Neurological conditions Flashcards
1
Q
What is the typical age for a subarachnoid haemorrhage to occur?
A
35-65
2
Q
Risk factors for subarachnoid haemorrhage?
A
Smoking Alcohol misuse Hypertension Bleeding disorders Mycotic aneurysm Close relatives have a 3-6 fold increased risk
3
Q
Incidence of subarachnoid haemorrhage?
A
6-9 per 100,000
4
Q
Presentation of Subarachnoid haemorrhage?
A
Sudden diffuse ‘thunderclap’ headache (usually within seconds)
Incredibly severe pain
Lasts a week or two
Vomiting may occur
Seizures occur in about 7%
Neck stiffness and other signs of meningism may be present, although usually after 6 hours
5
Q
Do any patients with SAH have decreased conscious level, if os how many?
A
Two thirds have depressed level of consciousness of whom half are in a coma
6
Q
What would isolated pupillary dilation show in a suspected SAH patient?
A
brain herniation as a result of rising ICP
7
Q
What is the first line of investigation
A
CT scan. This will correctly identify 95-98% of cases particularly if performed within 24 hours of onset
8
Q
If the CT is negative but the history is suggestive what investigation should be undertaken?
A
Lumbar puncture. This should ideally take place over 12 hours after the onset of the headache.
9
Q
What is the management for SAH?
A
Neurosurgery (endovascular coiling/clipping)
Maintain cerebral perfusion
Nimodipine
10
Q
What is nimodipine?
A
A Calcium antagonist that reduces vasospasm
11
Q
Before neurosurgery managemnt of SAH what investigation should be undertaken?
A
Ct angiography to identify single vs multiple aneurysms
12
Q
What are the two biggest complications of SAH?
A
Rebleeding (40% risk after 24 hrs for the following four weeks)
Cerebral ischaemia due to vasospasm
13
Q
What is the prognosis of SAH?
A
Case mortality is around 50% overall and one third of survivors remain dependant
14
Q
What is meningitis?
A
Meningitis is an inflammation of the leptomeninges and underlying subarachoid cerebrospinal fluid. It may be caused by infection with viruses, bacteria, other micro organisms or non-infective causes
15
Q
Who is more predisposed to meningitis?
A
Infants, young children and the elderly
16
Q
What is the most common cause of meningitis?
A
Viral meningitis
17
Q
Risk factors for meningitis?
A
Patients with CSF shunts or dural defects
Patients having spinal procedures are at increased risk
18
Q
What organisms commonly cause meningitis?
A
Meningococcus
Pneumococcus
Haemophilus influenzae (less common)
19
Q
What are the early features of meningitis?
A
Headache
leg pains
cold hands and feet
abnormal skin colour
20
Q
What are the later features of meningitis?
A
Meningism Reduced conscious level/coma Seizures Focal neurological deficits Petechial rash (non blanching) Signs of galloping sepsis
21
Q
What are the features of meningism?
A
Neck stiffness
Photophobia
Kernigs sign (pain and resistance on passive knee extension with hip fully flexed)
22
Q
How do we distinguish between viral and bacterial meningitis?
A
They are clinically indistinguishable (Viral features may be more mild). Because of this any person with suspected meningitis is managed as having viral meningitis.
23
Q
What is opisthotonus?
A
A type of spasm in which the head and heals arch backwards in extreme hyperextension
24
Q
What is the first line investigation?
A
Lumbar puncture should be performed immediately provided there are no signs of raised intracranial pressure or focal neurology
25
What is the general management for meningitis?
Supportive treatment (fluids, antipyretics, antiemetics)
Treatment of any causative organism
Treatment of any complication
26
What investigations (after LP) should be undertaken in meningitis?
FBC, U&Es, LFT, glucose, coagulation screen
| Blood culture, throat swabs, rectal swabs, serology
27
What is the first line medical treatment for bacterial meningitis?
Ceftriaxone (Broad spectrum antibiotic)
Dexamthasone (corticosteroid)
28
What is an epilepsy
A recurrent tendency to sponatneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures
29
How many epileptics are idiopathic?
2/3rds
30
What are the structural causes of epilepsy?
```
Cortical scarring
developmental
Space occupying lesion
Hippocampal sclerosis
Vascular malformations
```
31
What are the cerebrovascular causes of epilepsy?
cerebral infarction
cerebral haemorrhage
venous thrombosis
32
What are non-epileptic causes of seizures?
```
Trauma
Stroke
Haemorrhage
Increased ICP
Alcohol or benzodiazapene withdrawal
Metabolic disturbance
Infection (eg meningitis, encephalitis)
```
33
What are two good diagnostic signs that a seizure is the result of tonic-clonic epilepsy?
Tongue biting
Slow recovery
Incontinence
34
What is a partial seizure?
Focal onset, with features referable to a part of one hemisphere, often with underlying structural disease. They can be simple, complex or with secondary generalization
35
Explain a simple partial seizure?
Awareness is unimpaired with focal motor, sensory (olfactory, visual, etc), autonomic or psychic symptoms. No post-ictal symptoms
36
Explain a complex partial seizure
Awareness is impaired with focal motor, sensory (olfactory, visual, etc), autonomic or psychic symptoms.Post-ictal confusion is common in temporal lobe seizures.
37
What is a partial seizure with secondary generalization?
In 2/3rds of patients with partial seizures the electrical disturbance spreads widely causing a secondary generalized seizure.
38
What is a primary generalized seizure?
Simultaneous onset of electrical discharge throughout cortex with no localizing features.
39
What types of primary generalized seizures are there?
Absence
Tonic-clonic
Myoclonic
Atonic
40
What occurs in an absence seizure?
Brief pauses (
41
What occurs in a Tonic-clonic seizure?
Loss of consciousness. Limbs stiffen (tonic), then jerk (clonic). Post-ictal confusion and drowsiness.
42
What occurs in a Myoclonic seizure?
Sudden jerk of a limb, face or trunk. The patient may be suddenly thrown to the ground or have a violently disobedient limb
43
What is an atonic seizure?
A sudden loss of muscle tone causing a fall. No loss of consciousness
44
What is SUDEP?
Sudden unexpected death in epilepsy
45
What is the recommended medication for generalized tonic-clonic seizures?
Sodium Valproate/Lamotrigine are first line.
| Others include carbamezapine or topiramate
46
What is the recommended medication for tonic, atonic and myoclonic seizures?
Sodium Valproate or Lamotrigine (avoid carbamezapine and oxcarbazepine which may worsen seizures)
47
What is the recommended medication for partial seizures with or without secondary generalization
Carbamazepine is 1st line, then sodium valproate, lamotrigine oxcarbazepine or topiramate
48
Can patients take more than one epilepsy medication?
No. They should be treated with one drug with one doctor in charge only.
49
When should non-epileptic attack disorder (psuedo- or psychogenic seizures) be suspected?
If there are uncontrollable symptoms, no learning disabilities, and CNS exam, MRI and EEg are normal
50
What are the side effects of sodium valproate?
```
appetite increase and weight gain
liver failure
pancreatitis
reversible hair loss
oedema
ataxia
teratogenicity, tremor, thrombocytopenia
encephalopathy
```
51
What are the 3 cardinal signs of Parkinsonism
Tremor (worse at rest)
Rigidity
Bradykinesia/hypokinesia
52
What are some non motor features of parkinsons disease?
```
Sense of smell reduced
Constipation
Visual hallucinations
Frequency/urgency
Dribbling of saliva
Depression and dementia
```
53
What are the causes of parkinsonism?
```
Idiopathic
Drug induced (neuroleptics, metoclopramide, prochlorperazine)
```
54
What is the typical age of onset of parkinsons?
65 years
55
What is the pathology of parkinsons?
Degeneration of dopaminergic neurons in the substantia nigra pars compacta
56
When is bradykinesia particularly noticable?
In reduced arm swing when walking
57
How is parkinsons gait characterised?
Small shuffling steps with unsteadiness on turning and difficulty in stopping (festination).
58
How can we distinguish between parkinsons and a benign essential tremor?
Benign essential tremor is worse on movement and rare while at rest. The opposite occurs with a parkinsons tremor
59
Investigations for parkinsons
The diagnosis is clinical. Other investigations such as CT and MRI are for excluding other causes
60
What is the prevalence of dementia in parkinsons patients?
20-40%
61
What is the prevalence of depression in parkinsons
45%
62
What is ataxia
Ataxia is a term that describes a group of neurological disorders that affect co-ordination, balance and speech.
63
What non medical management is important in parkinsons?
arranging nursing assesment
considering carer support
Driving- patient should inform DVLA and insurers
64
How often should a parkinsons patient be reviewed?
NICE suggests specialist review every 6-12 months
65
What is the most efffective drug in the treatment of parkinsons disease?
Levodopa
66
What drugs are used in treating motor features of PD?
Dopamine agonists (Ropinirole, pramipexole)
67
Which parkinsons medication can result in compulsive behaviour (gambling, hypersexuality)
Dopamine agonists
68
What additional medications are available for parkinsons?
Apomorphine (potent Dopamine agonist used with SC infusion)
Anticholinergics (benzhexol, orphenadrine)
MAO-B inhibitors (alternative to Dopamine agonists)
COMT inhibitors
69
If a headache presents with meningism what are the three possibilities?
meningitis
encephalitis
subarachnoid haemorrhage
70
What diagnosis needs to be excluded in all >50 year olds with a headache lasting a few weeks with tenderm thickened pulseless temporal arteries: jaw claudication
Giant cell arteritis. Treat with steroids to avoid blindness
71
What are the symptoms of a tension headache?
Bilateral, non-pulsatile, headache plus possible scalp muscle tenderness. No vomiting or sensitivity to head movements
72
How do cluster headaches present?
Rapid onset of excruciating pain around on eyethat may become watery and bloodshot with lid swelling, lacrimation, facial flushing, rhinnorrhoea. Pain is strictly unilateral.
73
How long do cluster headaches usually last?
15-160 minutes occuring once or twice a day, and is often nocturnal. clusters last 4-12 weeks and are followed by pain free periods of months to years before the next cluster. Can be chronic
74
How do migraines classically present?
Visual or other aura lasting 15-30 mins followed within 1hr by unilateral throbbing headache
75
What are the three common types of migraine?
Migraine with aura
Migraine without aura
Chronic migraine
76
Over 80% of people have their first migraine by what age?
30
77
What other symptoms could a migraine present with?
```
Nausea
vomiting
Photophobia
Phonophobia
General light headedness
```
78
How can a premonitory phase present (prodrome)?
```
Occurs hours to days before headache. Features are:
depression
tiredness
difficulty concentrating
irritability
stiff neck
food cravings
```
79
How do auras present?
5 mins to an hour before headache:
visual disturbance
Sensory symptoms (paraesthesia/numbness)
80
What triggers are there for migraines? (seen in 50%)
```
CHOCOLATE:
chocolate
hangovers
orgasms
cheese
oral contraceptives
lie-ins
alcohol
tumult
exercise
```
81
What are the three main goals of migraine management?
To relieve symptoms of an acute attack
To reduce the frequency and severity of attacks
To identify possible trigger factors
82
What pharmaceutical management options are available for migraines?
NSAIDS
| Triptans (Rizatriptan)
83
What non pharmaceutical options are available for treating migraines?
Warm or cold packs to the head
Rebreathing into paper bag
Spinal manipulation
84
What prevention methods are there for migraines?
Remove triggers
1st line: Beta Blockers (Propranalol)
Amitriptyline
2nd line: Antiepileptics (Sodium Valproate)
pizotifin, gabapentin, pregablin, ACE inhibitors, NSAIDS
85
What sort of analgesic should be avoided in migraine patients?
Opiate containing medication including codeine
86
What is the main contraindication for triptans?
Uncontrolled hypertension
| People with or with risk of coronary heart disease, cerebrovascular disease
87
When should patients be offered migraine prophylaxis?
If they are having two or more migraines a month
88
What medication should not be offered to a patient with aura migraine or migraine with ischaemic attack risk factors?
Combined Oral contraceptive pill
89
What percentage of strokes are caused by cerebral infarction?
70%
90
15% of strokes are caused by?
Primary haemorrhage
91
Causes of stroke in a young patient?
```
Vasculitis
Thrombophilia
Subarachnoid haemorrhage
Venous sinus thrombosis
Carotid artery dissection
```
92
Causes of stroke in an older patient?
```
Thrombosis
Athero-thromboembolism
Heart emboli
CNS bleed
Sudden blood pressure drop by more than 40mmHg
Vasculitis
Venous sinus thrombosis
```
93
How many people have a stroke in the UK every year?
150,000
94
What are the risk factors for stroke?
```
Hypertension
Smoking
Diabetes mellitus
Heart disease
Peripheral vascular disease
Post TIA
Combined oral contraceptive pill
Excess alcohol
Hyperlipidaemia
Carotid artery occlusion
Clotting disordes
```
95
What must be always excluded as a cause of sudden-onset neurological symptoms?
Hypoglycaemia
96
What is the typical timing of stroke onset?
Sudden onset or a step wise progression of symptoms and signs over hours (or even days)
97
How do cerebral hemisphere infarcts (50%) present
Contralateral hemiplegia (initially flaccid and then spastic)
Contralateral sensory loss
Homonymous hemianopia
Dysphasia
98
How do brianstem infarctions (25%)present
Quadriplegia
Disturbances of gaze and vision
Locked in syndrome
Lateral medullary syndrome
99
What are lacunar infarcts (25%)?
Small infarcts around the basal ganglia, internal capsule, thalamus and pons
100
How do lacunar infarcts present?
May cause pure motor, pure sensory, mixed motor and sensory signs or ataxia
Intact cognition/consciousness
101
What action should be taken in the first hour of a stroke?
```
Protect the airway
Pulse, BP and ECG
Blood glucose
Urgent CT/MRI (if high risk of haemorrhages)
Thrombolysis
Antiplatelet agents (aspirin 300mg)
Swallowing screened
```
102
What symptoms may indicate a haemorrhagic stroke?
Meningism
Severe headache
Reduced consciousness/coma
103
Within what time frame should thrombolysis be adminstered?
Within four and a half hours of onset of stroke
104
What is the ABCD prognostic score for people with a TIA?
A-age (>60)
B-blood pressure (>140/90)
C-clinical feautures
D-Duration of symptoms
1 point is added for the presence of diabetes
105
After a stroke or TIA there is a high risk of stroke and other serious vascular events. As such preventative medical treatments include?
Lowering blood pressure
Lowering blood cholesterol
Antiplatelet treatment
Warfarin instead of antiplatelet in patients who have AF and no contra-indications to anticoagulation
106
For what percentage of strokes is AF responsible?
25%
107
How many strokes are preceded by TIA?
15%
