Neurology Flashcards
Give an example of a primary headache.
- Migraine.
- Tension headache.
- Cluster headache.
Give an example of a secondary headache.
- Meningitis.
- Subarachnoid haemorrhage.
- Giant cell arteritis.
- Medication overuse headache.
Give 6 questions that are important to ask when taking a history of headache.
- Time: onset, duration, frequency, pattern.
- Pain: severity, quality, site and spread.
- Associated symptoms e.g. nausea, vomiting, photophobia, phonophobia.
- Triggers/aggravating/relieving factors.
- Response to attack: is medication useful?
- What are symptoms like between attacks?
Give 5 red flags for suspected brain tumour in a patient presenting with a headache.
- New onset headache and history of cancer.
- Cluster headache.
- Seizure.
- Significantly altered consciousness, memory, confusion.
- Papilloedema (swollen optic disc).
- Other abnormal neuro exam.
How long do migraine attacks tend to last for?
Between 4 and 72 hours.
Describe the pain of a migraine.
- Unilateral.
- Throbbing.
- Moderate/severe pain.
- Aggravated by physical activity.
Would a patient with migraine experience any other symptoms?
Photophobia and/or phonophobia are common complaints. May have nausea but not vomiting.
How can migraines be subdivided?
- Episodic with (20%)/without (80%) aura.
- Chronic migraine.
What would a patient experiencing migraine with aura complain of?
- Visual disturbances e.g. flashing lights, zig-zag lines.
- Sensory disturbances e.g. tingling in hands and feet.
- Language aura and motor aura.
Describe the treatment for migraines.
- Ensure an accurate diagnosis.
- Lifestyle modification and trigger management.
- Psychological and behavioural treatment.
- Abortive treatment: PO triptan and NSAIDs.
- Anti-emetics.
- Preventative treatment: propranolol, acupuncture, amitriptyline.
What is the most common type of primary headache?
Tension headache.
How long do tension headaches usually last for?
From 30 minutes to 7 days.
Describe the pain of a tension headache.
- Bilateral.
- Pressing/tight.
- Mild/moderate pain.
- Not aggravated by physical activty.
Would a patient with a tension headache experience any other symptoms?
No!
Nausea, vomiting, photo/phonophobia would not be associated.
What is the most common type of secondary headache?
Medication overuse headache.
What is the diagnostic criteria for medication overuse headache?
- Headache present for >15 days/month.
- Regular use for >3 months of >1 symptomatic treatment drugs.
- Headache has developed or markedly worsened during drug use.
Describe the pain of a cluster headache.
- Severe/very severe pain.
- Pain around the eye/temporal area.
- Unilateral.
- Headache is accompanied by cranial autonomic features.
How long do cluster headaches usually last for?
15 minutes to 3 hours.
Name a type of headache that is accompanied with cranial autonomic features.
Cluster headache.
Describe the pain of trigeminal neuralgia.
- Unilateral face pain.
- Pain commonly in V3 distribution.
- Very severe.
- Electric shock like/shooting/sharp.
How long does the pain associated with trigeminal neuralgia usually last for?
A few seconds.
What features might be present in the history of a headache that make you suspect meningitis?
- Pyrexia.
- Photophobia.
- Neck stiffness.
- Non-blanching purpura rash.
What investigations might you do if you suspect someone has meningitis?
- Bloods.
- Blood cultures.
- Throat swab.
- Blood for serology and PCR.
- CT head.
How would you describe the headache associated with sub-arachnoid haemorrhage?
Thunderclap headache - maximum severity within seconds.
Name 2 investigations you could do to determine whether someone has a subarachnoid haemorrhage?
- CT of the head.
- Cerebral angiography.
Describe the treatment/management for subarachnoid haemorrhage.
- Resuscitation.
- Nimodipine (CCB).
- Early intervention and close monitoring will improve prognosis.
What muscle is essential for correcting the extorsion action of lateral rectus when walking downstairs?
Super oblique (Cn 4 innervation).
What muscle needs to be working in order to test the action of superior and inferior rectus?
Lateral rectus.
To test superior and inferior rectus the patient is asked to abduct their eye 30 degrees first, this requires lateral rectus.
Superior and inferior oblique can never have isolated action. How can they be tested?
Position the eye so that superior and inferior recti are giving maximal rotation and look for complete correction.
Name 3 organisms that can cause meningitis in adults.
- N.meningitidis (g-ve diplococci).
- S.pneumoniae (g+ve cocci chain).
- Listeria monocytogenes (g+ve bacilli).
Name 3 organisms that can cause meningitis in children.
- E.coli (g-ve bacilli).
- Group B streptococci e.g. s.agalactiae.
- Listeria monocytogenes.
Give 5 symptoms of meningitis.
- Non-blanching petechial rash.
- Neck stiffness.
- Headache.
- Photophobia.
- Papilloedema.
- Fever.
How would you describe the rash that is characteristic of meningitis?
Non-blanching petechial rash.
What investigations might you do in someone who you suspect has meningitis.
- Blood cultures.
- Bloods: FBC, U+E, CRP, serum glucose, lactate.
- Lumbar puncture.
- CT head.
- Throat swabs.
What antibiotic is commonly given for the treatment of meningitis?
Cefotaxime.
What is the treatment of meningitis?
Cefotaxime.
+ amoxicillin if L.monocytogenes infection.
+ steroids to reduce inflammation in S.pneumoniae infection.
When is a child vaccinated against meningitis B?
At 8 weeks and 16 weeks.
When is a child vaccinated against meningitis C?
At 12 weeks and 1 year.
When is a child vaccinated against meningitis ACWY?
At age 14.
For which bacteria is meningitis prophylaxis effective against?
N.meningitidis.
What can be given as prophylaxis against N.meningitidis infection?
Ciprofloxacin.
At what vertebral level would you do a lumbar puncture?
L4/5.
Give 4 potential adverse effects of doing a lumbar puncture.
- Headache.
- Damage to spinal cord.
- Paraesthesia.
- CSF leak.
What investigations would you do on a CSF sample?
- Protein and glucose levels.
- MCS.
- Bacterial and viral PCR.
What is the most common cause of viral meningitis?
Enterovirus.
What is the colour of the CSF in someone with bacterial infection?
Cloudy.
It is normally clear.
In what group of people is encephalitis common?
The immunocompromised.
Give 4 symptoms of encephalitis.
- Fever.
- Headache.
- Lethargy.
- Behavioural change.
A lumbar puncture is done and a CSF sample is obtained from someone who is suspected to have encephalitis. Describe what the lymphocyte, protein and glucose levels would be like in someone with encephalitis.
- Lymphocytosis (raised lymphocytes).
- Raised protein.
- Normal glucose.
What is the treatment for encephalitis?
Acyclovir.
Give 4 symptoms of rabies.
- Fever.
- Anxiety.
- Confusion.
- Hydrophobia.
- Hyperactivity.
Name the organism responsible for causing tetanus.
Clostridium tetani (gram positive anaerobe).
It infects via dirty wounds.
Give 3 symptoms of tetanus.
- Trismus (lockjaw).
- Sustained muscle contraction.
- Facial muscle involvement.
Name the organism responsible for causing botulism.
Clostridium botulinum.
Give 3 symptoms of botulism.
- Diplopia (double vision).
- Dysphagia.
- Peripheral weakness.
If a patient has aphasia what region in the brain has been affected?
Broca’s area.
If a patient has receptive dysphasia what region in the brain has been affected?
Wernicke’s area.
Name 3 intra-cranial haemorrhages.
- Extra-dural.
- Sub-dural.
- Sub-arachnoid.
What can cause a sub-arachnoid haematoma?
Rupture of a berry aneurysm around the circle of willis.
Give 5 symptoms of a sub-arachnoid haemorrhage.
- Sudden onset ‘thunderclap’ headache.
- Photophobia.
- Reduced conciousness.
- Neck stiffness.
- Nausea and vomiting.
What investigations might you do to see if someone has a sub-arachnoid haemorrhage?
- CT scan of head - would show blood in sulci.
- Lumbar puncture.
- MRA.
What is the treatment for a sub-arachnoid haematoma?
- Bed rest and BP control.
- CCB to prevent cerebral artery spasm.
- IV saline.
What can cause a sub-dural haematoma?
Head injury -> vein rupture.
Describe the natural history of a sub-dural haematoma.
Latent period after the head injury. 8-10 weeks later the clot starts to break down and there is a massive increase in oncotic pressure, water is sucked up into the haematoma -> signs and symptoms develop. There is a gradual rise in ICP.
What causes water to be sucked up into a sub-dural haematoma 8-10 weeks after a head injury?
The clot starts to break down and there is a massive increase in oncotic pressure, water is sucked up by osmosis into the haematoma.
Give 3 symptoms of a sub-dural haematoma.
- Headache.
- Drowsiness.
- Confusion.
What is the treatment for a sub-dural haematoma?
Surgical removal.
What can cause an extra-dural haematoma?
Trauma to the temporal bone -> bleeding from the middle meningeal artery.
What do the ventricles do to prolong survival in someone with an extra-dural haemorrhage?
The ventricles get rid of their CSF to prevent the rise in inter-cranial pressure.
What is the treatment for an extra-dural haematoma?
Immediate surgical drainage.
What proportion of strokes are due to intracerebral haemorrhages?
10-15%.
Give 2 primary causes of intra-cerebral haemorrhage.
- Hypertension -> Berry or Charcot-Bouchard aneurysms -> rupture.
- Lobar (amyloid angiopathy).
Give 5 secondary causes of intra-cerebral haemorrhage.
- Tumour.
- Arterio-venous malformations (AVM).
- Cerebral aneurysm.
- Anticoagulants e.g. warfarin.
- Haemorrhagic transformation infarct.
Give 3 potential complications of Charcot-Bouchard aneurysms.
- Rupture (haemorrhage).
- Thrombosis.
- Leakage (microbleeds).
What is the likely cause of bleeds in the basal ganglia, pons and/or cerebellum?
Hypertension.
Describe the treatment for anti-coagulant related intra-cerebral haemorrhage.
Check warfarin INR and consider reversal with vitamin K.
If low platelets, platelet transfusion.
Define stroke.
Rapid onset of neurological deficit which is the result of a vascular lesion and is associated with infarction of central nervous tissue.
What can cause a stroke?
- Cerebral infarction due to embolism or thrombosis (85%).
- Intracerebral or sub-arachnoid haemorrhage (15%).
Give 5 risk factors for stroke.
- Hypertension.
- Diabetes mellitus.
- Cigarette smoking.
- Hyperlipidaemia.
- Obesity.
- Alcohol.
Give 5 signs of an ACA stroke.
- Lower limb weakness and loss of sensation to the lower limb.
- Gait apraxia (unable to initiate walking).
- Incontinence.
- Drowsiness.
- Decrease in spontaneous speech.
Give 5 signs of a MCA stroke.
- Upper limb weakness and loss of sensation to the upper limb.
- Hemianopia.
- Aphasia.
- Dysphasia.
- Facial drop.
Give 5 signs of a PCA stroke.
- Visual field defects.
- Cortical blindness.
- Visual agnosia.
- Prosopagnosia.
- Dyslexia.
- Unilateral headache.
What is visual agnosia?
An inability to recognise or interpret visual information.
What is prosopagnosia?
An inability to recognise a familiar face.
A patient presents with upper limb weakness and loss of sensory sensation to the upper limb. They also have aphasia and facial drop. Which artery is likely to have been occluded?
The middle cerebral artery.
A patient presents with lower limb weakness and loss of sensory sensation to the lower limb. They also have incontinence, drowsiness and gait apraxia. Which artery is likely to have been occluded?
The anterior cerebral artery.
A patient presents with a contralateral homonymous hemianopia. They are also unable to recognise familiar faces and complain of a headache on one side of their head. Which artery is likely to have been occluded?
The posterior cerebral artery.
What investigation could you do to determine whether someone has had a haemorrhagic or an ischaemic stroke?
A CT scan of the head.
What is the treatment for an ischaemic stroke?
Thrombolysis e.g. alteplase - IV infusion to break up the clot.
What non pharmacological treatment options are there for people after a stroke?
- Specialised stroke units.
- Swallowing and feeding help.
- Physiotherapy.
- Home modifications.
What is MS?
A chronic auto-immune disorder of the CNS. It is an inflammatory and demyelinating disease characterised by progressive disability.
Describe the epidemiology of MS.
- Presents between 20-40 y/o.
- Females > males.
- Rare in the tropics.
Describe the aetiology of MS.
- Environment e.g. EBV infection is shown to be associated.
- Genetic predisposition.
- Chance.
Briefly describe the pathophysiology of MS.
Genetic susceptibility + environmental trigger -> T cell activation -> B cell and macrophage activation -> inflammation, demyelination and axon destruction.
Where would MS plaques be seen histologically?
Around blood vessels: perivenular.
Does myelin regenerate in someone with MS?
Yes but it is much thinner which causes inefficient nerve conduction.
Give 3 major features of an MS plaque.
- Inflammation.
- Demyelination.
- Axon loss.
Describe the relapsing/remitting course of MS.
The patient has random attacks over a number of years. Between attacks there is no disease progression.
Describe the chronic progressive course of MS.
Slow decline in neurological functions from the onset.
What can exacerbate the symptoms of MS?
Heat - typically a warm shower.
Symptoms can be relieved by cool temperatures.
Give 5 signs of MS.
- Spasticity.
- Nystagmus and double vision.
- Optic neuritis: impaired vision and pain.
- Weakness.
- Sensory symptoms.
- Paraesthesia.
- Bladder and sexual dysfunction.
Give 3 atypical symptoms of MS e.g. if a patient presents with these they are unlikely to have MS.
- Aphasia.
- Hemianopia.
- Muscle wasting.
What is the diagnostic criteria for MS?
- > 2 CNS lesions disseminated in time and space.
- Exclusion of conditions that may give a similar clinical presentation.
Name 3 conditions in the differential diagnosis of MS.
- SLE.
- Sjögren’s.
- AIDS.
What investigations might you do in someone to see if they have MS?
- MRI of brain and spinal cord - lesions may be seen around ventricles.
- Lumbar puncture - CSF.
What might electrophoresis of CSF show for someone with MS?
Oligoclonal IgG bands.
What medication might you give to someone to reduce the relapse severity of MS?
Short course steroids e.g. methylprednisolone.
Describe the pharmacological treatment for MS.
- Beta interferon (anti-inflammatory).
- Natalizumab.
- Stem cell transplant.
- Muscle relaxants for spasticity and other symptom relief.
Describe the non-pharmacological treatment for MS.
- Psychological therapies and counselling.
- Speech therapists.
- Physiotherapy and occupational therapy.
What is a UMN?
A neurone that is located entirely in the CNS. Its cell body is located in the primary motor cortex.
Give 4 signs of UMN weakness.
- Spasticity.
- Increased muscle tone.
- Hyper-reflexia.
- Minimal muscle atrophy.
Give 3 causes of UMN weakness.
- MS.
- Brain tumour.
- Stroke.
What is a LMN?
A neurone that carries signals to effectors. The cell body is located in the brain stem or spinal cord.
Give 5 signs of LMN weakness.
- Flaccid.
- Reduced muscle tone.
- Hypo-reflexia.
- Muscle atrophy.
- Fasciculations.
What is epilepsy?
The tendency to have seizures.
Define seizure.
A convulsion caused by paroxysmal discharge of cerebral neurones.
Abnormal and excessive excitability of neurones.
Give 5 causes of transient loss of consciousness.
- Syncope.
- Epileptic seizures.
- Non-epileptic seizures.
- Intoxication e.g. alcohol.
- Ketoacidosis/hypoglycaemia.
- Trauma.
Give 5 causes of epilepsy.
- Flashing lights.
- Cerebrovascular disease e.g. stroke.
- Genetic predisposition.
- CNS infection e.g. meningitis.
- Trauma.
Give a definition for an epileptic seizure.
Excessive, unsynchronised neuronal discharges in the brain cause paroxysmal changes in behaviour, sensation or cognitive processes.
Give 5 signs of an epileptic seizure.
- 30-120s in duration.
- ‘Positive’ symptoms e.g. tingling and movement.
- Tongue biting.
- Head turning.
- Muscle pain.
Define syncope.
Insufficient blood or oxygen supply to the brain causes paroxysmal changes in behaviour, sensation and cognitive processes.
Give 5 signs that a transient loss of consciousness is due to syncope.
- Situational.
- 5-30s in duration.
- Sweating.
- Nausea.
- Pallor.
- Dehydration.
Give a definition for a non-epileptic seizure.
Mental processes associated with psychological distress cause paroxysmal changes in behaviour, sensation and cognitive processes.
Give 5 signs of a non-epileptic seizure.
- Situational.
- 1-20 minutes in duration (longer than epileptic).
- Eyes closed.
- Crying or speaking.
- Pelvic thrusting.
- History of psychiatric illness.
Which is likely to last for longer, an epileptic or a non-epileptic seizure?
A non-epileptic seizure can last from 1-20 minutes whereas an epileptic seizure lasts for 30-120 seconds.
A patient complains of having a seizure. An eye-witness account tells you that the patient had their eyes closed, was speaking and there was waxing/waning/pelvic thrusting. They say the seizure lasted for about 5 minutes. Is this likely to be an epileptic or a non-epileptic seizure?
This is likely to be a non-epileptic seizure.
A patient complains of having a seizure. An eye-witness account tells you that the patient was moving their head and biting their tongue. They say the seizure lasted for just under a minute. Is this likely to be an epileptic or a non-epileptic seizure?
This is likely to be an epileptic seizure.
A patient complains of having a ‘black out’. They tell you that before the ‘black out’ they felt nauseous and were sweating. They tell you that their friends all said they looked very pale. Is this likely to be due to a problem with blood circulation or a disturbance of brain function?
This is likely to be due to a blood circulation problem e.g. syncope.