Neuro ILAs Flashcards

Question

What is neurogenic syncope?

Answer 1

Inappropriate activation of cardio-inhibitory and vasodepressor reflex leading to hypotension

Answer 2

Vasovagal syncope Reflex syncope with specific precipitants - Micturition syncope - Cough syncope Carotid sinus hypersensitivity

Answer 3

- Orthostatic syncope (autonomic failure)- primary (multisystem atrophy) - Secondary (diabetes, drugs) Cardiac syncope - Arrhythmias - Valvular heart disease

Answer 4

Clinical manifestation of disordered electrical activity in the brain (paroxysmal discharge of cerebral neurones)

Answer 5

Tendency to recurrent seizures

Answer 6

``` Eye witness can be crucial Trigger Prodrome Description of the attack Recovery - how long, any confusion or headache Past medical/personal history ```

Answer 7

Stress/fear, prolonged standing, heat, venepuncuture, | cough, micturition

Answer 8

Sleep deprivation, flashing lights, menstruation, | alcohol and alcohol withdrawal

Answer 9

``` Hot, visual crowding and loss, feel faint, can feel dizzy (looks pale) ```

Answer 10

Aura gustatory, auditory, (partner, family friend may be able to tell when an attack is going to happen but this can also happen with non-epileptic attacks)

Answer 11

Onset - Quick but can sometimes prevent faint if sit or lie down quickly Duration – short (seconds to 1 minute) Convulsions – rare, brief Colour - pale Incontinence/Tongue biting – rare (unless bladder full)

Answer 12

Onset - Can have an aura but not always. In tonic-clonic seizures goes rigid then clonic movements of limbs Duration – 2 – 3 minutes Convulsions – GTC seizure, focal motor fits, myoclonic jerks (on awakening), frontal lobe motor fits Incontinence/Tongue biting – yes, tongue biting side of tongue

Answer 13

Duration – can last for 30 minutes Convulsions – Non-neuroanatomically accurate. Wild shaking. Arms flexing and extending. May lie completely still. Wax and wane, pelvic thrusting, eyes closed Incontinence/Tongue biting – can have injury to self

Answer 14

Syncope Little or no confusion, quick recovery. Seizure Confusion or headache. May not recognize family or friends for a few minutes. May have amnesia. First memory in ambulance/A&E. Needs to rest/sleep for 1-2 hours after. Can take several hours for full recovery. ``` Nonepileptic attacks (pseudoseizure/dissociative seizure) Recovery is atypically quick for a prolonged generalized fit. Can be very upset ```

Answer 15

Syncope Previous faints Cardiac causes include bradycardias (heart block), tachycardias (eg VT) and obstructive lesions eg aortic stenosis. Seizure Perinatal illnesses, education achievements, previous serious head injury/neurosurgery, neonatal seizures (prolonged), meningitis. If late onset (age >40) think stroke or tumours Nonepileptic attacks Previous unexplained medical symptoms. Past history of childhood trauma

Answer 16

``` Listen to heart (aortic stenosis) 12 lead ECG- long QT syndrome Blood tests (FBC) Brain imaging EEG ``` If suspect syncope cause consider 24 hr tape Tilt table Autonomic function tests

Answer 17

Video telemetry can rule out a NEA Different types- inter-ictal, provoked, sleep-deprived, prolonged and video telemetry

Answer 18

50%- about 50% of patients with epilepsy will have a normal first interictal EEG However this reduces to 30% after repeat EEG False negative rate is 20% after sleep-deprived EEG

Answer 19

Do it if- - Focal onset needs imaging - If over 25 and new onset seizure needs imaging - If suspected Idiopathic Generalized Epilepsy (GTC, Myoclonus, absences) does not need imaging because very rarely abnormal - Imaging ideally MRI but CT in emergency /semi-urgent situation

Answer 20

The interictal marker of a seizure focus is the spike or sharp wave Juvenile Myoclonic Epilepsy: Interictal EEG shows a normal background with frequent generalized polyspike and wave discharges.

Answer 21

In the normal brain the spread of electrical activity is limited. During a seizure there is a prolonged depolarization of a group of neurones, which spreads to adjacent or connected neurones There is a failure of inhibitory (GABA) neurotransmission

Answer 22

Focal (has a focus) -Simple partial (aura) -Complex partial Secondary generalized tonic-clonic ``` Idiopathic Generalized Epilepsy (generalized from outset) -Myoclonic Jerks -Typical absence -Primary generalized tonic-clonic ```

Answer 23

Often a manifestation of stress -a situation that is intolerable or unacceptable to a person and over which they have no control May be associated with history of abuse in childhood May occur in patients with epilepsy Commonly have other medically unexplained symptoms

Answer 24

Most neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present: - the patient has a neurological deficit - brain imaging shows a structural abnormality - the EEG shows unequivocal epileptic activity - the patient or their family or carers consider the risk of having a further seizure unacceptable

Answer 25

Generalised tonic-clonic seizures 1st line: sodium valproate second line: lamotrigine, carbamazepine

Answer 26

Absence seizures* (Petit mal) sodium valproate or ethosuximide sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy

Answer 27

Myoclonic seizures sodium valproate second line: clonazepam, lamotrigine

Answer 28

Focal** seizures carbamazepine or lamotrigine second line: levetiracetam, oxcarbazepine or sodium valproate

Answer 29

Sodium valproate- associated with neural tube defects Carbamazepine thought to be the least teratogenic Always give folic acid 5mg per day to pregnant women with epilepsy well before pregnancy to minimise the risk of neural tube defects.

Answer 30

- May be none - Hyperdense middle cerebral artery - Loss of grey white matter differentiation & sulcal effacement (superficial cortical infarction) - Hypodense basal ganglia (deep vessels)

Answer 31

Raised ICP -Cerebral oedema -Haemorrhage Signs:hypertension, new neurology, GCS - Aspiration - Pressure sores - Depression - Cognitive impairment - Other medical problems

Answer 32

Haemorrhage (1 in 20) | Reaction to rTPA (uncommon)

Answer 33

``` Congestive heart failure Hypertension Age >75 years DM Prior Stoke or TIA or TE ``` Vascular disease Age 65-74 years Sex category Risk of stroke in AF 2 or more- give apixaban

Answer 34

Risk of major bleeding with anticoagulation Hypertension (systolic >160mmHg) Abnormal renal function Abnormal liver function Age >65 years Stroke in past Bleeding Labile INR s Taking other drugs as well Alcohol intake at same time

Answer 35

``` Symptomatic disease (i.e. stroke/TIA) 50-90% stenosis ```

Answer 36

Age >60 years Blood pressure systolic >140 and/or diastolic >90mmHg Clinical features- 2 unilateral weakness, 1 speech disturbance w/o weakness Duration 2 if >60 mins, 1 if 10-59 Diabetes

Answer 37

involves middle and anterior cerebral arteries all 3 of the above criteria are present

Answer 38

involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery 2 of the above criteria are present

Answer 39

1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. homonymous hemianopia 3. higher cognitive dysfunction e.g. dysphasia

Answer 40

involves perforating arteries around the internal capsule, thalamus and basal ganglia presents with 1 of the following: 1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three. 2. pure sensory stroke. 3. ataxic hemiparesis

Answer 41

``` involves vertebrobasilar arteries presents with 1 of the following: 1. cerebellar or brainstem syndromes 2. loss of consciousness 3. isolated homonymous hemianopia ```

Answer 42

CT- rule out haemorrhage Offer thrombolysis in <4.5 hour onset and the patient hasn't had a previous intracranial haemorrhage Give aspirin 300mg ASAP and antiplatelet therapy should be continued

Answer 43

Immediate antithrombotic therapy: -give aspirin 300 mg immediately, unless contraindicated e.g. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)

Answer 44

7 days- arrange urgent assessment (within 24 hours) by a specialist stroke physician Over 7 days- refer for specialist assessment as soon as possible within 7 days

Answer 45

The vast majority of patients however are not suitable for surgical intervention. Management is therefore supportive as per haemorrhagic stroke. Anticoagulants (e.g. warfarin) and antithrombotic medications (e.g. clopidogrel) should be stopped to minimise further bleeding. If a patient is anticoagulated this should be reversed as quickly as possible.