Neurology 1 - Demyelination, Facial Pain And Cerebrovascular Flashcards

1
Q

Look at m recap

A
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2
Q

What is a stroke?
What are the 2 types?
What are the stroke common symptoms?

A

A focal neurological deficit which lasts longer than 24 hours resulting from a vascular lesion.

  1. Ischaemic
  2. Haemorrhagic

Face – Asymmetry of the face – Unilateral palsy
Arms – Weakness in the arms
Speech - Slurring of speech - (Dysarthria)
Time – Phone for help

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3
Q

Stroke symptoms?

A

Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
Palsy is paralysis.

Sudden severe headache with no known cause. (Haemorrhagic)

Confusion, trouble speaking, or difficulty understanding speech.

Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write.

Sudden trouble seeing in one or both eyes. (Visual Field Defects)

Ataxia - Sudden trouble walking (gait disturbance), dizziness, loss of balance, or lack of coordination.

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4
Q

Ischaemic stroke?
How do you treat it?

A

Area of the brain deprived of blood

Obstruction blocks the flow to part of the brain

Thrombus (Atheroma, Vegetations – IE) Atheroma / atherosclerotic plaques Severe hypoteinsion

80% of all stroke events

Treatment with thrombolysis in acute phase (Alteplase)

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5
Q

Haemorrhagic stroke?

A

Area of bleeding

Weakened vessel walls rupturing causing bleeding into the brain

Aneurysm

20% of all stroke events

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6
Q

What is a Transient Ischemic Attack ?

A

A focal neurological deficit which lasts less than 24 hours resulting from a vascular lesion. The deficit fully resolves

Temporary in nature

Requires active preventative treatment and investigation

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7
Q

Risk factors of a stroke?

A

Diabetes
Cigarettes
Obesity
Oestrogen OCP
Excess EtOH
Polycythaemia (Raised haemaglobin)
Atheroma (hypercholesterol / lipid aemia)

Hereditable nature
Hypertension

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8
Q

Is left side is damaged what side of body paralysed?

A
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9
Q

Lesions and outcomes of a stroke

A
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10
Q

What is the treatment and risk reduction of a stroke?

A

Nil by mouth = no food, drink or mouth medication (until salt therapy - language and speech assessment)

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11
Q

What can be given to prevent a TIA?

A

Carotid endarterectomy

Tia = warning shot / mini stroke

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12
Q

What is Subarachnoid Haemorrhage ?

A

Uncommon type of stroke caused by bleeding into the brain. - Arterial

Classic “Thunderclap headache” with neck stiffness
Circle of Willis Berry Aneurysm rupture
Sudden LOC – shortly after event

Menginism
High pressure so fast onset
MRI
Often Neuro surgery  clip & Tie bleeder if not stopped spontaneously

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13
Q

What is extradural haematoma?

A

Young patient

Involved in a head strike (either during sport or a result of a motor vehicle accident) may or may not lose consciousness transiently.

Following the injury they regain a normal level of consciousness (lucid interval).

Usually have an ongoing and often severe headache.

Over the next few hours they gradually lose consciousness.

Arterial Middle meningeal artery damage CT/MRI - convex blood mass

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14
Q

What is subdural haematoma?

A

“Below the dura”

Slower onset – venous

Collection between the dura and the brain

Blood collection causes ”mass effect”

Typically after fall (anti- coagulants)

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15
Q

What are the different types of brain haemorrhage?
(4)

A

1) epidural haematoma
2) subdural haematoma
3) subarachnoid haemorrhage
4) inter-cerebral haemorrhage

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16
Q

What is epilepsy?
What are the types of epilepsy?
Does epilepsy always have seizures?

A

A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain.

Various types of epilepsy – General, Focal (simple partial)

Not all have seizures

Temporary bursts of electrical activity in the brain that affects how the brain works.

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17
Q

When does epilepsy start?
How long does epilepsy last?
How is epilepsy managed?

A

Can start at any age, but usually in childhood or over 60
Can be secondary to other neurological pathologies – tumors / strokes
Life-long condition
Managed with anti-convulsants

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18
Q

What is a tonic clonic seizure? (Grand mal)

A

Muscle Contractions
Stiff, Jerking muscular movements
Unable to communicate – blank stare / aphasic
Vomiting or loss of bladder/bowels
Cheek and tongue biting
Breathing difficulties
Loss of consciousness
Recovery – Variable but 5 minute duration not unusual
“Feels like I ran a marathon”

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19
Q

What are simple partial seizures?

A

Simple partial (focal) seizures or “auras” can cause:

A simple partial seizure a general strange feeling that’s hard to describe

A feeling that events have happened before (déjà vu)

A sinking feeling in your abdomen – like when on a fairground ride

Unusual smells or tastes / tingling in your arms and legs stiffness or twitching in part of your body, such as an arm or hand
You remain awake and aware while this happens.
Considered as “warnings” or “auras” as they can be a herald of another type of seizure

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20
Q

What are complex partial seizures?

A

During a complex partial seizure, you lose your sense of awareness and make random body movements, such as:

Smacking of lips

Rubbing of hands

Making random noises

Moving arms around

Picking at clothes or fiddling with objects

Chewing or swallowing

Patient won’t be able to respond to anyone during seizure and won’t have any memory of it.

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21
Q

What is Absences (Petit-mal) ?
Absence Seizure

A

An absence seizure, is where you lose awareness of your surroundings for a short time. Mainly affect children, but can happen at any age.
During an absence seizure, a person may:
Stare blankly into space
Look like they’re “daydreaming”
Flutter their eyes
Make slight jerking movements of their body or limbs
The seizures usually only last up to 15 seconds and you won’t be able to remember them.
They can happen several times a day.

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22
Q

Other types of seizures?

A
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23
Q

Seizure - triggers
What are the triggers for a seizure?

A

Stress
Fatigue
Lights (Photosensitive 3%)
Alcohol
Missing medication
Coffee
Nicotine

24
Q

What are the investigations for a seizure?

A

CT Scan - First Seizure
MRI
EEG – electroencephalogram
Blood tests – to investigate underlying electrolyte cause
low glucose (hypoglycaemia) low sodium (hyponatraemia)

25
Q

What are the treatments for a seizure?

A

Treatment aims :- minimize or stop seizures completely

Treatments include:
Anti-epileptic drugs -the main treatment

Surgery to remove a small part of the brain that are causing the seizures (Rarely)

A procedure to put a small electrical device inside the body that can help control seizures – (Vegus nerve or deep brain stimulation)

A special diet (ketogenic diet) that can help control seizures

If triggers are known & can be avoided, treatment may be avoided

Some people need treatment for life but some might be able to stop treatment if your seizures disappear over time.

26
Q

What are anti epileptic drugs? (AED)
Do they cure epilepsy?
How often do you use them?
Examples?

A

AEDs are the most commonly used treatment for epilepsy. They help control seizures in about 70% of people.

AEDs work by changing the levels of chemicals in your brain. They don’t cure epilepsy, but can stop seizures happening.

Must be used EVERY day- sudden cessation can provoke a seizure – cessation is slow withdrawal.

• Phenytoin
• Sodium valproate
• Carbamazepine
• Lamotrigine
• Levetiracetam
• Oxcarbazepine
• Ethosuximide
• Topiramate

AED’s have a significant teratogenic profile (cause deformities in foetus in pregnant mum is taking it)

27
Q

AEDs - dental relevance?

A

Trauma
Broken restorations
Diet
Oral Hygiene Compliance
Drug Side Effects

Phenytoin induced gingival hyperplasia !!!!!

28
Q

Multiple sclerosis
What is it ?
Affects more males or females?
Cause?

A

Common Neurological Condition (1:1000)
Characterised by areas of demyelination in CNS

Higher female prevalence

Geographic variance in prevalence

Unknown cause - ?Viral / Autoimmune mechanism
More common in family members, but no known inheritance pattern

29
Q

Multiple sclerosis Pathology?
What doesn’t it involve?
Predilection for?

A

Peri-venular plaques of demyelination

Predilection for:
Optic nerves - (First presentation can be optic neuritis)
Periventricular white matter
Brainstem & cerebellar connections
Cervical spinal cord – corticospinal and dorsal columns

MS Does not involve the peripheral nerves.
N.B – Guillan Barre Syndrome (Locked in) does affect the peripheral nerves and results in peripheral demyelination)

30
Q

Multiple sclerosis symptoms?

A

Highly Variable

Any symptom starts rapidly before evolving over a few days – peak intensity
Symptoms then resolves partially / fully after a few weeks

Typically associated with periods of chronic fatigue
Axonal blockade -> slowing / ceasing of neuro-conduction

“Recovery”
Whole / partial regression of perineural oedema & partial re- myelination

31
Q

Multiple sclerosis investigations?

A

MRI

Brain & Spinal cord (CNS) 1st line Ix – demyelination plaques – white lesions –
Esp peri-ventricular & Brainstem - Rarely visible on CT

Electrophysiology

Visual evoked Potentials (light flash - record on optic cortex - ? slowed/ decr amplitude)
Auditory evoked Potentials (sound evoked version)
Somatosensory – touch smell etc

32
Q

Types of multiple sclerosis

A
33
Q

Multiple Sclerosis - Optic Neuritis

A
34
Q

Facial pain different types

A

Allodynia
Hyperalgesia
Dysaesthesia
Hypoalgesia
Paraesthesia
Anaesthesia
Neuralgia
Neuropathic
Neuropathy

35
Q

Facial pain: Allodynia?
Definition

A

pain from normally non- painful stimulus

36
Q

Facial pain: Hyperalgesia?
Definition

A

increased response to normally painful stimulus

37
Q

Facial pain : Dysaesthesia?
Definition

A

Unpleasant sensation spontaneous or evoked

38
Q

Facial pain : Paraesthesia?
Definition

A

abnormal sensation – spontaneous / evoked – not unpleasant

39
Q

Facial pain : Hypoalgesia?
Definition

A

diminished pain response to painful stimulus

40
Q

Facial pain : Anaesthesia
Definition

A

no pain from painful stimulus

41
Q

Facial pain : Neuralgia
Definition

A

nerve distribution pain

42
Q

Facial pain : Neuropathic
Definition

A

nerve pathol / damage pain

43
Q

Facial pain : Neuropathy
Definition

A

Nerve function / damage / pathology pain

44
Q

Common neurological presentations of facial pain?

A

Dental pain

Trigeminal neuralgia

Trigeminal neuropathic pain

Trigeminal autonomic cephalgia

Post herpetic neuralgia

45
Q

What could dental pain be in new case?

A

Acute/ chronic pulpitis
Dentine sensitivity
Perio / Perio-endo

46
Q

What could dental pain be when undergoing treatment ?

A

High filling
Pulp exposure
Chemical / thermal irritation (curing lights)
Crack cusp?
Phoenix abscess
Perio-endo
Lateral canals??

47
Q

What do we use to take a history of facial pain?

A

SOCRATES

Social history

Additional examinations and investigatioms

48
Q

How does Trigeminal neuralgia present?

A
49
Q

What are the causes and treatment of Trigeminal neuralgia?

A

Causes -
majority no cause identified
Some - vascular compression of Trigeminal nerve as it leaves skull base
Multiple sclerosis

Treatment -
Carbamazepine
Oxcarbaezpine
Lamotragine

• LA Injections (Temporary)
• Nerve ablation (Gamma knife, Thermo, Chemical)
• Vascular decompression

50
Q

Glossopharyngeal Neuralgia
What is it?
What does it affect?
What are the triggers?

A

Paroxysmal pain in ear, base of tongue, tonsillar fossa or angle of jaw

Similar treatment modalities as trigeminal neuralgia.

Affects sensory areas of IX nerve

Triggers chewing, swallowing, talking, yawning and coughing

51
Q

What is post herpetic neuralgia?

A

Occurs from shingles (herpes zoster)

In the elderly and immunosuppressed
Pain is steady and sustained
Persists for several months
Paroxysmal shooting pain
Erythema and typical herpetiform rash

52
Q

Trigeminal Autonomic Cephalgias

A

TN like History
Localised to V1/2
Recurrent episodic headaches
Males – 20-50y/o
Peri-orbital pain
Fast onset

Often autonomic features
Red eye
Tearing

53
Q

Trigeminal Neuropathic Pain

A

Pain caused by insult to the peripheral nerves.
Following removal of the painful stimulus, the pain or altered sensation persists.
Some patients report burning sensations.

Managed with anti-depressant therapy such as nortriptyline

Psychology

Self management

54
Q

Persistent Idiopathic Facial Pain

A

Nagging dull throbbing / persecuting pain
Doesn’t conform to anatomical boundaries – typically crosses midline
Typically doesn’t disturb sleep – awake for diff reason then appreciate the pain
Relieved by relaxation / rest

Management techniques include pychology – CBT
Self management – meditation, stress and lifestyle modulation
Antidepressants Nortryptyline, Amitryptiline

55
Q

Burning Mouth Syndrome

A

Idiopathic burning sensation on the tongue. Can also include unusual tastes.
Female predisposition
Age > 40
Must exclude low Ferritin, B12, Candida
Often subjective dry mouth
Stress and anxiety can modulate the level of burning
Psychology
Symptomatic relief (Difflam/lidocaine)
Anti-depressants