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3rd Year > Neurological conditions > Flashcards

Neurological conditions Flashcards

1
Q

What is the typical age for a subarachnoid haemorrhage to occur?

A

35-65

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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
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3
Q

Incidence of subarachnoid haemorrhage?

A

6-9 per 100,000

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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

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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

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6
Q

What would isolated pupillary dilation show in a suspected SAH patient?

A

brain herniation as a result of rising ICP

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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

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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.

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9
Q

What is the management for SAH?

A

Neurosurgery (endovascular coiling/clipping)
Maintain cerebral perfusion
Nimodipine

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10
Q

What is nimodipine?

A

A Calcium antagonist that reduces vasospasm

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11
Q

Before neurosurgery managemnt of SAH what investigation should be undertaken?

A

Ct angiography to identify single vs multiple aneurysms

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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

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13
Q

What is the prognosis of SAH?

A

Case mortality is around 50% overall and one third of survivors remain dependant

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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

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15
Q

Who is more predisposed to meningitis?

A

Infants, young children and the elderly

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16
Q

What is the most common cause of meningitis?

A

Viral meningitis

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17
Q

Risk factors for meningitis?

A

Patients with CSF shunts or dural defects

Patients having spinal procedures are at increased risk

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18
Q

What organisms commonly cause meningitis?

A

Meningococcus
Pneumococcus
Haemophilus influenzae (less common)

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19
Q

What are the early features of meningitis?

A

Headache
leg pains
cold hands and feet
abnormal skin colour

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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
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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)

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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.

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23
Q

What is opisthotonus?

A

A type of spasm in which the head and heals arch backwards in extreme hyperextension

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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

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25
Q

What is the general management for meningitis?

A

Supportive treatment (fluids, antipyretics, antiemetics)
Treatment of any causative organism
Treatment of any complication

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26
Q

What investigations (after LP) should be undertaken in meningitis?

A

FBC, U&Es, LFT, glucose, coagulation screen

Blood culture, throat swabs, rectal swabs, serology

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27
Q

What is the first line medical treatment for bacterial meningitis?

A

Ceftriaxone (Broad spectrum antibiotic)

Dexamthasone (corticosteroid)

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28
Q

What is an epilepsy

A

A recurrent tendency to sponatneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures

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29
Q

How many epileptics are idiopathic?

A

2/3rds

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30
Q

What are the structural causes of epilepsy?

A 
Cortical scarring
developmental
Space occupying lesion
Hippocampal sclerosis
Vascular malformations
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31
Q

What are the cerebrovascular causes of epilepsy?

A

cerebral infarction
cerebral haemorrhage
venous thrombosis

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32
Q

What are non-epileptic causes of seizures?

A 
Trauma
Stroke
Haemorrhage
Increased ICP
Alcohol or benzodiazapene withdrawal
Metabolic disturbance
Infection (eg meningitis, encephalitis)
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33
Q

What are two good diagnostic signs that a seizure is the result of tonic-clonic epilepsy?

A

Tongue biting

Slow recovery

Incontinence

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34
Q

What is a partial seizure?

A

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

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35
Q

Explain a simple partial seizure?

A

Awareness is unimpaired with focal motor, sensory (olfactory, visual, etc), autonomic or psychic symptoms. No post-ictal symptoms

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36
Q

Explain a complex partial seizure

A

Awareness is impaired with focal motor, sensory (olfactory, visual, etc), autonomic or psychic symptoms.Post-ictal confusion is common in temporal lobe seizures.

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37
Q

What is a partial seizure with secondary generalization?

A

In 2/3rds of patients with partial seizures the electrical disturbance spreads widely causing a secondary generalized seizure.

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38
Q

What is a primary generalized seizure?

A

Simultaneous onset of electrical discharge throughout cortex with no localizing features.

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39
Q

What types of primary generalized seizures are there?

A

Absence
Tonic-clonic
Myoclonic
Atonic

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40
Q

What occurs in an absence seizure?

A

Brief pauses (

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41
Q

What occurs in a Tonic-clonic seizure?

A

Loss of consciousness. Limbs stiffen (tonic), then jerk (clonic). Post-ictal confusion and drowsiness.

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42
Q

What occurs in a Myoclonic seizure?

A

Sudden jerk of a limb, face or trunk. The patient may be suddenly thrown to the ground or have a violently disobedient limb

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43
Q

What is an atonic seizure?

A

A sudden loss of muscle tone causing a fall. No loss of consciousness

44
Q

What is SUDEP?

A

Sudden unexpected death in epilepsy

45
Q

What is the recommended medication for generalized tonic-clonic seizures?

A

Sodium Valproate/Lamotrigine are first line.

Others include carbamezapine or topiramate

46
Q

What is the recommended medication for tonic, atonic and myoclonic seizures?

A

Sodium Valproate or Lamotrigine (avoid carbamezapine and oxcarbazepine which may worsen seizures)

47
Q

What is the recommended medication for partial seizures with or without secondary generalization

A

Carbamazepine is 1st line, then sodium valproate, lamotrigine oxcarbazepine or topiramate

48
Q

Can patients take more than one epilepsy medication?

A

No. They should be treated with one drug with one doctor in charge only.

49
Q

When should non-epileptic attack disorder (psuedo- or psychogenic seizures) be suspected?

A

If there are uncontrollable symptoms, no learning disabilities, and CNS exam, MRI and EEg are normal

50
Q

What are the side effects of sodium valproate?

A 
appetite increase and weight gain
liver failure
pancreatitis
reversible hair loss
oedema
ataxia
teratogenicity, tremor, thrombocytopenia
encephalopathy
51
Q

What are the 3 cardinal signs of Parkinsonism

A

Tremor (worse at rest)
Rigidity
Bradykinesia/hypokinesia

52
Q

What are some non motor features of parkinsons disease?

A 
Sense of smell reduced
Constipation
Visual hallucinations
Frequency/urgency
Dribbling of saliva
Depression and dementia
53
Q

What are the causes of parkinsonism?

A 
Idiopathic
Drug induced (neuroleptics, metoclopramide, prochlorperazine)
54
Q

What is the typical age of onset of parkinsons?

A

65 years

55
Q

What is the pathology of parkinsons?

A

Degeneration of dopaminergic neurons in the substantia nigra pars compacta

56
Q

When is bradykinesia particularly noticable?

A

In reduced arm swing when walking

57
Q

How is parkinsons gait characterised?

A

Small shuffling steps with unsteadiness on turning and difficulty in stopping (festination).

58
Q

How can we distinguish between parkinsons and a benign essential tremor?

A

Benign essential tremor is worse on movement and rare while at rest. The opposite occurs with a parkinsons tremor

59
Q

Investigations for parkinsons

A

The diagnosis is clinical. Other investigations such as CT and MRI are for excluding other causes

60
Q

What is the prevalence of dementia in parkinsons patients?

A

20-40%

61
Q

What is the prevalence of depression in parkinsons

A

45%

62
Q

What is ataxia

A

Ataxia is a term that describes a group of neurological disorders that affect co-ordination, balance and speech.

63
Q

What non medical management is important in parkinsons?

A

arranging nursing assesment
considering carer support
Driving- patient should inform DVLA and insurers

64
Q

How often should a parkinsons patient be reviewed?

A

NICE suggests specialist review every 6-12 months

65
Q

What is the most efffective drug in the treatment of parkinsons disease?

A

Levodopa

66
Q

What drugs are used in treating motor features of PD?

A

Dopamine agonists (Ropinirole, pramipexole)

67
Q

Which parkinsons medication can result in compulsive behaviour (gambling, hypersexuality)

A

Dopamine agonists

68
Q

What additional medications are available for parkinsons?

A

Apomorphine (potent Dopamine agonist used with SC infusion)
Anticholinergics (benzhexol, orphenadrine)
MAO-B inhibitors (alternative to Dopamine agonists)
COMT inhibitors

69
Q

If a headache presents with meningism what are the three possibilities?

A

meningitis
encephalitis
subarachnoid haemorrhage

70
Q

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

A

Giant cell arteritis. Treat with steroids to avoid blindness

71
Q

What are the symptoms of a tension headache?

A

Bilateral, non-pulsatile, headache plus possible scalp muscle tenderness. No vomiting or sensitivity to head movements

72
Q

How do cluster headaches present?

A

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
Q

How long do cluster headaches usually last?

A

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
Q

How do migraines classically present?

A

Visual or other aura lasting 15-30 mins followed within 1hr by unilateral throbbing headache

75
Q

What are the three common types of migraine?

A

Migraine with aura
Migraine without aura
Chronic migraine

76
Q

Over 80% of people have their first migraine by what age?

A

30

77
Q

What other symptoms could a migraine present with?

A 
Nausea
vomiting
Photophobia
Phonophobia
General light headedness
78
Q

How can a premonitory phase present (prodrome)?

A 
Occurs hours to days before headache. Features are:
depression
tiredness
difficulty concentrating
irritability
stiff neck 
food cravings
79
Q

How do auras present?

A

5 mins to an hour before headache:
visual disturbance
Sensory symptoms (paraesthesia/numbness)

80
Q

What triggers are there for migraines? (seen in 50%)

A 
CHOCOLATE:
chocolate
hangovers
orgasms
cheese
oral contraceptives
lie-ins
alcohol
tumult
exercise
81
Q

What are the three main goals of migraine management?

A

To relieve symptoms of an acute attack
To reduce the frequency and severity of attacks
To identify possible trigger factors

82
Q

What pharmaceutical management options are available for migraines?

A

NSAIDS

Triptans (Rizatriptan)

83
Q

What non pharmaceutical options are available for treating migraines?

A

Warm or cold packs to the head
Rebreathing into paper bag
Spinal manipulation

84
Q

What prevention methods are there for migraines?

A

Remove triggers
1st line: Beta Blockers (Propranalol)
Amitriptyline
2nd line: Antiepileptics (Sodium Valproate)
pizotifin, gabapentin, pregablin, ACE inhibitors, NSAIDS

85
Q

What sort of analgesic should be avoided in migraine patients?

A

Opiate containing medication including codeine

86
Q

What is the main contraindication for triptans?

A

Uncontrolled hypertension

People with or with risk of coronary heart disease, cerebrovascular disease

87
Q

When should patients be offered migraine prophylaxis?

A

If they are having two or more migraines a month

88
Q

What medication should not be offered to a patient with aura migraine or migraine with ischaemic attack risk factors?

A

Combined Oral contraceptive pill

89
Q

What percentage of strokes are caused by cerebral infarction?

A

70%

90
Q

15% of strokes are caused by?

A

Primary haemorrhage

91
Q

Causes of stroke in a young patient?

A 
Vasculitis
Thrombophilia
Subarachnoid haemorrhage
Venous sinus thrombosis
Carotid artery dissection
92
Q

Causes of stroke in an older patient?

A 
Thrombosis
Athero-thromboembolism
Heart emboli
CNS bleed
Sudden blood pressure drop by more than 40mmHg
Vasculitis
Venous sinus thrombosis
93
Q

How many people have a stroke in the UK every year?

A

150,000

94
Q

What are the risk factors for stroke?

A 
Hypertension
Smoking
Diabetes mellitus
Heart disease
Peripheral vascular disease
Post TIA
Combined oral contraceptive pill
Excess alcohol
Hyperlipidaemia
Carotid artery occlusion
Clotting disordes
95
Q

What must be always excluded as a cause of sudden-onset neurological symptoms?

A

Hypoglycaemia

96
Q

What is the typical timing of stroke onset?

A

Sudden onset or a step wise progression of symptoms and signs over hours (or even days)

97
Q

How do cerebral hemisphere infarcts (50%) present

A

Contralateral hemiplegia (initially flaccid and then spastic)
Contralateral sensory loss
Homonymous hemianopia
Dysphasia

98
Q

How do brianstem infarctions (25%)present

A

Quadriplegia
Disturbances of gaze and vision
Locked in syndrome
Lateral medullary syndrome

99
Q

What are lacunar infarcts (25%)?

A

Small infarcts around the basal ganglia, internal capsule, thalamus and pons

100
Q

How do lacunar infarcts present?

A

May cause pure motor, pure sensory, mixed motor and sensory signs or ataxia
Intact cognition/consciousness

101
Q

What action should be taken in the first hour of a stroke?

A 
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
Q

What symptoms may indicate a haemorrhagic stroke?

A

Meningism
Severe headache
Reduced consciousness/coma

103
Q

Within what time frame should thrombolysis be adminstered?

A

Within four and a half hours of onset of stroke

104
Q

What is the ABCD prognostic score for people with a TIA?

A

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
Q

After a stroke or TIA there is a high risk of stroke and other serious vascular events. As such preventative medical treatments include?

A

Lowering blood pressure
Lowering blood cholesterol
Antiplatelet treatment
Warfarin instead of antiplatelet in patients who have AF and no contra-indications to anticoagulation

106
Q

For what percentage of strokes is AF responsible?

A

25%

107
Q

How many strokes are preceded by TIA?

A

15%

3rd Year (18 decks)

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