan
- Methysergide
- Prednisolone
- Lithium
- Verapamil
Headache: Tensional Clinical findings
Symmetrical bilateral tightness (muscle contraction headaches)
Lasts from 30 minutes to 7 days
Non-pulsating, mild to moderate intensity
No nausea, vomiting, photophobia, or phonophobia
Headache: Tensional Management
Relaxation techniques
Lifestyle modifications
Avoid tranquilisers and stronger analgesics
Headache: Tensional Treatment
- CBT
- Mild non-opioid analgesics – aspirin, ibuprofen, paracetamol
Headache: Migraine Clinical Features
MC triggered by Stress
Headache lasts 4- 72 “hours”
Unilateral, Pulsatile in nature.
Moderate or severe intensity, inhibiting daily activities associated with nausea, vomiting, photophobia, or phonophobia
Not attributable to another disorder
Headache: MILD
Acute Migraine Management
1st line: ASPIRIN OR
PARACETAMOL + METOCLOPRAMIDE
ADVISE LYING DOWN
IN A QUIET DARK COOL ROOM.
COLD PACKS ON THE FOREHEAD OR NECK.
AVOID: COFFEE, TEA, MOVING AROUND TOO MUCH, READING, WATCHING TV
Headache: SEVERE
Acute Migraine Management
1st line: TRIPTANS (BEST AT START OF ATTACK)
AVOID IN:
- CORONARY ARTERY
- DISEASE
- ANGINA
- UNCONTROLLED HYPERTENSION
- PREGNANCY
Management of Acute Migraine attack during pregnancy
Paracetamol is the preferred non-opioid analgesic.
Avoid NSAIDs and
Aspirin in the first trimester and after 30 weeks of gestation
Management of severe refractory Acute Migraine attack during pregnancy
- IV fluids
- Short course of IV
- MgSO4 or oral steroids.
NOTE: Beta blockers can cause IUGR and should be weaned off before labour to prevent Fetal bradycardia.
Migraine Prophylaxis
1st line: Avoidance of known trigger factors.
Indication: 2 or more
severe migraine attacks per month attacks disrupting the
patient’s well being/lifestyle.
Drugs:
* Beta blockers (Propranolol)
* TCA (Amitryptyline)
* Sodium valproate
* CCBs ( Verapamil, Nifedipine)
* Candesartan
* Sumatriptan
* Gabapentin
* Botulinum toxin into the muscles of the face, scalp or neck
Headache: Temporal
arteritis (Giant cell arteritis) CLINICAL FEATURES
Persistent/intermittent unilateral throbbing headache in the
temporal region and scalp sensitivity with localized thickening
With or without loss of pulsation of the Superficial temporal artery.
Age > 50 years
Intermittent blurred vision
Tenderness on brushing hair
Jaw claudication on eating
Hypertension
Polymyalgia Rheumatica
Headache: Temporal
arteritis (Giant cell arteritis) MANAGEMENT
1) Very responsive to corticosteroids- start treatment immediately to prevent permanent blindness.
2) Aspirin to prevent ischemic events
Headache: Subarachnoid Hemorrhage CLINICAL FEATURES
Presentation: Acute severe headache “thunderclap” (in 75% patients); Loss of consciousness in the remaining 25%.
TRIAD
* Occipital Headache
* Vomiting
* Neck stiffness
Also:
- With or without seizures
- Kernig sign positive
Headache: Subarachnoid Hemorrhage INVESTIGATIONS
Dx: 1) CT Head – investigation of
choice
2) Lumbar puncture is used if CT scan is
negative – Homogenous blood staining of CSF
and Xanthochromia are diagnostic of SAH
Headache: Subarachnoid Hemorrhage CT Imagen
Areas of hyper density within the cisterns and sulci
Headache: Subarachnoid Hemorrhage Management
URGENT REFERRAL!!
Headache: Trigeminal
Neuralgia CLINICAL FEATURES
> 50 yo
Almost always unilateral
Presentation:
* Brief paroxysms of pain 1-2 minutes (upto 15 minutes)
* Excruciating burning knife or electric shock like pain.
* Precipitated by talking, chewing, touching trigger areas on face, cold weather, and wind.
Headache: Trigeminal
Neuralgia. Associated diseases
- Multiple sclerosis
- Neurosyphilis
- Posterior fossa Tumours
Headache: Trigeminal
Neuralgia Investigation
MRI
Headache: Trigeminal
Neuralgia MANAGEMENT
1st line: Patient education and reassurance.
2nd line: Carbamazepine (from onset of attack until resolution)
3rd line: Surgery. Just if medical treatment is ineffective: Decompression of the Trigeminal nerve root
CLINICAL FEATURES Idiopathic Intracranial Hypertension (Pseudotumour cerebri)
- Obese young patient
- Headache
- Nausea
- Visual obscuration or blurring (main concern
from high ICP) check papilledema.
FIRST INVESTIGATION Idiopathic Intracranial Hypertension (Pseudotumour cerebri)
CT and MRI are normal.
BEST INVESTIGATION Idiopathic Intracranial Hypertension (Pseudotumour cerebri)
Lumbar puncture: Increased CSF pressure 25 cm H2O with Normal CSF analysis.
MANAGEMENT Idiopathic Intracranial Hypertension (Pseudotumour cerebri)
1st: URGENT REFERRAL!!
2nd:
* Stop causative drugs
* Weight reduction
* Corticosteroids and diuretics
NOTE: Choice to alleviate
symptoms: Repeated Lumbar Puncture
Medication overuse Headache CLINICAL FEATURES
BILATERAL
“Headache all day everyday”
Medication overuse Headache CAUSE
NSAIDs, triptans, ergotamine.
Typically with regular use > 15 days per month for 3 months
Medication overuse Headache Treatment
Gradual withdrawal of the drugs; Bridging therapy with a short course of steroids or NSAID
GCS
MANAGEMENT of Coma of unknown cause in the ED
TONG(F) or Coma cocktail
Transient Ischemic Attack (TIA) CLINICAL FEATURES
- Short duration (< 60 minutes)
- Consciousness preserved
- Complete clinical recovery in < 24 hours (spontaneous)
Carotid TIAs CLINICAL FEATURES
90% ischemic attack in anterior circulation (Carotid)
Unilateral features:
* Amaurosis fugax
* Dysphasia
* Unilateral weakness, paralysis or numbness of face and arm (especially) and leg.
Vertebrobasilar TIAs CLINICAL FEATURES
Bilateral or crossed features:
- Homonymous hemianopia
- Bilateral blurring of vision, blindness, or diplopia
- Vertigo
- Nausea ± vomiting
- Dysarthria
- Hemiplegia
- Ataxia ± bilateral weakness or numbness, drop attacks.
TIA INVESTIGATIONS
- CT or MRI
- Carotid duplex Doppler
NOTE: Also ECG but depends on the question
TIA MEDICAL MANAGEMENT
FIRST:
Aspirin
or
(Clopidogrel + Aspirin)
or
(Dipyridamole + Aspirin)
or
Ticlopidine
NOTE: Dual therapy within 24 hours and cease at three weeks.
If failed antiplatelet therapy or vertebrabasilar ischemia:
WARFARIN
DOACs for non-valvular, AF >65 yo
TIA SURGICAL MANAGEMENT
Based on the Carotid duplex Doppler Results (CDUS):
Symptomatic (Ipsilateral TIA or Stroke)
– 70-99%: Intervention
– 50-69%: Grey area- REFER!
– <50%: Observe
Asymptomatic:
> 80%: Non-urgent intervention
< 80%: Annual survillance with CDUS
Surgery: Carotid Endarderectomy
STROKES TERRITORIES. Anterior Circulation Arteries
- Anterior Cerebral Artery
- Middle Cerebral Artery
- Lenticulo-striate Artery
STROKES TERRITORIES. Posterior Circulation Arteries
- Posterior Cerebral Artery
- Basilar Artery
- Anterior inferior cerebellar artery
- Posterior inferior cerebellar artery
- Anterior spinal artery
Anterior Cerebral Artery Stroke CLINICAL FEATURES
Middle Cerebral Artery Stroke CLINICAL FEATURES
Lenticulo-striate Artery Stroke CLINICAL FEATURES
Posterior Cerebral Artery Stroke CLINICAL FEATURES
Basilar Artery Stroke CLINICAL FEATURES
Anterior inferior cerebellar artery Stroke CLINICAL FEATURES
Lateral Pontine Syndrome
-
General
(VII Nerve Nuclei)
↓ Lacrimation
↓ Salivation
↓ Taste anterior 2/3 of the tongue
(Vestibular nuclei)
Vomiting
Vertigo
Nystagmus
-
Contralateral
BODY↓ Pain and temperature sensation -
Ipsilateral
FACE ↓ Pain and temperature sensation
Horner syndrome
Ataxia
Dysmetria
(Inner ear)
Sensorineural deafness
Posterior inferior cerebellar artery Stroke CLINICAL FEATURES
Lateral Medullary (Wallenberg) Syndrome
(IX, X, XI Nerves Nucleus)
Dysphagia
Hoarseness
Dysphonia
↓ Gag reflex
Hiccups
Vomiting
Vertigo
Diplopia
Nystagmus (horizontal and vertical)
-
Contralateral
BODY↓ Pain and temperature sensation -
Ipsilateral
FACE ↓ Pain and temperature sensation
Horner syndrome
Limb Ataxia
Dysmetria
Anterior spinal artery Stroke CLINICAL FEATURES
Medial Medullary Syndrome
Lacunar Infartcts Types
- Pure motor (contralateral)
- Pure sensory (contralateral)
- Ataxic hemiparesis
- Dysarthria-Clumsy hand Syndrome
Dominant side- Parietal Lobe Lesion
Gerstmann’s Syndrome Tetrad
1. dysgraphia
2. dyscalculia
3. finger agnosia (can’t touch the fingers together)
4. Left to right disorientation
ALSO:
Aphasia, dysphasia
Alexia, dyslexia
Non dominant
Parietal lobe lesion
- Geographical agnosia
- Phonagnosia (difficulty in recognizing familiar voices)
- Amusia
- Constructional Apraxia
- Asomatognosia
- Anosognosia
- Spatial neglect
- Neglect of contralateral limb
- Dressing apraxia
Vertigo
- Peripheral
- Central
Cause for periperal Vertigo
- Labyrinth ( Meniere, Labyrintitis, BPPV, trauma, CSOM)
- Eight cranial nerve ( Vestibular neuronitis, acustic Neurinoma, drugs)
- Cervical
Cause for central Vertigo
*brainstem ( vertebrobasilar insufficiency, infarction)
*cerebellum ( degeneration, tumor)
- Migrain/Ms
Vertigo - Red flags
- neurological symptoms
- Ataxia out of proportion of vertigo
- Nystagmus out of propotion of vertigo
- central Nystagmus
- central eye movement abnormalities
Vestibular neuronitis
- acute vertigo + nausea + vomiting
Vestibular neuronitis - Clinic
- young/middle age
- 50% prior URTI / herpes zoster infection
- vertigo + imbalance aggrevate with headpostion
- NO tinitus or hearing loss
- horizontal nystagmus , oszillation towards healthy ear
Drugs causing Vertigo
- Antibiotics ( Mycines, tetracycline)
- anticonvulsant
- cardiogenic drugs
- salycylate
Vestibular neuronitis - Management
- Bed rest
- Medication:
1. Promethazin
2. prochlorperazine
3. ondasentron
4. diazepam
Self limiting after 5-7 days ( or weeks)
Benign paroxismal postional vertigo BPPV- S/S
-elderly
-sudden ( induced by changing headpostion)
-attack 10-60sec
-Vertigo while going out of bed/travelling
-no vomitting deafness, tinitus
BPPV- Dx/Mx
Dx:
- Halpick manoever
- test for vestibular and hearing fct normal
Mx:
- reaessure
- exercise ( eg Cawthorne -Cooksey)
- reposional manoever
- no drugs
Meniere
Vertigo + vomiting + tinnitus + sensorineural deafness
Meniere - S/S
- 20-50a
- acute onset of vertigo, tinnitus, nausea, vomiting, heaing loss(low tone), nystagmus
- “ear fullness”
- attack : 30 min to several hours
Meniere - Dx/Mx
Dx
- caloric test - impaired vestibular function on effected side
Mx
- acute: prochloperazine or diazepam
- severe: diazepam+prochloperazine
- Prophylaxis: hydrochlorthiazide, refer, low salt diet, smocking and coffee
Labyrinthitis - S/S
- young and middle age
- 50% prior URTI / herpes zoster infection
- vertigo + imbalance aggrevate with headpostion
- tinitus or hearing loss (DD to Verstibular neuronitis)
- horizontal nystagmus , oszillation towards healthy ear
Frontal - temporal Dementia - S/S
-Insidious onset and slow progression.
-Preservation of memory to late-stage disease.
-Early and prominent personality changes (e.g., apathy, irritability, jocularity, euphoria, loss of personal and social awareness).
-Impaired judgment and insight.
-Mental rigidity and inflexibility.
-Unrestrained exploration of objects and the environment.
-Language difficulties (e.g., problems with word recall, circumlocution, word repetition.
Huntington disease
- inherited progressive neurodegenerative disorder
- characterized by
–> choreiform movements,
–> psychiatric problem (irritability, depression, dysphoria, agitation, apathy, anxiety, paranoia, delusions, and hallucinations)
–> dementia
Rett Syndrom
-neurodevelopmental disorder
-exclusively in females
- MECP2 gene defect
- initially normal development
Rett syndrom - Main Criteria
●Partial or complete loss of acquired purposeful hand skills
●Partial or complete loss of acquired spoken language
●Gait abnormalities: impaired (dyspraxic) or absence of ability
●Stereotypic hand movements such as hand wringing/squeezing, clapping/tapping, mouthing, and washing/rubbing automatisms
Rett Syndrom - Supportive criteria
●Breathing disturbances when awake
●Bruxism when awake
●Impaired sleep pattern
●Abnormal muscle tone
●Peripheral vasomotor disturbances
●Scoliosis/kyphosis
●Growth retardation
●Small cold hands and feet
●Inappropriate laughing/screaming spells
●Diminished response to pain
●Intense eye communication (“eye pointing”)
Bells Palsy RF
●pregnancy, severe pre- eclampsia
●hypertension
●diabetes
●upper respiratory illnesses such as influenza
●obesity
Third nerve Palsy
●sudden onset of binocular horizontal, vertical, or oblique diplopia and a droopy eyelid
●ptosis, a large unreactive pupil, and paralysis of adduction, elevation, and depression
Fourth nerve Palsy
●
Six nerve Palsy
weakness of abduction
horizontal diplopia
Ramsay Hunt Syndrom - Triad
ipsilateral facial paralysis
ear pain
vesicles in the auditory canal and auricle
severere + tinnitus, vertigo, hearing loss
Ramsay Hunt - Therapy
- Aciclovir and prednisolon
Lumbar puncture- Values
UMN
spastic paralysis
hyperreflexia
presence of a Babinski reflex
Everything is up in UMN disease
LMN
flaccid paralysis
significant atrophy
fasciculations
hyporeflexia,
everything is down in LMN disease
Normal pressure hydrocephalus - Clinic
Gait instability (wide-based) with frequent falls
Cognitive dysfunction
Urinary urgency/incontinence
Depressed affect (frontal lobe compression)
Upper motor neuron signs in lower extremities
Normal pressure hydrocepahlus - Dx/Mx
Dx
Marked improvement in gait with spinal fluid removal: Miller Fisher (lumbar tap) test
Enlarged ventricles out of proportion to the underlying brain atrophy on MRI
MX
Ventriculoperitoneal shunting
Idiopathic intracranial hypertension - Clinic
Headache
Vision loss; enlarged blind spot
Pulsatile tinnitus
Diplopia; palsy of the abducens nerve (CN VI)
Papilledema
Idiopathic intracranial hypertension - RF
obese women of childbearing age
Medication( retinoids, tetracyclines, growth hormone)
Idiopathic intracranial hypertension - Dx/Mx
Dx
Neuroimaging
Lumbar puncture: elevated opening pressure
Mx
Weight loss
Acetazolamide
Headache- Differential Symptomes
