Neuro part 2 Flashcards
describe a migraine
unilateral throbbing worse with movement at least 2 of photophobia, phobophobia, osmophobia or nausea 4-72 hours
acute migraine treatment
NSAIDs/paracetamol + oral triptan
consider nasal triptan in aged 12-17
acute migraine treatment in pregnancy
paracetamol 1st line (NSAIDs can be used 2nd line in 1st and 2nd trim)
treatment acute migraine if 1st line not working
non-oral preparation of metoclopramide or prochlorperazine + non-oral NSAID or triptan
side effect of metoclopramide
acute dystonic reaction
when are triptans CI
CVD
1st line migraine prophylaxis
propranolol
2nd line migraine prophylaxis
topiramate - teratogenic and reduces efficacy of hormonal contraceptive
tx menstrual migraine
triptan in acute setting
mefenamic acid or aspirin + paracetamol + caffeine
tension headache treatment
paracetamol / NSAID / aspirin
how many cluster headahce for diagnosis
at least 5 attacks for diagnosis
describe cluster headache
severe unilateral headache around the orbit with ipsilateral autonomic symptoms
multiple attacks most days over 1-3 month period
tx acute attack cluster headache
100% O2 + triptan SC
cluster headache prophylaxis
verapamil
tx paroxysmal hemicrania continua
indomethacin
describe medication overuse headache
someone who was experiencing episodic headaches so began regularly using analgesics and headache has now become chronic
tx medication overuse headache caused by simple analgesia/triptans
stop abruptly
tx medication overuse headache cause by opioid
withdraw gradually
tx trigeminal neuralgia
carbamazepine
facial nerve palsy UMN vs LMN
UMN: preservation of forehead wrinkling.
LMN: loss of forehead wrinkling on affected side. (forehead affected)
bells palsy UMN or LMN
LMN
tx bells palsy
if < 72 hours - 60mg prednisolone for 5 days
dx of sleep disorders
history and overnight sleep studies
non-REM sleep disorder - sleep paralysis - treatment if troublesome
clonazepam
dx of narcolepsy
multiple sleep latency test EEG
+ overnight sleep studies
tx day time somnolence in narcolepsy and night time cataplexy
modafinil
sodium oxybate
short term treatment insomnia
zopiclone
stroke: TACI
All three of the following:
• Unilateral weakness +/- sensory loss of face, arm or leg.
• Homonymous hemianopia.
• Higher cerebral dysfunction: dysphasia, visuospatial problems.
stroke: PACI
Two of the following present:
• Unilateral weakness +/- sensory loss of face, arm of leg.
• Homonymous hemianopia.
• Higher cerebral dysfunction: dysphasia, visuospatial problems
stroke: POCI
One of the following is present: • Isolated homonymous hemianopia. • Cerebellar or brainstem syndromes (ataxia, facial weakness, Nystagmus, diplopia). • Loss of consciousness
stroke: LACI
One of the following: • Purely sensory stroke. • Ataxic hemiparesis. • Unilateral weakness +/- sensory symptoms in face, arms or legs. High association with hypertension
vessels involved in TACI
anterior and middle cerebral
vessels involved in PACI
anterior or middle cerebral
vessels involved in POCI
vertebral basilar arteries
vessels involved in LACI
multiple small vessel infarcts in basal ganglia and thalamus and internal capsule
All three of the following:
• Unilateral weakness +/- sensory loss of face, arm or leg.
• Homonymous hemianopia.
• Higher cerebral dysfunction: dysphasia, visuospatial problems.
TACI
Two of the following present:
• Unilateral weakness +/- sensory loss of face, arm of leg.
• Homonymous hemianopia.
• Higher cerebral dysfunction: dysphasia, visuospatial problems
PACI
One of the following is present: • Isolated homonymous hemianopia. • Cerebellar or brainstem syndromes (ataxia, facial weakness, Nystagmus, diplopia). • Loss of consciousness
POCI
One of the following: • Purely sensory stroke. • Ataxic hemiparesis. • Unilateral weakness +/- sensory symptoms in face, arms or legs. High association with hypertension
LACI
clinical presentation of a stroke involving the ACA
Contra lateral weakness and sensory loss (hemiparesis), lower limb > upper limb
clinical presentation of a stroke involving the MCA
Contralateral weakness and sensory loss (hemiparesis), especially of arm and face.
Homonymous hemianopia (contralateral)
Aphasia
clinical presentation of a stroke involving the PCA
Contralateral homonymous hemianopia with macular sparing
clinical presentation of a stroke involving the ophthalmic artery
amaurosis fugax
clinical presentation of a stroke involving the Branches of the PCA that supply the midbrain (Webers syndrome)
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremities
clinical presentation of a stroke involving the Posterior inferior cerebellar artery (PICA) Wallenberg syndrome/lateral medullary syndrome
Ipsilateral facial pain and temperature loss
Contralateral limb/torso pain and temperature loss
Ataxia
Nystagmus
Ipsilateral horners
clinical presentation of a stroke involving the Anterior inferior cerebellar artery / lateral pontine syndrome
Symptoms similar to Wallenberg’s but ipsilateral facial paralysis and deafness
basilar artery stroke
locked in syndrome
most common cause of haemorrhagic stroke
uncontrolled hypertension
what kind of stroke does sudden drop in BP cause e.g. sepsis
watershed
1st line investigation for stroke
non-contrast CT
investigation of stroke if presenting 1 week after or with mild deficits suggesting small lesion
MRI
time frame for thrombolysis
4.5 hours
time frame for thrombectomy
6 hours (varies)
tx stroke if ischaemic confirmed
300mg aspirin
thrombolysis + thrombectomy - if within time frame
tx stroke > 4.5 hours and confirmed ischaemic
300mg aspirin
thrombectomy (under 6 hours)
how long is aspirin continued after stroke
14 days
medication post ischaemic stroke
- aspirin for 14 days
- clopidogrel + dipyridamole
- aspirin + dipyridamole if clopidogrel not tolerated
- statin
- if patient also has AF - warfarin or a direct thrombin or factor Xa inhibitor
tx suspected TIA
aspirin 300mg
tx suspected TIA if already taking anticoagulant
admit for imaging to exclude haemorrhage
tx post stroke
clopidogrel
dont drink alcohol or drive for 1 months
cant drive bus or lorry for 1 year
if patient also has AF - warfarin or a direct thrombin or factor Xa inhibitor
do you need to tell DVLA if you have had a TIA
no but need to be symptom free after 1 month/speak to doctor before restarting
gold standard IX for intracranial venous thrombosis
MRI venography
delta sign
Sudden onset, thunderclap headache that is usually occipital, develops within seconds and described as worst headache ever
SAH
ix SAH
CT brain
- Acute blood (hyperdense/bright on CT) distributed in the basal cisterns, sulci and in severe cases the ventricles
when is LP done in SAH
12 hours post presentation
what is seen on LP of SAH
xanthochromic CSF - turns yellow due to breakdown of RBC
ix to find out cause of SAH
CT angiogram
tx SAH
IV saline
nimodipine for 21 days
may need neurosurgery - coil or clipping
what metabolic complication can SAH lead to
hyponatraemia due to SIADH
minor trauma, fluctuating consciousness, dull headache, can be over weeks to months
SDH
ix SDH
CT brain - crescent shaped haematoma
vessels affected in SDH
bridging veins
vessels affected in EDH
middle meningeal
presentation of EDH
notable trauma
lucid interval
increasingly severe headache with sudden decline in consciousness
fixed dilated pupil would be a sign of what in context of EDH
brain herniation
ix EDH
CT brain: lens shaped (biconvex) hematoma
EDH is/is not limited by suture lines
EDH is restricted by suture lines
SDH is/is not limited by suture lines
SDH is not limited by suture lines
dx brain tumour
MRI
most common primary brain tumour
astrocytoma / glioma
most common primary brain tumour in adults
glioblastoma multiform
benign tumour occuring in frontal lobe, younger patients, chemosensitive and presents with seizures most often
oligodendroma
aggressive tumours of cerebellum almost exclusively seen in children
medulloblastoma
how do medulloblastoma spread
through CSF - drop down mets
extra axial tumours of the arachnoid cap cells
meningioma
when would bilateral vestibular schwannomas be seen
Neurofibromatosis type 2
what cranial nerves can be affected in vestibular schwanoma
V
VII
VIII
(VEStibular)
V - five
E - eight
S - seven
ocular symptom seen in vestibular schwanoma
loss of corneal reflex
tumour that presents with lower bitemporal hemianopia
craniopharyngioma
most common type of brain tumour
mets
- lung, breast, kidney, colon, melanoma
what tumour is sensitive to tenozolomide
glioblastoma
describe the headache of raised ICP
worse in morning
worse on lying down and coughing, bending
associated with N+V
what is cushings reflex
bradycardia
hypertension
wide pulse pressure
irregular breathing
1st line simple tx of raised ICP
elevate head to 30-40 degrees
treatment of raised ICP - reduce ICP
IV mannitol, hypertonic saline, intubate and hyperventilate
tx of raised ICP preventing cerebral oedema
dexamethasone
tx IIH
acetazolamide
2nd line - topiramate
repeated LP
brown sequard
Contralateral: loss of pain, temperature beginning 1-2 levels below the lesion
Ipsilateral: UMN paralysis – weakness, and loss of proprioception, vibration, light touch
central cord syndrome
Bilateral Upper limb weakness. (more than LL)
Band like loss of pain, temperature and gross touch on the back in cape distribution.
anteiror cord syndrome
paralysis and loss of pain and temperature below the level of injury with preserved proprioception and vibration sensation
common complaints in cervical myelopathy
loss of digital dexterity / clumsiness
imbalance and gait disturbance –> falls
gold standard IX for cervical myelopathy
MRI cervical spine