neuro to work on Flashcards
1
Q
Name 2 types of secondary headache
A
Underlying cause
- Meningitis
- Subarachnoid haemorrhage
- Giant cell arteritis
- Idiopathic intracranial hypertension
- Medication overuse headache
2
Q
Briefly describe the pathophysiology of migraines
A
- Cerebrovascular constriction –> aura, dilation –> headache
- Spreading of cortical depression
- Activation of CN V nerve terminals in meninges and cerebral vessels
3
Q
what are the differential diagnoses for a migraine?
A
- Other headache type
- Hypertension
- TIA
- Meningitis
- Subarachnoid haemorrhage
4
Q
How does triptan work?
A
Selectively stimulates 5-hydroxytryptamine (serotonin) receptors in the brain
5
Q
Give 3 causes of trigeminal neuralgia
A
- Compression of trigeminal nerve by a loop of vein or artery
- Aneurysms
- Meningeal inflammation
- Tumours
6
Q
What is the treatment for trigeminal neuralgia?
A
Carbamazepine - suppresses attacks
Less effective options = phenytoin, gabapentin and lamotrigine
Surgery = microvascular decompression, gamma knife surgery
7
Q
What does a small response on an nerve conduction study suggest?
A
There is axon loss
8
Q
What does a slow response on an nerve conduction study suggest?
A
There is myelin loss
9
Q
Name 2 organisms that can cause meningitis in immunocompromised patients
A
- CMV
- Cryptococcus
- TB
- HIV
- herpes simplex
10
Q
what are the signs of meningitis
A
Kernig’s sign = unable to straighten leg more than 135 degrees without pain when hip is flexed to 90 degrees
Brudzinski’s sign = severe neck stiffness cause hip and knees to flex when neck is flexed
11
Q
What investigations might you do in someone you suspect has meningitis?
A
- Blood cultures (pre LP)
- Bloods - FBC, U+E, CRP, ESR, serum glucose, lactate
- Lumbar puncture (contraindicated with raised ICP)
- CT head - exclude lesions
- Throat swabs - bacterial and viral
12
Q
What is the treatment of bacterial meningitis?
A
- ABCDE + support
- Empirical therapy = IV Benzylpenicillin
Assess GCS - First line = Ceftriaxone / Cefotaxime
- Add IV Benzylpenicillin for rash
- Penicillin allergy = Chloramphenicol
- Immunocompromised ( Risk of Listeria) = Amoxicillin / Ampicillin
oral dexamethasone to reduce cerebral oedema
13
Q
What is the treatment of viral meningitis?
A
Watch and wait
acyclovir
14
Q
What is the treatment for meningococcal septicaemia?
A
IV BENZYLPENICILLIN (in community)
IV CEFOTAXIME (in hospital)
15
Q
Give 4 reasons why a lumbar puncture might be contraindicated
A
- Thrombocytopenia
- Delay in Abx admin
- Signs of raised ICP
- Unstable cardio or resp systems
- Coagulation disorder
- Infections at LP site
- Focal neurological signs
16
Q
what are the non-viral causes of encephalitis
A
- Bacterial meningitis
- TB
- Malaria
- Lyme’s disease
17
Q
What investigations might you do on someone with encephalitis?
A
- MRI - shows areas of inflammation, may be midline shifting
- EEG - periodic sharp and slow wave complexes
- lumbar puncture
- blood and CSF serology
18
Q
what are the causes/risk factors of MS?
A
Unknown Environment and genetic components - exposure to EBV in childhood - low levels of sunlight and vitamin D - female - white - living far from equator
19
Q
what are the symptoms of MS?
A
TEAM
- Tingling
- Eye = optic neuritis
- Ataxia
- Motor - spastic paraparesis, pyramidal weakness (UL = extensors, LL = flexors)
- swallowing disorders
- bladder incontinence
- dizziness, falls
- constipation
- fatigue
- cognitive impairment, depression
20
Q
what are the signs of MS?
A
- Lhermitte sign - electric jolt felt down the spine when flexing neck
- Uhthoff phenomenon - symptoms worse with heat, e.g. hot bath/exercise
21
Q
Name 3 differential diagnosis’s of MS
A
- SLE
- Sjogren’s
- AIDS
- Syphilis
22
Q
Describe the pharmacological treatment for MS
A
acute relapse
- steroids = IV METHYLPREDNISOLONE
chronic/frequent relapse
- biological - SC BETA INTERFERON (contraindicated in pregnancy)
- DMARDs - IV alentuzumab, IV natalizumab
23
Q
What symptomatic treatments can you give to those with MS?
A
Spasticity
- BACLOFEN (GABA analogue, reduces Ca2+ influx)
- TIZANIDINE (alpha-2 agonist)
- BOTOX INJECTION (reduces ACh in neuromuscular junction)
urinary incontinence = catheterisation
incontinence
- DOXAZOSIN (anti-cholinergic alpha blocker drugs
24
Q
Define epilepsy
A
Recurrent, spontaneous, intermittent abnormal electrical activity in part of the brain, manifesting seizures
25
Define epileptic seizure
Paroxysmal event in which changes of behaviour, sensation or cognitive processes are caused by excess, hypersynchronous neuronal discharge in the brain
26
Give 5 causes of epilepsy
1. Idiopathic (2/3)
2. cortical scarring
3. tumour
4. stroke
5. alzheimers dementia
6. alcohol withdrawal
27
What is the treatment for focal epileptic seizures?
```
Lamotrigine = 1st line
Carbamazepine = 2nd line
```
28
How do lamotrigine and Carbamazepine work?
Inhibit pre-synaptic Na+ channels so prevent axonal firing
29
What is the treatment for generalised epileptic seizures?
Sodium valproate = 1st line
| Lamotrigine = 2nd line
30
How does sodium valproate work?
Inhibits voltage gated Na+ channels and increases GABA production
31
Give 4 potential side effects of anti-epileptic drugs (AED's)
1. Cognitive disturbances
2. Heart disease
3. Drug interactions
4. Teratogenic
32
Give 4 differential diagnosis's of epilepsy
1. Syncope
2. Non-epileptic seizure
3. Migraine
4. Hyperventilation
5. TIA
33
Define non-epileptic seizure
Mental processes associated with psychological distress causes paroxysmal changes in behaviour, sensation and cognitive processes
1-20 minute duration
Closed eyes and mouth
34
Name 3 intra-cranial haemorrhages
1. Sub-arachnoid haemorrhage
2. Sub-dural haemorrhage
3. Extra-dural haemorrhage
35
What can cause a subarachnoid haemorrhage?
- Traumatic injury
- Berry aneurysm rupture
(70-80%) - at common points round Circle of Willis
- Arteriovenous malformations (15%) - abnormal tangle of blood vessels connecting arteries and veins
- Idiopathic (15-20%)
36
Give 3 risk factors for a subarachnoid haemorrhage
Hypertension
Known aneurysm
Previous aneurysmal SAH
Smoking
Alcohol
Family history
Bleeding disorders
- associated with berry aneurysms:
- Polycystic Kidney Disease
- Coarctation of aorta
- Ehlers-Danlos syndrome & Marfan syndrome
37
Briefly describe the pathophysiology of a subarachnoid haemorrhage
1. tissue ischaemia - less blood, O2 and nutrients can reach the tissue due to bleeding loss -> cell death
2. raised ICP - fast flowing arterial blood is pumped into the cranial space
3. space occupying lesion - puts pressure on the brain
4. brain irritates meninges - these inflame causing meningism symptoms. This can obstruct CSF outflow -> hydrocephalus
5. vasospasm - bleeding irritates other vessels -> ischaemic injury
38
Describe the treatment for a subarachnoid haemorrhage
- NIMODIPINE for 3 weeks -> CCB which prevents vasospasm so reduces cerebral ischaemia
- surgery = endovascular coiling
- IV fluids - maintain cerebral perfusion
- ventricular drainage for hydrocephalus
39
Give 3 possible complications of a subarachnoid haemorrhage
1. Rebleeding (common = death)
2. Cerebral ischaemia
3. Hydrocephalus
4. Hyponatraemia
40
Give 3 risk factors of a subdural haematoma?
1. Elderly - brain atrophy, dementia
2. Frequent falls - epileptics, alcoholics
3. Anticoagulants
4. babies - traumatic injury ("shaking baby syndrome")
41
Name 3 differential diagnosis's of a subdural haematoma
1. Stroke
2. Dementia
3. CNS masses (tumour vs abscess)
42
What is the treatment for a subdural haematoma?
SURGERY
- 1* = irrigation via burr-hole craniostomy
- 2* = craniotomy
IV MANNITOL - to reduce ICP
address cause of trauma
43
Give 3 things that modulate LMN action potential transmission to effectors
1. Cerebellum
2. Basal ganglia
3. Sensory feedback
44
Give 3 disease that are associated with motor neurone damage
1. Motor neurone disease
2. Spinal atrophy
3. Poliomyelitis
4. Spinal cord compression
45
Give 3 pathologies that are associated with ventral spinal root damage
1. Prolapsed intervertebral disc
2. Tumours
3. Cervical or lumbar spondylosis
46
Describe the pyramidal pattern of weakness in the upper limbs
Flexors are stronger than extensors
47
Describe the pyramidal pattern of weakness in the lower limbs
Extensors are stronger than flexors
48
Give 3 causes of UMN weakness
1. MS
2. Brain tumour
3. Stroke
4. MND
49
Give 4 sites of UMN damage
1. Motor cortex lesions
2. Internal capsule
3. Brainstem
4. Spinal cord
50
Define motor neurone disease (MND)
A group of neuro degenerative disorders that selectively affect the motor neurons
Most in the anterior horn, cells of the spinal cord and the motor cranial nuclei
There are no sensory problems
51
What is the clinical presentation of MND?
- results in mixed UMN and LMN presentation (LMN symptoms predominate)
- wrist drop/foot drop
- change in appearance of hands - wasting
- gait disorders/tendencies to trip
- excessive fatigue
52
What investigations might you do in someone you suspect to have MND?
```
Head/spine MRI
Blood tests = muscle enzymes, autoantibodies
Nerve conduction studies
EMG
Lumbar Puncture
```
53
What is the diagnostic criteria for MND?
LMN + UMN signs in 3 regions
El Escorial criteria
1. Presences of LMN and UMN degeneration and progressive history
2. Absence of other disease processes
54
What is the treatment for MND?
- MDT care
- anti-glutaminergic drugs - ORAL RILUZOLE - Na+ channel blocker, inhibits glutamate release
- Drooling - ORAL PROPANTHELINE or ORAL AMITRIPTYLINE
- Dysphagia: NG tube
- Spasms: ORAL BACLOFEN
- Non-invasive ventilation
- Analgesia e.g. NSAIDs - DICLOFENAC
55
Give 3 limb onset symptoms of MND
1. Weakness
2. Clumsiness
3. Wasting of muscles
4. Foot drop
5. Tripping
56
Give 3 respiratory onset symptoms of MND
1. Dyspnoea
2. Orthopnoea
3. Poor sleep
57
What are the 4 cardinal presenting symptoms of brain tumours?
1. Raised ICP --> headache, decrease GCS, n+v, papilloedema
2. Progressive neurological deficit --> deficit of all major functions (motor, sensory, auditory, visual) + personality change
3. Epilepsy
4. lethargy/tiredness - caused by pressure on brainstem
58
Name 2 differential diagnosis's for a brain tumour
1. Aneurysm
2. Abscess
3. Cyst
4. Haemorrhage
5. Idiopathic intracranial hypertension
59
Where might secondary brain tumours arise from?
1. non-small cell lung cancer
2. small cell lung cancer
3. breast
4. melanoma
5. renal cell carcinoma
6. GI
60
Give 3 causes of dementia
1. Alzheimer's disease (50%)
2. Vascular dementia (25%)
3. Lewy body dementia (15%)
4. Fronto-temporal (Pick's)
5. Huntington's
6. Liver failure
7. Vitamin deficiency - B12 or folate
61
Give 3 risk factors of dementia
1. Family history
2. Age
3. Down's syndrome
4. Alcohol use, obesity, HTN, hyperlipidaemia, DM
5. Depression
6. ? Head injury
62
what is the clinical presentation of Alzheimer's Disease
```
● Memory - episodic and semantic
● Language - difficulty understanding or
finding words
● Attention and concentration issues
● Psychiatric changes, e.g. withdrawal,
delusions
● Disorientation, e.g. time and surroundings
```
63
What does vascular dementia often present with?
● Characterised by stepwise progression - Periods of stable symptoms, followed by a sudden increase in severity
● Presentation varies massively but can include:
- Visual disturbances,
- UMN signs (e.g. muscle weakness, overactive reflexes, clonus),
- attention deficit,
- depression,
- incontinence,
- emotional disturbances
○ If infarct was subcortical, then expect to see dysarthria and parkinsonisms
64
Describe the pathophysiology of Lewy body dementia
● Characterised by eosinophilic intracytoplasmic neuronal inclusion bodies (Lewy bodies) in the brainstem and neocortex
● Also see substantia nigra depigmentation and amyloid deposits
65
what are the clinical features of Lewy body dementia
● Dementia is often presented initially
○ Memory loss, spatial awareness difficulties,
loss of cognitive function
● Parkinsonisms, e.g. tremor, rigidity, change in gait
● Visual hallucinations
● Sleep disorders, restless leg syndrome
66
Give 3 symptoms of Fronto-temporal dementia
● Onset tends to be insidious and progressive
● Present with 3 main symptoms:
○ Behavioural issues, e.g. loss of inhibition/empathy, compulsive behaviours, difficulty planning
○ Progressive aphasia, e.g. slow, difficult speech, grammatical errors
○ Semantic dementia, e.g. loss of vocabulary, problems understanding
67
What is functional memory dysfunction?
Acquired dysfunction of memory that significantly affects a person's professional/private life in absence of an organic cause
68
What investigations can you do in primary care to determine whether someone might have dementia?
1. Good history of symptoms
2. 6 item cognitive impairment test (6CIT)
3. Blood tests - FBC, liver biochemistry, TFTs, vitamin B12 and folate
4. Mini mental state examination = screening
69
What questions are asked in 6CIT?
1. What year is it?
2. What month is it?
3. Give an address with 5 parts
4. Count backwards from 20
5. Say the months of the year in reverse
6. Repeat the address
70
Name the staging system that classifies the degree of pathology in AD
Braak staging
Stage 5/6 = high likelihood of AD
Stage 3/4 = intermediate likelihood
Stage 1/2 = low likelihood
71
Give 3 ways in which dementia can be prevented
1. Smoking cessation
2. Healthy diet
3. Regular exercise
4. Low alcohol
5. Engaging in leisure activités
72
What support should be offered to patients with dementia?
Social suport
Cognitive support
Specialist memory service
73
What medications might you use in someone with dementia?
```
Acetylcholinesterase inhibitors - increase ACh = donepezil, rivastigmine
Control BP (ACEi) to reduce further vascular damage
```
74
what are the causes/risk factors for myasthenia gravis?
If <50 = associated with other AI conditions (pernicious anaemia, SLE, RA) and more common in women
If >50 = associated with thymic atrophy, thymic tumour, SLE and RA and more common in men
75
what are the clinical features of myasthenia gravis?
1. Muscle weakness
2. Increasing muscular fatigue
3. Ptosis
4. Diplopia
5. Myasthenic snarl
6. Tendon reflexes normal but fatigable
```
● Weakness is more marked in proximal muscles
● Weakness might be seen in:
○ Small muscle of the hands
○ Deltoid and triceps muscles
○ Bulbar muscles
○ Muscles involved in chewing
● No muscle wasting, sensation is unimpaired
● Seizures can occur
```
76
What muscle groups are affected in myasthenia gravis?
muscle groups affected in order:
- extra-ocular
- bulbar - chewing and swallowing
- face
- neck
- trunk
77
What can weakness due to myasthenia gravis be worsened by?
```
Pregnancy
Hypokalaemia
Infection
Emotion
Exercise
Drugs (opiates, BB, gentamicin, tetracycline)
```
78
What investigations might you do to see if someone has myasthenia gravis?
- mostly clinical examination
- positive tensilon test
- anti-AChR antibodies
- TFTs
- EMG
- CT of thymus
- crushed ice test - ice is applies to ptosis for 3 mins, if it improves it is likely to be myasthenia gravis
79
Give 3 possible differential diagnosis's for myasthenia gravis
1. MS
2. Hyperthyroidism
3. Acute Guillain-Barre syndrome
4. Lamert-Eaton myasthenia syndrome
80
What is treatment for myasthenia gravis?
Anti-cholinesterase = pyridostigmine
Immunosuppression = prednisolone (with alendronate - bisphosphonate)
Steroids can be combined with azathioprine or methotrexate
Thymectomy
81
Give a complication of myasthenia gravis
Myasthenic crisis
Weakness of respiratory muscle during relapse
Treatment = plasmapheresis and IV immunoglobulin
82
Describe the pathophysiology of Parkinson's disease
destruction of dopaminergic neurones (in substantia nigra) --> reduced dopamine supply --> thalamus inhibits --> decrease in movement + symptoms
Lewy body formation in basal ganglia
83
What is the 3 cardinal symptoms for Parkinsonism?
resting tremor
rigidity
bradykinesia
postural instability
84
what are the clinical features of Parkinson's disease
● Often an insidious onset
- impaired dexterity,
- fixed facial expressions,
- foot drag
● Common associated symptoms:
- dementia,
- depression,
- urinary frequency,
- constipation,
- sleep disturbances
85
You ask a patient who you suspect to have Parkinson's disease to walk up and down the corridor to assess their gait, what features would be suggestive of PD?
Stooped posture
Asymmetrical arm swing
Small steps
Shuffling
86
What investigations might you do in someone you suspect to have PD?
DaTscan
Functional neuroimaging - PET
Can confirm by reaction to levodopa
87
Describe the pharmacological treatment for Parkinson's disease
young onset + fit
- Dopamine agonist (ropinirole)
- MAO-B inhibitor (rasagiline)
- L-DOPA (co-careldopa)
frail + co-morbidities
- L-DOPA (co-careldopa)
- MAO-B inhibitor (rasagiline)
88
How do dopamine agonists work in the treatment of PD and give an example of one?
Reduced risk of dyskinesia
First line in patient <60
Ropinirole, pramipexole
89
How do MAO-B inhibitors work in the treatment of PD and give an example of one?
Inhibit MAO-B enzymes which breakdown dopamine -> increases amount of dopamine available
Rasagiline, selegiline
90
How do COMT inhibitors work in the treatment of PD and give an example of one?
Inhibit COMT enzymes which breakdown dopamine
| Entacapone, tolcapone
91
What surgical treatment methods are there for Parkinson's disease?
Deep brain stimulation of the sub-thalamic nucleus
| Surgical ablation of overactive basal ganglia circuits
92
Define Huntington's disease
Neurodegenerative disorder characterised by the lack of inhibitory neurotransmitter GABA - too much dopamine
autosomal dominant - 100% penetrance
93
Briefly describe the pathophysiology of Huntington's disease
Less GABA causes less regulation of dopamine to striatum causing increased dopamine levels resulting in excessive thalamic stimulation and subsequently increased movement (chorea)
94
Name the cardinal features of Huntington's disease
● Main sign is hyperkinesia
● Characterised by:
○ Chorea, dystonia, and incoordination
● Psychiatric issues
● Depression
● Cognitive impairment, behavioural difficulties
● Irritability, agitation, anxiety
95
Name 3 signs of Huntington's disease
1. Abnormal eye movements
2. Dysarthria
3. Dysphagia
4. Rigidity
5. Ataxia
96
What investigations might you do in someone you suspect to have Huntington's disease?
● MRI/CT - loss of striatal volume
| ● Genetic testing
97
Describe the treatment of Huntington's disease
poor prognosis - no treatment
● Benzodiazepines/valproic acid - chorea
● SSRIs = depression
● Haloperidol = psychosis
98
what are the causes/risk factors of carpal tunnel syndrome
1. Pregnancy
2. Obesity
3. RA
4. DM
5. Hypothyroidism
6. Acromegaly
99
What investigations might you do in someone who you suspect to have carpal tunnel syndrome?
clinical diagnoses based on symptom presentation
EMG = slowing conduction velocity in median sensory nerves
Phalen's test = 1 min maximal wrist flexion --> symptoms
Tinel's test = tapping over nerve at wrist --> tingling
USS or MRI if other damage is suspected
100
What can cause Guillain-Barre syndrome?
Bacteria
- Camplylobacter jejuni
- Mycoplasma
Viruses
- CMV
- EBV
- HIV
- Herpes zoster
101
Describe the pathophysiology of Guillain-Barre syndrome
Same antigens on infectious organisms as Schwann cells (PNS) --> autoantibody mediated nerve cell damage -> via molecular mimicry
Schwann cell damage consists of demyelination, which results in a reduction in peripheral nerve conduction --> causes acute polyneuropathy
spreads from proximal to distal
102
what are the clinical features of Guillain-Barre syndrome
```
Breathing problems
Back pain
Sensory disturbance
Sweating
Urinary retention
```
1. Ascending symmetrical muscle weakness 1-3 weeks post-infection (proximal muscles most affected - trunk, respiratory, CN) TOES TO NOSE WEAKNESS
2. Pain in legs, back is rare
3. sensory loss in lower extremities
4. Reflexes lost early on (LMN sign)
5. Autonomic features =
- reduced sweating
- reduced heat tolerance
- paralytic ileus - intestinal obstruction w/o blockage
- urinary hesitancy
103
What investigations might you do in someone you suspect has Guillain-Barre syndrome?
- Nerve Conduction Studies (NCS) = diagnostic -> shows slowing of conduction
- Lumbar Puncture at L4 = raised protein and normal WCC (cyto-protein dissociation)
- bloods - FBC, U&E, LFT, TFT
- Spirometry = respiratory involvement
- ECG
104
Describe the treatment for Guillain-Barre syndrome
- If FVC <1.5L/80% = ventilate and ITU monitoring
- IV immunoglobulin (IvIg) for 5 days = decrease duration and severity of paralysis
- Plasma exchange
- Low molecular weight heparin (LMWH) - SC ENOXAPARIN
- Analgesia
105
What are the causes of an ischaemic stroke?
- small vessel occlusion by thrombus
- atherothromboembolism (e.g. from carotid artery)
- cardioembolism (post MI, valve disease, IE)
- hyper viscosity
- hypoperfusion
- vasculitis
- fat emboli from a long bone fracture
- venous sinus thrombosis
106
What are the causes of an haemorrhagic stroke
Bleeding from the brain vasculature
1. Hypertension - stiff and brittle vessels, prone to rupture
2. Secondary to ischaemic stroke - bleeding after reperfusion
3. Head trauma
4. Arteriovenous malformations
5. Vasculitis
6. Vascular tumours
6. Carotid artery dissection
107
what are the risk factors for ischaemic stroke?
1. Age
2. Male
3. Hypertension
4. Smoking
5. Diabetes
6. Recent/past TIA
7. Heart disease - IHD, AF, valve disease
8. Combined oral contraceptive
108
Give 3 signs of an ACA stroke
1. Leg weakness - contralateral
2. Sensory disturbance in legs
3. Gait apraxia
4. Incontinence
5. Drowsiness
6. Akinetic mutism - decrease in spontaneous speech (in a stupor)
7. truncal ataxia - can't sit or stand unsupported
109
Give 3 signs of a MCA stroke
1. Contralateral arm and leg weakness and sensory loss
2. Hemianopia
3. Aphasia
4. Dysphasia
5. Facial droop
110
Give 3 signs of a PCA stroke
visual issues
1. Contralateral homonymous hemianopia
2. Cortical blindness
3. Visual agonisa
4. Prosopagnoisa
5. Dyslexia
6. Unilateral headache
111
Give 3 differential diagnosis's for a stroke
1. Hypoglycaemia
2. Intracranial tumour
3. Head injury +/- haemorrhage
112
What is the treatment for an ischaemic stroke?
Immediate management:
- CT/MRI to exclude haemorrhagic stroke
- aspirin 300mg
Antiplatelet therapy
- aspirin 300mg for 2 weeks
- clopidogrel daily long term
Anticoagulation (e.g. warfarin) for AF
thrombolysis
- within 4.5 hrs of onset
- IV alteplase
- lots of contraindications (can cause massive bleeds)
mechanical thromboectomy
- endovascular removal of thrombus
113
How does alteplase work?
Converts plasminogen --> plasmin
| So promotes breakdown of fibrin clot
114
What is primary prevention of strokes?
Risk factor modifcaiton
- Antihypertensives for HTN
- Statins for hyperlipiaemia
- Smoking cessation
- Control DM
- AF treatment = warfarin/NOAC's
115
What is secondary prevention of strokes?
2 weeks of aspirin --> long term clopidogrel
116
Give 3 causes of a TIA
1. Artherothromboembolism of the carotid - main cause (can hear carotid bruit)
2. Cardioembolism - in AF, after MI, valve disease/prosthetic valve
3. Hyperviscosity - polycythaemia, sickle cell, high WBCC
4. hypoperfusion - postural hypotension, decreased flow
117
what are the signs of a carotid TIA?
1. Amaurosis fugax = retinal artery occlusion --> vision loss
2. Aphasia
3. Hemiparesis
4. Hemisensory loss
5. hemianopia
118
what are the signs of a vertebrobasilar TIA?
1. Diplopia, vertigo, vomiting
2. Choking and dysarthria
3. Ataxia
4. Hemisensory loss
5. Hemianopic/bilateral visual loss
6. tetraparesis
7. loss of consciousness
119
what are the differential diagnosis's for a TIA
1. Migraine aura
2. Epilepsy
3. Hypoglycaemia
4. Hyperventilation
5. retinal bleed
6. syncope - due to arrhythmia
120
What investigations would you do in someone who you suspect to have a TIA?
first line = diffusion weighted MRI or CT
second line = carotid imaging (doppler ultrasound followed by angiography if stenosis is found)
Bloods
- FBC - look for polycythaemia
- ESR - raised in vasculitis
- U&Es, glucose
ECG
echocardiogram
121
What is it essential to do in someone who has had a TIA?
Assess their risk of having stroke in the next 7 days = ABCD2 score
122
What is the ABCD2 score?
Assesses risk of stoke in the next 7 days for those who have had a TIA
- age
- BP
- clinical features - unilateral weakness, speech disturbance
- duration of TIA
- presence of diabetes mellitus
123
What classifies as a high risk stroke patient?
- have ABCD2 score >4
- have AF
- >1 TIA in a week
124
What is the treatment for a TIA?
immediate treatment = aspirin 300mg and refer to specialist within 24hrs
control CV risk factors
- BP control - ACEi (RAMIPRIL) or ARB (CANDESARTAN)
- smoking cessation
- statin - SIMVASTATIN
- no driving for 1 month
antiplatelet therapy
- ASPIRIN 75mg daily (With Dipyridamole)
or
- CLOPIDOGREL daily
anticoagulation (e.g. WARFARIN) for patients with AF
carotid endarterectomy
- if >70% carotid stenosis
- reduces stroke/TIA risk by 75%
125
Give 3 causes of spinal cord compression
- trauma,
- tumours - most common spinal metastases are
breast, prostate and lung cancer
- central disc protrusion,
- prolapsed disc (L4-5 and L5-S1 most common),
- epidural haematoma,
- infection,
- cervical spondylitic myelopathy
126
Give 3 signs and symptoms of spinal cord compression
```
Red flag signs:
- Loss of bladder or bowel function,
- UMN signs in the lower limbs (e.g. clonus, hyperreflexia),
- LMN signs in the upper
limbs (e.g. atrophy)
```
● Symptoms depend on the injury type and site
- Can include paraplegia,
- pain,
- paraesthesia,
- changes to tendon reflexes
127
What is the treatment for spinal cord compression?
● Acute spinal cord compression is a neurosurgical emergency
● Dexamethasone until treatment plan confirmed
● Catheterisation
● Analgesia
● Surgical decompression if indicated
● Chemotherapy if indicated
128
Give 3 causes of cauda equina syndrome
1. Lumbar disc herniation at L4/5 or L5/S1
2. Tumour
3. Trauma
4. Infection
5. late-stage ankylosing spondylitis
6. post-operative haematoma
7. sarcoidosis
129
what are the clinical features of cauda equina syndrome
```
● Sudden onset - hours
● Saddle paraesthesia
● bilateral sciatica
● Bladder/bowel dysfunction
● erectile dysfunction
● Motor problems
● Lower back pain
● Bilateral LMN weakness, absent ankle reflex (flaccid and areflexic)
```
130
What investigations might you do to see if someone has cauda equina syndrome?
● Medical emergency
- immediate referral
● Rectal exam - loss of anal tone/sensation
● MRI spine
● knee flexion (L5-S1) and ankle plantar flexion (S1-S2)
131
How do you treat cauda equina syndrome?
```
● Surgical decompression is essential
● Immobilise spine
● Anti-inflammatory agents
● Antibiotics if infection present
● Chemotherapy if indicated
```
* Microdiscectomy - removal of part of the disc - may tear dura!
* Epidural steroid injection - more effective for leg pain
* Surgical spine fixation - if vertebra slipped
* Spinal fusion - reduces pain from motion and nerve root inflammation
132
Define spondyloisthesis
Slippage of vertebra over the one below
133
Define spondylosis
Degenerative disc disease
134
what are the risk factors for Alzheimer's disease?
- Down’s syndrome,
- ApoE E4 allele homozygosity,
- reduced cognitive activity,
- depression/loneliness
135
what is the pathophysiology of frontotemporal dementia?
● Atrophy of the frontal and temporal lobes
● Loss of neurons, but no plaque formation
● Tau +ve or TDP-43 +ve inclusions
136
what are the risk factors for frontotemporal dementia?
50% dominant inheritance
137
what is the treatment for frontotemporal dementia?
● No cure
● Supportive therapy, e.g. carers, help setting up a stable routine, home changes for motor difficulties, speech and language therapy
● SSRIs - help with behaviour symptoms
● Levodopa/carbidopa if Parkinson’s symptoms present
● Stopping exacerbating drugs
138
what are the risk factors for vascular dementia?
```
smoking,
history of TIAs,
AF,
hypertension,
DMT1,
hyperlipidaemia,
obesity,
coronary heart disease
```
139
what is the treatment for vascular dementia?
● Supportive therapy, e.g. carers, home changes,
routine help, cognitive simulation programmes
● No pharmacological treatment for the dementia
itself
● SSRIs or anti-psychotics to control symptoms,
e.g. lorazepam
● Prognosis is 3-5 years from diagnosis
140
what are the investigations for Lewy Body dementia?
● MMSE or 6-item cognitive impairment test (6-CIT)
● Bloods - B12, TFTs, U&E, MRI (?other cause)
● MSU to check for urine infection
141
what is the diagnostic criteria for Lewy Body dementia?
○ Presence of dementia with 2 of:
- fluctuating attention and concentration,
- recurrent well-formed visual hallucinations,
- spontaneous Parkinsonism
○ If there is only 1 of the 3 core features, diagnosis can also be made with a SPECT or PET scan showing low dopamine transporter uptake in basal ganglia
142
what is the treatment for Lewy Body dementia?
● Refer to a specialist
● Supportive therapy - cognitive stimulation, exercise programmes, at-home care
● Cholinesterase inhibitors, e.g. rivastigmine suggested to treat cognitive decline
● Avoid use of neuroleptic drugs, e.g. haloperidol, as they can produce severe
sensitivity reactions
143
what are the other causes of Parkinson's disease?
- Drug induced Parkinsonism - caused by dopamine
antagonists, e.g. clozepine
- encephalitis
- exposure to certain toxins, e.g. manganese dust
144
what is the 3 step diagnostic pathway for diagnosing Parkinson's disease?
1) Diagnosis of Parkinsonian syndrome
○ Bradykinesia (required) plus one of rigidity, resting tremor, or postural instability
2) Exclusion criteria (none to be met)
○ History of stroke, repeated head injury, neuroleptic treatment, unilateral features after 3 years, cerebellar signs, babinski’s sign, early severe dementia, negative response to large L-dopa dose
3) Supportive criteria (3 or more required)
○ Unilateral onset, rest tremor present, progressive, excellent response to L-dope (70-100%), visual hallucinations
145
Damage to which nerve causes foot drop?
Caused by damage to the common peroneal nerve - L4-S1 (also called common fibular
nerve)
146
what are the causes of foot drop?
```
injury,
lower back damage,
tumour,
hip replacement,
cauda equina syndrome,
multiple sclerosis
```
147
what are the investigations for foot drop?
● Foot drop itself can be a clinical diagnosis
● Need to find the underlying cause:
○ X-ray, USS, CT, MRI
○ Nerve conduction study
148
what is the treatment for foot drop?
```
● Brace or splint
● Physiotherapy
● Specialised shoes - prevent foot drop when walking
● Nerve stimulation
● Surgery if indicated
```
149
what are the risk factors for TIA?
- age
- hypertension
- smoking
- diabetes
- heart disease - AF
- combined oral contraceptive pill
- hyperlipidaemia
- peripheral artery disease
- clotting disorder
- vasculitis
150
what are the differential diagnoses for TIA?
```
Hypoglycaemia
Migraine aura
Focal epilepsy
Vasculitis
Syncope - E.g. due to an arrythmia
Retinal bleed
```
151
what are lacunar infarcts (ischaemic stroke)?
- Small infarcts
- From occlusion of a single small perforating artery supplying a subcortical area
- Can happen in:
- Internal capsule
- Basal ganglia
- Thalamus
- Pons
152
what is the clinical presentation of lacunar infarcts (ischaemic stroke)?
Depends on the area affected
One of:
- Sensory loss
- Weakness (unilateral)
- Ataxic hemiparesis
- Dysarthria
- Motor speech problems
153
which areas of the brain can be affected by lacunar infarcts (ischaemic stroke)?
Internal capsule
Basal ganglia
Thalamus
Pons
154
what is the clinical presentation of brainstem infarcts (ischaemic stroke)?
- Quadriplegia
- Facial numbness & paralysis
- Gaze & vision disturbances
- Dysarthria & speech impairment
- Vertigo, nausea, vomiting
- Cerebellar signs
- Palatal paralysis & diminished gag reflex
- Altered consciousness
- Locked-in syndrome
- Coma
155
what are the investigations for ischaemic stroke?
- urgent head CT before treatment
- shows site
- pulse, BP and ECG
- look for AF and MI
- bloods
- FBC - look for polycythaemia
- glucose - rule out hypoglycaemia
- ESR - raised in vasculitis
- cholesterol
- INR - if on warfarin
- U&Es
- MRI
- more sensitive but may be negative in first few hours after infarct
- indicated if diagnosis is uncertain
156
what are the contraindications of thrombolysis (IV alteplase)?
- Recent surgery last 3 months
- Recent arterial puncture
- History of active malignancy (highly vascular thus increased
bleeding risk)
- Evidence of brain aneurysm
- Patient on anticoagulation
- Severe liver disease (abnormal clotting)
- Acute pancreatitis
- Clotting disorder
157
what is the treatment for haemorrhagic stroke?
- frequent GCS monitoring
- anticoagulants are contraindicated (any anticoagulants should be reversed with vitamin K)
- control hypertension
- decompression of raised ICP - MANNITOL
- surgery may be required
158
what are the causes of intracerebral haemorrhages?
- Hypertension
- Stiff & brittle vessels, prone to rupture
- Microaneurysms
- Secondary to ischaemic stroke
- Bleeding after reperfusion
- Head trauma
- Arteriovenous malformations
- Vasculitis
- Vascular tumours
- Brain tumours
- Cerebral amyloid angiopathy
- Carotid artery dissection
159
what is the clinical presentation of intracerebral haemorrhage?
similar to ischaemic stroke
pointers to haemorrhage:
- sudden loss of consciousness
- severe headache
- meningism
- coma
160
what is the management for intracerebral haemorrhage?
- stop anticoagulants immediately
- effects reversed with clotting factor replacement
- control of BP - IV drugs
- reduce ICP
- mechanical ventilation
- IV mannitol
- refer for neurosurgical intervention if:
- hydrocephalus
- coma
- brainstem compression
161
what are the differential diagnoses for subarachnoid haemorrhages?
- headache - migraine, cluster headache
- meningitis
- intracerebral haemorrhage
- cortical vein thrombosis
- carotid/vertebral artery dissection
162
what are the investigations for migraines?
- usually made with little/no investigations, however if there are red flags further investigation is required
- always examine eyes, BP, head and neck (muscles, scalp, temporal arteries)
- lab tests e.g. CRP, ESR
- CT/MRI
- LUMBAR PUNCTURE
163
what are the red flag indications for CT/MRI in migraines?
- worst/severe headache i.e. "thunderclap"
- change in pattern of migraine
- abnormal neurological exam
- onset > 50yrs
- epilepsy
- posteriorly located headache
164
what are the red flag indications for a lumbar puncture in migraines?
- thunderclap headache
| - severe, rapid onset headache / progressive headache / unresponsive headache
165
when are triptans contraindicated?
in ischaemic heart disease, coronary spasm and uncontrolled high BP
family history of CVD, stroke, DM and high cholesterol
166
what are the side effects of triptans?
- arrhythmias
- angina +/- MI
- recurrence of migraines - higher frequency
167
what are the risk factors of cluster headaches?
Smoker
Alcohol
Male
Genetics - autosomal dominant gene has a link
168
what are the preventative measures for cluster headaches?
- 1st line = verapamil (CCB)
- prednisolone
- reduce alcohol consumption and stop smoking
169
what are the triggers for tension headaches?
- stress
- sleep deprivation
- bad posture
- hunger
- eyestrain
- anxiety
- noise
170
what is wernicke's encephalopathy caused by?
depletion of thiamine (vitamin B1)
171
what is the clinical presentation of wernicke's encephalopathy?
- classic triad
- confusion
- ataxia
- ophthalmoplegia
- sign
- asterixis (liver flap) - general sign of metabolic encephalopathy
172
what diseases does wernicke's encephalopathy occur in?
- chronic alcoholism
- severe starvation
- prolonged vomiting
173
what are the investigations for wernicke's encephalopathy?
- diagnosed via clinical examination
174
what is the management for wernicke's encephalopathy?
- pabrinex - IV B-vitamins (including thiamine)
175
what are the complications of wernicke's encephalopathy?
if not managed appropriately
- fatal in 20%
- can progress to korsakoff's syndrome
176
what is korsakoff's syndrome?
- irreversible
- long term brain damage due to vitamin B1 deficiency
- symptoms = decreased ability to acquire new memories, retrograde amnesia, confabulation (invented memories)
177
what are the causes and risk factors of MND?
- usually sporadic and unknown cause
| - 5-10% are familial = SOD-1 mutation
178
what are the 4 different types of MND? do they affect LMN or UMN?
amyotrophic lateral sclerosis (ALS) - UMN + LMN
progressive muscular atrophy (PMA) - LMN only
progressive bulbar palsy (PBP) LMN only
primary lateral sclerosis (PLS) UMN only
179
what is the clinical presentation of ALS?
● Presents with signs of degeneration of upper and
lower motor neurons
● progressive paralysis and eventual respiratory failure
● Asymmetric onset
● Babinski sign +ve
● Fasciculations of the tongue
● Any corticobulbar signs indicate a worse prognosis:
○ Brisk jaw reflex
○ Dysarthria (difficulty speaking)
○ Dysphagia (difficulty swallowing)
○ Sialorrhoea (excess salivation)
180
what are the clinical features of progressive bulbar palsy (PBP) in MND?
CN 9-12
- LMN in the brain stem
- pharyngeal muscle weakness
- progressive loss of speech (hoarse, quiet, nasal)
- tongue atrophy (flaccid)
181
what are the clinical features of primary lateral sclerosis (PLS) in MND?
- UMN of the arm, legs and face
- movements become slow
- progressive tetraparesis
182
what are the clinical features of progressive muscular atrophy (PMA) in MND?
- LMNs only
- muscle wasting
- clumsy hand movements
- fasciculations
- muscle cramps
183
what are the side effects of pyridostigmine used to treat myasthenia gravis?
- increased salivation
- lacrimation
- sweats
- vomiting
- miosis (excessive pupillary constriction)
- diarrhoea
184
what is the treatment for myasthenic crisis?
- monitor FVC
- plasmapheresis and IV immunoglobulin
- identify and treat trigger of relapse e.g. infection, medications
185
where are MS demyelination plaques commonly found?
- optic nerves
- around ventricles of the brain
- brainstem and cerebellar connections
- corpus callosum
- cervical cord (corticospinal tract and dorsal columns)
186
what are the lumbar puncture results for meningitis caused by bacteria?
- cells = polymorphs
- proteins = raised
- glucose = low
- CSF = turbid colour
187
what are the lumbar puncture results for meningitis caused by TB?
- cells = lymphocytes
- proteins = raised
- glucose = normal/low
188
what are the lumbar puncture results for meningitis caused by viruses?
- cells = lymphocytes
- proteins = normal
- glucose = normal
189
what antibiotic is used in meningitis if S. Pneumoniae is suspected?
vancomycin
190
what antibiotic is used in meningitis if listeria is suspected?
ampicillin (or amoxicillin) and gentamycin
191
what is the treatment for viral meningitis?
no specific treatment
analgesia
antipyretics
hydration
192
what are the risk factors for meningitis?
- immunosuppression
- elderly
- pregnant
- crowding (university)
- diabetes
- malignancy
- IV drug use
- sickle cell anaemia
- adrenal insufficiency
193
what are the risk factors for epilepsy?
FHx
Premature babies, especially if they are small for their gestational age
Abnormal cerebral blood vessels
Drugs eg. cocaine
194
what are simple focal (partial) seizures?
- No affect on consciousness or memory
- Awareness unimpaired but will have focal motor, sensory, autonomic or psychic symptoms depending on the affected lobe
- No post-ictal symptoms
195
what are complex focal (partial) seizures?
Memory/awareness is affected before, during or immediately after the seizure
Most commonly arises from the temporal lobe > affects speech, memory & emotion
Post-ictal confusion is common if temporal lobe, whereas recovery is often swift if the frontal lobe is affected
196
what are the characteristics of temporal lobe specific seizures?
Aura (80%); deja-vu, auditory hallucinations, funny smells, fear
- Anxiety, out-of-body experiences
- Automatisms eg. lip smacking
197
what are the characteristics of frontal lobe specific seizures?
Motor features eg. posturing, peddling movements of leg
JACKSONIAN MARCH – seizures march up/down the motor homunculus
Post-Ictal Todd’s palsy
Starts distally in a limb & works its way upwards to the face
198
what is the emergency treatment for epilepsy?
- ABCDE
- check glucose
- RECTAL/IV DIAZEPAM or LORAZEPAM
- IV PHENYTOIN loading
- mechanical ventilation
199
what is the treatment for generalised tonic-clonic epilepsy?
Sodium Valproate for Males & women unable to childbear,
Lamotrigine to females of childbearing potential
200
what is the treatment for generalised tonic/atonic epilepsy?
Sodium Valproate for Males & women unable to childbear,
Lamotrigine to females of childbearing potential
201
what is the treatment for generalised myoclonic epilepsy?
Sodium Valproate for Males & women unable to childbear,
Levetiracetam/Topiramate to females of childbearing potential
202
what is the treatment for absence (petit mal) epilepsy?
Sodium Valproate for Males & women unable to childbear,
Ethosuximide to females of childbearing potential
203
what are the side effects of sodium valproate?
- weight gain
- hair loss
- liver failure
204
what are the side effects of lamotrigine?
maculopapular rash
blurred vision
vomiting
205
what are the side effects of carbamazepine?
```
diplopia
rashes
leucopenia
impaired balance
drowsiness
```
206
what are the side effects of ethosuximide?
rashes
| night terrors
207
what are the investigations for trigeminal neuralgia?
- In order to diagnose needs to be at least 3 attacks with unilateral facial pain
- Clinical diagnosis based on criteria above and based on history
- MRI to exclude secondary causes or other pathologies
- Not attributed to another disorder
208
what are brainstem lesions caused by?
- Tumour
- MS
- Trauma
- Aneurysm
- Vertebral artery dissection resulting in infarction
- Infection - cerebellar abscess from ear
209
what are the signs of a CN3 palsy?
- Ptosis - dropping eyelids
- Fixed dilated pupil - loss of PARASYMPATHETIC outflow from EDINGER
WESTPHAL NUCLEUS which supply pupillary sphincter and ciliary bodies -
lens accommodation
- Eye down and out
210
what are the causes of CN3 palsy?
* Raised ICP
* Diabetes
* Hypertension
* Giant cell arteritis
211
what are the signs of a CN4 palsy?
Innervate superior oblique muscle and results in a head tilt to correct the
extortion that results in diplopia on looking down e.g. walking downstairs
212
what are the causes of a CN4 palsy?
Trauma to the orbit - rare
213
what are the causes of CN6 palsy?
* MS
* Wernicke’s encephalopathy
* Pontine stroke - presents with fixed small pupils +/- quadriparesis
214
what are the causes of CN3,4,6 palsy?
* Storke
* Tumours
* Wernicke’s encephalopathy
215
what are the signs of CN5 palsy?
- Jaw deviates to side of lesion
| - Loss of corneal reflex
216
what are the causes of CN5 palsy?
trigeminal neuralgia (pain but no sensory loss),
herpes zoster,
nasopharyngeal cancer
217
what are the signs of CN7 palsy?
Facial droop and weakness
218
what are the causes of CN7 palsy?
• Bells palsy is the most common lesion of the facial nerve - will see
dribbling out the side of mouth
• Fractures of the petrous bones
• Middle ear infections
• Inflammation of the parotid gland - which facial nerve passes through
219
what are the signs of CN9,10 palsy?
- Gag reflex issues
- Swallowing issues
- Vocal issues
220
what are the causes of CN9,10 palsy?
jugular foramen lesion
221
which conditions are associated with berry aneurysms?
- Polycystic Kidney Disease
- Coarctation of aorta
- Ehlers-Danlos syndrome & Marfan syndrome
222
give an example of an SSRI
citalopram
fluoxetine
sertraline
223
what are the side effects of SSRIs?
- GI disturbance
- appetite and weight disturbance
- hypersensitivity reactions
- hyponatraemia
- suicidal thoughts
- seizures
- prolonged QT interval
224
what are the contraindications of SSRIs?
- contraindicated with other monamine oxidase inhibitors -> may cause serotonin syndrome
- other drugs that cause prolonged QT interval
- increase bleeding when used with anticoagulants
225
what are the indications for using tricyclic antidepressants?
As a second line treatment for moderate to severe depression where SSRIs
are ineffective
226
what is the mechanism of action for tricyclic antidepressants?
- inhibits neuronal uptake of serotonin and noradrenaline from the synaptic cleft -> increase availability for neurotransmission
227
why do tricyclic antidepressants have extensive side effects?
- they block a wide range of receptors
228
what are the side effects of tricyclic antidepressants?
- dry mouth
- constipation
- urinary retention
- blurred vision
- sedation
- hypotension
- arrhythmias
- QT and QRS prolongation
- hallucinations
- sexual dysfunction
229
when are tricyclic antidepressants contraindicated?
- with other monoamine oxidase inhibitors
230
what are the indications for using a benzodiazepine
- First line treatment of seizures and status epilepticus
- Management of alcohol withdrawal reactions
- SHORT TERM treatment of severe anxiety or insomnia
231
what is the mechanism of action for benzodiazepines?
- Benzodiazepines target the GABA-a receptor, which is a chloride channel that opens in response to binding by GABA (the main INHIBITORY NEUROTRANSMITTER)
- opening the channel allows chloride to enter making the cell more resistant to depolarisation
- They facilitate the enhanced binding of GABA to GABA-a receptors and have a widespread depressant effect on synaptic transmission
232
what are the side effects of benzodiazepines?
cause dose dependent drowsiness, sedation and coma
233
when are benzodiazepines contraindicated?
- in elderly
- those with respiratory or hepatic impairment
- neuromuscular disease
- has sedative effects with alcohol, opioids and CYP450 inhibitors
234
what are the side effects of carbamazepine?
- GI disturbance
- dizziness
- ataxia
- hypersensitivity rash
- oedema
- hyponatraemia
235
when is carbamazepine contraindicated?
- prior anti-epileptic hypersensitivity syndrome
| - caution in hepatic, renal and cardiac disease
236
what is the mechanism of action for gabapentin and pregabalin?
it is closely related to GABA
- It binds voltage sensitive Ca2+ channels, where it prevents inflow of Ca2+ and thus inhibits neurotransmitter release
- interfering with synaptic transmission and reducing neuronal excitability
237
what are the side effects of gabapentin and pregabalin?
- drowsiness
- dizziness
- ataxia
238
what are the contraindications of gabapentin and pregabalin?
- renal impairment
| - other sedating drugs
239
what are the side effects of levo-dopa?
```
nausea
drowsiness
confusion
hallucinations
hypertension
```
240
what are the contraindications for levo-dopa?
- take care in elderly
| - caution in CVS disease
241
why is levo-dopa always given alongside a decarboxylase inhibitor (Co-Careldopa)?
- reduce levo-dopa's peripheral conversion before it is able to enter the brain
this reduces nausea and lowers dose required
242
give an example of a dopamine deleting drug
reserpine
243
what are the indications for using a dopamine depleting drug (reserpine)?
- treat dyskinesia in Huntington's
| - can be used as antipsychotic and antihypertensive drug
244
what is the mechanism of action for dopamine depleting drugs (reserpine)?
- irreversibly blocks vescicular monoamine transporter (VMAT)
245
what are the side effects of dopamine depleting drugs (reserpine)?
- nasal congestion
- GI disturbance
- drowsiness/dizziness
- hypotension
- bradycardia
246
what are the contraindications for dopamine depleting drugs?
- asthma
| - CVS disease
247
give an example of MAO inhibitor?
selegiline
| rasagiline
248
what are the contraindications of MAO inhibitors?
- aged cheese and alcohol -> can cause hypertensive crisis
| - antidepressants and adrenaline
249
give an example of ACh inhibitor
rivastigmine
| donepezil
250
what are the indications for ACh inhibitors?
- alzheimers
- Lewy body dementia
- parkinsons
- myasthenia gravis
251
what is the mechanism of action for ACh inhibitors
inhibits ACh breakdown by blocking site of acetylcholinesterase
252
what are the side effects of ACh inhibitors?
- bradycardia
- hypotension
- hypersecretion
- bronchoconstriction
- GI tract hyper motility
- prolonged muscular contraction
253
what are the contraindications of ACh inhibitors?
urinary retention
| CVS disease
254
what are the causes of primary syncope?
Dehydration
Missed meals
Extended standing in a warm environment, such as a school assembly
A vasovagal response to a stimuli, such as sudden surprise, pain or the sight of blood
255
what is the treatment for Bell's palsy?
- prednisolone
- eye care
- ?antivirals
256
what are the characteristics of cushing's triad?
- bradycardia
- irregular respirations
- widened pulse pressure
257
what is cushing's reflex?
- nervous system response to increased ICP
- as ICP increases cerebral perfusion pressure (CPP) decreases, resulting in reduced cerebral perfusion
- sympathetic nervous system is activated which increases BP
258
what are the clinical presentation of cushing's reflex?
- cushing's triad - bradycardia, irregular respirations and widened pulse pressure
- hypertension
- headache
- vomiting
- blurred vision
259
what are the investigations for cushing's reflex?
- measure ICP - lumbar puncture or continuous monitoring via catheter in ventricle of brain
- CT/MRI
260
what is the treatment for cushing's reflex?
- mannitol
- duiretics - furosemide
- steroids - methylprednisolone
- sedatives - propofol
- hyperventilation
- elevate head to 30 degrees (reverse trendelenburg position)
- drain CSF
- craniotomy
261
what are the causes of 1st order horner's syndrome?
stroke, tumours of hypothalamus, spinal cord lesions
262
what are the causes of 2nd order horner's syndrome?
tumours of upper chest cavity, trauma to the neck
263
what are the causes of 3rd order horner's syndrome?
lesions to carotid artery, middle ear infections, injury to base of the skull
264
what are the clinical features of horner's syndrome?
MAPLE
- Miosis
- Anhydrosis
- Ptosis
- Loss of ciliospinal reflex
- Endophthalmos (sunken eyeball)
265
what is the treatment for horner's syndrome?
treat underlying cause
266
what are the investigations for horner's syndrome?
clinical examination
| MRI - detect lesions
267
what is the presentation of brown-sequard syndrome?
- DCML = ipsilateral loss of proprioception and vibration sensation
- spinothalamic = contralateral loss of temperature and pain sensation
- corticospinal = ipsilateral spastic paralysis below lesion
268
what are the signs of lateral medullary syndrome in ischaemic stroke?
Sudden vomiting and vertigo
| Ipsilateral Horner’s syndrome = reduced sweating, facial numbness, dysarthria, limb ataxia, dysphagia
269
what are the causes of status epilepticus?
- Abruptly stopping anti epileptic treatment
- Alcohol abuse
- Poor compliance to therapy
270
give one differential diagnosis for huntington's disease
Sydenham’s chorea (Rheumatic fever)
271
what are the secondary causes of syncope?
```
Hypoglycaemia
Dehydration
Anaemia
Infection
Anaphylaxis
Arrhythmias
Valvular heart disease
Hypertrophic obstructive cardiomyopathy
```
272
what are the clinical features of syncope?
```
Hot or clammy
Sweaty
Heavy
Dizzy or lightheaded
Vision going blurry or dark
Headache
```
273
`what are the investigations for syncope?
Full history and examination
ECG, particularly assessing for arrhythmia and the QT interval for long QT syndrome
24 hour ECG if paroxysmal arrhythmias are suspected
Echocardiogram if structural heart disease is suspected
Bloods, including a FBC (anaemia), U&E (arrhythmias and seizures) and blood glucose (diabetes)
274
what is the management for syncope?
avoid triggers in primary syncope.
| management of underlying pathology
275
what preventative measures should be taken for migraines?
- beta blockers - propranolol
- TCA - amitrityline
anticonvulsant - topiramate
- acupuncture
