Neurology Flashcards
What are the symptoms of a migraine headache?
Attacks last 4-72 hours
Two of:
Unilateral
Pulsing
Moderate/severe pain
Aggravated by routine physical activity
At least one of (during headache):
Nausea
Vomiting
Photophobia/phonophobia
What are the symptoms of a tension headache?
Attacks can last from 30 minutes to 7 days
No nausea/vomiting/photphobia
At least 2 of:
Bilateral
Tightening pain
Mild/moderate pain
Not aggravated by routine physical activity
What are the symptoms of a cluster headache?
Severe or very severe, unilateral, orbital/supraorbital/temporal pain
Lasts 15-180 minutes if not treated
Accompanied by ipsilateral cranial autonomic features (eg.miosis/ptosis, lacrimation) +/- restlessness/agitation
What are the symptoms of trigeminal neuralgia?
Occurs in one or more distribution of the trigeminal nerve
At least 3 of:
Unilateral
Severe
Recurring
Electric shock-like pain
Triggered by innocuous stimuli to the affected side of the face (eg. slight breeze of wind)
What are the management steps of migraines?
- Lifestyle changes –> avoid triggers, stress management, good sleep hygiene etc
- Simple analgesia eg. ibuprofen, paracetamol, aspirin
- Add a triptan (eg. sumatriptan) alone or with NSAID/paracetamol
(add antiemetic if required)
avoid overprescribing/overmedicating as can cause a medication overuse headache
What medications can be used to prevent recurrent migraines?
Topiramate
Propanolol
If unsuitable, gabapentin/amitriptyline
What is the management of a tension headache?
Reassurance
Basic analgesia
Relaxation techniques
Hot towels to local area
What is the first line treatment of trigeminal neuralgia?
Carbamazepine
Surgery to decompress/damage the trigeminal nerve is an option
What red flags are important to consider with a patient presenting with a headache?
Fever/photophobia/neck stiffness –> Meningitis
New neurology –> Haemorrhage/Stroke/Malignancy
Visual disturbance –> Temporal arteritis
Sudden onset –> SAH
Worse on coughing/straining/standing/bending over –> Raised ICP
Trauma –> Haemorrhage
Pregnancy –> Pre-eclampsia
What are triggers for cluster headache?
Alcohol
Smoking
Strong smells
Exercise
What is the acute management of a cluster headache?
Triptans eg. sumatriptan 6mg SC
High flow 100% oxygen
What medications can be used for prophylaxis of cluster headaches?
Verapamil
Lithium
Prednisolone
Which autoimmune condition has a strong link with temporal arteritis (GCA)?
Polymyalgia rheumatica
What are the symptoms of temporal arteritis?
Severe unilateral headache around temple and forehead
Scalp tenderness
Jaw claudication (jaw fatigue when chewing)
Blurred/double vision
Systemic symptoms such as fever, fatigue, loss of appetite etc
To diagnose temporal arteritis, a temporal artery biopsy is performed. What are the findings in the biopsy if positive?
Multinucleated giant cells
What is the initial management of temporal arteritis?
Prednisolone 40-60mg OD immediately
What are complications of temporal arteritis?
Vision loss
Stroke
What are classic presentations of a stroke?
Sudden onset of neurological symptoms
Typically asymmetrical
Limb weakness
Facial weakness
Dysphasia
Visual/sensory loss
What is the definition of a TIA?
Transient neurological dysfunction secondary to ischaemia without infarction
Stroke-like symptoms that resolve within 24 hours
What are the risk factors associated with stroke?
CVD such as angina, MI and peripheral vascular disease
Previous stroke or TIA
AF
Carotid artery disease
Hypertension
Diabetes
Smoking
Vasculitis
Thrombophilia
COCP
What is the management of stroke?
Admit to specialist centre
Exclude hypoglycaemia
CT brain exclude primary intracerebral haemorrhage
Aspirin 300mg immediately and continue for 2 weeks
Thrombolysis with alteplase within 4.5 hours or thrombectomy if indicated
What is the time frame to start thrombolysis with alteplase?
4.5 hours
What is the management of TIA?
Start aspirin 300mg daily
Start secondary prevention measures for CVD
What is the secondary prevention of stroke?
Clopidogrel 75mg OD
Atorvastatin 80mg
Carotid endarterectomy/stenting if carotid artery disease
Treat modifiable risk factors eg. hypertension, diabetes
What is the gold standard imaging used to establish the affected vascular territory?
Diffusion-weighted MRI
What are the clinical signs of cerebellar syndrome?
Dysdidokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
What are the clinical signs of a frontal lobe disorder?
Motor impairment
Expressive aphasia/dysphasia (Broca’s area)
Poor planning and cognition
What are the clinical signs of a parietal lobe disorder?
Sensory impairment
Vision problems
Spatial neglect
What are the clinical signs of a temporal lobe disorder?
Hearing difficulties
Receptive aphasia/dysphasia (Wernicke’s area)
Impaired memory
What are the clinical signs of a occipital lobe disorder?
Visual disturbance
What investigations should be performed if epilepsy is suspected?
EEG –> Identify form of epilepsy and support diagnosis
MRI Head –> Rule out other causes or visualise structural problems that could be causing seizures eg. tumours
ECG –> Rule out cardiac cause of seizure/syncope
What is the presentation of a tonic-clonic seizure?
Loss of consciousness
Muscle tensing (tonic)
Muscle jerking (clonic)
May be associated tongue biting, incontinence, groaning, irregular breathing
Post-ictal period where the person is confused, drowsy and can feel irritable or depressed
What is the management of tonic-clonic seizures?
1st line: Sodium valproate
2nd line or women of child-bearing age: Lamotrigine or Carbamazepine
What are the presentations of a focal seizure?
Hallucinations
Memory flashbacks
Deja vu
Hearing problems
Speech problems
Doing strange things on autopilot
What is the treatment for a focal seizure?
1st line: Levetiracetam or lamotrigine
2nd line: Sodium valproate or carbamazepine
What is the presentation of an absence seizure?
Often in children
The patient becomes blank and tares into space
Abruptly resolves and returns to normal
What is the management of absence seizures?
Sodium valproate or ethosuxamide
What is the presentation of an atonic seizure?
Limpness
Drop to floor if standing
Eyelids droop
Head nods forward
May drop things held in hand
What is the management of an atonic seizure?
1st line: Sodium valproate
2nd line: Lamotrigine
What is the presentation of a myoclonic seizure?
Typically happen in children (juvenile myoclonic epilepsy)
Sudden brief muscle contractions
Remains awake
What is the management of a myoclonic seizure?
1st line: Sodium valproate
2nd line: Lamotrigine, levetiracetam or topiramate
What are side effects of sodium valproate?
Liver damage and hepatitis
Hair loss
Tremor
Teratogenic –> Should be avoided in girls and women unless there is no suitable alternative and strict criteria are met around contraception to ensure they do not get pregnant
What is the definition of status epilepticus?
Seizures lasting more than 5 minutes or more than 3 seizures in 1 hour
Medical emergency
What is the management of status epilepticus in hospital?
ABCDE
IV lorazepam 4mg, repeated after 10 minutes if symptoms persist
If seizures still persist, IV phenobarbital or phenytoin
What options are available in the community to manage status epilepticus?
Buccal midazolam
Rectal diazepam
What suggests non-epileptic attack disorder rather than an epileptic seizure?
Can last for 30 minutes
Convulsions are not neuroanatomically accurate (pelvic thrust, wild shaking with arms flexing and extending)
Atypical quick recovery
PMH of childhood trauma, stress or previous unexplained medical symptoms
What are common presentations of narcolepsy?
Excessive daytime sleepiness
Sleep attacks (falling asleep suddenly)
Cataplexy (temporary loss of muscle control resulting in weakness and possible collapse)
Sleep paralysis
Excessive dreaming
Frequent night time wakening
What is the management of narcolepsy?
Implementing good sleep hygiene
Modafinil/dexamfetamine
SSRIs/SNRIs/TCAs
Korsakoff’s syndrome is caused by a deficiency in which vitamin?
Vitamin B1
Wernicke’s encephalopathy is caused by a deficiency in which vitamin?
Vitamin B1
What is the difference between Wernicke’s encephalopathy and Korsakoff’s syndrome?
Wernicke’s encephalopathy represents the acute stage of B1 deficiency, where Korsakoff’s syndrome represents the disease progressing to a chronic stage
What is the presentation of Wernicke-Korsakoff syndrome?
Amnesia
Tremor
Coma
Disorientation
Vision problems
Inability to form new memories
What is the management of Wernicke-Korsakoff syndrome?
Thiamine replacement
Providing proper nutrition and hydration
Alcohol cessation
What type of inheritance is seen in Huntington’s disease?
Autosomal dominant
What is the presentation of Huntington’s disease?
Starts with cognitive, psychiatric or mood problems
Chorea –> involuntary abnormal movements
Eye movement disorder
Speech difficulties
Swallowing difficulties
What is the management of Huntington’s disease?
No treatment options
Support the patient and their family
Speech and language therapy
Genetic counselling
What is the classic triad of Parkinson’s disease features?
Resting tremor (pill rolling, unilateral, improves with voluntary movement, worsens if patient is distracted)
Rigidity (cogwheel rigidity)
Bradykinesia
What are the other symptoms of Parkinson’s disease?
Shuffling gait –> Stooped posture, reduced arm swing
Facial masking
Micrographia
Depression
Sleep disturbance
Loss of sense of smell
Cognitive impairment
Memory problems
What is the first line treatment of Parkinson’s disease?
Levodopa –> If motor symptoms are impacting quality of life
Dopamine agonists or MOA-B inhibitors –> If motor symptoms are not impacting quality of life
What are the side effects of levodopa?
Dystonia
Chorea
Athetosis –> Abnormal twisting or writhing movements usually in the fingers, hands or feet