Neurology Flashcards
What is the definition of TIA?
a transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischaemia, without acute infarction
TIA investigations?
Bedside: BP, ECG, 24 hour hotter, carotid USS
Bloods: cholesterol, lipids, glucose, clotting
Imaging: CT head,CT angiogram
Management of TIA?
Antithrombotic:
Initially aspirin 300 mg
ongoing: Clopidogrel 75 mg + statin
2nd line: aspirin + dipyridamole + statin
Surgical:
carotid artery endarterectomy if stenosis >50% and <2w S/S [NASCET criteria]
When do you not give aspirin in TIA?
> 7 days since symptoms
bleeding disorder/ on anticoagulant
takes regular low dose aspirin
aspirin CI
What is the definition of stroke?
rapid onset neurological deficit of a vascular origin that does not completely resolve within 24 hours
What are the types of ischaemic stroke?
thrombotic, embolic
What are the types of haemorrhage stroke?
intracerebral haemorrhage, SAH
What signs are seen in anterior cerebral artery stroke?
weakness in legs > arms
What signs are seen in an MCA stroke?
weakness in arms >legs
What criteria are considered as part of the bamford stroke classification?
- unilateral hemiparesis and or hemisensory loss
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphagia
What features are seen in total anterior circulation stroke?
- unilateral hemiparesis and or hemisensory loss
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphagia, neglect, apraxia
(ALL 3 FEATURES)
Which vessels are affected in TACS?
middle/anterior cerebral arteries
What features are seen in partial anterior circulation stroke?
2/3 of TACS
Which vessels are affected in PACS?
smaller arteries of the anterior circulation e.g. upper lower division of MCA
What features are seen in posterior stroke?
cerebellar syndrome
brainstem stroke (locked in)
homonymous hemianopia
LOC
Which vessels are affected in POCS?
vertebrobasillar arteries
What is lateral medullary syndrome aka wallenberg?
PICA infarct
What features are seen in lateral medullary syndrome?
ipsilateral: ataxia, nystagmus, dysphagia, cranial nerve palsy e.g. horners, facial numbness
contralateral: limb sensory loss
What is weber syndrome?
ipsilateral CNIII palsy, contralateral weakness
What features are seen in lacunar anterior circulation stroke?
pure motor -> posterior limb of internal capsule
pure sensory -> posterior thalamus (VPL)
mixed sensorimotor-> internal capsule
dysarthria/clumsy hand
ataxic hemiparesis -> anterior limb of internal capsule
What investigations do you do for stroke?
bedside: exam, obs, ECG
bloods: FBC, U&E, CRP, clotting, lipids, glucose
imaging: non contrast CT, carotid doppler
SPECIAL: swąllow assessment
What scoring systems may be used for stroke?
NIHSS - quantifies severity
ROSIER - assess symptoms in acute setting
CT ASPECT - assess early CT changes
what is penumbra?
area of hypoxic parenchyma that is still salvageable
What are investigations for SAH?
CT head (if -ve do LP for xanthochromia >12 h later)
what is the management of SAH/haemorrhagic stroke?
- Nimodipine (CCB; 21 days)
- coiling (IR)
- surgical clipping (requires craniotomy)
may benefit from acutely lowering BP (See trust guidance)
what is the medical management of ischaemic stroke?
aspirin 300 mg
no AF -> clopi (life long) + statin (2nd line clopi + dipyradimole + statin)
AF -> apixaban/warfarin + statin
What is the surgical/radiological management of ischaemic stroke?
<4.5h -> thrombolysis (alteplase)
<4.5h + occluded proximal anterior circulation -> throbolysis and thrombectomy
<6h ->thrombectomy
What are some absolute contraindications to thrombolysis?
previous/suspected intracranial haemorrhage seizure at onset of stroke intracranial neoplasm stroke or TBI in last 3m LP in last 7d GI haemorrhage in last 3w Active bleed pregnancy oesophageal varices HTN >200/120
What are some relative contraindications to thrombolysis?
concurrent anticoagulation (INR >1.7) haemorrhagic diathesis active diabetic haemorrhagic retinopathy intracardiac thrombus major surgery/trauma in last 2w
What is the other/wider management of stroke
fluid -keep balanced glycemic control BP control cholesterol control-statin if cholesterol >3.5 feeding assessment and management - NG? disability scales - barthel index
When would you use BP medications in stroke management
thrombolysis if BP >185/110 OR Hypertensive emergency +1 of: - hypertensive encephalopathy - hypertensive cardiac failure/MI - pre-eclampsia/eclampsia - hypertensive nephropathy - aortic dissection
Which BP medications would you use in stroke management
IV labetalol, nicardipine, clevidpine
What are the key S/S of PD?
Bradykiniesia
Tremor
Hypertonia
Stooped shuffling gait
What eye signs might you see in PD?
Nystagmus (MSA), vertical gaze palsy (PSP), slow saccades
What autonomic symptoms might be present in PD?
Postural hypotension, constipation, frequency, ED, hyper salivation, hyperhidrosis
What are the Parkinson’s plus syndromes
- multiple system atrophy (shy drager syndrome)
- progressive supra nuclear palsy (PSP)
- corticobasilar degeneration (CBD)
- dementia with lewy bodes (DLB)
What are the features of multiple system atrophy?
autonomic dysfunction (postural hypotension, bladder dysfunction)
cerebellar ataxia
rigidity >tremor
What are the features of PSP?
Vertical gaze palsy Postural instability - falls speech disturbance dementia cognitive impairment poor response to L-DOPA
What are the features of corticobasilar degeneration?
unilateral parkinsonism, aphasia, astereognosis (alien limb)
What are the features of dementia with lewy bodies?
visual hallucinatoins
fluctuating cognition
dementia - parkinsonism
Investigations of Parkinson’s?
CT/MRI to rule out vascular causes
DaTScan = dopamine transporter scan
What is the management of PD?
GENERAL:
MDT
Physio
Depression screening
MEDICAL:
Levodopa/co-careldopa
MAO-B inhibitors: selegiline
DA agonists: ropinerole
2nd line adjuncts: COMT inhibitors (entacapone/tolcapone) amantadine apomorphine deep brain stimulation
Which medications should avoided in PD and why?
metoclopramide
haloperidol
dopamine antagonists that cross BBB
What can be given for psychosis in PD?
Quetiapine
What are the side effects of levodopa?
DOPAMINE Dyskinesia On/off phenomena Psychosis Arterial BP down Mouth dryness Insomnia N&V EDS
What is the difference between parkinsonism and PD?
Distribution: symmetrical vs not
Progression: rapid vs progressive
Responseto levodopa: poor vs good
What are the causes of parkinsonism?
Vascular: Strokes Infection: syphilis, CJD, HIV Trauma Autoimmune encephalopathy Metabolic Iatrogenic (drugs)L: antipsychotics, metoclopramide Neoplasm Congenital: Wilsons
What is parkinsons disease?
a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people. It is associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter dopamine.
What is parkinsons disease?
a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, It is associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter dopamine.
What is the aetiology of AD?
- amyloid- amyloid A
- tau - neurofibrillary tangles
- inflammation - decreased neuroprotective proteins
RF for AD?
Bio: age genetics - APEN, APP, ApoE presenilin 1 gene presenilin 2 gene APP gene head injury vascular RF
Psychosocial:
LOW IQ
Poor educational level
Pathophysiology of AD?
Atrophy from neuronal loss
Plaque formation
Neurofibrillary tangle formation
Cholinergic loss
What are the 4 A’s of AD?
Amnesia
Aphasia
Agnosia
Apraxia
What are some bad prognostic indicators of AD?
MALE, depression, behavioural problems, severe focal cognitive deficit
What are some good prognostic indicators of AD?
Female
Management of AD?
BIO:
1ST - anti cholinesterase (donepezil, galantamine, rivastgmine)
2nd - NMDA agonist (memantine)
PSYCHO: Structured group cognitive stimulation sessions Group reminiscence therapy Validation therapy Multisensory therapy
SOCIAL: Optimise health in other areas Future wishes - advance directives etc House changes eg. electric etc, dosset box Carer assessment Social support Tell DVLA AND INSURERS
What should be checked before starting anticholinesterases?
ECG
CI: anticholinergics, beta blockers, NSAIDS, muscle relaxants
relative CI: asthma, COPD, GI disease, bradycardia, sick sinus syndrome, AV block
what is MS?
an autoimmune demyelinating disorder of the CNS characterised by multiple plaques in separate time and space
Aetiology of MS?
HLA-DRB1, environmental, viral
Types of MS?
Relapsing remitting (80%)
Primary progressive (10%)
Secondary progressive
Progressive relapsing
What are the signs and symptoms of MS?
TEAM Tingling Eye/optic neuritis Ataxia (and other cerebellar/DNAISH signs) Motor
Lhermitte’s sign - neck flexion gives electric shocks in trunk
Uhthoff’s sign - worsening of symptoms with raised temperature
Internuclear ophthalmoplegia
What are the symptoms of optic neuritis?
CRAP Central scotoma RAPD Acuity (decreased central and colour vision) Pain on movement
IX of MS?
Contrast MRI
LP (IgG Oligoclonal bands)
Blood Abs: Anti-MBP, NMO-IgG
Evoked potentials: delayed but well preserved waveform
Non contrast MRI: for monitoring therapies
What is Devic’s syndrome?
MS + transverse myelitis + optic atrophy
neuromyelitis optica
What is the acute management of MS?
Methylprednisolone 1g IV/PO OD for 3 days
What is the chronic management of MS?
DMARDs
- IFN beta
- Glatiramer
Biologicals
Natalizumab (anti VLA4 AB) reduces relapse by 66%
Alemtuzumab (anti CD52)
What are some good prognostic signs in MS?
Female <25yo Sensory signs at onset Few MRI lesions Long interval in relapses
What are some bad prognostic signs in MS?
Male older motor signs at onset Many MRI lesions Axonal loss Short interval in relapses
What is myaesthenia gravis?
An autoimmune disorder characterised by insufficient functioning nicotinic acetylcholine receptors