Neuro Presentations Flashcards
EDH
young - assault/sports
brief LOC then lucid interval
progressive hemiparesis and stupor
lentiform/egg-shaped, white, crosses midline
middle meningeal artery and pterion
burr hole/craniotomy: release pressure
SDH
chronic: elderly/alcohol (shrink + fall)
acute: severe accel/decel + brain damage
Sx fluctuant, may have latent period; GCS, focal, headache
crescent shape, sulcal loss, doesn’t cross midline
venous bleed; chronic/old = darker + liquifaction
may self-resolve; may need craniotomy/burr holes
SAH
occipital thunderclap, sudden and severe, exertion trigger
meningism, photophobia, focal neuro, N&V
aneurysm: ACoA commonest site, PCoA commonest rupture
AVM: can cause epilepsy, more re-bleeds
CT +/- LP (>12h)
anti-HTN, analgesia, hydrate, dex (oedema), NIMODIPINE (vasospasm)
clips, coils, embolise, drain, direct surgery/RDT for AVM
SAH complications
death (30% immediate)
ischaemia and infarction (commonest morbidity)
Intracerebral haemorrhage and ^ICP
acute hydrocephalus: vascular spasm + oedema
chronic hydrocephalus: fibrosis blocks granulations
re-bleed: 30% <1y (most <1/12); commonest CoD
ICH (intracerebral haemorrhage)
10% of strokes (40% of young strokes)
deep: Charcot-Bouchard aneurysms rupture: subcortical
lobar: older patients; cortical
headache, rapid LOC, BS/Cb signs, hydroceph, coma
CT: bright ‘blotches’ + dark edge (oedema), sulcal loss, ventricular
Mx: HTN control + neurosurgery consult
Tension Headache
tight band throbbing/bursting retro-orbital pressure triggers (stress, noise, visual effort, fumes) neck/scalp tenderness and tension
Migraine
recurrent headache + visual/GI disturbance
NO FEVER but similar to meningitis
unilateral pulsing, photo/phono
Classic: prodrome (visual +/- focal neuro), attack, post-migraine (sleepy)
Common: vague prodrome (no aura); N&V + malaise
Basilar: BS/Cb aura (oral tingle, vertigo, ataxia)
rare: Hemiparetic, opthalmo (CN III/IV), facioplegic (unilat facial weakness)
*RULE OUT TIA and SAH
prevent (BB, topiramate) and rescue (triptan)
Cluster Headache
intense pain, crescendo
unilateral, one eye, cheek/nose congestion
wakes from sleep, vomiting, +/- transient Horner’s
Attacks in clusters
Tx: O2, triptan, prevent with pred/verapamil
ICP
‘pressure’ - dull, persistent ache, AM/waking
positional, and straining/coughing triggers
N&V
CN III/papilloedema (painful CN III = PCA aneurysm)
focal neuro, CVA, Cushing’s Triad, Cheyne-stokes
*IIH: obese females; blurred vision; give topoimerate and diuretics (acetazolamide)
Temporal Arteritis/PMR
TA/GCA: headache, jaw claudication, visual issues (CRAO, ION), scalp
normo anaemia, ESR, Bx
HD-CST for 12-18months (+Ca/vitD/BPP)
PMR: severe limb-girdle pain, stiff, weak; AM
Brain tumours
^ICP, epilepsy, or progressive neuro deficit
CT (Gadolinium) + dex (oedema), AED, surgery
paraneoplastic: MG, hormones, LES (better with exertion; SCC), CB degeneration
Glioma/blioblastoma; astrocytoma; oligodendroglioma; ependymomas; meningioma; medulloblastoma; PNET; neuronal
Meningitis
Meningism: headache, neck stiffness, FEVER
photophobia, irritability, N&V
rash = immediate ABx
CT + LP (CSF); cultures, swabs, glucose, bloods
Benpen/Ceftriaxone/Cefotaxime 10 days
Contacts: rifampicin/ciprofloxacin
Bacterial Meningitis Complications
hydrocephalus, chronic headache oedema, abscess venous sinus thrombosis seizures, ataxia focal neuro, hearing loss, hemi/quadraparesis septicaemia, gangrene death (20-30% pn., septic shock >50%)
Epilepsy types
Abscene: ‘trance’ +/- automatism; LOC; 3Hz spike-and-wave
Myoclonic: mornings; bilateral ‘shocks;
tonic-clonic: groan + rigid, then rapid-to-slow jerks
tonic and akinteic: LOC, generalised
simple partial: unilateral, +/- aura, focal neuro
complex partial: altered LOC, automatism, focal (EEG/effect)
Epilepsy Management (Ix + Tx)
video, syncope tests (ECG/tile), bloods, EEG, echo, CT/MRI, ABG
generalised: valproate; 2nd lamotrigine; ethoxux for absence
partial: lamotrigine/carbamazepine; 2nd valproate/leve/topiramate
pregnant: levetiracetam
DVLA 1y
stop meds 2-3 year seizure free
Syncope vs. epilespy vs. NEA
epilepsy: tongue biting, at rest, infrequent, post-ictal, injury
syncope: prodome (SANS), short and rapid recovery, triggers
* orthrostatic, neuro (vagal), cardo (!!)
NEA: psychosical; frequent, fluctuant, fast strong jerks
*can mimic syncope or epilepsy e.g. automatism
MS presentation
Dx: time and space (MRI/clinical; McDonald)
asymmetrical/ unilateral;
visual: optic neuritis, visual loss
brainstem: diplopia, vertigo, dysarthria, nystagmus
SC/sensorimotor: UMN, Lhermitte’s, Uhthoff, urinary
MS Management (Ix + Tx)
bloods (incl, TFT + anti-NMO), MRI, EMG (velocity)
CSF: IgG, oligoclonal bands
non-pharma: MDT, support, triggers, lifestyle etc.
prevent: immunomodulators (INF-b), mabs, aza/cyclo
symptoms: neuropathic pain, urinary, spasticity (baclofen)
acute relapse: infection, CST (IV methylpred)
Parkinson’s Disease Presentation
‘TRAP’: tremor, rigidity (cogwheel), akinesia, postural instability
asymmetrical at onset
Motor: mask facies, fatigabiltiy, stoop, gait, speech, hyperreflexia
non-M: sleepy, halls, REM, anx/depp, GI, ANS, urine
Tx: non until disabling Sx
DA agonists (bromo, ropinirole), MAOI (selegine)
L-DOPA + carbidopa +/- Entacapone
SE: dyskinesia, on-off, fibrosis (DA), N&V, chorea, cognition/halls
Parkinson Plus Syndromes
PSP: limited down gaze, dementia, falls
MSA: horizontal nystagmus, postural hypoTN, bladder
CBD:
LBD: vivid hallucinations, dementia
PD DDx
VODKA = ?secondary
idiopathic vs. genetic (Parkin gene)
vascular: bilateral; gait prominent
drugs: haloperidol, TCA, chlorpromazine, APD/anti-Da, anti-H
Wilson’s disease, hypothyroidism
Dementia, severe depression, hypdrocephalus
*Dx: DAT scan (decreased SN uptake)
MND
PMA: best prognosis; spinal LMN; distal first
PLS: cortical UMN only; rare; progressive tetraparesis
ALS: commonest; LMN in arms, UMN in legs
*spastic tetraparesis or paraparesis
Progressive bulbar/pseudobulbar: lower CN UMN/LMN; worst prognosis;
- motor only; fasciculations common; middle-age
- riluzole: prolongs life in ALS ~3/12
MG
AI IgG against post-synaptic ACh-R NMJ
fatigability; ocular, ptosis, dysphagia, speech, proximal weakness
*progression: eyes > bulbar > face > trunk
MG crisis: respiratory weakness
Tx: anticholinesterases, IVIG, immunosupp, thymectomy
- 25% have thymom, 65% have hyperplasia
- AI assoc: SLE, pernicious, RhA
GBS
DDx: polio, CIDP, cord compression, MD
post-infection (1-3/52); progressive; resolves ~6/52
ascending numbness and weakness; affects proximal>distal
CN involved (esp. CN VII), LMN signs, pain common
may have SANS and sensory
Tx: IVIG (reduce duration/severity), SC heparin, ventilatory if rapid (resp in 20%)
Peripheral Neuropathy DDx
mono: compression/entrapment, systemic, DM
mono mulit: vasculitis, DM, infection, systemic
poly axonal (amplitude): toxins, drugs, FH/genetic
poly demye (speed): GBS, myeloma, DM, infection
radiculopathy (root): disc prolapse, stenosis, spondylosis
mono multi: asymmetrical
poly: symmetrical; sensorimotor, sensory, motor, ANS
radiculopathy: pain +/- paraesthesia, LMN
- motor: GBS, CMT, CIDP
- sensory: DM, alcohol, uraemia, B12, amyloid
Specific neuropathy
B12: DC before paraesthesia
alcohol: widespread, non-dermatomal, GGT
CMT: pes cavus, hammer/claw toe, champagne legs, ataxic, foot drop, heavy step
Carpal tunnel: worse in morning/night wake, sensorimotor; wrist splint Tx
Myopathy
DMD: XLR; childhood weakness, ^CK, ^calves, Gower’s sign, cardiomyopathy
Myotonic Dystrophy: AD; weak, contracted; distal/facial weakness
Polymyositis: CTD-assoc; proximal/facial weak, ptosis + dysphagia; myalgia
dermatomyositis: heliotrope rash
Inclusion body: polymyositis but DISTAL > proximal
*EMG: short, spiky, polyphasic +/- fibrillation
Alzheimer’s
memory loss, aphasia, apraxia, agnosia, exec function
later: behaviour gait, sensorimotor
bilateral temporal/hippocampal lesions
anticholinesterases: donepezil, rivastigmine, galantamine
NMDA-agonists: mimantine
Vascular Dementia
stepwise
vascular history e.g. TIA and CVA
focal neuro (infarct site-dependent))
LBD Dementia
fluctuating cognition/attention/alertness
early memory loss
visuospatial hallucination, depp, sleep disorder
parkinsonism
*sensitive to neuroleptics (e.g. haloperidol)
Picks (FTD)
behavioural/social > memory
progressive dis-inhibition and personality change
memory/IQ/language later
Delerium
acute/subacute onset, rapid freq fluctuations
attention, arousal, alertness
delusions, hallucinations, disorientated
abnormal movements (tremor, myoclonus) and ANS
hypo/hyper/mixed
