Neurology Flashcards

1
Q

When is a HINTS exam indicated?

A

In Acute Vestibular Syndrome:
Acute-onset, continuous vertigo, associated with:
Gait unsteadiness
Nausea and/or vomiting
Spontaneous or gaze-evoked nystagmus

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2
Q

What is a positive HINTS exam and what does it mean?

A

Head impulse - loss of corrective saccade
Nystagmus - direction-changing OR any nystagmus other than unidirectional in the direction of gaze
Skew - horizontal skew
Positive test is ANY of these and indicates a central cause for vertigo

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3
Q

Diagnostic criteria for Meniere’s disease

A

Recurrent attacks of spontaneous vertigo associated with tinnitus and hearing loss in the same ear.
-2 episodes lasting >20mins
-audiometric confirmation of sensorineural hearing loss
-tinnitus and/or perception of aural fullness
-exclusion of other causes

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4
Q

Diagnostic criteria for BPPV

A

Brief recurrent episodes of vertigo triggered by head movements

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5
Q

Canadian CT head rule

A

Inclusions:
GCS 13-15
LOC
Witnessed deterioration
Amnesia to HI event

Exclusions:
Age <16
Blood thinners
Seizure following HI

High risk criteria:
-Vomiting >2x
-GCS <15 at 2 hours
-Age >65
-Suspected open or depression skull fracture
-Evidence of basilar skull fracture

Medium risk criteria:
-RETROGRADE amnesia >30mins
-“Dangerous” mechanism

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6
Q

PECARN or other paediatric CTH high risk criteria

A

(PECARN)
Any age
-GCS <14
-Signs of open/depressed/basilar skull fracture
-Signs of AMS

Other
-Concern for NAI
-Seizure
-Focal neurological deficit
-Visible trauma to scalp
-GCS <15

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7
Q

GCS

A

Eyes
4 - spontaneously open
3 - open to voice
2 - open to pain
1 - no response

Voice
5 - coherent
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1- no response

Motor
6 - obeys commands
5 - localises to pain
4 - withdraws from pain
3 - decorticate posturing (flexion to pain)
2 - decerebrate posturing (extension to pain)
1 - no response

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8
Q

Diagnosis Orthostatic Hypotension

A

Measure BP and HR when lying supine for 5 mins, repeat after 1 and 3 mins standing
OH = >20mmHg drop in BP
Associated increase in HR indicates benign reversible causes eg dehydration

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9
Q

Medication causes/exacerbations of orthostatic hypotension

A

Alpha blockers
Beta blockers
TCAs
Vaso/venodilators (ISMN/GTN/sildenafil)
Anticholinergics
Dopamine agonists
Diuretics

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10
Q

Aetiology of orthostatic hypotension

A

Primary autonomic dysfunction:
Multisystem atrophy
Parkinsons
Lewy body Dementia
Primary autonomic failure (chronic)
Acute autonomic neuropathy

Secondary autonomic dysfunction:
Clear association with another illness
Dehydration/volume loss
Medications
UTI
Deconditioning/immobilisation/hospitalisation
Several known associated medical conditions:
-amyloid
-DM
-alzheimers
-malignancy
-MS
-autoimmune
-renal failure

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11
Q

Treatment of orthostatic hypotension (non-pharmacologic and pharmacologic)

A

Non-pharmacologic:
-avoid prolonged standing - use cocktail posture, squatting, hand clasping
-liberalise salt and water intake (10g salt, 1.5-2L water per day)
-avoid medication triggers
-raise head of bed
-care with standing
-exercise programme
-avoid hot environments eg showers
-stockings or abdominal binder
-cup of water
-small frequent meals
-avoid alcohol

Pharmacologic:
-fludrocortisone 0.1-0.3mg/day (unless background HTN/CHF)
-midodrine 2.5-10mg tds
-desmopressin nasal spray
-atomoxetine
-methylphenidate
-pyridostigmine

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12
Q

First seizure in adults. Causes and management.

A

Infections
Epilepsy
SOL
Metabolic derangement
Medications/toxins

Check glucose and Na
CTH
LP if immunocompromised
Pregnancy test
Not to drive

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13
Q

Definition and Management of status epilepticus

A

> 5mins of seizure activity OR
More than one seizure in a 24 hour period without recovery between

Check glucose
Monitor vital signs
Give 4-8mg lorazepam or 10mg diazepam IV
18mg/kg phenytoin
50ml of 50% glucose (or 2ml/kg of 25% in children)
Thiamine 100mg IV
ECG monitoring
Control hyperthermia
Assess acid base balance

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14
Q

Risk factors for stroke

A

Increasing age
Fijian Indian
Smoking
HTN
Hypercholesterolaemia
DM
AF
Carotid bruit
FHx heart disease

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15
Q

Management of TIA

A

Acute assessment <7 days if:
-crescendo TIAs
-AF
-on anticoagulants already
-known carotid stenosis
-ABCD2 score =/> 3
Discuss all other cases

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16
Q

Cervical artery dissection
Risks
Hx
Exam

A

Risks
Marfans/EDS/IO/fibromuscular dysplasia
Trauma
Migraine with aura
Recent infection
Vasculopaths
Smoking
HTN
Increased age

Hx
Neck pain (esp if vertebral) and neurological defect
Headache - sudden onset, unilateral
Vision changes (carotid) OR
Ataxia/dysarthria/diplopia/vertigo/visual field defect (posterior)

Exam
Expanding neck haematoma
Horners syndrome
Neuro deficit
Neck tenderness
Vascular bruit

17
Q

Cluster headache risk factors

A

Male 4:1
Age 40-50
Smoking
FHx
Alcohol

18
Q

Cluster headache features

A

Unilateral HA + autonomic features eg
-lacrimation
-sweating
-mitosis
-ptosis
-conjunctival effusion
-nasal congestion/rhinorrhoea
Associated restlessness/agitation
Lasting 15-180 mins
Occurring in clusters (up to 8 per day)

19
Q

Cluster HA treatment

A

High flow O2
IM/IN tryptans

20
Q

Ottawa SAH rule

A

HA peaking <1 hour and no neurological findings:
-age 40+
-thunderclap headache
-neck stiffness
-onset during exertion
-witnessed LOC
-neck stiffness on exam
Has sensitivity of 100%, specificity 15%

21
Q

Migraine diagnosis

A

At least 5 episodes lasting 4-72 hours
POUND
Pulsating intensity, photophobia/photophobia
Of 4-24 hours duration
Unilateral
Nausea/vomiting
Disabling

22
Q

Migraine with aura

A

Visual, sensory or speech symptoms developing gradually, lasting 5-60 mins and completely reversible
Associated headache

23
Q

Headache red flags

A

Age >50
Cancer
Thunderclap
Onset with exercise/sex/cough
Worst headache of life
Neurological sx
Fever
Neck pain or stiffness
HIV
Associated with exertion
Pregnancy or postpartum

Orange flags
Temporal artery tenderness
Personality change

24
Q

Cerebral venous thrombosis features

A

Women:men 3:1
Young adults and children affected
Headache
Papilloedema
Decreased visual acuity
Pain with eye movements
Seizures
Decreased LOC
Focal neuro deficits
Peripartum
Oestrogen use