Neurology Flashcards
What is the definition of a transient ischaemic attack?
A transient episode of neurological dysfunction caused by ischaemia, but not acute infarction; sudden onset and symptoms last less than 24 hours (longer than this is a stroke)
What are the key diagnostic factors for a transient ischaemic attack?
Sudden onset and brief duration of symptoms
Unilateral weakness or paralysis
Dysphasia (disruption in language production and comprehension)
Ataxia, vertigo, or loss of balance
Vision loss, diplopia
What are the risk factors for TIA?
Cardiovascular disease (atrial fibrillation, valvular heart disease, carotid stenosis, congestive heart failure, hypertension)
Diabetes mellitus
Hyperlipidaemia
Excessive alcohol and smoking
What are the 1st line investigations for a TIA?
Blood glucose (to exclude hypoglycaemia as cause)
FBC and platelet count (to exclude infection)
Fasting lipid profile (to evaluate for treatable atherosclerotic risk factors)
Serum electrolytes (to exclude electrolyte imbalance)
ECG (AF/arrhythmias/myocardial infarction?)
CT scan only if patient has bleeding disorder or taking anticoagulants
MRI
Carotid doppler
How is TIA treated?
300mg aspirin - unless patient has bleeding disorder or taking anticoagulant
secondary prevention: clopidogrel, 20-80mg atorvastatin
How does a migraine present?
Prolonged headache (4 to 72 hours) that is worse with activity - throbbing sensation, often unilateral
Nausea
Photophobia and phonophobia
Aura
What are the characteristics of aura?
Positive phenomena (visual sparkles, flashing lights)
Negative phenomena (visual loss or scintillating scotoma)
Sensory symptoms (numbness, tingling)
What are some risk factors for migraine?
Family history
Female sex
Obesity
Stressful life events
Medication overuse
Sleep disorders
How is migraine treated?
1st line: oral triptan (sumatriptain) and NSAID (aspirin, diclofenac, ibuprofen, naproxen)/paracetamol
Anti-emetic (metoclopramide or promethazine) - non-oral preparation
Oral or IV fluids
Can use corticosteroids (e.g. dexamethasone or prednisolone)
What preventative therapies are given for migraines?
Propranolol or topiramate (although, topiramate is teratogenic) - propranolol should be avoided in asthmatics
2nd line: acupuncture, riboflavin, frovatriptan for people with predictable menstrual migraines
How does a tension-type headache present?
Generalised head pain (often bilateral pressure-like and non-throbbing, constricting pain) - frontal or occipital
Not aggravated by routine physical activity
Mild-to-moderate intensity
May have peri-cranial tenderness
How is tension-type headache treated?
Simple analgesics (aspirin, paracetamol, ibuprofen, naproxen)
Low-dose tricyclic antidepressants (amitriptyline) may reduce the frequency and intensity of attacks
How does idiopathic raised intracranial hypertension present?
headache (pressure-like or throbbing) - worst first thing in morning and last thing at night
visual field loss (enlarged blind spot)
photophobia
optic disc swelling
blurred vision
sixth nerve palsy - cannot abduct the eye
What are the risk factors for idiopathic intracranial hypertension?
Female sex
Obesity and weight gain
Certain medication use (OCP, steroids, tetracyclines, lithium)
How is idiopathic intracranial hypertension investigated?
Visual field testing (enlarged blind spot, inferonasal loss, other nerve fibre bundle defects, or constriction of the field)
Dilated fundoscopy (papilloedema)
MRI brain
Lumbar puncture at L3/L4 (raised pressure)
How is idiopathic intracranial hypertension treated?
Weight loss
Acetazolamide or furosemide (diuretics) or topiramate
Analgesia (amitriptyline or naproxen)
Surgery (optic nerve sheath decompression, CSF shunting)
What are the key diagnostic factors of trigeminal neuralgia?
Facial pain (restriction to trigeminal distributions)
Usually unilateral
Electric shock-like, sharp, shooting
Multiple attacks a day, lasting few seconds - minutes; periods of remission for months
What are the possible triggers of trigeminal neuralgia?
Vibration
Skin contact (e.g. shaving, washing)
Brushing teeth
Oral intake
Exposure to the wind
What are the risk factors for trigeminal neuralgia?
Increased age
Multiple sclerosis
More common in females
How is trigeminal neuralgia diagnosed?
Diagnosis is usually clinical
Brain MRI to exclude other causes
How is trigeminal neuralgia treated?
anticonvulsant (carbamazepine)
referral to neurology if unresponsive to carbammazepine
Baclofen if unresponsive to anticonvulsants
Microvascular decompression or ablative surgery if unresponsive to medication
What are the key diagnostic factors for chronic fatigue syndrome?
Persistent disabling fatigue (>50% of time) not alleviated by rest
Exertional exhaustion
Short-term memory/concentration impairment
Sore throat
Generalised arthralgia without inflammation
Headaches
Orthostatic intolerence
Widespread muscle pain
Tender lymph nodes and flu-like symptoms
Dizziness/lightheadedness
Temperature hypersensitivity
Co-morbid depression/anxiety
What are the risk factors for chronic fatigue syndrome?
Female sex
30-50 years
Epstein-Barr infection in adolescents
How is chronic fatigue syndrome investigated?
DePaul symptom questionnaire
FBC, ESR, CRP, TSH, HIV antibody test (normal)
What are the symptoms of an anterior cerebral artery stroke?
MEDIAL FRONTAL AND TEMPORAL LOBES
Paralysis of contralateral structures (leg >arm, face)
Disturbance of intellect and executive function
Loss of appropriate social behaviour
What are the symptoms of a middle cerebral artery stroke?
LATERAL FRONTAL AND TEMPORAL LOBES
Contralateral hemiplegia (arm>face)
Contralateral hemisensory deficits
Hemianopia
Aphasia (left sided weakness)
What are the symptoms of a posterior cerebral artery stroke?
Visual agnosia
Homonymous hemianopia
What are the risk factors for stroke?
CVD, e.g. angina, MI, peripheral vascular disease
Previous stroke or MIA
Atrial fibrillation
Hypertension
Diabetes
Smoking
Combined contraceptive pill
Vasculitis
Thrombophilia
How is stroke investigated?
Non-contrast CT head (first line)
Diffuse-weighted MRI
Angiography
Carotid ultrasound to assess for carotid stenosis
Serum glucose (exclude hypoglycaemia)
Serum electrolytes (exclude hyponatraemia)
How is ischaemic stroke treated?
Thrombolysis with alteplase (tissue plasminogen activator that breaks down clots) - only if hemorrhage excluded and within 4.5 hours of symptom onset
Aspirin 300mg to prevent further clots
Thrombectomy if occlusion confirmed on imaging - within 6 hours
Secondary prevention: clopidogrel, atorvastatin, carotid endarterectomy/stenting
What are the features of a total anterior circulation infarct (TACI)?
Involves middle and anterior cerebral arteries
Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
Homonymous hemianopia
Higher cognitive dysfunction e.g. dysphasia
What are the features of a partial anterior circulation infarct (PACI)?
Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of:
Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
Homonymous hemianopia
Higher cognitive dysfunction e.g. dysphasia
What are the features of a lacunar infarct?
Involves perforating arteries around the internal capsule, thalamus, and basal ganglia
Presents with 1 of the following:
Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
Pure sensory stroke.
Ataxic hemiparesis
What are the features of a posterior circulation infarct?
Involves vertebrobasilar arteries
Presents with 1 of the following:
Cerebellar or brainstem syndromes
Loss of consciousness
Isolated homonymous hemianopia
What are the risk factors for subdural haemorrhage?
Head trauma
Coagulopathy and anticoagulant use
Advanced age (>65 years)
Chronic alcohol use
What are the symptoms of subdural haemorrhage?
Evidence of trauma
Headache
Nausea and vomiting
Diminished eye, motor and verbal response
Confusion
Loss of consciousness/decreased alertness
Seizure
Speech, vision, sensory changes
How is subdural haemorrhage investigated?
Non-contrast CT scan (crescent shape, can cross over sutures)
How is an acute subdural haemorrhage treated?
If small or incidental finding, conservative management
Surgical options include monitoring of ICP and decompressive craniectomy
What are some causes of subarachnoid haemorrhage?
Head trauma
Ruptured intracranial aneurysm (most common)
Arteriovenous malformations
Anticoagulant use
How is a chronic subdural haematoma treated?
If small in size or incidental finding with no associated deficit, can be managed conservatively
If patient is confused, has neurological deficits or severe image findings, surgical decompression with burr holes
What are the risk factors for subarachnoid haemorrhage?
Hypertension
Smoking
FHx
Autosomal dominant polycystic kidney disease
Alcohol use
Age >50 years
Marfan’s/Ehlers-Danlos
What are the symptoms of subarachnoid haemorrhage?
Severe sudden-onset thunderclap headache (lasts an hour)
Loss of/depressed consciousness
Neck stiffness and muscle aches
Photophobia
Nausea and vomiting
Seizures
Can compress CNIII, causing eyelid drooping, diplopia, orbital pain
How is subarachnoid haemorrhage investigated?
Non-contrast CT head (hyperdense areas in subarachnoid space)
U&Es (hyponatraemia due to SIADH)
ECG (arrhythmias, long QT, ST segment or T-wave abnormalities)
CT angiography to identify causal pathogen
Lumbar puncture: xanthochromia, blood in CSF
How is subarachnoid haemorrhage treated?
Nimodipine (CCB) to prevent vasospasm/delayed cerebral ischaemia
Consider prophylactic sodium valproate if seizures occurring
Stop and reverse anticoagulation
Endovascular coiling for intracranial aneurysms
What are the symptoms of extradural haemorrhage?
Patient initially loses, briefly regains and then loses consciousness again after low-impact head injury - lucid period
Fixed and dilated pupil (compression of parasympathetic fibres of CNIII)
What is the most common cause of extradural haemorrhage?
Damage to the pterion, leading to rupture of the middle meningeal artery
How is extradural haemorrhage investigated?
CT head shows biconvex haematoma
How is extradural haemorrhage managed?
No neurological deficit: cautious clinical and radiological observation
Otherwise, craniotomy and evacuation of haematoma
What are the symptoms of Bell’s palsy?
Facial nerve palsy (CNVII) - involvement of all nerve branches
Unilateral facial weakness and drooping (non-forehead sparing)
Keratoconjunctivitis sicca (dry eye) - inability to close eye
Post-auricular pain
Hyperacusis (sensitivity to sound)
Loss of taste on anterior 2/3 of tongue
How is Bell’s palsy diagnosed?
Clinical diagnosis of exclusion
Exclude stroke, infections (Lyme, TB, HIV), systemic disease (DM, sarcoidosis)
How is Bell’s palsy treated?
Oral prednisolone
Eye protection (e.g. eye drops) as dry eye is common - may lead to exposure keratopathy
Surgical Decompression & Anti-Virals (Acicolvir) if severe palsy
What are the risk factors for Bell’s palsy?
Intranasal influenza vaccination
Pregnancy (particularly in third term)
Upper RTI
Arid/cold climate
FHx
What are the symptoms of Parkinson’s disease?
CLINICAL DIAGNOSIS
Resting unilateral ‘pill rolling’ tremor
Cogwheel rigidity
Bradykinesia (shuffling gait, hypomimia, smaller handwriting)
Depression
Postural instability
Cognitive impairment and memory problems
Insomnia
How is Parkinson’s treated?
Levodopa (synthetic dopamine) - co-careldopa or co-benyldopa, becomes less effective over time
COMT inhibitor (stops degradation of levodopa) - entacapone
Dopamine agonists - cabergoline, pergolide (prolonged use can cause pulmonary fibrosis)
Monoamine oxidase-B inhibitors - rasagiline
What are the side effects of levodopa?
Dyskinesias (excessive motor activity)
Dystonia (abnormal postures or exaggerated movements)
Chorea (jerking movements)
Athetosis (writhing movements)
What is the difference between Parkinson’s and an essential tremor?
Parkinson’s: worse with rest, unilateral, improves with intentional movement, no change with alcohol
Essential tremor: improves with rest, symmetrical, worse with intentional movement, improves with alcohol
What are the risk factors for essential tremor?
Advancing age
Family history
White ancestry
Environmental toxins (pesticides, lead, mercury)
What are the symptoms of essential tremor?
Bilateral upper limb tremor
More prominent with intentional movement
Improved by alcohol
CLINICAL DIAGNOSIS
How is essential tremor managed?
Not treated if no functional or psychological problems
Propranolol
Primidone (anti-epileptic)