Neurological Conditions Flashcards
Brain tumour (parietal, frontal, occipital)
Parietal
- Presentation: seizures, numbness or paralysis, difficulty with handwriting, inability to perform simple mathematical
problems, difficulty with certain movements, and loss of the sense of touch.
Frontal
- Presentation: personality change, intellectual impairment, urinary incontinence and mono or hemiparesis.
Occipital
- Presentation: visual field and visuospatial defects.
Cerebellar disease (key features)
Key features: Fred’s ataxia, dysarthria and intention tremor
Wernicke’s encephalopathy (cause, presentation, treatment)
Cause: Poor nutrition (cancer, chronic diarrhoea), alcoholism resulting in low thiamine
Presentation: ophthalmoplegia, ataxia and confusion
Treatment: Thiamine 300 mg IV or IM for 3 days → 100mg IV/IM TDS for 1-2 weeks → 100mg PO daily
Delirium - Causes
Medical ● Infections ● Metabolic ● Drugs ● Organ failure ● Intracerebral ● Cardiac ● Seizure ● Withdrawal ● Pain
Medication ● Anticholinergics (sedating antihistamine, oxybutynin, amitriptyline, benztropine) ● Benzodiazepines ● Opioids ● Corticosteroids ● NSAIDs ● Dopaminergic (levodopa) ● Sotalol and propranolol ● Alcohol and illicit drugs
Delirium - prevention, non-pharmacological management
Prevention: ● Adequate hydration and nutrition ● Adequate pain relief ● Promotion of sleep ● Correction of visual or hearing impairments ● Avoidance of restraints ● Provision of lighting appropriate to the time of day ● Quiet ● Availability of clock and calendar ● Involvement of family members
Non-pharmacological management: ● Close observation ● Monitoring of hydration nutrition and pain relief ● Calm and quiet atmosphere ● Frequent prompts for orientation ● Approach from the front ● Involve a familiar person
Delirium - pharmacological management
Delusions/hallucinations causing stress → antipsychotic
Oral - Haloperidol 0.5mg PO single dose - Olanzapine 2.5mg PO as single dose - Risperidone 0.5mg PO as single dose Intramuscular (severe) - Haloperidol 0.5mg IM as single dose - Olanzapine 2.5mg IM as single dose
Caution Parkinson’s - Avoid haloperidol (EPSE) - Avoid metoclopramide (exacerbates symptoms) Non-ETOH related withdrawal or seizures - Avoid benzodiazepines due to increased risk of delirium and long-term complications
Alzheimer - pharmacological treatment
Key words: insidious onset, memory impairment with dysphasia, dyspraxia and personality change.
Pharmacological treatment
Acetylcholinesterase inhibitor
- Mechanism: reduce breakdown of acetylcholine
- Indication: mild-moderate Alzhiemers
- PBS criteria: diagnosis confirmed by
geriatrician/neurologist/psychiatrist + MMSE >=10.
- Medications: donepezil, galantamine and rivastigmine
- ADRs: GI-related, dizziness, drowsiness, bradycardia
and syncope, anorexia, depression, headache, vivid
dreams and muscle cramps.
Memantine
- Mechanism: reduces glutamate-induced neuronal
degradation
- Indication: moderate-severe Alzheimers, intolerance to
AChEIs
- Contraindication: history of seizure
- ADR: GI upset, confusion, dizziness, drowsiness,
headache and agitation,
88F, nursing home resident, with advanced Alzheimer’s disease. Her behaviour has been different for the past 2
days. Complaining of nausea. Hx of depression, OA, osteopenia. Medications: sertraline, quetiapine, galantamine,
paracetamol, tramadol.
- What are the 4 possible causes for this presentation?
- Your physical examination and bedside tests are all unremarkable. What initial investigations will you organise for Shirley at this stage?
- What are your 3 management strategies while waiting for the investigation results?
What are the 4 possible causes for this presentation?
● Serotonin syndrome - due to combination of tramadol and sertraline
● Polypharmacy - due to sedative effects of tramadol and quetiapine
● Occult infection - due to UTI
● Cerebrovascular event - due to advanced age vasculopathy
● Hyponatraemia - due to sertraline
Your physical examination and bedside tests are all unremarkable. What initial investigations will you organise for
Shirley at this stage?
● FBE
● UEC
● Urine MCS
What are your 3 management strategies while waiting for the investigation results?
● Cease tramadol
● Change paracetamol from PRN to regular
● Give metoclopramide 10mg TDS for nausea
● Close monitoring by nursing staff
Dementia - frontal, Lewy body, vascular
Frontal
- Key words: personality change, social disinhibition, apathetic and withdrawn.
Lewy body
- Any two of: visual hallucinations, parkinsonism, fluctuations in mental state in absence of clear cause for delirium.
- Management of cognitive impairment: donepezil 5 mg PO at night for 4 weeks, then increase to 10mg at night (if tolerated).
Vascular
- Key words: sudden, focal neurology with imaging evidence, evidence of atherosclerotic disease elsewhere.
38M with Down syndrome living in a supported group home. Staff have reported incidents of increased aggression.
Has been throwing cutlery in the dining room. Calm during review.
- What are the 5 most important causes to consider for Simon’s presentation?
- Staff members are concerned that Simon may become agitated again so they are asking you for help. What are 5
non-pharmacological measures that you would advise the staff to consider?
What are the 5 most important causes to consider for Simon’s presentation?
● Depression
● Pain
● Sleep disturbance
● Constipation
● Urinary tract infection
● Early onset dementia of Down syndrome
Staff members are concerned that Simon may become agitated again so they are asking you for help. What are 5
non-pharmacological measures that you would advise the staff to consider?
● Ensure low stimulus environment
● Involve family members for support
● Advise staff to lock away sharp objects
● Provide one on one nursing
● For Simon to receive care from staff members that are more familiar with him
● Provide constant orientation to time, person and place
** Adults with Down syndrome usually develop changes typical of Alzheimer disease by 60
Diplopia (key points, office test, tests)
Key point
● Should be differentiated from blurred vision
● Exclude 3rd/6th nerve palsy (can be secondary to life-threatening cause)
● Refer urgently if diplopia is binocular, of recent onset and persistent
Office test
● Test for double vision with each eye occluded
● If persists then uniocular
● If disappears when either eye is covered then defect of one of the muscles
○ 3rd nerve - eye turned out, divergent squint
○ 6th nerve - failure to abduct, convergent squint
Laboratory test: ESR
** LR6SO4 (everything else 3)
Distal symmetrical polyneuropathy (key points, treatment)
Key points
● Up to 50% experience pain
● Exclude other causes inc. B12 deficiency, myeloma
Treatment:
● Amitriptyline 25mg PO nocte, slowly increase up to 150mg nocte
● If not well tolerated can add capsaicin cream
Essential tremor (clinical features, management)
Key point
● Most common movement disorder
AKA: benign, familial, senile or juvenile tremor
Clinical features:
● Autosomal dominant disorder
● Early adult life
● Head, chin and tongue involvement (maybe)
● Affect writing (not micrographic), handling cups of tea
● May affect speech (bulbar musculature)
● Relieved by alcohol
Management:
- Reassurance and explanation (most cases)
- Medication (if necessary) - propranolol (10-20mg BD) or primidone (62.5mg nocte)
- Modest alcohol intake
Brain abscess (key point, RF, history)
Key point
● Uncommon cause of headache but most serious
Risk factors: Hx bronchiectasis, recent hx of sinus and middle ear infection
History: nature (localised, constant, worsening, worst in the morning), neurological symptoms (irritability, aphasia)
Huntington disease (buzzwords, features, genetic testing indications)
Chorea + abnormal behaviour + dementia + family history of Huntington disease
Key points:
● Autosomal dominant disease
Clinical features:
● Chorea
● 35-55 years
● Mental changes (behaviour and intellectual)
● Motor symptoms (flicking movements, lilting gait, facial grimacing, ataxia, dystonia)
Genetic testing indications:
● Symptomatic adult with unequivocal motor signs
● At risk family members
● Family planning if parents would consider terminating if foetus tests positive
