Neuro guidelines Flashcards
investigations following first seizure
EEG and brain MRI
investigation to determine true from pseudoseizure
raised serum prolactin for a couple hours
when do you NORMALLY start AEDs?
After second seizurE
what would make you start AEDs after a first seizure
EEG shows unequivocal epileptiform activity There is a structural abnormality on brain MRI There is a persisting neurological deficit Family or family considers risk of second seizure unacceptable
driving ban after 1st seizure
6 months
how long do you need to be seizure free for to drive if you have epilepsy
12 months
1st line epilepsy meds: - generalised - absence - partial - pregnancy
generalised = valproate absence = valproate or ethosuximide partial = carbamazepine pregnancy = lamotrigine (usually 2nd line as well)
status epilepticus and timing
0m = O2 and ABCDE 5m = buccal midaz or IV loraz 10m = IV lorazepam 15m = escalate + phenytoin 45m = intubate
Parkinson’s investigations
clinical diagnosis Use DaT scan (SPECT) and MRI brian to exclude P+ syndromes and to ensure diagnosis if unsure
1st line for PD and SE
if motor Sx = levodopa and carbidopa/benserazide if no motor Sx predominate = can chose from any SE = dyskinesia
2nd line PD and SE
non-ergot derived dopamine agonists (bromocriptine, cabergoline, pergolide, ropinorole) SE = impulse, hallucinations MAO-Bi = seleginine. SE = ? COMTi = entacapone. SE = orange urine and diarrhoea
Mx for drug induced parkinsonism
procyclidine
investigations that help MS diagnosis
contrast brain MRI shows dawson fingers and periventricular plaques. McDonald criteria. CSF shows oligoclonal bands (doesn’t NEED to be present for diagnosis)
Acute relapse of MS Mx
IV methylprednisolone for 5d, shortens flares
1st line DMARD for MS and criteria to get it
beta interferon need 2 relapses in past 2 years and also be able to walk 10-100m unaided
2nd line drugs for MS - glatiramer - natalizumab - fingolimod
glatiramer = immune decoy natalizumab = alpha4beta1 inhibitor preventing leucocyte transmission through the BBB fingolimod = sphingosine receptor modulator preventing lymphocytes leaving the lymph nodes
Symptom treatment for MS: - fatigue - spasticity - bladder dysfunction - ossciloscopia
- fatigue = amantadine + CBT - spasticity = baclofen + gabapentin - bladder dysfunction –> residual volume = self catherisation –> no residual volume = anticholinergics - ossciloscopia = gabapentin
when are anticholinesterses CI in alzheimers
DONEPEZIL is CI bradycardia. not the others
name 3 anticholinesterases for AD
galantaine
rivastigmine (can be given as patch if not able to swallow)
donepezil
what is 1st and 2nd line in AD
1st = anticholinesterases 2nd = memantine
How do you treat Frontotemporal Dementia
You cant really. acetylcholinesterases/memantine don’t work because those systems aren’t affected the same way as AD and LBD
Lewy body dementia Tx
same as AD
ROSIER score
rule out of stroke in the emergency room any score of >0 means stroke is likely +1 = speech problem, face/arm/leg weakness, vision problem -1 = TLOC, seizure, syncope
Immediate Mx of ischaemic stroke
Always = 300mg aspirin for 2 weeks within 4.5 hours = thrombolyse within 6 hours (or 24 if have done scan and ischaemic bit is still small) if MCA/ACA proximal = thrombectomy ALONGSIDE thrombolysis
Immediate Mx of haemorhagic stroke
control BP to 100-120 with labetolol and consult neurosurgery
Ongoing Mx of ischaemic stroke
After 2w, stop aspirin and give clopidogrel lifelong 75mg
What is clopidogrel is CI, what do you give for long term secondary preventions
aspirin + dipyridamole
DVT prophylaxis of stroke in hospital
intermitten pneumatic calf devices
when do you do a carotid endarterectomy after a stroke
if stenosis >50%
when do you start a statin after a stroke
if cholesterol >3.5
ABCD2 score
for TIA age >60 BP 140>90 clinical features = speech 1p, unilateral weakness 2p duration (10-59m, 60+m) = 1 and 2 points diabetes
immediate management of TIA
300mg aspirin
when do you NOT give 300mg aspirin in a TIA and what do you do in those cases
anti coagulated/bleeding disorder –> admit for head CT already on low dose aspirin –> just continue at same dose until TIA appointment
when do you arrange TIA appointment
crescendo TIA = discuss admission now TIA in last 7d = assessment within 24 hours TIA >7d ago = assessment within 7d
drug for life in TIA?
Yes, clopidogrel 75mg as in stroke
first line sedative in delerium
0.5mg haloperidol CI in PD so use lorazepam instead
investigation for meningitis
Serum PCR and blood culture LP unless CI (meningococcal septicaemia or raised ICP)
turbid CSF
think its meningitis and you’re a GP?
Give IM benzylpenicillin as long as it doesn’t delay transfer to hospital
empirical Abx for menignitis in hospital depending on age
<3m = cefotaxime + amoxicillin 3m-50y = ceftriaxone/cefotaxime >50y = ceftriaxone/cefotaxime + amoxicillin
IV antibiotic for specific meningitis bug: - meningiococcal - pneumococcal/hamophilus - listeria –what else do you give to everyone
- M = benzylpenicillin + cefotaxime - P/H = cefotaxime - L = amoxicillin + gentamicin You give dexamethasone alongside first dose of antibiotic to everyone to reduce neuro complication rate
how do you confirm a SAH has occurred
1st do CT head if negative, check CSF for xanthchromia (yellow CSF) at least 12 hours later
management for SAH when waiting for surgery
strict bed rest, stool softness, no straining, BP control
medical management for SAH after surgery
21 days nimodipine (CCB) to prevent vasospasm
presentation and Mx of vasospasm post SAH
presents 4-9d after surgery for SAH with focal deficits +/- reduced cognitive function triple H therapy - hypervolaemia, induced hypertension, haemodilution
1st line Ix for Lyme disease
ELISA for antibodies against burrelia burgdorferi can diagnose clinically if symptoms present and bull eye erythema migrans present
Mx of Lyme: - early - disseminated
early = doxycycline disseminated = ceftriaxone beware of Jarisch-Herxheimer reaction
Encephalitis best Ix two other Ixs
Best = MRI shows hyperdensitiy in temporal lobe EEG shows lateralised periodic discharges at 2Hz CSF shows lymphocytosis and elevated protein
Mx of encephalitis
IV aciclovir as most common cause is HSV1
trigeminal neuralgia
presentation
Mx when do you refer
any stimulation of nerve (sensation of face) elicits excruciating pain
carbamazepine
refer if <50yo or fails to respond to above
Bells palsy Mx time cutoff for Tx
1mg/kg 10d prednisolone eye care give within 72 hours for best effect
myasthenia gravis presentation
Best Ix
other Ix needed
autoimmune antibodies to acetylcholine receptors –> insufficient functioning
symptoms worse when fatigued, better in morning after rest
presentation:
- ptosis (drooping of eye)
diplopia (double vision)
face muscle weakness
dysphagia (difficulty swallowing)
weak arms, legs or neck
shortness of breath and occasionally serious breathing difficulties
- muscle weakness (peripherally in later stages)
Best = single fibre EMG (trace decreases in amplitude with receptive stimulation)
others = CT chest to exclude thymoma
antibodies to acetylcholine receptors 85-95% patients
Tensilon test (IV edrophinium) NOT used anymore
Mx for Myaesthenia gravis - flare
flare = prednisolone
Mx for Myaesthenia gravis - ongoing - how do you monitor respiratory function
ongoing = antcholinesterase inhibitor long acting:
- pyridostigmine first line
immunosuppression may be used: pred initially
thymectomy
Monitor with FVC
Mx for Myaesthenia gravis - crisis
plasmapheresis and IV immunoglobulin
Guillain barre syndrome: - LP - nerve conduction studies - antibody
- LP shows isolated protein rise (normal WCC)
- nerve conduction studies (slow response due to demyelination)
- anti-GM1
GBS Mx
IVIG
plasma exchange (plasmapheresis) – an alternative to IVIG where a machine is used to filter your blood to remove the harmful substances that are attacking your nerves
MND Ix
Normal nerve conduction study EMG shows few APs with normal amplitude + fibrillation
Mx for MND
riluzole and BiPAP at night
acute Mx of migraine 1st and 2nd line
1st = NSAID + oral triptan + paracetamol ——-> if <17yrs old use nasal triptan instead 2nd = non-ral metoclopromide/prochlorperazine (beware of dystonic reaction)
cutoff for migraine prophylaxis frequency
2+ per month
migraine prophylaxis Mx 1st and 2nd line adjunct?
1 = propranolol (or topiramate if not woman of childbearing age) 2 = acupuncture —> can also use riboflavin as adjunct
cluster headache acute Mx
100% oxygen and subcut triptan
prophylaxis cluster headache
verapamil
tension headache acute Mx
NSAID, paracetamol
Tension headache propylaxis
acupuncture (NOT amitriptyline which is often used)
When do you do a head CT within 1 hour after a head injury
GCS <15 2 hours after injury GCS <13 on clerking focal neurological deficit post-traumatic seizure 2+ episodes of vomiting open or depressed skull fracture
when do you do a head CT within 8 hours after a head injury
Need to have some loss of consciousness and: - be over 65 - be on warfarin or have bleeding disorder - have 30mins amnesia before event - dangerous mechanism of injury (struck by vehicle, ejected from vehicle, fall >1m/5 stairs)
lumbar puncture anatomy
iliac crests
L3/4 , L4/5
termination of spinal cord:
adult: L1
baby: L3
lumbar puncture analysis
21
photophobic
pyrexial
headache
protein raised
glucose low
white cell raised
pressure: raised
diagnosis
bacterial meningitis
37
worst headache ever
lumbar puncture:
protein normal
glucose normal
WCC normal
opening pressure normal
appearance:
xanthochromia - yellow CSF
diagnosis?
subarachnoid haemorrhage
- can get xanthochromia - yellow CSF
GBS presentation
muscle weakness
ascending weakness lower extremities first but proximal muscles earlier than distal ones
reflexes reduced/absent
numbness/tingling
back/leg pain
immune response causing demyelination of peripheral nerves
often triggered by infection (Campylobacter jejuni) - hx of gastroenteritis
can be treated
causes of bilateral facial nerve palsy
sarcoidosis
guillain-Barre syndrome
lyme disease
bilateral acoustic neuromas (as in neurofibromatosis type 2)
Bell’s palsy (mostly unilateral)
cause of unilateral facial nerve palsy
bilateral causes can also be unilateral
lower motor neuron:
Bells palsy
Ramsay-Hunt syndrome (due to herpes zoster- rash in ear)
acoustic neuroma
parotid tumours
HIV
multiple sclerosis (may also be UMN palsy)
diabetes mellitus
Upper motor neuron: (forehead sparing)
stroke
interpretation of pupillary findings in head injuries
diagnosis
most likely affected people
chronic subdural haemorrhage
chronic as darker (infarct of cells)
patients on anticoagulation
alcoholics
old people
patients with bleeding disorders
with fall
slower onset of symptoms than extradural
can be chronic or acute
diagnosis
subarachnoid haemorrhage
blood seen within CSF spaces
most likely berry aneurysm rupture in circle of willis
thunderclap headache
diagnosis
intracerebral haemorrhage
surrounding low density due to oedema
history of intractable HTN
sudden onset severe posterior headache
dysphasia (difficulty speaking) and vomiting
right hemiparesis
diagnosis
cerebral metastesis
multiple ‘ring-enhancing lesions’ due to cerebral mets
known hx of lung cancer
increasing headaches and clumsiness
diagnosis
glioma
large enhancing mass invades corpus callosum and crosses midline
headaches
visual field defect
diagnosis
meningioma
large enhancing mass
makes broad contact with meningeal surface
headaches - worse in morning
loss of balance
increasingly irritable
increased tone on right
diagnosis
scalp haematoma
swelling of scalp soft tissues
if you see scalp haematoma, check for underlying skull fracture and intracranial haemorrhage
direct blunt trauma to right side of head
scalp swelling and bleeding
diagnosis
skull mets
multiple destructive (lytic) bone lesions of skull due to bone mets
known hx of breast cancer
headaches and palpable lumps on scalp
diagnosis
acute infarct
string sign - dense middle cerebral artery due to thrombus
acute onset right hemiparesis
diagnosis
old infarct -MCA territory
goes low density (dark) when infarcted area dies
diagnosis
extradural haemorrhage with contracoup injury
lens shaped collection of blood: extradural haemorrhage
usually from damage to middle meningeal artery
runs behind pterion (weakest part of skull)
post traumatic intracranial haemorrhage at site of impact = coup injury
can have contracoup injury on opposite side of brain to site of impact - caused by acceleration-deceleration forces at time of injury
fall fron height with direct trauma to left side of head
management of head injury
whilst waiting for surgery may need IV mannitol/furosemide if rising ICP
surgery
diffuse cerebral oedema may require decompressive craniotomy
depressed skull fracture: if open require surgical reduction and debridement
ICP monitoring appropriate: GCS 3-8 and normal CT
ICP monitoring mandatory: GCS 3-8 and abnormal CT
hyponatraemia most likely due to syndrome of inappropriate ADH secretion
minimum cerebral perfusion pressure in adults: 70mmHg
minimum cerebral perfusion pressure in children: 40-70mmHg
common side effect after lumbar puncture
post lumbar puncture headache
24-48hrs following LP
may last several days
worsens in upright position
improves with recumbent position
more common in young females and with low BMI
Mx:
- if pain continues >72hrs: blood patch, epidural saline, intravenous caffeine
to prevent subdural haematoma
syncope classification
reflex syncope (most common):
- vasovagal (fainting): emotion, pain, stress
situational: cough, micturition, gastrointestinal
carotid sinus syncope
orthostatic syncope:
- primary autonomic failure: parkinsons, lewy body dementia
- secondary autonomic failure: diabetic neuropathy
drug induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhagic, diarrhoea
cardiac syncope:
- arrhythmias
structural: valvular, MI
PE
investigations for syncope
cardio exam
postural BP:
- symptomatic fall in systolic BP>20 or diastolic BP>10
- or decrease in systolic BP<90
considered diagnostic
ECG
carotid sinus massage
tilt table test
24h ECG
diabetic neuropathy Mx
sensory loss
first line Mx: amitriptyline, duloxetine, gabapentin or pregabalin
if one doesnt work try one of the others
tramadol : rescue therapy for exaccerbations of neuropathic pain
what is cervical spondylosis
extremely common
age-related wear and tear affecting the spinal disks in your neck - osteoarthritis of neck
neck pain
referred pain may mimic headache
complications:
- radiculopathy (pinched nerve)
- myelopathy (injury to spinal cord due to compression)
Mx for cervical spondylosis
NSAIDs
corticosteroid injections
most common complication of meningitis
sensorineural hearing loss
infective: sepsis, intracerebral abscess
pressure: brain herniation, hydrocephalus
cerebral abscess presentation
high temp
Increased ICP symptoms:
- headache in single section of head
- seizures
- nause and vomiting
- stiff neck
- changes in vision
- changes in mental state
- problems with nerve function
cerebral abscess Ix and Mx
medical emergency
Ix: CT
Mx: CT-guided aspiration through hole in skull
aspiration MC&S
empirical abx/ antifungals
symptoms of raised intracranial pressure
benign (idiopathic) intracranial hypertension
links?
overweight - more common in overweight women in 20s/30s
endocrine problems
meds: abx, steroids, COCP
lack of red blood cells (iron deficiency anaemia) or too many RBCs (polycythaemia)
CKD
lupus
chronic benign intracranial hypertension
Ix and Mx
Ix: CT
lumbar puncture
Mx:
- lose weight
- stop meds causing symptoms
take off contraceptive
diuretics
oral pred to relieve headaches and reduce risk of vision loss
regular lumpar punctures to remove excess fluid from spine
what is motor neurone disease
presentation
affects motor neurones –> muscle weakness
risk factor: frontotemporal dementia
presentation:
- muscle weakness - decreased dexterity, falls trips
- dysphagia, dysphasia, tongue fasciculations (bulbar presentation)
- muscle weakness, wasting, twitching
- breathing problems- SOB
- fatigue, excessive daytime sleepiness
- may include behavioural changes, emotional lability, frontotemporal dementia
types of motor neurone disease
amyotrophic lateral sclerosis (ALS): most common
- both upper and lower motor neurones affected
- limb muscle weakness and wasting
- stiffness
- over-active reflexes
- speech and swalllowing signs later affected
progressive bulbar palsy (PBP)
- speech and swallowing
- when ALS begins in muscles of speech and swallowing it is PBP (muscles of speech and swallowing as nerves that control these are in the bulb)
- limb muscles may later be affected
progressive musclar atrophy
- much slower progression and longer survival
lower motor neurones affected
if it moves to upper limbs = ALS
primary lateral sclerosis
upper motor neurones
very rare
what is bulbar palsy
paralysis of muscles of swallowing and speech
–> dysphagia + dysphasia
Mx for ALS type MND
riluzole
for treatment of ALS MND
for slowing progression
no cure
quinine for muscle cramps
baclofen for stiffness, spasticity, increased tone
measuring resp function after diagnosis of MND
O2 sats
forced vital capacity
and/or sniff nasal inspiratory pressure and/or maximal inspiratory pressure
if severe bulbar impairment or cognitive impairment that affects resp:
- O2 sats
- dont need to do other tests
repeat tests every 2-3 months
neurofibromatosis types and chromosome mutations
both inherited autosomal dominant
two types:
- NF1 (von Recklinghausen’s syndrome):
chromosome 17 mutation
- NF2:
chromosome 22 mutation
neurofibromatosis features
NF1:
- cafe-au-lait spots (>=6, 15mm in diameter)
- axillary/groin freckles
- peripheral neurofibromas
- iris hamatomas (Lisch nodules) in >90%
- scoliosis
- pheochromocytomas
NF2
- bilateral vestibular schwannomas (acoustic neuroma) (deafness, vertigo)
- multiple intracranial schwannomas
mengiomas and ependymomas
differences between neurofibromatosis and tuberous sclerosis
Neurofibromatosis:
- cafe-au-lait spots (can be in tuberous sclerosis but more common in neurofibromatosis)
- axillary/ groin freckles
- pheochromocytomas
- iris hamartomas (Lisch nodules)
- NF2: acoustic neuromas
tuberous sclerosis:
- ash leaf spots
- adenoma sebaceum
- shagreen patches
- subungal fibromata
- epilepsy
- retinal hamartomas
multiple sclerosis
tingling in hands which comes on when flexes neck
sign?
Lhermitte’s sign = indicates disease near dorsal column nuclei of cervical cord
also seen in subacute combined degeneration of cord and in cervical stenosis
multiple sclerosis features
clinical diagnosis
>= 2 relapses plus either:
- clinical evidence of two or more lesions
- or one lesion + reasonable historical evidence of previous relapse
visual:
- optic neuritis: common presenting feature
Uhthoff’s phenomenon: worseing of vision following rise in body temp
sensory:
- pins and needles
- numbness
- trigeminal neuralgia
- Lhermittes syndrome: paraesthesiae in limbs on neck flexion
motor: spastic weakness: most commonly in legs
cerebellar:
- ataxia: in acute relapse
- tremor
is Bells palsy U/LMN
do you get forehead sparing
its lower motor neurone
the entire side of the patients face is affected (no forehead sparing)
reduced reflexes
still have facial sensation
hypersensitivity to sound
Mx of Bells palsy
prednisolone 1mg/kg for 10 days within 72hrs of onset (not after)
can give artificial tears and eye lubricants
weakness to left hand
wasting of hypothenar eminence
weakness of finger abduction
weakness of thumb adduction
which nerve affected
which nerve is damaged in claw hand
ulner nerve
claw hand: hyperextension of metacarpophalangeal joints and flexion at distal and proximal interphalangeal joints of 4th and 5th digits
what signs do you get with ulner damage at wrist
claw hand
wasting and paralysis of intrinsic hand muscles (except lateral two - big two)
wasting and paralysis of hypothenar muscles
sensory loss to medial 1 1/2 fingers
damage to ulner nerve at elbow features
same as damage at wrist +
- ulner paradox (clawing is more severe in distal lesions therefore at elbow less severe)
radial deviation of wrist
what makes an essential tremor worse
essential tremor worse on outstretched hand
often strong Fhx
first line mx for essential tremor
what else makes it better
first line Mx: propanolol
other: alcohol makes it better
what is the frequency of a pill rolling tremor
4-6Hz
how long can a cluster headache last
btwn 15mins to 2hrs
what are timings of migraines
4-72hrs
features of migraine
one sided headache
patient lying still
potential photophobia / phonophobia
vomiting
2second -3min severe unilateral pain on head/face
evoked by light touch (e.g. wind, washing, shaving, talking) can cause sharp shooting pain (electric-shock like)
particularly susceptable areas: nasolabial fold, chin
diagnosis
trigeminal neuralgia
patient would not be clutchin pain as so sensitive
headaches in bursts lasting several weeks
usually once a year
each episode lasting 15mins -2hrs
intense sharp, stabbing pain around one eye
restless and agitated
redness, watering and lid swelling of same eye
diagnosis
cluster headache
mx of cluster headache
acute:
- 100% O2
- s/c triptan
prophylaxis: verapamil (CCB)
mx of ischaemic stroke
if <4.5 of onset and excluded haemorrhagic via imaging: thrombolysis - alteplase
acute ischaemic stroke + confirmed occlusion of proximal anterior circulation (by CTA or MRA) =
thrombectomy (within 6hrs onset) + thrombolysis (if within 4.5hrs onset)
ishaemic stroke btwn 6-24hrs onset + confirmed occlusion of proximal anterior circulation + confirmed potential to salvage brain tissue =
thrombectectomy
Mx of ischaemic stroke >6hrs onset
if >6hrs onset cant do thrombolysis or thrombectomy
aspirin 300mg orally or rectally ASAP if haemorrhagic stroke excluded
secondary prevention of stroke
after 14days
clopidogrel 75mg
if clopidogrel CI then aspirin + dipridamole
if cholesterol >3.5 = statin (atorvastatin 20-80mg)
target systolic BP< 130
how long can you not drive for after a stroke
4 weeks
when to do a carotid artery endartectomy after stroke
recommended if patient had stroke or TIA in carotid territory and not severely disabled
if carotid stenosis >70% (ECST criteria)
or >50% (NASCET criteria)
ptosis + dilated pupil + eye deviated ‘down and out’
what nerve palsy
third nerve palsy (occulomotor)
ptosis + constricted pupil
diagnosis
Horner’s
constricted pupil: miosis
what is webers syndrome
ipsilateral third nerve palsy (occulomotor) with contralateral hemiplegia - caused by midbrain strokes
Mx for trigeminal neuralgia
first line: carbamazepine 100mg DB
features of parkinsonism
resting pill rolling tremor - 4-6Hz
bradykinesia
rigidity
flexed posture
short shuffling steps
micrographia (writing gets smaller as writing)
mask like face (emotionless)
depression and dementia are common
may be hx of anti-psychotic use
weight loss + tremor
pulse: 102
diagnosis
thyrotoxicosis
tachycardia
fine tremor when hands outstretched
weight loss
COPD + flap when arms both outstretched
diagnosis
CO2 retention
which seizures can you display automatism (unaware of what youre doing/ unresponsiveness) and emptional disturbance
focal seizure with impaired awareness (also called complex focal seizure)
emotional disturbance
automatism
followed by post-ictal tiredness
absence seizures dont involve gross motor movement
focal aware seizures and absence seizures involve rapid recovery without spleepiness
loses consciousness immediately
falls to ground
stiffens and straightens limbs alternatively
during seizure bites tongue
type of seizure
tonic clonic
young boy
occasional periods where he stares blankly in class
diagnosis
absence seizure
next most important step in mx for bells palsy after prescribing prednisolone
prescribe artificial tears and advise eye taping at night
wide based gait + loss of heel to toe walking
most likely location of patients lesion
cerebellum
wide-based gait with loss of heel to toe walking is called an ataxic gait
cerebellar vermis = gait ataxia
cerebellar hemisphere = peripheral (finger-nose ataxia)
shuffling gait
diagnsois
parkinsons
hesitant motion, short, small steps and reduced arm swinging
what is wrong in a high stepping gait
neuropathic gait
occurs when patient loses function of ankle dorsiflexor muscles
to prevent toes from dragging, patients lift feet higher during swing phase
problem in trendelenburg gait
when hip abductors are too weak to stabilise leg in swing phase
waddling appearance
32yr F
3day hx altered sensation in left foot and right forearm
episode of visual blurring in right eye a few months ago which resolved after a few days
brisk reflexes
diagnosis
multiple sclerosis
visual loss likely 2ndry to optic neuritis
Mx: referral to neurology
stiffness and pain in left shoulder started 1 month ago
similar episode that self resolved
global restriction of shoulder movement particularly external rotation
diagnosis
adhesive capsulitis (frozen shoulder)
restriction of shoulder movements
- especially external rotation
Mx: early physiotherapy
features of degenerative cervical myelopathy
pain (neck, upper, lower limbs)
loss of motor function (loss of digital dexterity)
loss of sensory function - numbness
loss of autonomic function (urinary/ foecal incontinence)
Hoffman’s sign: reflex test for cervical myelopathy (gently flicking one finger:
+ve result = reflex twitching of other fingers
degenerative cervical myelopathy Ix and Mx
Ix: MRI - gold standard
Mx: urgent referral to spinal surgery - decompressive surgery
LOC + rapid recovery + short post-ictal period
diagnosis
syncope
todd’s paresis
weakness after LOC –> seizure
can affect one part of body or the whole body
typically resolves within 48hrs
6months - 5yrs old
early during viral infection
temp rises rapidly
seizure bried and generalised tonic/tonic-clonic
diagnosis
febrile convulsion
what is the peak time incidence of alcohol withdrawal seizure
36hrs following cessation of alcohol
epileptic seizure Ix and mx
Ix:
after 1st seizure: EEG + MRI
Mx:
following 2nd epileptic seizure
generalised seizures: sodium valproate
partial seizures: carbamazepine
what do you have to think about in Mx of epilepsy
patients who drive:
- cant drive for 6months following seizure
- with established epilepsy must be fit free for 12 months before driving
patients taking other meds:
- can affect warfarin
women wanting to get pregnant:
- antiepileptics are teratogenic (esp sodium valproate)
- fine to breast feed
women taking contraception:
- can have effects on eachother
second line med for generalised/ partial seizures
side effect
lamotrigine
side effect: stevens-Johnsons syndrome
side effect of carbamazepine
used as first line for partial seizures
main side effect: leucopenia + agranulocytosis
main side effect of sodium volproate
teratogenic
acute management of seizures
if dont terminate after 5-10mins
rescue medication: Benzodiazepines (diazepam) rectally/ intranasally/under tongue
if they continue to fit after this = status epilepticus
medical emergency
further benzos, infusions of antiepileptics or use of general aneasthesia after 45mins
78yr
feels too young to be slowing down and using zimmer frame
fine tremor in one hand
6months
trouble picking up a pen
next step?
parkinsons disease
slowing down: bradykinesia
zimmer suggests balance problems
unilateral tremor
reduced fine motor control
diagnosed and mx initiated by elderly care doctor - urgent referral
parkinsons disease mx
clinical diagnosis
Mx:
- motor symptoms affecting QOL: levodopa
- not affecting QOL: dopamine agonist, levodopa, or monoamine oxidase B inhibitor (MAO-B)
which conditions can you get from not taking parkinsons meds properly
acute akinesia or neuroleptic malignant syndrome
which antiparkinson drug has the highest chance of inhibition disorders
dopamine agonist therapy
what can happen if you stop levodopa acutely
mx to stop this
levodopa should not be stopped acutely if patient is admitted
rescue medication to prevent acute dystonia: give dopamine agonist patch if levodopa cannot be taken orally
DVLA guidence on provoked seizure by head injury for bus driver
must inform DVLA and await guidence before driving again
syncope DVLA guidelines
simple faint: no restriction
single episode: explained and treated: 4 wks off
single episode unexplained: 6 months off
two or more episodes: 12 months off
facial and contralateral body loss of pain sensation
nystagmus
ataxia
diagnosis?
which artery affected
lateral medullary syndrome
most often due to a posterior inferior cerebellar artery (PICA) stroke
on same side as facial symptoms
affects brain stem
facial and contralateral body loss of pain sensation
nystamus
ataxia
same sided facial weakness
loss of hearing
which artery stroke?
anterior inferior cerebellar artery infarct
locked in syndrome
which artery infarct
basilar artery infarct
locked in: patient unable to move or communicate but is fully conscious
contralateral hemiparesis and sensory loss
lower extremity >upper
which artery infarct
anterior cerebral artery
contralateral hemiparesis and sensory loss
upper extremity > lower
contralateral homonymous hemianopia
aphasia
infarct which artery
middle cerebral artery
contralateral homonymous hemianopia with macular sparing
visual agnosia
infarct which artery
posterior cerebral artery
homonymous hemianopia (with macula sparing) = occipital lesion
visual field defect for pituitary gland tumour
pituitary tumour = bitemporal hemianopia, upper quadrant defect
lower quadrant = superior chiasmal compression (craniopharyngioma)
visual field defect in open angle glaucoma in right eye
unilateral peripheral visual field loss
extensive stroke with right sided hemiplegia
what side would the homonymous hemianopia be on
which side is the lesion
right side
homonymous hemianopia on same side as paresis
lesion is contralateral (left side)
homonymous quadrantanopias
PITS
parietal: inferior
temporal: superior
to find out lesion in either parietal or temporal
incongrous defects and congruous defects
incongruous defects (incomplete/ asymmetric visual field loss):
optic tract lesion
congrous defect (complete or symmetrical visual field loss):
optic radiation lesion or occipital cortex
vertigo + hearing loss (right ear) + tinnitus (right ear) + absent corneal reflex
hearing loss getting progressively worse over last 9 months
webers test lateralizes to left ear
diagnosis
acoustic neuroma
vestibular schwannoma includes a combination of vertigo, hearing loss, (unilateral) tinnitus and an absent corneal reflex
absent corneal reflex (lack of eyelid movement after touching eye with cotton wool)
bilateral acoustic neuroma is seen in which type of neurofibromatosis
neurofibromatosis 2
investigation of choice for vestibular schwannoma (acoustic neuroma)
MRI of cerebellopontine angle
27yr
severe morning headache associated with nausea
MRI: large tumour arising from falx cerebri and pushing on brain
well defined border btwn tumour and brain parenchyma
diagnosis
meningioma
typically benign tumours
develop from dura mater of meninges
- dont invade brain substance so cause symptoms by compression and are well defined
usually in falx cerebri, superior saggital sinus, convexity or skull base
most common primary brain tumour
glioblastoma multiforme
poor prognosis
on imaging: solid tumour with central necrosis and rim that enhances with contrast
which cancer is most likely to cause brain mets
lung cancer
also
breast
bowel
skin (melanoma)
kidney
diagnosis
glioblastoma multiforme
peripherally enhancing lesion
necrosis inside
diagnosis
meningioma
well circumscribed
dural tail where tumor connects to dura
recent parkinsonism diagnosis + associated autonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)
multisystem atrophy
with recent parkinsons diagnosis
idiopathic parkinsons disease can also cause autonomic instability but usually very late development
chronic HTN
unconsciousness
reduced GCS
quadraplegia
miosis (constriction)
absent horizontal eye movements
pontine haemorrhage
complication 2ndry to chronic HTN
TACI vs PACI
total anterior circulation infarcts (TACI)
- middle and anterior arteries
- unilateral hemiparesis and/or hemisensory loss of face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
partial anterior circulation infarcts (PACI)
- smaller arteries of anterior circulation
- 2 of above are present
what does this show
homonymous hemianopia (of right side)
what visual defect?
homonymous hemianopia with macular sparing
from posterior infarcts
visual defect?
bitemporal hemianopia
upper quadrant defect = pituitary adenoma
lower quadrant defect = craniopharyngioma
lacunar infarcts (LACI)
presents with 1 of the following
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three
- pure sensory stroke
- ataxic hemiparesis
posterior circulation infarcts (POCI)
presents with 1 of the following
cerebellar or brainstem syndrome
loss of consciousness
isolated homonymous hemianopia
amyotrophic lateral sclerosis
associated with mixed UMN and LMN signs (usually no sensory deficits)
Charcot-Marie-Tooth syndrome
hereditary
sensory and motor peripheral neuropathy
LMN signs in all limbs
reduced sensation (more pronounced distally)
fasciculations
which disease
motor neuron disease
mixed UMN and LMN signs
no sensory deficit
which type of motor neurone disease
amyotrophic lateral sclerosis
Ix for motor neurone disease
clinical diagnosis
normal motor conduction in conduction studies - exlcudes neuropathy
MRI to exclusee cervical cord compression and myelopathy
neck stiffness
photophobia
fever
altered mental state
diagnosis
encephalitis
altered mental status = encephalitis
cerebral function intact = meningitis
what should you prescribe for all cases of suspected encephalitis
acyclovir IV
- to cover herpes simplex virus (HSV) -1 infection
uses of carbamazepine
epilepsy - particularly partial seizures (1st line Mx)
trigeminal neuralgia
bipolar disorder
ineffective in absence seizures
CT head scan
hypodense collection around convexity of brain not limited to suture lines
chronic subdural haematoma
hypotense: darker = chronic
hyperdense: lighter = acute
not limited to sutures = subdural
limited to sutures = extradural
Ix and Mx for acute subdural haematoma
Ix: CT
Mx:
- monitoring of intracranial pressure
- decompressive craniectomy
Ix and Mx of chronic subdural haematoma
Ix: CT (hypodense)
Mx:
- if incidental or no symptoms: conservative
- if confused + neurological deficit = surgical decompression with Burr holes
neuroleptic malignant syndrome bloods
raised CK
leukocytosis
raised CK due to rhabdomyolysis
can lead to kidney damage therefore can have hyperkalaemia and hypocalcaemia
typical features of neuroleptic malignant syndrome
tetrad
fever
muscle rigidity
autonomic instability: hypertension, tachycardia, tachypnoea
altered mental state
Mx of neuroleptic malignant syndrome
stop antipsychotic
IV fluids to stop renal failure
differences between serotonin syndrome and neuroleptic malignant syndrome
GCS scoring
if testing motor response to pain (in supraorbital region)
arm must be brought above clavicle for localising otherwise will be scored as flexing
epilepsy review
medication change
reduced sensation in glove and stocking distribution
reduced ankle reflex
lymphadenopathy in cervical and inguinal region
bleeding around gums
which is most likely anti-epileptic
phenytoin
gingival hyperplasia (overgrowth of gum)
lymphadenopathy
peripheral neuropathy
dyskinesia
monitoring:
- trough levels immediately before dose if:
adjustment
suspected toxicity
non-adherence
DVLA dementia
legally obliged to tell DVLA if diagnosed with dementia
if patient is unable to do this such as not having mental capacity, doctor needs to tell DVLA asap
most common complication following meningitis
sensorineural hearing loss
- hearing tests routinely performed to assess for this
diagnosis of Meningitis
if partially treated with abx
negative CSF culture
glucose, protein and wcc unchanged
what should a patient presenting to GP within 7 days of clinically suspected TIA get
TIA: focal neurological deficit lasting <24hrs (ischaemia without infarct)
300mg aspirin immediately
referral for specialist review within 24hrs
if already taking low-dose aspirin continue current dose until reviewed by specialist
most important next step for patient presenting with TIA that has a bleeding disorder or is taking anticoagulant
needs immediate admission for imaging to exclude haemorrhage
reflexes nerve roots
when is Bells palsy more common
pregnancy
isolated hemisensory loss
lacunar infarct
homonymous hemianopia with macular sparing
posterior cerebral artery infarct
degenerative cervical myelopathy features
loss of fine motor function in both upper limbs
delay in diagnosis
multiple sclerosis features
affects both sensory and motor
motor mostly UMN
dissociated sensory loss that is numbness at different unlinked sites
more common in women
usually presents before 45yrs
Mx degenerative cervical myelopathy
decompressive surgery
headache triggered by cough, valsalva (breathing out against closed mouth and nose), sneeze or exercise
raised ICP until proven otherwise
LP contraindicated
ascending weakness following an infection
diagnosis
Guillain-Barre syndrome
progressive ascending weakness to akk four limbs
back/ leg pain
after gastroenteritis infection - caused by campylobacter jejuni
Guillain-Barre syndrome Ix
lumbar puncture - rise in protein with normal white blood cell count
nerve conduction studies may be performed
trigeminal neuralgia red flags suggesting serious underlying cause
sensory changes
hearing loss
hx of skin or oral lesions
pain only in opthalmic division
optic neuritis
FHx of multiple sclerosis
age onset <40yrs
Mx: urgent referral for specialist assessment if red flags
brain abscess mx
IV 3rd gen cephalosporin (ceftriaxone) + metronidazole
cranial nerves
main side effect of levodopa
dyskinesia
what side effect can you get from stopping levodopa abruptly
acute dystonia
use patch if patient cant take orally
what should levodopa be taken with
levodopa + carbidopa or benserazide (stops peripheral conversion of levodopa to dopamine)
man stares into space
non responsive
then repeatedly smacks his lips and appears to be chewing
lasts for around 1 min
focal impaired awareness seizure
- not aware of surroundings whilst having seizure
- include automatims (lip smacking, picking at clothes, fumbling)
- wandering
focal aware seizure
fully awake, alert, able to recall events during seizure
some are frozen
usually last 1-2 mins
absence seizure
children
staring into space, blank look
generalise seizure
usually a change in muscle tone and movement:
Blinking over and over that may look like fluttering of the eyelids
Smacking the lips or chewing movements
Rubbing fingers together or making other hand motions
wernicke’s aphasia - which part of brain affected
temporal lobe lesion
- results in word substitution and neologisms (new words)
speech still fluent
expressive (Broca’s aphasia) - which part of brain affected
frontal lobe
- speech non-fluent, laboured, halting
when can you consider stopping antiepileptics
can be considered if seizure free for >2yrs
AED stopped over 2-3 months
aniscoria worse in bright light
left pupil smaller than right
which anatomical location most likely damaged
aniscoria = pupil of one eye differs in size from other
in bright light implies problem with dilated pupil (as should constrict in bright light)
right ciliary ganglion - decreased parasympathetic innervation of her right eye
topiramate contraindication use for prophylaxis of migraine
teratogenic
parkinsons mx
L-dopa + carbidopa/ benserazide
if cant eat: dopamine agnoists
apomorphine injection
rotigotine patch - works after 12hrs
temporal lobe petechial haemorrhages
aphasia
fever
headache
confusion
herpes simplex encephalitis (HSV-1)
most likely affects temporal lobe
therefore aphasia
fever, headache, psychiatric symptoms, seizures, vomiting
Mx: IV acyclovir
vet
cervical lymphadenopathy
malaise
for two weeks
negative EBV serology
acute toxoplasmosis
in immunocopetent patient can mimic EBV infection- low grade fever, generalised lymphadenopathy, prominant cervical lymph nodes, malaise
usually carried by cats
should be suspected in negative EBV serology
pregnancy testing and counselling is paramount due to risk of congenital toxoplasmosis
in immunocompromised patients can cause anaemia, seizures, chorioretinitis
EBV = glandular fever
tests for glandular fever
monospot test
serology testing:
- VCA IgM - positive in currently infected patients
- VCA IgG - appears in acute phase of infection and persists for life
EBNA IgG - seen 2-4months after infection - persists for life
definitive ix for degenerative cervical myelopathy
MRI cervical spine
vision worse going down stairs
cause of blown pupil from head trauma
extrdural haemorrhage
transtentorial herniation - ipsilateral dilated pupil - affects occulomotor nerve
what type of ventilation can be used to help raised ICP
hyperventilation –> reduced CO2 –> vasoconstriction of cerebral arteries –> reduced ICP
wernicke’s aphasia lesion location
fluent speech but abnormal comprehesion
-
location: superior temporal gyrus
brocas (expressive) aphasia
non-fluent speech, laboured, halting
normal comprehension
location: inferior frontal gyrus
- supplied by left MCA
in status epilepticus what do you need to rule out before thinking of other causes
rule out hypoxia and hypoglycaemia
- do capillary blood glucose
O2
obese young female with headaches and blurred vision
+ papilloedema
idiopathic intracranial HTN (BP can be normal)
laughter –> fall/ collapse
cataplexy
common trigger for cluster headaches
acohol
also noctural sleep
more common in men and smokers
urinary incontinence
gait ataxia
dementia
normal pressure hydrocephalus
wet, wobbly and whacky
