Neuro4 Flashcards
Headaches
What are the clinical features of raised ICP?
Bilateral, gradual headache Worse in the morning Vomiting/drowsiness/irritability Seizures/papilloedema Worse when lying down/coughing Cushing's response Cheyne-Stokes respiration
What is Cushing’s response?
Raised ICP causes:
- raised BP
- irregular breathing
- bradycardia
What is Cheyne-Stokes respiration?
Gradual increases and decreases in breathing
What are the causes of raised ICP?
SOL
Hydrocephalus
Truma
What are the investigations for raised ICP?
Urgent CT/MRI
What is meningitis?
Infection and inflammation of the meninges
What is the aetiology of meningitis?
Meningococcus/pneumococcus/E. coli/haemophilus
HSV/mumps
Fungal
Aseptic
Mollaret’s (recurrent aseptic meningitis)
What are the risk factors of meningitis?
Close contact
Skull fractures
Immunodeficiencies
Surgery/shunts
What are the features of meningitis?
Headache Stiff neck Photophobia Non-blanching rash Kernig's sign (can't flex knee when hip is flexed) Brudzinski's sign (hip/knee flexion when neck is flexed) Reduced GCS Shock
What is the management for meningitis?
Take blood cultures If there are no signs of ICP: -get help -LP -IV ABx -dexamethasone
If raised ICP:
- IV ABx
- airway support
- fluid resus/symptomatic relief
What ABx would you give a Pt in hospital with meningitis?
3rd generation cephalosporin eg. ceftriaxome
Add amoxicillin if immunocompromised
What ABx would you give a Pt in primary care with meningitis?
IM benzylpenicillin
Send straight to hospital
What are the complications of meningitis?
Septicaemia Shock DIC Renal failure Seizures Peripheral gangrene Cerebral oedema Cranial nerve lesions Cerebral venous thrombosis Hydrocephalus Waterhouse-Friderichsen Syndrome
What is Waterhouse-Friderichsen Syndrome?
Bilateral adrenal haemorrhage caused by severe meningococcal infection
What is the commonest cause of encephalitis?
HSV
What are the investigations for encephalitis?
Bloods: cultures, viral PCR, toxoplasma
Contrast enhanced CT/MRI (bilateral temporal oedema = HSV infection)
LP
EEG
What are the risk factors for a SAH?
HTN Smoking CTD PCKD/berry aneurysms AVM (arteriovenous malformation)
What are the clinical features of a SAH?
Occipital thunderclap headache Syncope/nausea/vomiting Meningism due to irritation Raised ICP Terson's syndrome
What is Terson’s syndrome?
Vitreous haemorrhage secondary to a SAH
What are the investigations for a SAH?
Urgent CT
LP if CT is normal
-xanthochromia/oxyhaemoglobin
What are the risk factors for a SDH?
Trauma
Coagulopathy
What are the clinical features of a SDH?
Gradual onset
Fluctuating consciousness
What are the investigations for a SDH?
Urgent non-contrast CT
What are the clinical features of an EDH?
Syncope then lucid period
Acute detioration
History of direct trauma
What are the investigations for an EDH?
Urgent non-contrast CT
What is the management for cranial haemorrhages?
ABC- maintain blood pressure
Reduce ICP eg. mannitol
SAH- nimodipene
SDH/EDH- craniotomy/Burr hole
What are the complications of cranial haemorrhages?
Raised ICP Cerebral oedema Herniation Coma Post-op- seizures, recurrence, intracerebral haemorrhage, brain abscess, meningitis, tension pneumocephalus
What is a primary headache and name the common types?
Headache without an identifiable cause
Tension
Cluster
Migraine
What are the clinical features of a tension headache?
Generalised tight band around head
Dull, with alleviation from analgesics
What are the investigations for a tension headache?
Clinical diagnosis
What is the management for a tension headache?
Analgesia
What are the clinical features of a migraine?
Usually unilateral paroxysmal throbbing pain
Visual changes, aphasia, tingling aura
Associated vomiting/nausea
F>M
Worsened by wine/chocolate/cheese/triggers
What are the investigations for a migraine?
Clinical diagnosis
What is the management for a migraine?
Avoid preciptating factors
Sumitriptan, NSAIDS, metoclopramide
Propranolol/topiramate/amitriptyline prophylaxis
What are the clinical features of a cluster headache?
Unilateral headache, behind the eye Acute onset, same time each day Swollen eyelid/nasal congestion Very severe/disabling M>F
What are the investigations for a cluster headache?
Clinical diagnosis
What is the management for a cluster headache?
100% O2 and sumitriptan subcut (faster than oral)
Verapamil prophylaxis
What are the clinical features of trigeminal neuralgia?
Shooting pain long a CN V branch, usually V2-3
Provoked by chewing/shaving/washing
60-80yrs
May have MS
What are the investigations for trigeminal neuralgia?
Clinical diagnosis
Can consider MRI
What is the management for trigeminal neuralgia?
Anticonvulsants (carbamazepine)
What are the differences between diffuse and anaplastic astrocytomas?
D- grade 2, slow growing, follows white matter tracts, good resection prognosis but can regrow.
A- grade 3, more aggressive, seizures are common, associated with young females
What is the most common brain cancer?
Glioblastoma multiforme (GBM)
What are the investigations for CNS tumours?
CT scan- in emergency MRI- for high spatial resolution Bloods fMRI- oxygen usage PET Biopsy
What is the mangement for CNS tumours?
Watch and wait (e.g. schwannoma and meningioma)
Surgery
Stereotactic biopsy- inoperative and diagnostic (0.5cm)
Open biopsy- inoperable but approachable (1cm)
Craniotomy for debulking
Radiotherapy
Chemotherapy
Combination – malignant tumours
Plutarch is a 77-year-old male who has come in with a right sided headache. This started yesterday morning and have been getting progressively worse. His memory is a little off because of his dementia, but he says there is a possibility of trauma. His shoulders and neck also feel a little stiff. On examination, there is pain on palpation of the right forehead.
A. Intracranial space-occupying lesions B. Meningitis C. Subarachnoid haemorrhage D. Subdural haemorrhage E. Temporal arteritis
E. Temporal arteritis
Right sided, getting progressively worse, with pain on palpation.
No red flags for SOL, men, SAH, SDH
Euclid is a 19-year-old male currently studying Maths at university. He has been very unwell for the last few days with fever and headache and admits to becoming a little confused lately. He is very anxious about his upcoming exams. He has been taking caffeine pills to help him with revision, however this has affected his sleep and for the last couple of nights he has developed a stiff neck.
A. Medication overuse headache B. Meningitis C. Migraine D. Tension headache E. Sinusitis
B. Meningitis
Aphrodite, a 19-year-old female sex-worker presents to A&E with a sudden onset headache that is the worst pain she has ever experienced. She occasionally gets mild headaches after sex and has been given some medication by her GP for his. She has some neck stiffness and refuses to open her eyes wide or allow them to be examined.
A. Acute glaucoma B. Meningitis C. Migraine D. Subarachnoid haemorrhage E. Trigeminal neuralgia
D. Subarachnoid haemorrhage
Leonidas, a 24-year-old male, was fencing and suffered an injury to the head when his rival, Xerxes hit him on the head with his shield. Leonidas recovered quickly and was able to continue to fight for the next 20 minutes. However he quickly developed an excruciating headache, started to lose consciousness and had to stop the fight to go to the nearest A&E. He has had a blocked nose for the last week.
A. Epidural haemorrhage B. Intraventricular haemorrhage C. Meningitis D. Subarachnoid haemorrhage E. Subdural haemorrhage
A. Epidural haemorrhage
Homer, a 45-year-old male has had excruciating headaches for the last month. He gets them about 5 times a week and notices his eyes watering. He had a similar episode 6 months ago. They are very disruptive to his poetry.
A. Cluster headache B. Intracranial space-occupying lesion C. Migraine D. Subarachnoid haemorrhage E. Meningitis
A. Cluster headache
Andromeda, a 32-year-old female presents with recurrent headaches. They are severe, on the right side of her head and often continue for the rest of the day. Before the headaches start, she gets tingling in her arms,and when the headaches start she goes to bed. She is worried they might affect her relationship with her new boyfriend.
A. Cluster headache B. Intracranial space-occupying lesion C. Medication overuse D. Migraine E. Tension headache
D. Migraine
Helen is a 40-year-old woman with a history of multiple sclerosis. She has developed a headache over the last couple of days. She has travelled the world and rarely had headaches in the past. She has stopped eating, as chewing simply makes her feel worse.
A. Meningitis B. Migraine C. Temporal arteritis D. Tension headache E. Trigeminal neuralgia
E. Trigeminal neuralgia
Zeus, a 56-year-old man has been complaining of a headache that has progressively worsened over the past three weeks. He has tried taking simple analgesia, but the pain does not seem to go away. On examination he has weakness in his lower right limb. What is the most likely diagnosis?
A. CNS Tumour B. Migraine C. Cluster Headache D. Subarachnoid Haemorrhage E. Temporal Arteritis
A. CNS Tumour
70-year-old Herodotus is brought in by his daughter to the GP.Over the last week he has developed a headache which lasts most of the day and rarely goes. He lives with his daughter and son-in-law as he is prone to falls due to his recent left hip replacement. The daughter also mentions that his father’s behaviour has changed lately and tends to exaggerate some of his stories.
What do you think is the most important step in your management plan?
A. MRI scan B. Routine CT scan C. Sumatriptan + NSAIDs D. Urgent CT scan E. Watchful waiting
D. Urgent CT scan
Alexander, known to his mates as Alex the Great, is a 32-year-old soldier who has just returned from a tour in Iran. He tells you that he has been getting throbbing bilateral head pain and puts this down to lack of sleep. As a general, he has multiple reports to write and is finding this difficult with his four friends constantly bickering about one thing or the other. He hasn’t tried any medication and asks that you prescribe some sleeping pills. What is the most appropriate management?
A. Diazepam B. Codeine C. NSAIDs D. Topiramate E. Refer to A&E
C. NSAIDs
Pythagoras is a 40-year-old man who suffers from headaches. 3 weeks ago he was prescribed ibuprofen and has taken it religiously. Initially these worked well, however now the headaches have returned and are worse than ever. He is very angry and does not think you are taking the right angle towards managing his issue. What is the next course of management?
A. Antibiotics B. Add a β-blocker C. Refer to A&E D. Switch medication to carbamazepine E. Ask to stop ibuprofen and see in 2 weeks
E. Ask to stop ibuprofen and see in 2 weeks
Hippocrates is a 71-year-old homeopath who presents with a left sided headache which came on yesterday morning. He tried to treat it with a clever paste made of garlic, vinegar and honey. When he applied the paste he was in great pain, and so believed that his remedy was working. However, his sceptical son told him to see “another doctor” for treatment. What is the most important next step?
A. Prescribe prednisolone and refer patient to A&E
B. Prescribe sumatriptan and send home
C. Refer to A&E for urgent CT scan
D. Refer to A&E for urgent non-contrast CT scan
E. Refer to A&E for MRI
A. Prescribe prednisolone and refer patient to A&E
