Neurology Flashcards
Symptoms of idiopathic intracranial hypertension
The symptoms include:
Headache behind the eyes
Ringing in the ears
Blurred vision
Double vision
Short temporary episodes of blindness
Nausea and vomiting
Dizziness
Papilledema (swelling of the optic disc in the eyeball) (fundoscopy)
Symptoms of raised intracranial pressure (red flag)
- headaches worse in morning and upon bending over
- headaches improve after vomiting or lying down
- May be associated with neurological deficits due to compression of cranial structures by a space-occupying lesion, such as a tumour or haemorrhage.
Migraine definition
- headache lastin 4-72hrs
at least 2 of following characteristics: - unilateral location
- pulsating quality
- ## moderate or severe pain intensity
Chronic migraines definition
Headache > or on 15 days
Acute treatments for migraines
- ## painkillers i.e paracetamol NSAIDs
Preventative treatments for migraines
- Amitryptiline
- Propanolol
Can also use botox for chronic migraines
New treatment: fremanuzumab
Symptoms of cluster headaches
- recurrent attacks of sudden unilateral periorbital pain
- associated with watery eyes, runny nose (rhinorrhoea), blood shot eye, lacrimation, miosis, ptosis, lid swelling, and facial flushing
- last 15 minutes to 3 hours, occur once or twice a day, over a period of 4-12 weeks, and are followed by a pain-free period of months before the next cluster begins
- pts tend to bang head in first attack as it relieves pain slightly
Management of cluster headaches
Acute management:
- high flow oxygen with 100% via non-breathable mask (contraindication COPD) with subcutaneous or nasal Triptan (CI: ischaemic heart disease)
- steroids can also be used
Preventative/avoid triggers:
- prophylaxis with Verapamil (calcium channel blocker)
Definition of cluster headaches
1 in 500 people
one sided
cranial autonomic features (tears, runny nose, red eye, drooping eyelid)
30-120 mins (bit shorter than migraines)
pt can be really agitated unlike a migraine
- need a scan - 10% people may have abnormality in pituitary gland
Symptoms of migraines:
- a unilateral throbbing headache preceded by an aura, such as visual (eg. lines, zigzags) or sensory (paraesthesia spreading from fingers to face) symptoms
- headache may last 4-72 hours
- associated with photofobia or phonophobia
- May be identifible triggers
- vomiting common
Definition of myasthenia gravis
autoimmune
progressive muscle weakness
nictitonic acetylcholine receptor antibodies produced by immune system, blocks post synaptic receptors, acetylcholine can’t bind, unable to contract/communication with muscles
linked to thymus gland tumours (thymomas)
Symptoms of myasthenia gravis
weakness of proximal limbs, facial muscles, eye lid muscles
worse in evening/end of day, better in morning
worsens with activity, better with rest
Investigations for myasthenia gravis
Bloods:
- serum acetylcholine receptor antibody
- muscle-specific tyrosine kinase antibodies (should be ordered if the acetylcholine receptor antibody is negative or equivocal)
- CT of the chest look for tumours of thymus
Give 3 examples of trinucleotide repeat disorders which result in neurological conditions
huntington’s (CAG repeat in HTT gene, chr 4)
Fragile X (CGG repeat in FMR1 gene on chr X)
Myotonic dystrophy (CTG repeat in DMPK gene on Chr 19).
Clinical features of small fibre peripheral neuropathy
burning pain
allodynia (non-painful stimuli experienced as pain)
hyperalgesia (painful stimuli experienced as severe pain)
Causes of motor-predominant peripheral neuropathy
gullain barre syndrome
hereditory motor neuropathies
acute intermittent porphyria
lead poisoning
paraneoplastic syndrome
definition of motor peripheral neuropathy
damage to peripheral nerves responsible for motor functions e.g foot drop
Causes of cerebellar syndrome
vascular: stroke
Infective: Lyme disease
Inflammatory: Multiple scleorisis
Traumatic: traum to posterior fossa
Metabolic: alcoholism
Iatrogenix: phenytoin, carbamazapine
tumours
vitamine E deficiecny
What is subdural haemorrhage
caused by collection of venous blood accumulating in potential space between dura mate and arachnoid mater (subdural space)
Aetiology of subdural haemorrhage
elderly pts following minor trauma
Risk factors for subdural haemorrhage
advancing age >65
Bleeding disorders or anticoagulation therapy
chronic alcohol use
recent trauma
Presentation of subdural haemorrhage
typically sub acute (within 3 days to 3 weeks) chronic (>3 weeks)
headache, nausea, vomiting, confusion, diminished eye/verbal/motor response
may be focal signs in haematoma site
dx of subdural haemorrhage
CT scan
-
What is the ROSIER screening?
scoring system used in acute settings such as A&E to recognise stroke
What is the definition of vertigo?
Hallucination of movement of oneself or one’s environment
movement often rotatory e.g floor is tilting
Causes of vertigo
benign positional paroxysmal vertigo (BPPV)
acute labyrinthitis
Meiniere’s disease
acoustic neuroma
Ramsay hunt
Ototoxicity
features of benign positional paroxysmal vertigo (BPPV)
presence of debris in semicircular canals of ears cause vertigo upon head movements
Hallpike manourve is diagnostic
epley manourves treat by clearing debris
Features of acute labyrinthitis
inflammation of vestibular nerve causing acute severe vertigo, may be associated with vomiting
hearing loss, and tinitus
associated with recent illness or vascular lesion
often resolves over a month, treatment is conservative
Meniere’s disease features
endolymphatic system pressures increase causing recurrent episodes of vertigo, sensorineural hearing loss, tinnitus and feeling or aural fullness
tx: antihistamines and bed rest
features of acoustic neuroma
/
Ramsey Hunt syndrome features
herpetic infection of facial nerve causing facial nerve palsy, with or without vertigo, tinnitus and hearing loss
Tx: aciclovir and prenisalone
Ototoxicity features
Aminoglycoside abx (gentamicin, vancomycin) and loop diuretics (furesomide)
What type of brainstem stroke can cause locked in syndrome?
Acute basilar artery infarct
Which is the first line of treatment in cases of optic neuritis?
Intravenous methylprednisolone
What is the management of a haemorrhagic stroke following ABCDE assessment?
Obtain neurosurgical opinion regarding surgical intervention (e.g decompressive hemicraniectomy)
What are the features of lateral pontine syndrome?
Lateral pontine syndrome (anterior inferior cerebellar artery): contralateral loss of pain/temperature on the body , ipsilateral nystagmus & vertigo & nausea/vomiting ipsilateral facial paralysis , ipsilateral deafness and tinnitus, ipsilateral ataxia ipsilateral impaired facial sensation
Features of posterior circulation infarct?
cerebellar dysfunction OR
conjugate eye movement disorder OR
Bilateral motor/sensory deficit OR
ipsilateral cranial nerve palsy with contralateral motor/sensory deficit OR
cortical blindness/isolated hemianopia
What is Foville’s syndrome?
/
What is Horner’s syndrome
interruption of the sympathetic nervous supply to the eye
Causes of Horner’s syndrome
pancoast tumour (affecting sympathetic nervous supply)
Stroke
Carotid artery dissection (red flag: neck pain)
Clinical presentation of Wallenburg syndrome
DANVAH
Dysphagia
ipsilateral Ataxia
ipsilateral Nystagmus
Vertigo
Anaethesia (ipsilateral facial numbness and contralateral pain loss on the body)
ipsilateral Horner’s syndrome
What causes Wallenburg syndrome
infarction of posterior inferior cerebellar artery (PICA)
Features of cerebellar syndrome
DANISH
dysdiadochokinesia (inability to perform rapid alternating hand movements)
Ataxia (broad based unsteady gait)
Nystagmus (involuntary eye movements)
Intention tremor (finger nose test)
Slurred speech
hypotonia
Causes of cerebellar syndrome
VITAMIN C
vascular: stroke
Infective: Lyme disease
Inflammatory: multiple scleorisis
Traumatic: trauma to posterior fossa
Metabolic: alcoholism
Iatrogenic: phenytoin and carbamezepine
Neoplastic: primary tumours (cerebellopontine angle tumour)
Congenital: Friedrich’s ataxia
A 70 year old male patient presents to the emergency department with sudden onset unsteadiness. His wife reports that his speech is slurred and he appears to be walking as if drunk. He has a past medical history of hypertension and hypercholesterolaemia.
On physical examination there is ataxia, right-sided intention tremor, dysarthria and nystagmus.
Which of the following is the most appropriate urgent investigation?
CT head
most appropiate in pts with suspected stoke
A patient presents with unsteadiness on their feet. The doctor performs a test whereby the patient is asked to stand up with their eyes open, and then they are asked to close their eyes. The patient is stable with their eyes open, however upon closing the eyes, they become unsteady. Which of the following is the most appropriate conclusion?
pt is Rhomberg’s positive and has sensory ataxia
its sensory because it happens when eyes are closed
Clinical features of Herpes Zoster ophthalmicus
painful red eye, fever, malaise and headache
precede typical erythematous vesicular rash over trigeminal division of opthalmic nerve
Treatment of Herpes Zoster ophthalmicus
Oral aciclovir with topical steroids.
What is encephalitis
infalmmation of encephalon or brain parenchyma
Clinical features of encephalitis
altered mental state
fever
flu like symptoms
early seizures
Cause of encephalitis
herpes simplex virus type 1
What causes encephalopathy
hypoglycaemia
hepatic encephalopathy
DKA
drug induced
SLE
Investigations for encephalitis
suspected in any pt with sudden onset behavioural change, new seizures and unexplained acute headache with meningism
blood tests, blood cultures, viral PCR
CSF
malaria blood forms
treatment of encephalitis
broad specturm abx with 2g IV ceftriaxone BD and 10mg/kg aciclovir TDS for 2 weeks
side effects of aciclovir
generalised fatigue/malaise
GI disturbance
photosensitivity and urticarial rash
acute renal failure
haem abnormalities
hepatitis
neurological reactions
What are focal seizures with impairment of consciousness (complex focal seziures)?
pts lose consciousness either after an aura or at seizure onset
most commonly originate from temporal lobe
post-ictal sx common e.g confusion in temporal lobe seizures.
What are simple focal seizures?
without impairment of consciousness
pts don’t lose consciousness, only experience focal sx
post-itcal sx don’t occur
What are secondary generalised focal seizures
focal seizure –> tonic-clonic
Features of temporal-lobe specific focal sezirue
automatisms (lip-smacking, deje vu, jamais vu, emotional disturbance ‘sudden terror’, olfactory, gustatory or auditory hallucinations
Features of frontal-lobe specific focal sezirue
motor features e.g jacksonian features, dysphasia, Todd’s palsy
Features of parietal-lobe specific focal sezirue
sensory symptoms; tingling and numbness, motor sx: spread of electrical activity to pre-central gyrus in frontal lobe
Features of occipital-lobe specific focal sezirue
visual symptoms such as spots and lines in visual field
What are absent seizures
pts often children pause briefly, for less than 10 seconds, then carry on where they left off.
Tx: sodium valporate (SE: weight gain, hair loss, oedema, ataxis, tremor, tetraogenicity) or ethosuximide 1st line
AVOID carbamazepine as makes seizures worse
What are tonic clonic seizures
pts lose consciouness
limbs stiffen and then start jerking
post-ictal confusion
TX: sodium valporate or lamotrigine 1st line
What are myoclonic seizure
sudden jerk of limb, trunk or face.
Tx: sodium valporate 1st line unless pt is woman of child bearing age then it’s levetiracetam or topiramate.
AVOID carbamazapine
What are atonic seizures
sudden loss of muscle tone, causing pt to fall whilst retaining consciousness
Tx: sodium valporate or lamotrigine
What are complications of epilepsy
status eplicticus (treat with IV lorazepam/buccal midazolam, then phenytoin
depression
suicide
sudden unexpected death in epilepsy
mx for focal seizures
carbamazepine, gabapentin and phenytoin
What is giant cell arteritis
arteries on side of head become inflammed
Presentation of giant cell arteritis
temporal headache
jaw claudication (pain on chewing food)
amaurosis fugax (like dark curtain descending vertically in vision)
thickened, tender temporal artery on examination
scalp tenderness
complications of giant cell arteritis
stroke
permenant monocular blindness
investigations for giant cell arteritis
ESR, FBC, LFTS
definitive investigation: temporal artery biopsy
mx for giant cell arteritis
high dose steroid: 60mg OD prednisolone
What is cauda equina syndrome
compression of cauda equina
L1
Cause of cauda equina syndrome
lumbar disc herniation at L4/5 and L5/s1
Clinical features of cauda equina syndrome
lower back pain
bilateral radicular pain
saddle anaethesia
bladder and bowel disturbance
Mx of cauda equina syndrome
urgent WHOLE spine MRI
surgical decompression
in pts where malignancy seen or suspicion high: 16mg OD dexamethasone with PPI cover
What is brown-sequard syndrome
anatomical dsiruption of nerve fibre tracts in one half of spinal cord
Clinical features of brown-sequard syndrome
disruption of descending lateral corticospinal tracts, ascending dorsal column and ascending spinothalamic tracts
ispilateral hemiplegia
ipsilateral loss of proprioception and vibration
contralateral loss of pain and temp sensation
Causes of brown-sequard syndrome
cord trauma
neoplasma
disk herniation
demyelination
infective/inflammatory lesions
epidural haematomas
Mx of brown-sequard syndrome
surgery or medical
What is Guillain- Barre syndrome
ascending inflammatory demyelinating polyneuropathy
Clincial features of Guillain- Barre syndrome
progressive ascending symmetrical limb weakness, starts from feet and moves up
reduced reflexes and loss of sensation
4 WEEKS AFTER INFECTION OF GASTRITIS/DIARRHOEA/FOOD POISONING
mx of Guillain- Barre syndrome
IV immunoglobulins
Intubation/ventiliation IF RESP FAILURE
FVC NEEDS TO BE MONITORED
Causes of Guillain-Barre Syndrome
Campylobacter jejuni infection
what cranial nerve lesion is seen in left sided Bell’s palsy
Left 7th cranial nerve LMN lesion
mx of TIA
300mg aspirin
review in 24hrs
1st line treatment of optic neuritis
IV methlyprednisolone
1st line imaging investigation in acute stroke
non-contrast CT head
why? exclude haemorrhage
secondary stroke prevention
HALTSS
hypertension: anti-tensive therapy
Antiplatlet therapy: clopidogrel 75mg OD
lipid lowering drugs: 20-80mg ON atorvastatin
smoking cessation
diabetes managed appropiately
surgey
What type of brainstem stroke can cause locked in syndrome?
acute basilar artery infarct
cardinal signs of middle cerebral artery stroke
contralateral hemiplegia
contralateral homonymous hemianopia
dysphasia
how do lesions in medulla present
cranial nerve IX, X, XI, XII palsies
What are the features of a total anterior circulation infarct according to the bamford classification?
contralateral hemiplagia or haemparesis AND
contralateral homonymous hemianopia AND
higher cerebral dysfunction (aphasia, neglect)
What are the features of a posterior circulation infarct according to the bamford classification?
Cerebellar dysfunction, OR
Conjugate eye movement disorder, OR
Bilateral motor/sensory deficit, OR
Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit, OR
Cortical blindness/isolated hemianopia.
What is the Oxford-Bamford criteria for a total anterior circulation stroke?
All three of 1) Unilateral weakness and/or sensory deficit in the face, arm and leg 2) Homonymous hemianopia 3) Higher cerebral dysfunction (dysphasia, visuospatial disorder)
To be eligible for thrombolysis, which time window must patients with ischaemic stroke present in?
less than 4.5 hrs sx onset
What are the features of a partial anterior circulation infarct according to the bamford classification?
A partial anterior circulation infarct (PACI) is defined by:
2 of the following:
Contralateral hemiplegia or hemiparesis, AND
Contralateral homonymous hemianopia, AND
Higher cerebral dysfunction (e.g. aphasia, neglect) OR Higher cerebral dysfunction alone.
Which stroke syndrome affects the medulla?
Lateral medullary syndrome (posterior inferior cerebellar artery)
If speech is affected, which hemisphere is affected?
Dominant hemisphere strokes (Left side of the brain for most people) can cause dysphasia or aphasia.
Which stroke syndrome affects the Pons?
Lateral pontine syndrome (anterior inferior cerebellar artery)
What symptoms do MCA lesions produce?
Middle cerebral artery infarcts affect the contralateral arm, leg and face.
4 causes of painless monocular visual loss
anterior ischaemia optic neuritis
amaourosis fugaz
vitreous hamorrhage
retinal detachment
Risk factors for haemorrhagic stroke
age, male, haemophilia, cerebral amyloid angiopathy/hypertension, anti-coagulation, sympathomimetic drugs (cocaine, amphetamines)
mx of Myasthenia gravis
acute - steroids
long term - acetylcholinesterase inhibitors (pyridostigmine or neostigmine)
mx of myasthenic crisis
Ventiliation (resp failure)
IV immunoglobulins
pathophysiology of guillain-barre syndrome
b cells produce antibodies to infection antigen (campylobacter jejuni)
antibodies also match receptors of neurons
antibodies produced attack nerves (motor)
pathophysiology of multiple sclerosis
demeylenation of CNS neurons
immune system attacks neurones - struggle to commincate –> results in sensory, motor + cognitive problems
4 types of multiple sclerosis
relapsing - remitting
secondary progressive
primary progressive
progressive relapsing
acute progressive weakness
spasitic paraparesis, brisk reflexes
patchy sensory disturbances
white matter plaques on brain MRI
optic neuritis
oligoclonal bands in CSF
periventricular plaques
presentation of what neurological disease?
Multiple sclerosis
mx of acute attack Multiple sclerosis
IV methyl prednisolone (1g)
if doesnt work - plasma exchange
chronic mx of Multiple sclerosis
injectable beta interferon
investigations to support dx of Multiple sclerosis
CSF
MRI
