Neurology 1 Flashcards
Definitions
Seizure
Epilepsy
Syncope
Seizure - Clinical manifestation of abnormal and excessive neuronal discharge
Epilepsy - A tendency to have seizures
(2 or more seizures > 24 hours apart)
Syncope - Transient global cerebral hypoperfusion
Epilepsy - Associated conditions
Cerebral palsy Tuberous sclerosis Downs Mitochondrial disease SLE Cerebral vascular disease
Focal seizures
Focal aware
- No LOC
- No memory loss
- No post-ictal symptoms
Focal impaired awareness
- LOC
- Memory loss
- Post-ictal confusion
Jacksonian - Spreads distal to proximal
Todd’s - Paralysis after a seizure
Temporal seizures
Hallucinations
Deja vu
Post-ictal dysphasia
Automatisms
- Lip smacking
- Grabbing
- Pulling
Frontal seizures
Parietal seizures
Occipital seizures
Frontal seizures
- Movements
- Post-ictal weakness
- Jacksonian march
Parietal seizures - Paraesthesia
Occipital seizures
- Floaters
- Flashes
General seizures
Both hemispheres
Always LOC
Incontinence
Tongue biting
Pre-ictal symptoms
Prodrome - Change in mood or behaviour
Aura
- Strange feeling in gut
- Deja vu
- Flashing lights
- Olfactory changes
Post-ictal symptoms
Headache Confusion Myalgia Sore tongue Temporary weakness - Frontal lobe Dysphasia - Temporal lobe
Organic causes of seizures
VITAMIN D
Vascular - Stroke, SAH, haematoma Infection - Meningitis, abscess Trauma Autoimmune - SLE Metabolic - See separate card! Iatrogenic - See separate card! Neoplasm - Primary and secondary metastases Degenerative
Metabolic causes of seizures
Iatrogenic causes of seizures
Metabolic
- Hypoglycaemia
- Hypoxia
- Alcohol withdrawal
- Hyponatraemia
- Hypocalcaemia
- Hypokalaemia
- Hypernatraemia
- Hypercalcaemia
- Uraemia
Iatrogenic
- Tricyclics
- Benzos
- Tramadol
Epilepsy investigations and management
EEG / MRI
Start management after second epileptic seizure
Start after first seizure if…
- FND
- Brain imaging shows structural abnormality
Focal seizure management
Carbamazepine
Lamotrigine
Valproate
Levetiracetam
Generalised seizure management
Absence - Valproate + Ethosuximide
Tonic-clonic - Valproate + Lamotrigine + Carbamazepine
Myoclonic - Valproate + Lamotrigine + Clonazepam
Valproate side effects
Vomiting Anorexia / ataxia Liver toxicity Pancreatitis Retention of weight Oedema Alopecia Teratogenic - Neural tube defects Enzyme inhibitor - CP450
Epilepsy driving rules
Cannot drive for 6 months after first unprovoked seizure
(If no structural defect on imaging + No epilepsy on EEG)
If epilepsy - Must be seizure free for 12 months
Status epilepticus
Seizure > 5 minutes
> 2 seizures in 5 minutes
Causes
- Stopping anti-epileptic drugs
- Alcohol withdrawal
Status epilepticus management
ABCDE Buccal midazolam Rectal diazepam IV lorazepam Phenytoin / Phenobarbitol
Status epilepticus complications
AKI from rhabdomyolysis Lactic acidosis Hypercapnia Vomiting Hypoxia Pneumonia
Headache red flags
Raised ICP - SOL
Jaw claudication - GCA
Paraesthesia and FND - Stroke / migraine
Visual disturbance - TN / SAH / meningitis
Thunderclap headache - SAH
Neck stiffness - Meningitis / SAH
Personality changes - Stroke / tumour / frontal lobe pathology
Migraine criteria
ABCDE
At least 5 incidents, fulfilling the criteria…
B - Headache lasting 4-72 hours
Characteristics - 2 of…
- Unilateral
- Pulsating
- Moderate/severe pain
- Aggravated by / or avoidance of physical activity
During - 1 of…
- N/V
- Photophobia
Examination/history does not suggest secondary headache
Migraine investigations
Ophthalmoscopy
BP
Full neuro assessment
Migraine management
Acute
- Combination therapy - Sumatriptan + NSAIDs
- Metoclopramide
- Prochlorperazine
Prophylaxis > 2 attacks per month
- Topiramate - CI in pregnancy
- Propranolol - CI in asthma
- Acupuncture
- Riboflavin
Tension headache management
Avoid triggers (LADS)
- Sleep hygiene
- Meditation
Acute
- Aspirin
- Paracetamol
- NSAIDs
Prophylaxis - Acupuncture
Cluster headache
More common in men
Severe unilateral orbital stabbing pain
“ Worst pain of all time”
Relieved by movement
Worse at night
Once a year
15-180 minutes
Clusters of 6-12 weeks
Cluster headache triggers
Alcohol Smoking Exercise Heat Histamine
Cluster headache management
Avoid triggers
Acute
- Sumatriptan
- O2
Prophylaxis
- Verapamil
- Topiramate
- Prednisolone
Trigeminal neuralgia aetiology and triggers
Associated with MS
Triggers - Light skin contact
- Washing
- Shaving
- Talking
- Brushing teeth
+ Smoking!
Trigeminal neuralgia presentation
Shock-like sensations in trigeminal nerve
Most commonly the maxillary branch
Severe unilateral pain
Worse on touching face
Up to 100 attacks per day
1-180 seconds
Trigeminal neuralgia investigations
CT/MRI - Rule out SOL
Referral if red flags…
- Sensory deficit
- Optic neuritis
- Family history MS
- Onset < 40
Trigeminal neuralgia management
Carbamazepine
Alternatives…
- Lamotrigine
- Phenytoin
- Gabapentin
- Surgery
- Radiotherapy
GCA aetiology
Associated with PMR
(Proximal muscle and joint pain)
Cause - Vasculitis
More common in females
GCA presentation
Women and older men
Severe pain
- Jaw claudication
- Scalp pain - Worse with chewing, talking, brushing hair
Amaurosis fugax
Muscle and joint pain
B symptoms
GCA investigations
Bloods
- ESR ^
- Platelets ^
- ALP ^
- Hb - LOW
Colour duplex USS + Temporal artery biopsy
- Granulomatous inflammation
- May be negative due to skip lesions!
GCA management
Prednisolone (+Bisphosphonate)
Asprin (+Omeprazole)
Urgent ophthalmology review if visual symptoms
GCA complications
Irreversible bilateral visual loss
Aneurysms
CVA
Seizures
SAH causes
Aneurysm - HTN, PKD, AVM
Common places…
- ACA and anterior communicating
- MCA bifurcation
- Posterior communicating and internal carotid
SAH presentation
Sudden onset
Severe “thunderclap” headache
Meningism Focal neurological deficit CN3 palsy - Posterior communicating Seizures Reduced GCS Vomiting
Similar to meningitis - Are they systemically unwell?
SAH investigations
CT - Star shaped lesion in basal cistern
LP
- Xanthochromia - RBD breakdown product
- Protein ^
ECG
- Long QT
- ST elevation
Ophthalmoscopy
- Loss of light reflex
- Intraocular haemorrhage
SAH management
Neurosurgery - Endovascular coiling
Nimodipine - Reduces spasm
Shunt if ICP ^
SAH complications
Rebleed
Vasospasm - Stroke
Hyponatraemia
Hydrocephalus
Loss of sympathetic reflex - HTN ^^^
SDH aetiology
Tear in bridging veins
Alcoholics
Elderly - Anticoagulants?
Shaken babies
SDH presentation
Head trauma followed by…
LOC FND Headache Personality changes Reduced GCS
SDH investigations
CT - Concave lesion - Not limited by suture lines
Dark lesion = Old bleed
Bright lesion = New bleed
Midline shift?
SDH management
Burr holes
Craniotomy
Old lesion = Conservative management
EDH aetiology
Low-impact head trauma
Pterion - Joining of parietal, frontal, temporal, sphenoid bones
Middle meningeal artery - 90%
Dural venous sinus - 10%
EDH presentation
Trauma followed by lucid interval
Sudden drop in GCS
Headache
^ ICP symptoms
Brisk reflexes
Upward plantars
Symptoms of skull fracture
- Asymmetrical face
- CSF rhinorrhoea
EDH investigations and management
CT - Convex lesion - Limited by suture lines
XR - Skull fracture
LP is contraindicated!
Management
- Mannitol to treat raised ICP
- Burr holes
Parkinson’s aetiology
Degenerative
Loss of dopaminergic neurons in SN
More common in men
Mean age of diagnosis is 65
(Associated with ^ age)
Repeated head trauma - Boxing?
Iatrogenic
- Metoclopramide
- Neuroleptics
Alternative causes of tremor
Other causes of tremor…
- SSRIs
- Amphetamines
- Salbutamol
- Lithium
- Alcohol
- Thyroid disease
Wilson's disease Cerebellar trauma EPSE NPH LBD
Parkinson’s presentation
- Bradykinesia
- Resting tremor - Pill rolling
- Rigidity - Cog wheel
Shuffling gait
Reduced arm swing
REM sleep disorders Anosmia Monotone voice Micrographia Loss of facial expression Dementia Depression Urinary incontinence - NPH? Sexual dysfunction
Parkinson’s investigations
Clinical diagnosis - Bradykinesia + 1 other
Histology
- Lewy bodies
- Eosinophilic cytoplasmic inclusions consisting of alpha synuclein
Exclude differentials
- Medications?
- Cerebellar disorder - Imaging?
- Wilson’s - Bloods?
Screen for depression
Parkinson’s pharmacological management
Increase dopamine - Levodopa
Dopamine agonist - Ropinirole
Decrease dopamine breakdown
- Rasagiline
- Entacapone
Tremor
- Amantidine
- Anticholinergics
Depression - SSRI?
Parkinson’s non-pharmacological management
PT SALT OT DBS Surgery - Interruption of overactive BG circuits
Parkinson’s meds S/E
Ropinirole
- Drowsiness
- Impulsivity
- Inhibition disorder
- N/V
- Dizziness
- Visual hallucinations
Anti-ACh - Falls
Levodopa
- Reduced efficacy with time
- On/off effect - Fluctuations
- Freezing
- N/V
- Dry mouth
- Hypotension
- Dyskinesia
- Arrhythmias
Parkinson’s PLUS
VIVID
Vertical gaze palsy - Supranuclear gaze palsy
Impotence / incontinence - Multiple system atrophy
Visual hallucinations - LBD
Interfering limb - Cortico-basal degeneration
Diabetes / HTN - Vascular Parkinson’s
Tremor causes
Cerebellar disease - DANISH
Parkinson’s
Essential tremor
- Vocal cords
- Worse with arms outstretched
- Improved by alcohol and rest
- BBs
Orthostatic - Legs
Multiple system atrophy - Autonomic symptoms
Iatrogenic - See separate card
Drugs causing tremor
CALVSS
Caffeine Amphetamines Lithium Valproate Salbutamol SSRIs
NPH aetiology
Reduced CSF resorption at arachnoid villi
Idiopathic Meningitis Head injury CNS tumour SAH
NPH presentation / investigations / management
Wet Whacky Wobbly
- Urinary incontinence
- Dementia
- Falls
Investigations
- CT - Enlarged 4th ventricle
- LP - Normal opening CSF pressure
Management
- VP shunt
- Acetazolamide
Hydrocephalus aetiology
Obstructive
- Tumour
- Haemorrhage
Non-obstructive
- NPH
- Increased production - Choroid plexus tumour
Hydrocephalus presentation / investigations / management
Raised ICP symptoms
- Headache
- N/V
- Papilloedema
Investigations
- CT - Dilatation of ventricles above lesion
- LP - Diagnostic and therapeutic
Management
- Eternal ventricular drain
- VP shunt
Huntington’s aetiology
Mutation of Huntingtin gene 4p16.3
AD
Trinucleotide repeat CAG
Degeneration of cholinergic and GABA neurons in BG
Huntington’s presentation
Early
- Personality changes - Apathy
- Chorea / tics / myoclonus
Late
- Seizures
- Spasticity / clonus
- Supranuclear gaze palsy
Psych
- Dementia
- Depression
Huntington’s investigations
Genetic testing
MRI
- Loss of corpus striatum volume
- Large frontal horns of lateral ventricles
Huntington’s management
Chorea
- Benzodiazepines
- Valproate
Dopamine depleting agents - Tetrabenzene
DBS
SSRI
Antipsychotics
Reflex syncope
Vasovagal
- Emotion
- Stress
- Standing too long
Situational
- Coughing
- Micturition
- GI
- Exercise
Carotid sinus hypersensitivity
Cardiogenic syncope
All arrhythmias
Structural defects
- MI
- Valve disease
- Aortic stenosis
- Tamponade
- Dissection
BBB
Brugada syndrome
Heart block
WPW
Orthostatic hypotension
Dehydration
- Infection
- Haemorrhage
Drugs
- Diuretics
- Alcohol
- Vasodilators
AI failure
- Parkinson’s
- LBD
- Uraemia
- Diabetic neuropathy
Syncope investigations
Lying / standing BP
Change > 20/10 = Abnormal
Systolic BP < 90
24hr ECG
Cardiology exam
Neurology exam
Tilt table test
FBC - Anaemia?
Inflammatory markers
EEG
NEAD
Disorder of movement, sensation or experience
Resembles an epileptic seizure without cerebral ictal discharge
More common in females
Attacks do not occur when patient is alone
NEAD aetiology
Family history - Epilepsy?
Childhood abuse
Neglect
Psychiatric illness
- Depression
- Schizophrenia
NEAD presentation
Pelvic thrusting
Post-ictal crying
Gradual onset
Long duration
Violent thrashing
Ability to control seizure location
NEAD investigations and management
Prolactin - Normal
Video telemetry
Management - Talking therapy / CBT
Stroke classification
Anterior - ACA/MCA
- Weakness
- Paraesthesia
- Homonymous hemianopia
- Higher cognitive disorder - Dysphasia?
Posterior - Vertebrobasilar
- LOC
- Homonymous hemianopia
- Cerebellar disorder
- CN palsy
- Contralateral motor/sensory deficit
Lacunar - Perforating arteries
- Pure motor
- Pure sensory
- Ataxic hemiparesis
- Mixed sensory/motor
Additional strokes
Weber - PCA
- CN3
- Contralateral hemiparesis
Wallenberg - Posterior inferior cerebellar artery
- Ipsilateral sensory loss of pain
- Loss of gag reflex
- Hoarse voice
- Horner’s syndrome
Lateral pontine syndrome - Anterior inferior cerebellar artery
- Same as Wallenberg
+ Ipsilateral face paralysis
+ Deafness
Locked in syndrome - Basilar artery
- Unable to move except eyes
- Extraocular muscles
Aphasia
Wernicke’s - Superior temporal gyrus - MCA
- Fluent
- Impaired comprehension
Broca’s - Inferior frontal gyrus - MCA
- Not fluent
- Normal comprehension
Conduction aphasia - Arcuate fasciculus
- Fluent
- Normal comprehension
- Poor repetition
- Aware of errors
Global aphasia - All 3 areas
Stroke investigations
Glucose U&E Cardiac enzymes Clotting - INR / PT FBC ECG
CT head - Non-contrast
Ischaemic stroke management
Acute - ABCDE
- Aspirin 300mg
- Presentation < 4.5 hours - Thrombolysis (IV alteplase)
- Presentation > 4.5 hours - Endovascular thrombectomy
Secondary prevention - Aspirin 300mg - 2 weeks - Clopidogrel 75mg - For life - Statin if cholesterol > 3.5mmol/L after 48 hours Anticoags - AF patients
Haemorrhagic stroke management
Factor 7A
Reverse warfarin - Vitamin K
Reverse heparin - Protamine
Symptom control
- Seizures - Lamotrigine
- ICP - Mannitol
- BP - BB
Surgical evacuation
TIA definition
Transient episode of neurological dysfunction
Caused by focal brain, spinal cord, or retinal ischaemia
WITHOUT acute infarction
TIA presentation and investigations
Presentation - Same as stroke
- Amaurosis fugax
Investigations
- 24 hour ECG
- MRI
- Carotid doppler
TIA management
Aspirin 300mg
Clopidogrel 75mg
Statin
Carotid endarterectomy
Lifestyle changes
