Neurology Flashcards
TIA
Acute loss of cerebral/ ocular Function with symptoms lasting <24hrs.
- Due to atherothromboembolism from an artery.
TIA Risk Factors
- Age
- HTN
- smoking
- CVD
- AF
- Diabetes
2 Types of TIAs
→ Carotid Artery
→ Vertebrobasilar Artery
Carotid Artery TIA Presentation
In anterior cerebral circulation
- Amaurosis fugax (leg weakness, temporary reduction in ciliary blood flow)
- Aphasia
- Hemiparesis
- Hemisensory loss
Vertebrobasilar Artery TIA Presentation
- Diplopia
- vomiting
- Choking
- vertigo
- Ataxia
- Hemisensory loss
TIA Investigations
1st line = Diffusion weighted MRI or CT.
2nd line = Carotid imaging - doppler ultrasound followed by angiography if stenosis is found.
TIA Management
Antiplatelet therapy: 75mg of Aspirin daily + Clopidogrel
Anticoagulation (warfarin) - for those with AF
Carotid endarterectomy
Ischaemic stroke
⇒ Blood vessel to / in brain occluded by a clot.
Ischaemic Stroke Types
- Anterior Cerebral Artery
- Middle Cerebral Artery
- Posterior Cerebral Artery
- Vertebrobasilar Artery
- Lateral Medullary Syndrome
- Brainstem Infarction
Ischaemic Stroke ACA Presentation
→ Contralateral weakness and sensory loss of the lower limb.
→ Incontinence
→ Drowsiness
→ Truncal ataxia
Ischaemic Stroke MCA Presentation
→ Contralateral motor weakness + Sensory loss
→ Hemiparesis
→ Speech issues
→ Facial droop
Ischaemic stroke PCA presentation
→ Perception
→ Homonymous hemianopia
Ischaemic stroke Vertebrobasilar Artery Presentation
→ Coordination and balance
Ischaemic Stroke lateral medullary Syndrome Presentation
→ Sudden vomiting & vertigo
→ Ipsilateral Horner ‘s syndrome = Reduced sweating , facial numbness , limb ataxia , dysphagia
Ischaemic stroke Brainstem Infarction Presentation
→ Quadriplegia
→ Facial paralysis/ numbness
→ Coma
→ locked in syndrome
→ Altered consciousness , vertigo , vomiting
Ischaemic Stroke Management
- CT / MRI to exclude haemorrhage
- Aspirin for 2 weeks
- Then Clopidogrel
- Anticoagulation (e.g. Warfarin) - Atrial fib. patients
- Thrombolysis - IV Alteplase
- Mechanical thrombectomy
Extradural Haematoma
Bleeding between the skull and the dura mater - usually due to fracture of the skull affecting the middle meningeal artery.
Extradural haemorrhage Presentation
- Deterioration in GCS [ Glasgow Coma Scale ] - Lucid interval
- Symptoms of increased Intracranial pressure - headache, vomiting, confusion, fits, hemiparesis
- Symptoms of brainstem compression - deep irregular breathing, death by cardiorespiratory arrest
Extradural Haematoma Management
- Ventilation
- Craniectomy → Clot evacuation & ligation
- IV Mannitol - for Increased ICP
Extradural Haematoma identification
Lemon-shaped lesion on a CT Skull fracture - Temporal or Parietal bone
Subarachnoid Haematoma
Bleeding between the arachnoid mater & Pia mater.
Subarachnoid Haematoma Presentation
- Sudden onset Occipital Thunderclap headache
- Meningism (fever, headache, neck stiffness)
- Collapse
- Seizures
- Loss of consciousness
Subarachnoid Haematoma Investigation
- CT
- Lumbar Puncture ( Xanthochromia)
Subarachnoid Haematoma Identification
Star - shaped lesion on a CT Berry aneurysm rupture
” Thunderclap headache”
Subarachnoid Haematoma Management
- Nimodipine for 3 weeks (CCB)
- Endovascular coiling
Subdural Haematoma
Bleeding between the dura mater & arachnoid mater
Subdural Haematoma Presentation
- Headache
- Fluctuating GCS
- Sleepiness
- Gradual mental / physical slowing
- Unsteadiness
Subdural Haematoma Investigations
- CT
Midline shift of brain
Subdural Haematoma Management
1st = Irrigation via burr-hole craniotomy
2nd = Craniotomy
Subdural Haematoma Identification
Banana shaped lesion on a CT clot turns from White to Grey over time
Small trauma long time ago
Epilepsy
Recurrent to spontaneous, intermittent, abnormal electrical activity in part of brain - manifesting in seizures
Epilepsy causes
- Idiopathic
- Cortical scarring
- Tumour
- Stroke / alzheimer
- Alcohol withdrawal
Epilepsy Risks
Fx
Cocaine
Premature babies
Epilepsy Criteria
2 unprovoked seizures occurring > 24 hr apart
One unprovoked seizure + probability of future seizures
Epilepsy Diagnosis
EEG
MRI /CT head
Bloods
Epilepsy treatment
Sodium Valproate
Pregnant: Lamotrigine
Myoclinic = Levitiracetam / Topiramate Absence = Ethosuximide
Partial seizure = Lamotrigine / Carbamazepine
Status epilepticus management
IV Lorazepam
if ineffective = Phenytoin
Non epileptic seizures
Metabolic disturbance
Don’t occur in sleep
No muscle pain
Components of seizure
Prodrome: Weird feeling
Aura: Patient aware, strange feeling in gut, Strange smells, deja vu
Postictal: Temporary weakness after focal seizure in motor cortex = Postictal Todd’s palsy
→ Dysphagia after temporal lobe seizure
Types of Seizures
→ Primary generalised
→ Partial focal seizure
→ Partial seizure with 2° generalisation
1° Generalised seizure types
→ Tonic = high hove (stiff limbs) → Clonic = muscle jerking → Tonic Clonic = muscle jerking & rigidity → Atonic = loss of muscle tone (fIoppy) → Absence = childhood - Stares blankly
Parkinson’s Disease
Destruction of dopaminergic neurons.
Parkinson’s Presentation
- Tremor & rigidity
- Parkinsonion gait
- Bradykinesia
- Dementia
- Disordered sleep
Parkinson’s Investigation
DaTscan
- B amyloid plaques, Tremor, Cog-wheel walk, Stooped gait
Parkinson’s Management
Young & fit:
→ Dopamine agonist = Ropinirole
→ MOA- B inhibitor = Rasagiline
→ Levo-DOPA = Co - Careldopa
Frail & unfit:
→ L-DOPA
→ MOA - B inhibitor
Huntington’s
Progressive neurodegenerative disorder with 100% Penetrance.
- Loss of main inhibitory neurotransmitter GABA
Huntington’s Pathophysiology
Less GABA → Less dopamine regulation to striatum → Increased dopamine levels → Excessive thalamic stimulation & increased movement.
Repeated CAG
Mutation on chrome. 4
Huntington’s Features
- Chorea
- Dystonia
- Incoordination
- Cognitive
- Irritability, Agitation
Huntington’s Investigations
MRI/ CT = loss of striatal volume
Genetic testing
Huntington ‘s Treatment
- Benzodiazepines / Valproic acid for chorea
- SSRI for depression
- Haloperidol, Risperidone for psychosis
Huntington’s Differential Diagnosis
Sydenham’s chorea (Rheumatic fever)
Dementia Types
- Alzheimer’s
- Vascular
- Lewy body
- Frontotemporal
- Other causes : Infection, SLE, Sarcoidosis
Alzheimer’s
Ix
Tx
B- amyloid plaques Neurofibrillary tangles, Damaged synapses
Ix = MRI
Tx = Acetylcholinesterase e.g. Donepezil, Galantine
Vascular Dementia
lx
Tx
Multiple infarcts.
Stepwise deterioration pathy deficits.
Ix = MRI - Infarcts
Tx = Manage predisposing factors i.e. hypertension
Lewy Body
Sx
Tx
Lewybodies in occipito - parietal region.
Sx = Fluctuating cognitive dysfunction, visual hallucinations, Parkinsonism
Tx = Manage Predisposing factors
Frontotemporal
Sx
Ix
Pick bodies
Sx : Disinhibition, Personality change, early memory present., aphasia
Ix : MRI - frontal or temporal atrophy
Headache types
1°:
→ Migraines
→ Tension
→ Cluster
2°:
→ Giant Cell / temporal arteritis
→ Trauma
→ Med. overuse
Migraine
Recurrent throbbing headache often preceded by aura + associated with nausea, vomiting & visual change.
Migraine Presentation
Prodrome: Yawning, craving, sleep change
Aura: Visual disturbance (line, dots), Somatosensory (Paraesthesia, Pins & needles)
→ Unilateral pain
→ Throbbing pain
→ Photophobia + Phonophobia
Migraine Management
Mild = NSAIDs Severe = Oral Triptans e.g. Sumatriptan
Prophylaxis = Beta blockers, Acupuncture, Amitriptyline, Topiramate
Tension headache
Most chronic & recurrent daily headache.
Tension Headache Causes
- Missed meals
- Stress
- Fatigue
- Depression
Tension Headache Presentation
- Bilateral, Pressing headache
- Not aggravated by movement
- No Nausea + vomiting
- Scalp tenderness
Tension Headache Management
- Reassurance
- Stress relief
- NSAIDs
- TCA - Amitriptyline
- Analgesia
Tension Headache Diff. Diagnosis
- Migraine
- Cluster
- GCA
- Drug induced
Cluster headache
risks
→ Pain localised to orbital / Supraorbital region
- male
- Smoker
- Alcohol
- Genetic
Cluster headache Signs & Symp.
→ Rhinorrhoea → lid swelling → lacrimation & nasal congestion → Miosis → Sweating
Cluster headache
Ix
Management
Ix: Clinical exam. & history
Tx:
→ O2
→ Sumatriptan
→ CCB - Verapamil
Multiple Sclerosis
Chronic inflammation of the CNS - CD4 cell- mediated destruction.
Multiple plaques of demyelination
MS Presentation
- Paraesthesia
- Incontinence
- Sensory ataxia
Charcot’s Triad :
→ Nystagmus (uncontrolled eye movements)
→ Inattention Tremor
→ Dysarthria (slurred speech)
MS investigation
MRI Scans - typical lesions
Lumbar puncture - Oligoclonal bands in CSF
MS Managment
MDT approach
Acute = Methylprednisolone
Relapse = DMARDS or Biologicals (Methotrexate)
Myasthenia Gravis Presentation
Autoimmune disease.
Muscular fatigue
Worsened by pregnancy, Infection, Emotion, Drugs
MG Investigations
Positive tensiIon test
MG Management
Symptom Control
Immunosuppression
Meningitis
Risks
Inflammation of meninges, due to infection.
Risk = Travel, Immunocompromised, Pregnancy
Meningitis Bacterial Causes
Bacterial:
Baby = Group B strep.
Child = Strep. Pneumoniae
< 50 = Neisseria Meningitis + Strep. Pneum.
> 50 = Strep. Pneum. + Listeria Monocytogenes
Neis. can cause Meningococcal septicaemia
Meningitis Viral & Fungal cause
Viral :
Enterovirus, HSV (Herpes)
Fungal :
Cryptococcus , Candida
Meningitis Symptoms
Triad of Fever, Headache, Neck Stiffness
Photophobia
Non- blanching petechial & purpuric rash
Meningitis Signs
Kerning’s & Brudzinski’s - + ve
Glass test = blanching or non blanching rash
Meningitis Diagnosis
1st Line = Blood cultures
Lumbar puncture + CT Scan
CSF analysis:
→ Bacterial = Increased neutrophils, less glucose, release Proteins into CSF.
→ Viral = Increased lymphocytes, increased glucose, small protein release into CSF
Meningitis Treatment
Bacterial = Ciprofloxacin Viral = Acyclovir
Guillain - Barre Syndrome
Neuropathy often after infection.
G- B Syndrome Presentation
- Breathing problem
- Back pain
- Sensory disturbance
- Sweating
- Urinary retention
G- B Syndrome Investigations
- Slow conduction velocities
- Protein in CSP
G-B Syndrome
Da agonist = Ropinirole
MOA - B inhibitor = Rasagiline
L-DOPA = Co - careldopa
Syncope
Temporarily losing consciousness due to a disruption of blood flow to brain, leading to a fall.
Syncopal episodes aka. Vasovagal episodes.
Syncope Types & Causes
1 ° = Dehydration, Missed meal, Vasovagal Stimuli.
2° = Hypoglycaemia, Dehydration, Anaemia, infection
Syncope Signs & Symptoms
Hot or Clammy
Sweaty
Dizzy
Blurry vision
Syncope Investigations
- ECG: long QT syndrome
- Echo: Struc. heart disease
- Bloods: Anaemia, electrolytes, blood glucose
Syncope Management
Avoid triggers, manage underlying
Motor Neurone Disease
Risks
Group of neurodegenerative disorders by selective loss of neurons in motor cortex, cranial nerve nuclei & anterior horn cells.
Risks: Smoking
Motor Neurone Disease Sx
Upper Motor Neuron Lesions:
→ Hypertonia : spasticity
→ Clonus - Increased reflex
Lower MNL
→ Hypotonia : Muscle wasting
→ FascicuIations - reduced reflex
MND Treatment
Riluzole - slow Progression
MDT
Palliative
Types of MND
→ Amytrophic Lateral Sclerosis = Loss of neurones in motor cortex & anterior horn. [ UMN + LMN signs ]
→ Progressive Bulbar palsy = Cranial nerve 9 -12. [ UMN + LMN ]
→ Progressive Muscular Atrophy = Anterior horn cells. [ LMN ]
→ Primary Lateral Sclerosis = [ UMN ]
Cauda Equina Syndrome
Nerve roots of cauda equina at the bottom of the spine are compressed.
Cauda Equina Pathophysiology
Cauda Equina [nerve root collection travelling through spinal cord, terminates at L2/3.
Spinal cord tapers at end called Conus medullaris.
Nerve roots exit at L3, L4, L5, S1, S2, S3, S4, S5
Cauda Equina Nerve supply
Sensation to lower limbs, Perineum, bladder & Rectum.
Motor innervation to lower limbs & anal & Urethral sphincters.
Parasympathetic innervation of bladder & rectum.
Cauda Equina Causes
Herniated disc
Tumours - Metastasis
Prostate cancer - metastasise to spine via venous blood flow.
Cauda Equina Red flags
Lower Motor neuron signs [reduced tone & reduced reflexes]
- Saddle Anaesthesia
- Loss of sensation in bladder & rectum
- Incontinence
Cauda Equina Management
Immediate Hospital Admission
MRI Scan
Neurosurgical input - Lumbar decompression surgery
Metastatic Spinal Cord Compression
Sx
Metastatic lesion compresses spinal cord.
Upper motor neuron signs [ Increased tone, brisk reflex,upping plantar response]
Sx = back pain (worse on coughing)
MSCC treatment
- Dexamethasone
- Analgesia
- Surgery
- Radio/ Chemotherapy
Sciatica -
Refers to symptoms associated with irritation of the sciatic nerve.
Sciatica Pathophysiology
L4 - S3 form sciatica nerve.
It exits through great sciatic foramen, travelling in bullocks area, down the leg. It divides at the knee to tibial nerve & Common peroneal nerve.
Sciatica Presentation
- Unilateral electric / shooting pain from buttock radiating to back of thigh to below knee/ feet.
- Paraesthesia
- Numbness & tenderness
- Motor weakness & reduced anal tone
Sciatica Diagnosis
Sciatic Stretch test
STarT Back Screening Tool
X Ray / CT
MRI
Sciatica Management
lnitial :
NSAIDs or Codeine
Diazepam
Worsening :
Amitriptyline
Duloxetine
Corticosteroid injection
Cancers that metastasise to bone
Prostate Renal Thyroid Breast Lung
Types of MS
Relapsing Remitting MS = Autoimmune attack causes rapid development in symptoms followed by remyelination (symptoms improve), & return to constant level, but new baseline has more disability.
Progressive Relapsing MS = Steady increase (symptoms get worse), flares superimpose, some remyelination but Symptoms also get worse.
Encephalitis
Sx
Cx
Ix
Tx
InfIamm. of brain Parenchyma caused by viruses
Sx: Altered consciousness & cognition, Unusual behaviour
Cx. Herpes Simplex virus or Varicella Zoster virus
Ix: lumbar Puncture with CSF viral PCR testing
Tx: IV acyclovir
Carpal tunnel Syndrome
Sx
Ix
Pressure & compression on median nerve - Originates from brachial plexus at C6,7,8,T1
Sx: Numbness, tingling, relieved by wake & shake
Ix: Phalen’s test - only flex wrist for 1 minute
Tinel’s test - tapping on nerve causes tingling
