Neurological & Neck Lumps Flashcards
Ischemic Stroke:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - acute neurological deficit lasting > 24 hours caused by a cerebrovascular aetiology
Epidemiology - leading cause of death >65
Pathogenesis - atherosclerosis, arterial dissection, vasculitis, hypercoagulability, angina, smoking, thrombophilia
Presentation - motor weakness, dysphasia. dysphagia, homogenous hemianopia, aphasia, ataxia
Investigations - neurological examination inc. cranial nerve, U&E, creatinine, troponins, cardiac panel, FBC, coagulability screen, CT head, MRI
Differentials - intracerebral haemorrhage, TIA, hypertensive encephalopathy, hypoglycemia, complicated migraine
Risk Factors - >age, Hx, hypertension, smoking, diabetes, AF, comorbid cardiac conditions
Treatment - aspirin 300mg, clopidogrel (DOAC if AF), atorvastatin, smoking cessation
Haemorrhagic Stroke:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - acute neurological deficit due to rupture of cerebrospinal artery resulting in interparenchymal subarachnoid and interventricular haemorrhage
Epidemiology - age>65, 110,000 strokes per year
Pathogenesis - Intracerebral : hypertension, Subarachnoid: traumatic spontaneous, aneurysms around the circle of willis
Presentation - motor weakness, photophobia, headache, seizures, visual field deficit
Thunderclap headache seen in subarachnoid
Investigations - neurological examination inc. cranial nerve, FBC, clotting, biochemistry panel, non-infused head CT, MRI = gold standard
Differentials - ischaemic stroke, hypertensive encephalopathy, hypoglycemia, complicated migraine, seizure disorder
Risk Factors - hypertension, increased age, male, Asian/black/Hispanic, haemophilia, cerebral amyloid angiopathy, anticoagulation
Treatment - stop anticoagulants, lower BP
Subarachnoid: endovascular coiling + nimodipine to decrease vasospasm
TIA:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia without acute infarction
Epidemiology - age>65
Pathogenesis - in situ thrombosis of intracranial artery or artery-artery embolism, small vessel occlusion
Presentation - neurological deficit, unilateral symptoms, increase BP on presentation, history of cardiac disease
Investigations -neurological exam inc. cranial nerve, BM, FBC, prothrombin time, INR, activated PTT, fasting lipid profile, MRI with diffusion, ECG
Differentials : hypoglycemia, seizure with past seizure paralysis, complicated migraine, conversion disorder, MS, peripheral neuropathy
Risk Factors - AF, valvular disease, carotid stenosis, hypertension, diabetes, smoker and alcohol use, increased age
Treatment - antiplatelet therapy: aspirin 300mg, statin (atorvastatin)
Subarachnoid Haemorrhage:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - bleeding into the subarachnoid space
Epidemiology - 5% of strokes, 6 per 100,000 per year
Pathogenesis - spontaneous arterial bleeding into subarachnoid space: berry aneurysms, congenital arteriovenous malformations, no lesion is found in 20% of cases
Presentation - thunderclap headache pulsing towards the back of head, vomiting, seizures, confusion, neck stiffness
Investigations - neurological examination inc. cranial nerve, CT, lumbar puncture, MR angiography
Differentials -migraine, aneurysm, trauma, seizure, hypoglycemia, mass lesion
Risk Factors - hypertension, diabetes, anticoagulation
Treatment - antihypertensive: Ramipril, calcium channel blockers: nimodipine, surgery: obliteration of aneurysm by clipping or insertion of fine wire coil
Peripheral Neuropathy:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - decreased sensation in peripheries
Epidemiology - common presentation of infection and malignancy, affects mainly adults
Pathogenesis - mononeuropathy, multiple mono-neuropathy/monocuritis multiplex, poly neuropathy
Presentation - DAM IT BITCH
D - Drugs: metronidazole, amiodarone, hydrlazine, vincristine, nitrofurantoin
A - Alcohol: with or without thiamine deficiency
M - Metabolic: diabetes, hypoglycemia, uremia
I - Infection: HIV, leprosy, Lyme, diphtheria, syphilis
T - Tumour: paraneoplastic, lung, lymphoma, myeloma
B - B12: + other vitamin deficiency - pyridoxine excess
I - Idiopathic + infiltrative: amyloidosis
T - Toxins: botulism, ciguatera, tetradoxin, saxitoxin
C - Connective Tissue Disease: SLE, PAN, RA
H - Hypothyroidism
Investigations - neurological examination. FBC, U&E, CRP/ESR, LFT, B12, nerve conduction, electromyography
Differentials - diabetes, trauma, MS, cord compression, brain lesion
Risk Factors - diabetes alcohol abuse, vitamin deficiency, infections
Treatment - treat underlying cause, pain: amitriptyline, duloxetine, pregabalin, gabapentin
Epilepsy/Seizures:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - transient occurrence of sign/symptoms due to abnormal excessive or synchronous neuronal activity in the brain
Epidemiology - 1 in 103 people, commonly starts in children or >60, commonly misdiagnosed
Pathogenesis - idiopathic, genetic, cerebrovascular disease
Considered when:
1. At least 2 unprovoked seizures occurring 24 hours apart
2. One unprovoked seizure and a probability of further seizures similar to the general recurrence risk 60% after two unprovoked seizures occurring over the next 10 years
3. Diagnosis of epilepsy syndrome
Presentation -
Tonic: impairment of consciousness and stiffening
Clonic: jerking and impairment of consciousness
Typical Absence Seizures: begin in childhood - sharp onset with no residual symptoms
Myoclonic: brief, shock-like contraction of limbs without consciousness impairment
Atonic: sudden brief attacks of loss of tone associated with falls and LOC
Focal Motor: jerking movement beginning in the face or one hand
Focal Sensory: temporal lobe seizures that may cause sensory autonomic cognitive or other changes
Investigations - lymph node examination, neurological examination, FBC, CXR, EEG
Differentials - syncope, cardiac arrhythmias, panic attacks with ventilation, non-epileptic attacks disorder, night terrors, stereotyped behavioural phenomena
Risk Factors - Fx, genetic conditions, previous febrile seizure, previous intracranial infarction, brain trauma
Treatment - A-E assessment, IV lorazapam, IV phynytoin
Community: rectal diazepam and buccal midezolam
Viral Meningitis:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - inflammation of the meninges caused by viruses
Epidemiology - adults and children, 2.5 per 100,000
Pathogenesis - enteroviruses (coxsackie A+B), HSV, HIV, VZV
Presentation - fever, neck stiffness, headache, vomiting, photophobia, altered consciousness, seizures, non-blanching rash
Kernig’s sign - patient is Uspine and thigh flexed to a right angle, attempts t straighten or extend the leg are met with resistance
Brudzinski’s sign - flexion of the neck causes involuntary flexion of the knees and hip
Investigations - neurological examination, CT/MRI head, CSF microscopy: WBC>5 cells/m-3 for children and adults, glucose may be low, bacterial culture, gram stain negative and protein either normal or elevated
Differentials - encephalitis, bacterial meningitis, drug induced meningitis, TB meningitis and cryptococcal meningitis
Risk Factors - infants, children, young adults, elderly, summer + autumn periods, exposure to mosquito, unvaccinated
Treatment - supportive care, fluids, antipyretics, antiemetics, analgesics, IV aciclovir
Bacterial Meningitis:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - serious inflammation of meninges caused by bacteria
Epidemiology - 2.5 per 100,000, adults and children
Pathogenesis - meningococcal disease: neisseria meningitides
Pneumococcal disease: streptococcus pneumonia
Neonates: strep agalactia, e.coli, Strep pneumoniae, listeria monocytogenes
Haematogenous spread
Presentation - headache, neck stiffness, fever, altered mental status, confusion, photophobia, vomiting, seizures
Investigations - neurological examination, FBC, U&E, LFT, CSF cell count (polymorphnuclear pleocytosis) protein = elevated, glucose = low, gram stain and culture = positive
Differentials - encephalalitis, viral meningitis, drug induced meningitis, TB meningitis, Fungal meningitis
Risk Factors - under 5 or over 65, crowding, exposure to pathogens, non immunised infants
Treatment - empiric antibiotics: benzylpenicillin IV, IV amoxicillin +ceftriaxone
Migraine:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - chronic genetically determined episodic neurological headaches
Epidemiology - women 18% mean onset 18
Men 6% mean onset 14
Pathogenesis - neurogenic inflammation of 1st division trigeminal sensory neurones
Presentation - prolonged headache 4-72 hours, nausea, decreased ability to function, light sensitivity, aura
Investigations - neurological examination, ICH-IIB criteria
1. 5 or more headaches meeting a-d
a. unilateral b. pulsating c. moderate- severe pain d. worsening or changing routine
Differentials - tension headache, cluster headache, PTSD, SAH, cerebral neuplasm
Risk Factors - Fx, increased caffeine intake, obesity, habitual snoring
Treatment -
Mild-moderate: aspirin/ibuprophen, metoclopramide (antiemetic)
Severe: triptan-almotriptan - to be taken ate the start of headache not aura
Tension Headache:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - episodic or chronic tension type headache
Epidemiology - lifetime risk 70-80%
Pathogenesis - stress, insomnia + other sleep disorders
Presentation - head pain: bilateral pressure non pulsatile, tight band headache: constricting pain
Investigations - neurological examination: usually normal
Differentials - chronic migraine, medicine over use, sphenoid sinusitus, giant cell arteritis, temporomandibular tumour
Risk Factors - mental tension, stress, missing meals, fatigue
Treatment - paracetamol + NSAIDs, chronic: antidepressants - amitriptyline
Parkinson’s disease:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - chronic progressive neurological disorder characterised by motor symptoms
Epidemiology - 120-230 per 100,000, 1% of people>65, 4-8% below 50, more common in men
Pathogenesis - selective loss of nigrostriatal dopaminergic neurones in substantial nigra pars compact
Presentation - bradykinesia, resting tremor, rigidity, postural instability
Investigations - neurological examination
Differentials - progressive supra nuclear palsy, Lewy body dementia, corticobasal degeneration, Alzheimers with Parkinsonism
Risk Factors - increased age, Fx, mutation in GBA, neurotoxin exposure
Treatment - 1st line: levodopa carboxylase inhibitor
2nd line: oral monoamine oxidase B inhibitors - rasagiline, safinamide
Multiple Sclerosis:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - inflammatory demyelinating disease characterised by the presence of episodic neurological dysfunction in at least two areas of CNS separated in time and space
Epidemiology - most common cause of neurological disability among young adults, F3:M1
Pathogenesis - inflammation followed by degeneration, multifocal areas of demyelination loss of oligodendrocytes
Presentation - visual disturbances, peculiar sensory phenomena, leg cramping, LHERMITTE’S sign (electric shock sensation down cervical spine), foot dragging, trigeminal neuropathy
Investigations - neurological examination, FBC, TSH, B12, metabolic panel, MRI brain and spine
Differentials - myelopathy due to cervical spondylosis, fibromyalgia, sleep disorders, B12 deficiency
Risk Factors - female, northern latitude, genetics, smoking, Vitamin D deficiency
Treatment - corticosteroids - 3 day high dose prednisolone, disease modifying drugs: beta interferon cytokine
Proximal Myopathy:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - neurological problem presenting as symmetrical weakness of proximal upper/lower limbs
Epidemiology - relatively uncommon
Pathogenesis - muscular dystrophy, congenital myopathies, metabolic myopathies, endocrine myopathies
Presentation - weakness affecting proximal muscle groups, reduced muscle strength, myalgia, malaise, fatigue
Investigations - urinalysis, MSK examination, FBC, U&E, ESR, antinuclear antibodies, serum myoglobin, ECG, electromyography
Differentials - guillan-barre syndrome, lamber-eaton myasthenia syndrome, myasthenia graves, cerebral palsy, spinal muscular atrophy
Risk Factors - female, older age, hypertension, untreated hypothyroidism, renal/hepatic disease
Treatment - monitor pulmonary function, surgical tendon release
Cervical Lymphadenopathy:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - swelling of cervical lymph nodes
Epidemiology - common in infection and malignancy
Pathogenesis - bacterial, viral or parasitic, non-infective
Presentation - acute painful swelling, mass in lymph nodes, virchows node, generalised, cancer red flag symptoms
Investigations - lymph node examination, FBC, CXR
Differentials - skin infection, benign tumour, malignant primary or secondary tumour, thyroid tumour, salivary gland tumour, aneurysms, trauma
Risk Factors - any risk factors for cause
Treatment - treat causes i.e infection - antibiotics, consider >45 laryngeal cancer, consider oral cancer with unexplained oral ulcers
Salivary Gland Swellings - Sialadenitis:
Definition
Epidemiology
Pathogenesis
Presentation
Investigations
Differentials
Risk Factors
Treatment
Definition - inflammation or parotid, submandibular, sublingual or minor glands
Epidemiology - unknown
Pathogenesis - accumulation of bacteria, neutrophils and inspissated fluid in lumen of ductal structures, chronic, autoimmune
Presentation - exudates of pus, mandibular truisms, cranial nerve palsy of 7, 9, 12
Investigations - cranial nerve and general examination, FBC, facial radiographs, exudate cultures
Differentials - mumps, sarcoidosis, TB, parotid + sublingual tumours, Ludwig’s angina, angio-oedema
Risk Factors - volume depletion + Mal nutrition, immunosuppression, Sjrogens, women 50-60
Treatment - broad spectrum IV antibiotics, possible surgery dependent on gland
