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SJ Phase 2a > Neurology > Flashcards

Neurology Flashcards

1
Q

Define stroke

A
  1. Neurological deficit lasting > 24h
  2. Due to vascular compromise
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2
Q

Define Transient Ischaemic Attack (TIA)

A
  1. Neurological deficit lasting < 24h
  2. Due to vascular compromise
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3
Q

State and define the 2 main types of stroke

A
  1. Ischaemic
    • Reduction in cerebral blood flow
    • Due to arterial occlusion or stenosis
  2. Haemorrhagic
    • Ruptured blood vessel
      -> Reduced blood flow
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4
Q

State the 3 types of ischaemic stroke with aetiology

A
  1. Cardiac
    • Atherosclerotic disease
    • AF
  2. Vascular
    • Aortic dissection
    • Vertebral dissection
  3. Haematological
    • antiphospholipid syndrome
    • sickle cell disease
    • Polycythaemia
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5
Q

State the 4 types of haemorrhagic stroke with aetiology

A
  1. Intracerebral
    • Trauma
    • Hypertension
    • Cerebral amyloid
  2. Subarachnoid
    • Trauma
    • Berry aneurysm
    • Atriovenous malformation
  3. Extradural
    • A bleed but not classed as haemorrhagic stroke
  4. Subdural
    • A bleed but not classed as haemorrhagic stroke
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6
Q

Clinical presentation of Anterior cerebral artery stroke

A
  1. Contralateral hemiparesis
  2. Sensory loss lower limb > upper limb
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7
Q

Clinical presentation of Middle cerebral artery stroke

A
  1. Contralateral hemiparesis
  2. Sensory loss with upper limbs > lower limbs
  3. Homonymous heminopia (2 right or 2 left halves of visual field)
  4. Aphasia (difficulty with language or speech) - if dominant hemisphere
  5. Hemineglect syndrome - if non-dominant hemisphere
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8
Q

Clinical presentation of Posterior cerebral artery stroke

A
  1. Contralateral homonymous heminopia (both outside or both inside visual field) + macular sparing (central visual field spared)
  2. Visual agnosia (inability to recognise objects despite seeing them)
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9
Q

Clinical presentation of vertebrobasilar artery stroke

A
  1. Cerebellar signs
  2. Reduced consciousness
  3. Quadriplegia or hemiplegia
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10
Q

Clinical presentation of Midbrain infarct stroke

A
  1. Oculomotor palsy
  2. Contralateral hemiplegia
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11
Q

Clinical presentation of posterior inferior cerebellar artery occlusion

A
  1. Ipsilateral facial loss of pain and temp
  2. Ipsilateral cerebellar signs
  3. Contralateral loss of pain + temp
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12
Q

Clinical presentation of retinal/opthalmic artery stroke

A

Amaurosis fugax - transient loss of vision

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13
Q

Clinical presentation of basilar artery stroke

A

‘locked in’ syndrome - fully paralysis except eye movement

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14
Q

Diagnosis of stroke

A
  1. Urgent CT/MRI
    • Differentiate between haemorrhage and ischaemic
  2. ECG
    • AF
  3. Bloods
    • FBC = Rule out thrombocytopenia & polycythaemia
    • Blood glucose = rule out hypoglycaemia
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15
Q

Treatment of ischaemic stroke

A
  1. Maximise reversible ischaemic tissue
    • Hydration
    • O2 > 95%
    • If ischaemic -> proceed to THROMBOLYSIS
  2. THROMBOLYSIS
    • up to 4.5h post onset of symptoms
    • MUST CT TO RULE OUT HAEMORRHAGE or made worse
    • Tissue plasminogen activator = IV ALTEPLASE
    • Antiplatelet therapy = CLOPIDOGREL 2Hh AFTER THROMBOLYSIS
  3. CONTRAINDICATIONS
    • Surgery in past 3 months
    • Recent arterial puncture
    • History of active malignancy
    • Brain aneurysm
    • Anticoagulant use
    • Severe liver disease
    • Acute pancreatitis
    • Clotting disorder
  4. IF ONSET UNKOWN
    -> thrombolysis not suitable
    -> aspirin daily for 2 weeks then lifelong CLOPIDOGREL
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16
Q

Treatment of hemorrhagic stroke

A
  1. Frequent GCS (glasgow coma scale) monitoring
  2. Antiplatelets need to be contraindicated
  3. Anticoagulants reversed with BERIPLEX + Vit K
  4. Control hypertension
  5. Manual decompression of raised ICP and/or with diuretics = MANNITOL
  6. Surgery
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17
Q

Clinical presentation of subarachnoid haemorrhage (SAH)

A
  1. Sudden onset severe occipital headache
    • kicked in the head description
  2. Vomit, collapse, seizure coma
  3. Neck stiffness
  4. Kernig sign = unable extend leg at knee when thigh flexed
  5. Brudzinski sign = neck flexed -> hips and knees get flexed too
  6. MUST be differentiated from migraine
    • Short time to maximal headache intensity = SAH
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18
Q

Diagnosis of SAH

A
  1. CT head
    • star shaped lesion
  2. Lumbar puncture
    • IF CT normal but SAH suspected
    • Xanthochromia (bilirubin in CSF) = SAH
  3. ABG
    • Exclude hypoxia
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19
Q

Treatment of SAH

A
  1. Refer to neurosurgeon immediately
  2. Maintain cerebral perfusion + BP < 160mmHg
  3. Ca2+ blockers = reduce vasospasm
    • IV/ORAL NIMODIPINE
  4. ENDOVASCULAR COILING - 1ST LINE
  5. Surgery
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20
Q

Clinical presentation of subdural haemorrhage (SDH)

A
  1. Interval between injury and symptoms
  2. Fluctuating consciousness
  3. Sleepiness
  4. Headache
  5. Personality change
  6. Signs of ICP
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21
Q

Diagnosis of SDH

A
  1. CT HEAD
    • CRESCENT SHAPE = SDH
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22
Q

Clinical presentation of EDH

A
  1. Head injury
  2. Brief post trauma loss of consciousness
  3. Lucid interval before severe symptoms appear
  4. ICP symptoms
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23
Q

Diagnosis of EDH

A
  1. CT head
    • Hyperdense haematoma
    • Lense shaped
    • Adjacent to skull
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24
Q

Treatment of SDH & EDH

A
  1. ABCDE management
  2. IV MANNITOL = reduce ICP
  3. Neurosurgery referral
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25
Clinical presentation of TIA
Sudden loss of function, last few mins, complete recovery
26
Diagnosis of TIA
1. Bloods - FBC = polycythaemia - ESR = raised in vasculitis - Glucose = hypoglycaemic 2. Carotid artery doppler ultrasound 3. MR/CT 4. ECG - AF
27
Define meningitis
1. Inflammation of leptomeninges 2. Due to bacterial, viral or fungal infection
28
Aetiology of meningitis
1. Bacterial (rare but fatal) - N. meningitidis - S. pneumoniae 2. Viral - Enteroviruses - HSV - VZV 3. Fungal - Cryptococcus neoformans - Candida
29
Clinical presentation of meningitis
1. Meningism - Headache - Photophobia - Neck stiffness 2. Kernig's sign ->. Hip flexed + knee at 90 degrees -> pain on knee extension 3. Brudzinski sign - Severe neck stiffness -> hips and knee flex when neck flexed 4. N+V 5. Fever
30
Diagnosis of meningitis
1. Lumbar Puncture (LP) & Cerebrospinal fluid (CSF) - CSF gram stain - S. pneumoniae = gram+ve; cocci; chain - N. meningitidis = gram -ve; diplococci - CSF culture - CSF PCR - virus 2. FBC - leukocytosis 3. CRP - raised 4. Blood glucose - COMPULSORY to compare with CSF glucose 5. Blood culture
31
Treatment of meningitis
1. IV/IM BENZYLPENICILLIN (PRIMARY CARE) 2. CEFOTAXIME (SECONDARY CARE) 3. DEXAMETHASONE 4. VIRAL - ACICLOVIR
32
CSF interpretation for BACTERIAL meningitis
1. PRESSURE - Elevated 2. APPEARANCE - Cloudy 3. WBC - 10-5000/mm3 4. MAIN CELL TYPE - Neutrophils 5. GLUCOSE - <50% serum glucose 6. PROTEIN - >1g/L
33
CSF interpretation for VIRAL meningitis
1. PRESSURE - Normal or elevated 2. APPEARANCE - Clear 3. WBC - < 1000/mm3 4. MAIN CELL TYPE - Lymphocytes 5. GLUCOSE - >60% serum glucose 6. PROTEIN - <1g/L
34
CSF interpretation for FUNGAL meningitis
1. PRESSURE - Elevated 2. APPEARANCE - Cloudy/fibrin web 3. WBC - < 1000/mm3 4. MAIN CELL TYPE - Lymphocytes 5. GLUCOSE - <50% serum glucose 6. PROTEIN - >1g/L
35
Define encephalitis
1. Inflammation of brain parenchyma 2. HSV = main cause
36
Clinical presentation of encephalitis
1. Fever 2. Headache 3. Reduced GCS 4. Behavioural changes - Memory disturbance - Psychotic behaviour 5. Aphasia (difficulty speaking)
37
Diagnosis of encephalitis
1. CSF - Analysis - lymphocytosis + raised protein - PCR - viral infection detection - Culture - Bacterial detection - Serology - Antibodies against specific viral antigens 2. Bloods - FBC - CRP - U&E - Cultures 3. Throat swab - Viral culture 4. HIV serology 5. CT or MRI Head
38
Treatment of encephalitis
1. Aciclovir (generic) 2. Further treatment underlying organism dependent
39
Define Multiple Sclerosis
1. Autoimmune 2. Cell mediated 3. Demyelinating disease 4. Of CNS
40
Describe the disease patterns of MS
1. Relapsing-remitting 2. Secondary progressive (no remission stage at all) 3. Primary progressive
41
Clinical presentation of MS
1. Blurred vision 2. Red desaturation of eyes (inability to see red) 3. Numbness + tingling 4. Weakness 5. Upper motor neuron signs (spastic paraparesis) 6. Bowel + bladder dysfunction 7. Worsening of symptoms upon raised environment temp (e.g. bath)
42
Diagnosis of MS
1. MRI brain + spine - Demyelinating plaques - High signal T2 lesion 2. Lumbar puncture - Oligoclonal bands found in CSF but NOT in serum = increased IgG 3. FOR SUCCESSFUL DIAGNOSIS NEED: - 2 or more relapses AND EITHER - Clinical evidence of 2 or more lesions OR- clinical evidence of 1 lesion + history of relapse
43
Treatment of MS
- Oral or IV METHYLPREDNISOLONE - BACLOFEN
44
Define Guillain-Barré syndrome (GBS)
1. Autoimmune 2. Rapidly progressive demyelination 3. Of PNS 4. Often triggered by infection
45
Aetiology of GBS
1. Molecular mimicry - Pathogenic antigen resembles myelin gangliosides in PNS - Immune system targets antigen - Attacks myelin sheath of sensory and motor nerves - Anti-ganglioside antibodies produced (Anti-GMI)
46
Clinical presentation of GBS
1. Peak symptoms within 2-3 weeks of disease 2. Tingling + numbness 2. Symmetrical, progressive, ascending weakness 3. Unsteady walk 4. Autonomic dysfunction 5. Respiratory distress
47
Diagnosis of GBS
1. Bloods to exclude differentials - U&E - electrolyte abnormalities causing neuropathic symptoms - B12 and folate - deficiency -> neuro features - TFTs - exclude hypothyroidism - LFTs - Elevated hepatic enzymes = more severe disease - Anti-GMI - to differentiate GBS variants 2. Cultures - Stool or sputum to exclude infective features 3. Lumbar puncture - raised protein + normal WBC = usually GBS 4. Spirometry - Monitor respiratory function
48
Treatment of GBS
1. IV immunoglobulins - 5 day treatment - Within first 2 weeks of symptoms 2. Plasma exchange - Within first 4 weeks
49
Define Parkinson's disease (PD)
1. Neurodegenerative 2. Loss of dopaminergic neurones 3. Within substantia nigra pars compacta of basal ganglia 4. Idiopathic 5. Impaired control of voluntary movements
50
Clinical presentation of PD
1. Bradykinesia 2. Tremor 3. Rigidity 4. Sleep disturbance 5. Psychiatric symptoms
51
Diagnosis of PD
1. Bradykinesia + at least one of following: - Tremor - Rigidity - Postural instability 2. MRI brain
52
Treatment of PD
1. For motor symptoms affecting quality of life - Levodopa + decarboxylase inhibitor - CO-BENELDOPA 2. For motor symptoms not affecting quality of life - Dopamine agonist - PRAMIPEXOLE 3. Deep Brain Stimulation
53
Define Dementia
1. Progressive decline in cognitive function 2. Affecting multiple domains such as 3. language 4. Exec. function 5. Memory 6. Social cognition
54
State the commonest type of Dementia
Alzheimer's
55
Pathophysiology of Alzheimer's
1. Deposition of extracellular beta-amyloid 2. And intracellular tau protein 3. Leads to neurotoxicity + reduced cholinergic transmission
56
Clinical presentation of Alzheimer's
1. Characteristic order of language impairment - Naming -> comprehension -> fluency 2. Memory impairment
57
Diagnosis of Alzheimer's
1. No specific tests for dementia .˙. diagnosis by - MMSE - Excluding reversible caused of cognitive decline 2. EXCLUDING REVERSIBLE CAUSES - Medication review: Opioids, benzodiazepines - Bloods: FBC, U&E, LFTs, TFT, B12 & folate - CT/MRI head
58
Treatment of Alzheimer's
1. Access to memory service 2. Education 3. Cognitive stimulation therapy 4. Acetylcholinesterase inhibitor - Donepezil 5. Memantine
59
Define migraine
1. Primary headache 2. Episodic 3. Sometimes preceded by aura
60
Aetiology of migraine
1. Neuronal hyper-excitability 2. Leads to trigeminal nerves initiating inflammatory response 3. Leads to dilation of meningeal blood vessels + sensitisation surrounding nerve fibres
61
Clinical presentation of migraine
1. Severe, unilateral, pulsating headache up to 72h 2. N+V 3. Photophobia & phonophobia 4. Aura
62
Diagnosis of migraine
1. CT or MRI head to rule out secondary headache 2. ESR to rule out giant cell arteritis
63
Treatment of migraine
1. Analgesia - Aspirin etc - Antiemetic = metoclopramide - Avoid opiates
64
Clinical presentation of tension headache
1. Episodic or chronic 2. One of the following - Bilateral - Pressing/tight non-pulsatile - Mild/moderate intensity - +/- scalp muscle tenderness 3. N+V 4. Sensitivity to head movement 5. NO AURA
65
Clinical presentation of cluster headache
1. Abrupt onset 2. Excruciating pain around: - one eye or - temple or - Forehead 3. Ipsilateral cranial autonomic features - watery/bloodshot eye - Facial flush - Rhinorrhea 4. +/- vomiting
66
Treatment of cluster headaches
1. Analgesic UNHELPFUL 2. 100% 15L O2 for 15mins via non-rebreathable mask 3. SC SUMATRIPTAN 4. PREVENTION - CCB = VERAPAMIL - Corticosteroid = PREDNISOLONE
67
Define trigeminal neuralgia
1. Severe unilateral pain 2. Distributed in one or more trigeminal branches 3. Usually due to nerve compression
68
Clinical presentation of trigeminal neuralgia
1. Trigem distribution 2. Severe 3. Unilateral 4. Electric shock-like sensation 5. Provoked
69
Diagnosis of trigeminal neuralgia
1. MRI brain to exclude differential diagnosis
70
Treatment of trigeminal neuralgia
1. CARBAMAZEPINE = first line 2. Neurology if severe pain
71
Define epilepsy
1. Neurological disorder 2. Recurrent seizures 3. Due to hyper-synchronous discharge of neurones
72
Aetiology/epidemiology of epilepsy
1. INHERITED - Premature birth - Cerebral palsy - Family history 2. ACQUIRED - Traumatic brain injury - Neurodegen disease - Ischaemic stroke - Brain tumour - Cocaine 3. MIXED - Dementia
73
Clinical presentation of epilepsy
1. Seizure triggers (alcohol, etc) 2. Aura 3. Jerking (tonic-clonic) or behavioural arrest (absence) 4. Spread from distal part of limbs towards face 5. Urinary incontinence 6. Amnesia post seizure
74
State the types of seizures in epilepsy
1. Focal seizures - Focal aware - Focal impaired awareness - Awareness unknown - Focal motor seizure - Focal non-motor seizure 2. Generalised seizures - both hemispheres - Generalised motor seizure - Generalised non-motor seizure
75
Diagnosis of epilepsy
1. Urinalysis - nitrites or leucocytes = infection 2. Capillary blood glucose - exclude hypoglycaemia 3. ECG - exclude cardio differentials 4. FBC - leucocytosis 5. CRP + ESR - infection 6. U&E + bone profile - electrolyte imbalance 7. Toxicology - drug differentials 8. CT head - exclude intracranial causes (e.g. haemorrhage)
76
Treatment of epilepsy
1. STOP DRIVING - 1st unprovoked seizure without structural abnormality = 6 month suspension - 1st unprovoked seizure WITH structural abnormality = 12 month suspension 2. Anti-epileptic drugs (AEDs) - Generalised epilepsy = SODIUM VALPROATE - Focal epilepsy = CARBAMAZEPINE
77
Define spinal cord compression (SCC)
1, Injury to spinal cord due to external pressure 2. Leads to injury to white and grey matter
78
Clinical presentation of SCC
1. Upper motor neuron weakness - Loss of muscle power - Increased tone 2. Sensory deficit 3. Spinal shock 4. Weakness
79
Diagnosis of SCC
1. Full neuro examination 2. MRI whole spine 3. Blood culture - Osteomyelitis differential 4. CSF culture - CNS infection 5. CT thorax, abdomen and pelvis - Metastatic differential
80
Treatment of SCC
Multidisciplinary team involvement required Management dependent on cause of SCC
81
Define Cauda Equine syndrome
1. Medical emergency 2. Spinal damage at or caudal to L1 3. Flaccid & areflexic weakness
82
Clinical presentation of Cauda Equine syndrome
1. Difference to lesions higher up - CES = leg weakness is flaccid and areflexic - Other lesions = spastic and hyperreflexic 2. Sciatica = radiating pain from lower back to toes 3. Bladder/bowel dysfunction 4. ED
83
Diagnosis of Cauda Equine syndrome
1. MRI - localise lesion 2. Neuro tests
84
Treatment of Cauda equine syndrome
1. Refer neurosurgery asap 2. Microdiscectomy 3. Epidural steroid injection
85
Define Motor Neuron Disease (MND)
Disorder of both upper and lower motor neurons
86
State the types of MND
1. Amyotrophic lateral sclerosis = UMN&LMN 2. Progressive muscular atrophy = LMN 3. Primary lateral sclerosis = UMN 4. Progressive bulbar palsy = speech+swallow issue
87
Clinical presentation of MND
1. Progressive weakness 2. Spastic paraparesis 3. Muscle twitch 4. Language and speech issues 5. Muscle wasting CHARACTERISTIC ABSCENT SIGNS 1. NO sensory abnormalities 2. NO extraocular involvement 3. NO cerebellar involvement 4. Abdominal reflexes usually preserved
88
Diagnosis of MND
CLINICAL DIAGNOSIS BUT 1. Electromyography 2. MRI spine
89
Treatment of MND
1. RILUZOLE 2. Resp. support 3. Antiaspasmodics
90
Define Myasthenia Gravis (MG)
1. Chronic autoimmune disorder 2. Postsynaptic membrane of neuromuscular junction of skeletal muscle 3. Due to circulating autoantibodies against nicotinic acetylcholine receptor (AChR) 4. Leads to fewer available binding sites for ACh at postsynaptic membrane
91
Clinical presentation of MG
1. Lethargy 2. Proximal muscle weakness - worse at EOD 3. Ptosis exacerbated by upward gaze (eyelid droop) 4. Double vision 5. Slurred speech 6. Snarl when trying to smile
92
Diagnosis of MG
1. Antibody tests - AchR antibody test = first line - anti-MuSK = if AchR negative 2. Electrophysiological study 3. CT thorax - exclude thymoma 4. Thyroid function
93
Treatment of MG
1. ACh-esterase inhibitor - PYRIDOSTIGMINE 2. 2nd line = PREDNISOLONE
94
Define Carpel Tunnel Syndrome (CTS)
Pressure and compression on median nerve as it passes through carpal tunnel in the wrist
95
Clinical presentation of CTS
1. Intermittent + gradual onset symptoms 2. Aching pain in hand and arm especially at night 3. Tingling in: - Thumb - Index - Middle - 1/2 ring + palm 4. Relieved by hanging hand off edge of bed
96
Diagnosis of CTS
1. Electromyography (EMG) - Slowing of conduction velocity in median sensory nerves 2. Phalen's test - Maximally flex wrist for 1 min only
97
Treatment of CTS
1. Wrist splint at night 2. Local steroid 3. Decompression surgery
98
State the nerves involved in wrist drop
LMN lesion
99
State the nerves involved in claw hand
Ulnar nerve
100
State the nerves involved in foot drop
Sciatic nerve
101
Clinical presentation of depression
Usual bs
102
Diagnosis of depression
DSM-IV 1. Symptoms present most days > 2w 2. Total 5 symptoms minimum with at least one as core 3. Symptoms must cause functional impairment 4. Exclude differentials BLOODS - Exclude differentials
103
Treatment of depression
1. Psychosocial intervention 2. SSRIs - CITALOPRAM 3. Electroconvulsive therapy in severe cases

SJ Phase 2a (13 decks)

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