Neurology Flashcards
Epilepsy:
- Definition
- Other causes of seizures (6)
- Key questions to ask in history
- Risk factors (5)
- DD (6)
- Investigations
- Types (7)
- Management - During seizure, general, drugs
Epilepsy:
- Definition: 2 unprovoked seizures occurring more than 24 hours apart, or one seizure with a high probability of another occurring with no apparent reason for the seizure identified (seizures are transient episodes of abnormal electrical activity changing someones movement, awareness, behaviour
- Other causes of seizures: encephalitis, stroke, sepsis, tumours, hypoglycemia, febrile convulsions
- Key questions to ask in history: symptoms before (aura = focal), triggers (sleep deprivation, stress, lights), what did seizure look like, symptoms after
- Risk factors: premature, fam, head trauma, tumour, learning disabilities
- DD: vasovagal syncope, arrhythmias, TIA, hypoglycaemia, breath holding attacks, febrile convulsions
- Investigations: history + videos, ecg (excludes heart problems), bloods (u+es (excludes electrolytes), glucose (diabetes), cultures (encephalitis), eeg (after 2nd seizure), mri brain (structural abnorm/tumour if child was <2 years, focal seizures, no response to 1st antiepileptic)
- Types:
Generalised seizures involve both sides brain and focal only 1 specific area
Tonic clonic: loss consciousness, tonic (muscle tensing) then clonic movements (muscle jerking), tongue biting, incontinence, groaning, irregular breathing. Post ictal period is confused, drowsy, irritable. Manage: sodium valporate, 2- carbamezapine
Focal: in temporal lobe hence affects hearing/speech/emotion hence hallucinations, memory flashbacks, deja vu, doing strange things. Can be conscious or unconscious (complex). Manage: carbamezapine or lamotrigine 2-sodium valporate
Absence: in children, stares into blank space unaware surroundings/unresponsive for 10-20 secs and then abruptly returns to normal. Manage: sodium valp or ethosuximide
Atonic: ‘drop attacks’ where brief lapses in muscle tone <3 mins. Can be indicative of Lennox Gastaut syndrome which is severe form epilepsy. Manage: sodium valp 2-lamotrigine
Myoclonic: sudden brief muscle contractions, awake. Manage: sodium valp
Infantile spams: Also known as West syndrome presenting at 6 months. Flexion of head/trunk/arms then extension of arms for few seconds multiple times. EEG shows hypsarrythmia and CT shows brain disease. Manage: prednisolone, vigabatrin but poor outcome
Benign rolandic: in 4-12 years old at night where parathesia of face and maybe tonic clonic movements but stop when adults
-
Management:
During seizure: put child in safe place, recovery position, something soft under head, remove dangerous objects, time seizure, call ambulance if >5 mins
General: showers not baths, careful with swimming/heights/equipment, older children need to inform DVLA and need certain criteria to drive. Aim is monotherapy and to keep symptom free
Sodium valp: inc GABA to relax brain. SE: teratogenic, liver damage, hair loss, tremor
Carbamazepine: SE: agranulocytosis, aplastic anaemia, inducer p450
Phenytoin: SE: folate/vit D def hence osteomalacia + megaloblastic anaemia
Ethosuximide: SE: night tremors, rashes
Lamotrigine: steve johnson syndrome, leukopenia
Extradural haemorrhage:
- Definition
- Layers of skull
- Pathophysiology
- Symptoms (4)
- Signs (3)
- Causes (3)
- Investigations (2)
- Management
- Complications
Extradural haemorrhage:
- Definition: an intracranial bleed
- Layers of skull: scalp, skull, periosteal layer of dura mater, meningeal layer of dura mater, arachnoid mater, pia mater - picture in word document
- Pathophysiology: rupture of middle meningeal artery in temporo parietal region. Can be associated with fracture of temporal bone at pterion. Occurs between skull and periosteal layer of dura mater
- Symptoms: initial loss of consciousness, lucid period, further rapiddeterioration. Headache, N+V, drowsy
- Signs: low conscious level, signs of raised ICP, neurology signs. Cushings reflex which aims to maintain cerebral perfusion (HTN, bradycardia, irregular pattern breathing)
- Causes: non accidental, blunt force head trauma from road accident, sports injury
- Investigations: if reduced GCS CBG to check if hypoglycemia, urgent bloods (fbc, u+es, crp, clotting profile, g&s), CT head (hyperdense biconvex shape as limited by cranial sutures)
- Management: reverse any coagulopathies, prophylactic abx if open skull fracture, anticonvulsants if risk seizures, mannitol to reduce icp, considerer intubation. Then once stabilised surgical craniotomy. Then HDU and routine post op scans to ensure adequate clot removal and ongoing neurorehabilitation
- Complications: coma/death if not treated as ICP rises causing midline shift and tentorial herniation, seizures, infection, cerebral ischaemia, hemiparesis
Spinal Muscular Atrophy:
- Definition
- Types (4)
- Symptoms (3)
- Signs (5)
- Investigations
- Management
Spinal Muscular Atrophy:
- Definition: autosomal recessive condition that causes progressive loss of lmn in sc leading to progressive muscle weakness
-
Types:
SMA1: onset in first few months, death in 2 years
2: onset within 18 months, most don’t walk, survive into adulthood
3: onset after first year, most walk but loose ability
4: onset in 20s, most retain ability to walk but wheelchair as fatigue, resp muscles + life expect not affected - Symptoms: weakness, swallowing problems, difficulty walking/sitting up
- Signs: fasciculation’s, reduced muscle bulk, reduced tone, reduced power, reduced/absent reflexes
- Investigations: genetic testing for SMN1 gene
- Management: MDT, physio to increase muscles/resp muscles strength/function, splints, wheelchairs, non invasive ventilation if resp failure. If SMA1maybe tracheostomy, mechanical ventilation, peg if swallow muscles week
Muscular dystrophies:
- Definition
- Signs (1)
- Investigations (3)
- Management
- Complications (2)
- Types (7)
Muscular dystrophies:
- Definition: genetic conditions that cause progressive weakening and wasting of muscles
- Signs: Gower’s sign indicates proximal muscle weakness (when standing up children get on hands and knees and push hips back and work hands up till standing as pelvic muscles not strong enough)
- Investigations: bloods, electrical tests on nerves/muscles, muscle biopsy,
- Management: no cure, occupational t, physio, wheelchair, braces, surgery if scoliosis
- Complications: spinal scoliosis, HF (muscles of heart/resp affected), dilated cardiomyopathy (hence regular echos needed)
-
Types:
Duchennes muscular dystrophy - another flashcard on this
Beckers: similar to duchennes but dystrophin gene less affected so can maintain some function so symptoms start around 8-12years and can walk until 20-30s. Survive until 30-40s
Myotonic dystrophy: autosomal dominant presenting into late adulthood of progressive muscle weakness, prolonged muscle contractions, cataracts, cardiac arrhythmias.
Facioscapulohumeral dystrophy: weakness around face (sleep with eyes slightly open and weakness in pursing lips and unable to blow cheeks without air leaking) in childhood and progresses to shoulders/arms
Oculopharyngeal dystrophy: late adulthood weakness in ocular muscles and pharynx so bilateral ptosis, restricted eye movement, swallowing problems. Also problems with limb girdles
Limb girdle: teenagers progressive hip and shoulder weakness
Emery Dreifuss: childhood contractures esp elbows/ankles (shortening of muscles/tendons which restrict rom in limbs) + wasting
Tension headaches:
- Symptoms (4)
- Triggers (5)
- Management
- Headache red flags
Tension headaches:
A primary headache has no known underlying cause. A secondary headache is the result of another condition
- Symptoms: mild ache across forehead in band like pattern, comes on gradually + worse at end of day, no visual changes, no pulsating sensation, symmetrical. In child: quiet, stop playing, turning pale, tired, resolves more quickly than adults (30 mins). Normal clinical exam
- Triggers: stress, fear, skip meals, dehydration, infection
- Management: reassure, analgesia, regular meals, avoid dehydration, avoid stress
- Headache red flags: systemic signs, neurolog symptoms, thunderclap onset, papilloedema/ precipitated by exercise
Migraines:
- Definition
- Types (5)
- Symptoms (7)
- Management - acute, prophylaxis
Migraines:
- Definition: complex neurolog condition causing headache 4-72 hours and other symptoms
- Types: without aura, with aura, silent (aura no headache), hemiplegic, abdo (central abdo pain over an hour, N+V, anorexia, headache, pallor)
- Symptoms: unilateral/severe/throbbing headache, takes longer to resolve, visual aura, photophobia, phonophobia, N+V, abdo pain
-
Management: headache diary 8 weeks, rest, fluids, paracet/ibuop. Then if not nasal sumatriptan, antiemetics
Prophylaxis (if severe/missing school): propranolol (not if asthmatic), pizotifen (drowsiness), topiramate (teratogenic)
If <12 refer immediately if: wakes them up, persistent on waking up, progressively worsens, vomiting, aggravating by coughing - Headache red flags: systemic signs, neurolog symptoms, thunderclap onset, papilloedema/ precipitated by exercise
Duchennes muscular dystrophy:
- Definition
- Symptoms (7)
- Signs (3)
- Investigations
- Management
- Complications
- DD (2)
- Extra facts
Duchennes muscular dystrophy:
- Definition: defective gene for dystrophin on X chromo which holds muscles together (part of cytoskeleton in cells) and needed for stability/muscle contraction. X linked recessive hence more common in boys. Is progressive disease with 25-35 years life expectancy
- Symptoms: 3-5yr old muscle weakness around pelvis (gower’s sign), shoulders + arms held back when walking + difficulty lifting things (proximal muscle weakness), sway back, calf pseudohypertrophy (degenerated muscle replaced by fat), protruding belly (weak belly muscles), poor balance /clumsy, walks on toes (tight heel cord is contracture), delayed milestones, faltering growth, fatigue, intellectual impairment
- Signs: flat feet, waddling gait, toe walking
- Investigations: CK raised, genetic testing, muscle biopsy
- Management: oral steroids slow progression, creatine supplement can help muscle strength, genetic counselling
- Complications: usually die of resp failure, dilated cardiomyopathy
- DD: spinal muscular atrophy, limb girdle muscular dystrophy (later onset, auto dom)
-
Extra facts:
CHECK CK IF CAN’T WALK BY 18 MONTHS
Subarachnoid haemorrhage:
- Definition
- Layers of skull
- Pathophysiology
- Causes
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
- Complications
Subarachnoid haemorrhage:
- Definition: bleeding in subarachnoid space where csf located
- Layers of skull: scalp, skull, periosteal layer of dura mater, meningeal layer of dura mater, arachnoid mater, pia mater - picture in word document
- Pathophysiology: usually due to rupture cerebral aneurysm
- Causes: genetic/infections predisposing to development of aneurysms (sickle cell anae, HIV, margams, syphilis), arteriovenous malformations, tumours, trauma
- Risk factors: F, fam hist, marfans/ehlers danlos, PCKD
- Symptoms: sudden onset occipital headache ‘thunderclap’, poor eating, decreased muscular tone, vomiting, irritable, neurolog symptoms (visual changes, dysphasia, focal weakness, seizures, reduced consciousness)
- Signs: seizures, vomiting, poor breathing, altered consciousness, papilloedema
- Investigations: non contrast CT (hyperattenutation in subarach space within 6 hours), if CT normal then LP 12 hours after symptoms start so bilirubin can accummulate in csf showing raised wcc + xanthochromia, CT angiograph after diagnosis to locate bleeding source
- Management: neuro surgeon, intubation if unconscious, surgery such as coil embolisation, nimodipine ccb prevents vasospasm which can cause brain ischaemia
- Complications: vasospasm, stroke, hydrocephalus (treat with external ventricular drain), herniation, hence brain damage and paralysis
Spinal cord injury:
- Definition
- Types of injury
- Causes (6)
- Symptoms
- Investigations
- Management
- Complications
Spinal cord injury:
- Definition: when the sc becomes damaged. If complete injury can cause loss of motor and sensory below below the level of injury
- Types injury: bruised (contusion), partial tear, complete tear (transection) (no motor or sensory below the point)
- Causes: delivery during birth, falls, car accident, sports injury, abscess/infection, diving
- Symptoms: firstly acute spinal shock where loss of feeling, muscle movement, reflexes. Also weakness, breathing problems, loss bladder/bowel function, sweating, shivering (abnormal autonomic regulation). Symptoms depend where sc injured, if to neck then tetraplegia with sensory loss, if upper sc/thoracic then weak chest muscles, if lower sc then paraplegia
- Investigations: vital signs, (if c1-c4 paralysis of diaphragm hence breathing), xray, mri is gold standard
- Management: ITU, steroids to decreased swelling in sc, ventilation, catheter, feeding tube, surgery
- Complications: pressure sores, pneumonia, UTI, constipation
Subdural haemorrhage:
- Definition
- Layers of skull
- Signs
- Investigations
- Management
Subdural haemorrhage:
- Definition: If <3 days acute, if 3-21 then subacute, if chronic then >21 which can happen in infants as fragile bridging veins which can rupture in shaken baby syndrome
- Layers of skull: scalp, skull, periosteal layer of dura mater, meningeal layer of dura mater, arachnoid mater, pia mater - picture in word document
- Signs: FLUCTUATIONS of consciousness, weakness/visual field defects (unilat dilated pupil means compressing cn3), headache, seizures, papilledema, ataxia, behaviour changes, n+v if inc ICP
- Investigations: safeguarding, non contrast CT (crescent shape as not limited by sutures only by falx cerebri = FOR ACUTE HYPERDENSE, FOR CHRONIC HYPODENSE (DARK)), look for retinal haemorrhages (also common in shaken baby)
- Management: reverse coagulopathies, start antiemetics for 1 week, craniotomies
Raised ICP:
- Definition
- Pathophysiology
- Types herniation
- Causes
- Symptoms (3)
- Signs (7) - normal, severe
- Investigations (5)
- Management
Raised ICP:
- Definition: as brain and ventricles are enclosed in rigid skull they can’t accommodate for additional volume
- Types herniation: subfalcine, tonsillar, uncal
-
Pathophysiology: cerebral perfusion pressure = MABP - ICP. If MABP inc then CPP inc triggering autoregulation to maintain cerebral blood flow so get vasoconstriction. If ICP inc then CPP dec so you get vasodil to inc MABP
As intracranial vol inc initially ICP stays same due to this mechanism. However when gets to certain volume ICP will increased. Cushings triad = bradycardia, HTN, abnormal breathing and is due to impending herniation of bstem - Causes: blood (intracranial haemorrhage, raised arterial bp due to malignant HTN due to renal cause. Raised venous pressure due to SVCO caused by non hodgkins), csf/hydrocephalus (congenital aqueduct stenosis connecting 3/4 ventricles where enlargement head circumference/bulging fontanelle/poor feed/sleepy and need ventriculoperitoneal / atrial shunt. Or acquired due to infection/trauma/tumour/intraventricular haematoma), brain/cerebral oedema (vasogenic where disruption of BBB inc perm, osmotic, cytotoxic, interstitial), leukaemia, venous sinus thrombosis
- Symptoms: headache worse in morning, change in mood, fluctuating level conciousness
-
Signs: irritable, sleepy, vomit, stiff neck, trouble walking, eye changes, tight fontanelle, abnormal pupils
Severe signs: bradycardia/htn (cushings response), papilloedema with change in conscious level, sunsetting eyes (medial and inferior), GCS <9 -
Investigations: vital signs, ecg, fundoscopy, bloods (clotting, crp, fbc, g&s), CT/mri
DO NOT DO LP OTHERWISE HERNIATION BSTEM - Management: A-E, high flow oxy, elevate head, avoid pyrexia, analgesia, anticonvulsants, sedation, mannitol if likely due to bleed, iv dexamethasone if likely due to tumour, ventriculosotmy, decompressive craniotomy
Status epilepticus:
- Definition
- Management
Status epilepticus:
- Definition: seizure lasting more than 5 mins or 2 or more seizures without regaining consciousness inbetween
-
Management: A-E including airway securing, high flow oxy, assess cardiac + resp function, BGC, IV access, IV lorazepam (repeat after 10 mins if not working) (if in community buccal midazolam or rectal diazepam)
If still not IV levetiracetam, phenytoin, sodium valp + consider intubation - Other causes: hypoglycemia, alc withdrawal
