Neurological Flashcards
What is a TIA?
A transient ischaemic attack is a similar presentation to a stroke, but it resolves in 24hrs.
How common is stroke?
How common is TIA?
150,000 people have a stroke in UK each year
20,000 people have TIA in UK each year
Who does stroke/TIA affect?
Can affect anyone
Most cases in people aged >65
What causes a stroke/TIA?
Infarction due to ischaemia (80%) Intracerebral haemorrhage (20%)
Caused by:
- small vessel occlusion it thrombosis in situ
- cardiac emboli
- Atherothromboembolism
- CNS bleeds
- other: sudden⬇️ in BP as in sepsis watershed stroke; carotid artery dissection; vasculitis; subarachnoid haemorrhage
What are the risk factors for stroke/TIA?
Hypertension Smoking Diabetes ⬆️ Lipids Family history
Cardiac risk factors: AF; valve disease; peripheral vascular disease, previous stroke
Ethnicity - higher risk in blacks and Asians
What are the symptoms of stroke/TIA?
Weakness of arm/leg/both- ranging from total paralysis of one side of body to mere clumsiness of one hand
Weakness and twisting of one side of the face- can cause drooling
Problems with balance coordination, vision, speech, communication, or swallowing
Dizziness or unsteadiness Numbness in a part of the body Headache Confusion Loss of consciousness
What are the signs of a stroke on examination?
Bleeding = meningism, headache, coma Ischaemia = carotid bruit, AF, IHD, past TIA
Dysphasia affects large proportion of stroke patients
What are the 3 different areas mainly affected by infarcts and how do they present?
Cerebral Hemisphere infarcts (50%) = contralateral hemiplegia which is initially flaccid (floppy limb falls like a dead weight when lifted) and then becomes spastic, contralateral sensory loss, homonymous hemianopia, dysphagia.
Brainstem Infarction (25%) = a wider range of effects which include quadriplegia, disturbances of gaze and vision, locked-in syndrome, later medullary syndrome from vertebrobasilar occlusion
Lacunar infarcts (25%) = small infarcts around the basal ganglia, internal capsule, thalamus and pons, may cause pure motor, pure sensory, mixed motor and sensory signs, or ataxia, intact cognition and consciousness.
What are the possible differential diagnoses of stroke/TIA?
Head injury ⬆️/⬇️ glucose Space occupying lesion Hemiplegic migraine Todd's palsy Infections: encephalitis; abscesses, HIV Drugs: opiate overdose
What investigations are necessary to diagnose a stroke/TIA?
Pulse (AF), BP, ECG
Blood glucose (hypo/hyperglycaemia)
Urgent CT
Blood tests: FBC, ESR, sylhilis test
What are the treatments for stroke/TIA?
Stroke- Thrombolysis if onset was less than 4.5 hours ago
- NBM if unsafe swallow
- Antiplatelet agents - only when haemorrhagic stroke excluded
TIA - control CV risk factors
- start Antiplatelet drugs, clopidogrel/aspirin, consider warfarin and consider carotid endarterectomy
What is a subarachnoid haemorrhage?
Spontaneous bleeding into the subarachnoid space
Can be caused by berry aneurysm
Popular sites: junction of posterior communicating and internal carotid artery, junction of anterior communicating and anterior cerebral or bifurcation of middle cerebral artery
How common is subarachnoid haemorrhage?
9/100000/year
Who does it affect?
Typical age 35-65
What causes a subarachnoid haemorrhage?
Rupture of saccular aneurysms (80%)
Arteriovenous malformations (15%)
No cause found
What are the risk factors for subarachnoid haemorrhage?
Smoking Alcohol misuse Hypertension Bleeding disorders Micotic aneurysms
What are the symptoms of a subarachnoid haemorrhage?
Sudden thunderclap headache Vomiting Collapse Seizures Coma may follow
What are the signs of a subarachnoid haemorrhage on examination?
Neck stiffness
Kernigs sign
Retinal/subhyloid/vitreous bleeds
What are the possible differential diagnoses of subarachnoid haemorrhage?
Meningitis
Migraine
Intracerebral bleed
Cortical vein thrombosis
What investigations are necessary to diagnose subarachnoid haemorrhage?
CT within 48hrs
LP if CT is negative and >12h headache onset
- CSF in subarachnoid haemorrhage is bloody early on and then xanthochromic (yellow) after several hours due to bilirubin
What are the treatments of subarachnoid haemorrhage?
Refer to neurosurgery immediately
Maintain cerebral perfusion by keeping well hydrated
Nimodipine (ca2+ antagonist that reduces vasospasms)
Pain relief
Anticonvulsants and antiemetics
Surgery- endovascular coiling or neurosurgical clipping
What is peripheral neuropathy?
Damage to one or more of your peripheral nerves meaning impulses traveling from CNS to PNS are disrupted
Symptoms depend on which nerves affected (sensory, motor or autonomic)
How common is peripheral neuropathy?
2/100 people
Increases with age
Who does peripheral neuropathy affect?
Can affect anyone
Most commonly diabetics
What are the causes and risk factors of peripheral neuropathy?
Hyperglycaemia - in poorly controlled diabetes
Dietary deficiencies - B12 or folate
Medicines - chemotherapy and HIV therapy
Toxins - insecticides or solvents
Cancers
Alcohol excess
CKD- poorly functioning kidneys leads to salts and chemicals imbalance in bloodstream➡️PN
Injuries- broken bones and compression injuries can put direct pressure on PNs
Infections - eg Guillain-Barré syndrome
Connective tissue diseases
Inflammatory conditions
What are the symptoms of peripheral neuropathy?
Sensory neuropathy:
- tingling and numbness
- loss of sensation to pain, temperature
- loss of coordination
- burning/shooting pains
- feet and hands often affected first
Motor neuropathy:
- muscle weakness (can lead to falling, breathing & swallowing problems)
- muscle wasting
- muscle twitching (fasiculations) and cramps
- muscle paralysis
Autonomic Neuropathy:
- dizziness&fainting (lack of BP control➡️lowBP)
- reduced ability to sweat ➡️ inability to tolerate heat
- urinary incontinence - loss of bladder control
- bloating, constipation/diarrhoea
- impotence
What investigations are necessary to diagnose peripheral neuropathy?
Nerve conduction tests Electromyography- tests electrical activity of muscles Nerve biopsy Skin biopsy X-Ray/CT for underlying cause
What is the treatment for peripheral neuropathy?
Depends on underlying cause
Diabetes - controlling blood sugars
Vitamin deficiencies - consuming more vitamins
What is epilepsy?
Epilepsy is the recurrent tendency to have spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting in seizure
How common is epilepsy?
1% of population
Who does epilepsy affect?
Most commonly starts in children/over 60’s
More common in people with learning disability
Feature of >200 genetic disorders
What causes epilepsy?
Most idiopathic Cerebrovascular disease Head injury Cranial surgery CNS infections - meningitis/encephalitis Neurogenerative diseases Autoimmune diseases Brain neoplasm Genetic diseases
What are the risk factors for epilepsy?
Stress
Poor sleep
Alcohol misuse
All these lower seizure threshold
What are the symptoms of epilepsy?
Sudden falls Involuntary jerky movements of limbs whilst awake Blank spells Olfactory, gustatory, visual, auditory hallucinations Unexplained urinary incontinence simple partial seizures Epigastric fullness sensation Deja vu Premonition Extreme emotions Inability to understand or express language Loss of memory
What are the signs of epilepsy on examination?
Usually unremarkable
Check for neurological/cerebrovascular signs
What are the possible differential diagnoses of epilepsy?
Syncope Cardiac arrhythmia TIA Migraine Non- epileptic seizures Paroxysmal vertigo Acute encephalopathy Sleep disorders Hyperventilation Panic attacks
What are the 3 diagnostic questions?
Are they really seizures?
What type of seizures are they?
Are there any triggers?
What investigations an be done to diagnose epilepsy?
Neuroimaging (MRI) Electroencephalograph (EEG) to confirm diagnosis Blood tests ECG Neuropsychological assessment
What are the possible treatments of epilepsy?
Drug choice depends on type of seizure
Generalised tonic-clonic seizures and tonic, atonic, myoclonic seizures - sodium valproate/lamotrigine, 2nd line carbamazepine
Absence seizures- sodium valproate, lamotrigine
If drugs don’t work then neurological resection or vagaries nerve stimulation
What are the classification of epileptic seizures?
1) focal (partial seizures)
2) primary generalised seizures
What are focal (partial) seizures?
60% of people with epilepsy have
Can be unsubtle or unnoticeable
Simple partial seizures - awareness unimpaired with no post octal symptoms
Complex partial seizures - awareness impaired, mainly temporal lobe
Partial seizure with secondary generalisation - electrical disturbance spreads widely, typically convulsive
What are primary generalised seizures?
Simultaneous onset of electrical discharge throughout cortex - because of this, consciousness is lost at the onset of the seizure
What are the types of primary generalised seizures?
- absence- brief, less then 10secs, presents in childhood
- tonic-clonic - loss of consciousness, limbs stiffen (tonic) then jerk (clonic) with post ictal confusion and drowsiness
- myoclonic - sudden jerk of limb, face or trunk
- atonic - no loss of consciousness, sudden loss of muscle tone causing a fall
- infantile spasms - associated with tuberous sclerosis
What is meningitis?
An inflammation of the leptomeninges and underlying subarachnoid cerebrospinal fluid.
The inflammation can be caused by infection with viruses or bacteria or micro-organisms, or non-infective causes.
How common is meningitis?
~3,200 cases of bacterial meningitis in UK per year.
Who does meningitis affect?
More common in infants, young children and elderly.
What causes meningitis?
Neonates: group B streptococci, listeria monocytogenes, E. coli
Infants: H. Influenzae type b (
What are the risk factors for meningitis?
Pts with CSF shunts or dural defects
Pts having spinal procedures
Bacterial endocarditis, diabetes, alcoholism and cirrhosis, IVDUs
Splenectomy and sickle cell disease
Crowding
What are the symptoms of meningitis?
Fever Headache Stiff neck Back rigidity Photophobia Opisthotonos if severe Unconscious Seizures
What are the signs of meningitis on examination?
Kernig's sign Non- blanching rash Brudzinski's sign Focal neurological defects Shock - tachycardia and/or hypotension, respiratory distress, altered mental state and ⬇️ urine output Bulging fontanelle
What are the possible differential diagnoses of meningitis?
Intracranial abscess
Encephalitis
Subarachnoid Haemorrhage
Brain tumour
What investigations are necessary to diagnose meningitis?
Lumbar puncture (provided no signs of ⬆️ICP)
Renal function tests
Coagulation profile
Chest X-Ray for lung abscess
Urine cultures, nasal swabs and stool virology
MRI
What is the treatment of meningitis?
Supportive therapy (fluids, antipyretics, antiemetics, analgesia and nutritional support)
Treatment of causative organism (antibiotics)
Treatment of any complications (seizures/⬆️ICP)
How are migraines classified?
Episodic or Chronic
Migraine without aura
Migraine with aura
Migraine aura without headache
How common is migraine?
Affects 6% of men and 18% of women
What causes migraine?
Cause not clear
Theory: blood vessels in part of the brain go into spasm (which accounts for the aura) then dilate (which accounts for the headache)
Some things trigger migraines:
Diet (certain foods)
Environmental (smoking, glaring light, loud noises, strong smells)
Psychological (depression, anxiety, anger, tiredness, stress, sudden relaxation)
Medicines (HRT)
Other (periods, menopause)
What are the risk factors for migraine?
Family history
Age (most people experience their first at adolescence)
Gender (women 3x more likely)
What are the symptoms of migraine?
Migraine without aura:
- headache: usually on one side, pain moderate or severe throbbing or pulsating
- other migraine symptoms that are common: nausea/vomiting/photophobia
- other symptoms that sometimes occur: being off food/blurred vision/poor concentration/hunger/diarrhoea
Migraine with aura
- symptoms same but include an aura before headache
- visual most common (temp loss of vision, flashing lights etc)
- numbness and pins and needles
- speech problems
- smells
What are the phases of a migraine attack?
Premonitory phase
Aura phase
Headache phase
Resolution phase
What are the differential diagnoses of migraines?
Cluster headache Tension headache Increased BP Intracranial pathology TIA
What investigations are necessary to diagnose migraine?
Optic fundoscopy BP Head and neck exam Head circumference Neurological exam
What are the possible treatments for migraine?
Non- pharmacological = warm or cold packs to head, rebreathe no into paper bag
Pharmacological =
- NSAIDs
- 5HT agonists (triptans)- cause constriction of blood vessels in brain which dilate in migraines
- antiemetics
How common are tension headaches?
Lifetime prevalence 30-80%
Who do tension headaches affect?
More common in women
Most common in young adults
What causes tension headaches?
Anxiety Depression Poor posture Poor sleep Stress Muscular tightness
What are the risk factors for tension headaches?
Being a young adult
Being female
How can tension headaches be classified?
EPISODIC:
- fewer than 15 days each month
- can evolve into chronic
CHRONIC:
- occurs on more than 15 days each month
- more likely to be medication induced
- more likely to be associated with comorbidity such as depression
What are the symptoms of a tension headache?
30 minutes- 7days duration
Pain is mild to moderate in intensity
- described as “fullness/tightness/squeezing/pressure/like a skull cap/like a band or vice
Pain bilateral, occipito-nuchal or bi frontal
Associated symptoms:
- muscular tightness/stiffness in neck
- difficulty concentrating
- stress & anxiety
What are the possible differential diagnoses of tension headaches?
Migraine Giant cell arteritis Trigeminal neuralgia Subarachnoid haemorrhage Sinusitis
What investigations are necessary in tension headaches?
No real investigations
Examine head and neck
BP
Optic fundi
What are the possible treatments of tension headaches?
Non pharmacological:
Treat stress, anxiety or depression
Exercise and posture
Pharmacological:
NSAIDs
Aspirin
Tricyclic antidepressants - amytriptyline
How common is Parkinson’s Disease?
Prevalence 65.6-125/100,000
>60s = 5/1000 >80s = 40/1000
Who does Parkinson’s Disease affect?
More common with increasing age
Mainly >50s
Slightly more common in Males
What causes Parkinson’s Disease?
Mitochondrial DNA dysfunction causes degeneration of dopaminergic neurones in the substantia nigra pars compacta which is associated with Lewy bodies.
This causes a decrease in striatal dopamine levels
What are the risk factors for Parkinson’s disease?
Increasing age
Male
Pesticide exposure
What are the symptoms of Parkinson’s Disease?
Bradykinesia or hypokinesia with one or more of:
- resting tremor
- postural instability
- muscular rigidity
What are the signs of Parkinson’s disease on examination?
Reduced facial expression
Reduced blinking
Slow monotonous speech
What are the possible differential diagnoses of Parkinson’s disease?
Benign essential tremor - tremor worse on movement Drug induced Parkinsonism Huntingtons Multi infarct dementia Lewy body dementia
What investigations are necessary to diagnose Parkinson’s disease?
CT or MRI brain scan
- if pt fails to respond to therapeutic dose of L-dopa for 12 weeks
PET scan
- scanning with fluorodopa can localise dopamine deficiency in the basal ganglia
Transcranial sonography
- differentiate PD from atypical and secondary parkinsonian disorders
What are the possible treatments for Parkinson’s disease?
Currently no cure but treatments help relieve symptoms and maintain quality of life
Medicines:
Levodopa - body converts to dopamine. Always given with another medicine (benserazide or carbidopa) to prevent levodopa being converted into dopamine in the blood
Dopamine agonists - act as substitute for dopamine (ropinerole, pramioexole)
What is a Parkinsonism?
A condition that mimics the main characteristics of Parkinson's disease: Tremor Rigidity Postural instability Bradykinesia
How can Parkinson’s disease be differentiated from a Parkinsonism?
Parkinson’s disease symptoms will go away with dopamine replacement therapy
What are the main types of Parkinsonism?
Corticobasal degeneration
Dementia with Lewy bodies
Drug induced Parkinsonism
Vascular Parkinsonism
What is proximal Myopathy?
Muscular disease in which muscle fibres do not function for one of many reasons, resulting in muscular weakness.
It usually affects muscles without involving the nervous system or any disorder of the neuromuscular junction
What are the most common proximal myopathies?
The muscular dystrophies are the most common of such disorders.
Duchenne muscular dystrophy is the most common muscular dystrophy
What is the difference between neuropathy and myopathy?
MYOPATHY:
- gradual onset
- symmetrical proximal weakness
- dystrophies usually affect specific muscle groups
- preserved tendon reflexes
NEUROPATHY:
- paraesthesia, bladder problems
- distal weakness
What is multiple sclerosis?
MS is a disease where patches of inflammation occur in parts of the brain and/or spinal cord.
This can cause damage to parts of the brain and lead to various symptoms
What causes MS?
Multiple areas of scar tissue (sclerosis) form along the neurons.
This slows or blocks transmission of impulses to and from brain and spinal cord.
In this way movement and sensation may be impaired
What are the different patterns of MS?
Relapsing/remitting MS:
remission and relapsing of symptoms
Secondary progressive MS:
Follows on from relapsing/remitting
Gradually more or worsening symptoms with fewer remissions
Primary progressive MS:
From beginning symptoms gradually develop and worsen over time
Benign MS
What are the symptoms of MS?
Visual - demyelination of optic nerve, optic neuritis is common presenting symptom of MS
Eye movements - double vision, nystagmus
Facial weakness - Bell’s palsy, trigeminal neuralgia
Hearing and balance - deafness, demyelination in brain stem can cause severe positional vertigo
Cognitive symptoms
Psychological symptoms
Taste and smell
Unpleasant sensations - tightness, burning, twisting, tearing and pulling sensations due to damage to dorsal column
Paraesthesia and numbness
What investigations are necessary to diagnose MS?
Exclude differentials by checking:
- FBC, CRP, U&Es, LFT, TFT, glucose calcium and B12
Electrophysiology can detect demyelination in apparently unaffected pathways with characteristic delays
MRI scan: 95% of pets have periventricular lesions and over 90% show discrete white master abnormalities
What are the treatments of MS?
Medicines that aim to modify disease process:
- immunomodulatory agents (interferon beta-1a/b)
- reduce number of relapses
- small effect on slowing down progression
Steroid medication to treat relapse:
- given if relapse causes disability
- reduces inflammation
- course of steroids shorten relapse duration. It do not affect progression of disease
Other medications to help ease symptoms:
- anti-spasm drugs
- painkillers for neuropathic pain
- medicines for urinary problems
- antidepressants
- medicines for erectile problems
Other treatments therapies and support
- eg physio, speech therapy, counselling
What is a stroke?
Cerebrovascular event is caused by disruption of blood supply to the brain.
It is characterised by rapidly developing signs of focal or global disturbance or cerebral functions lasting for more than 24hrs or leading to death.
