Neurology Flashcards
What is the typical presentation of a tension headache
It is a type of headache that typically occurs at the frontal or occiput, classically described as a tight band around their head
Usually comes around at the end of a stressful day and lasts a few hours
Relief from OTC
What is the most common cause of a tension headache. What are some other causes (3)
Psychosocial stressors (major change in the family or difficulties at school/bullying
Meningitis
Gastritis
Encephalitis
Space occupying lesion
Brain abscess
What would you expect to see when doing clinical examination of a patient with a tension headache?
Scalp tenderness (due to tightness and spasm of scalp muscles)
Extra: symptoms of stress/anxiety (sweaty palms, shakiness)
Why do we advise patients with a headache to avoid frequent analgesia
Increases the likelihood of a rebound headache which was worse than the original
When do we prescribe preventative medications? Give the first line. What is the maximum duration it can be prescribed for?
Only if affecting daily life
Pizotifin
6 months max
How would you manage a tension headache?
Reassurance that this is normal
advise against frequent use of analgesia especially opioid
Migraines are typically separated based on aura or w/out aura. What is the typical presentation of any migraine?
Sx of migraine:
Severe !throbbing! unilateral headache often frontal (but may be occiput)
Occurs rarely around a few times a month or less
Nausea and vomiting
Associated with photo and phonophobia
Relief by sleep, sitting in a quiet dark room, or early administration of analgesia
Migraines are typically separated based on aura or w/out aura. What is an aura? What are some examples (4)
If someone has a migraine with aura they have the same features of the migraine but with an added neurological symptoms (aura). Examples include:
1. Classic: Visual phenomena - Flashing bright lights, or jagged spectrum of light
2. Double vision
3. Blurring of vision
4. Hemiplegia (weakness on one side)
How do symptoms of migraine in a child differ from what is seen typically in teenagers or adults. (5)
Less intense headaches
More vomiting
Abdominal pain
Paroxysmal Vertigo (dizziness and feeling the world is moving around you)
Paroxysmal torticollis (tilting of the neck due to headache. Not to be confused with the torticollis caused by shortening of the SCM.
10 year old girl with a chronic headache presents to you. She has the headache 3 times a month for 3 years. During this, she feels dizzy and sees lights. Loud noises annoy her and she is relieved by sitting in a dark quiet room. What is the diagnosis?
Migraine with aura
Fun note: Children usually grow out of their migraines but post-puberty, teens and adults have it for longer with 2x amount of girls and women than boys and men
How would you manage a child with migraine?
Non-pharmacological:
1. Food: Make sure you are taking regular meals as hunger can precipitate a migraine and also Avoid chocolate and cheese (not due to dairy)
2. Exercise: increase exercise and ensure you have a small snack and are well hydrated before
Pharmacological:
1. Analgesia: Paracetamol (ibuprofen and naproxen for more severe) but not frequent use!
Remind to not take it frequently to avoid rebound
2. Antiemetic: Metoclopramide (must include)
3. TCA: Simitriptan nasally (must include)
A teenager is worried that their migraines are going to affect their performance in their exams as it has before. She asks you if there’s anything you can do to help. What do you do?
There is a clear history of these migraines affecting her daily living and hence there is an indication of using preventative medications.
Pizotifen (antihistamine)
Propanalol (beta blocker)
IMPORTANT: only to be used while patient needs it (for the cause theyre presenting with, in this case it is exams) Maximum duration is 6 months
Differentiate between meningitis and encephalitis clinically. State 3 in common and 4 differences
Meningitis is inflammation of the meninges whereas encephalitis is the inflammation of the brain parenchyma
Both: fever, headache, !double vision!
Meningitis: Distinctive rash, photophobia, stiff neck, nausea/vomiting
Encephalitis: Seizure, speech and hearing problems, behavioral changes, disorientation, hallucinations
What is the distinctive rash found in meningitis?
Pinprick non-blanching rash that eventually becomes larger red and purple bruises
What do you ask in any history of seizure, headache, loss of consciousness. anything neuro
Brain trauma
What are red flag symptoms in headaches that might indicate the presence of a space occupying lesion/increase ICP.
How would you tell in a history if the patient is having symptoms of meningitis vs space occupying lesion?
Headaches occurring in the middle of the night
Vomiting
Worse with sudden motion such as sneezing or coughing
Focal neurological abnormality (cranial nerves, hemiplegia, papilloedema on fundoscopy)
Faltering growth (weight stagnation)
In meningitis the patient will appear acutely unwell and headaches wouldn’t have been occurring before that.
What is a crescendo pattern?
pattern of gradually increasing intensity
A 14 year old girl moved back from Australia. She presents with a chronic headache for the past 6 weeks. It occurs everyday for 2 hours on average and describes it as having a crescendo pattern. Mom reports that the girl looks pale and feels nauseated. What is the most likely diagnosis. Give your differentials
Space occupying lesion
Raised ICP: CSF obstruction, ICH
Brain abscess
Meningitis
Encephalitis
A teenager that you are familiar with presents with a chronic headache occurring everyday. Last time you saw her, 3 years go, she was having a migraine 2/weeks. What is the most likely diagnosis, investigations, and management.
Constant daily headache lol
Investigation: We must eliminate anything serious. Brain MRI, bloods
Avoid analgesia
Involve clinical psychology (must include)
Involve MDT if complex background.
A child infront of you has just had a seizure lasting 30s and is not unconscious. What do you do
ABCD
Put child in recovery position. place on side and ensure airway is open
Glucometer
A child infront of you has just had a seizure lasting 6 minutes and hasnt stopped seizing. What do you do
ABCDE
Buccal Medazolam
What rapid bedside test can you conduct on a patient that just had a seizure?
Glucometer reading.
What are some easily (3) and hard to (3) treat illnesses that may cause a seizure.
Easy: Meningitis, encephalitis, CNS infection
Hard: Brain tumor, ICH, stroke
All children with epilepsy have seizures but not all seizures in children are due to epilepsy. What is a febrile seizure
A febrile seizure is one that occurs in children with a fever >38.5 celcius and a NON-CNS infection e.g. sepsis, UTI, ear infection
You must exclude epilepsy in children presenting with high fever and seizure as high temperatures alone may precipitate a seizure in patients with epilepsy. What may increase the risk of a patient to have another febrile seizure?
1st seizure occurring in 1st year of life
developmental delay
prolonged seizure
A mother comes to clinic with their child. She complains of regular seizures with any illness even if it is mild and temperature is at 37.8. What is the most likely diagnosis?
Dravet Syndrome: This occurs with children who get seizures at <38 degress so even if minimally febrile.
What is the aetiology of Dravet Syndrome
Genetic mutation in SCN1A gene
Define the following
Epileptic seizure:
Epilepsy:
Focal Epilepsy/seizure:
Generalized Epilepsy/seizure:
Epileptic seizure: manifestation of excessive or hypersynchronous epileptic activity of neurons in the brain
Epilepsy: Chronic condition in which there is recurrent epileptic seizures that recur and are often unprovoked
Focal Epilepsy/seizure: Seizure originating from one point in the brain
Generalized Epilepsy/seizure: Seizure from all over the brain
What is Todd’s paresis?
What is the typical seizure that causes it.
It is a post-ictal feature where there is temporary weakness of one side that can last hours to a day.
Usually occurs after a prolonged focal seizure
How are seizures classified?
According to whether it was focal vs generalized and whether the patient retained consciousness during the episode
Run through what you would ask during history taking
Very important to include witness
1) Prodrome: how it started, what were they doing, where?
2) During: Consciousness, describe the episode, video of episode, duration
3) Post-ictal: how it stopped? (did you try waking them up), what happened after?
Give 2 examples of common post-ictal features
Post-ictal sleepiness/tiredness (Infantile spasms)
Post-ictal crying (Infantile spasms)
Todd’s Paresis - Temporary weakness of one side (prolonged focal seizures)
After a seizure, you are asked to conduct an examination. You find this on the patient’s face. What are these? What is it a sign of?
What type of seizure did the child likely have?
Ash leaf spots associated with Tuberous sclerosis (autosomal dominant) which causes several benign tumors in the brain, CNS, and other organs
West Syndrome (infantile spasms)
Give some etiological causes of seizures. These will help you with investigations! (yeah state those too!)
Genetically influenced: Tuberous sclerosis, Trisomy 21, Micro/macrocephaly (clinical exam)
Structural Brain abnormality: Lissencephaly (smooth brain) and microcephaly (MRI)
Acquired lesions: Post infection (History)
Causes of CP: Hypoxic Ischemic brain injury, ICH (CT/MRI)
Metabolic (Metabolic Panel)
Give 3 conditions that can mimic epilepsy:
Syncope
Breath-holding spells after throwing a fit
Night terrors (family related)
Anoxic seizures (after head injury)
Self-gratification episode
What type of epilepsy is associated with Trisomy 21?
West Syndrome (infantile spasms)
14 year old child presents with a chronic history of migraines. She says she is having trouble with her appetite at night when they occur. What antiemetic will you give them?
Metoclopramide
What is the Insula part of the brain responsible for?
What epilepsy syndrome is associated with this part of the brain?
Responsible for salience detection, pain, addiction, and self-awareness
Benign focal epilepsy of childhood
A 7 year old boy presents to the OD with a history of seizures that occur only during the night especially when coming out of sleep. He describes sensations of choking, drooling, and pulling of his tongue. He has full awareness of what happened (obv hes telling you). What is the most likely diagnosis?
How is it diagnosed?
How is it treated?
Benign focal epilepsy pf childhood
Diagnosed via EEG (sleep deprived to ensure that the patient will fall asleep and show these episodes)
No treatment as it is usually self-resolving by the age of 16
What are the characteristic features of benign focal epilepsy of childhood?
What are some red flag signs?
Nocturnal, coming out of sleep episodes (almost always)
Hemifacial twitching with drooling and choking (may progress to bilateral)
Sensation of tongue being pulled sideways
Fully conscious
Red flags: Daytime episodes, many episodes within the night or prolonged convulsions
What do you expect to find on an EEG of childhood absence epilepsy?
What is used to induce the seizure in clinic for the EEG?
3 Hz generalized spike wave activity
Hyperventilation induces the seizure
An 8 year old girl presents to the emergency department with recurring staring episodes. The girl describes it as “zoning out” out of nowhere but has no recollection of what happens. The mother describes her child lip smacking continuously and swallowing. What additional questions would you like to ask?
What is the most likely diagnosis?
What is the Lip smacking and excessive swallowing called?
How would you diagnose this?
How would you treat?
We need to ask
How does it start? How does it end? => It comes on suddenly and ends abruptly as if nothing happened
How frequent? Many episodes throughout the day >10
How long do they last for? 10-15 seconds (never longer)
Extra points! School performance affected
Diagnosis: Childhood absence epilepsy
Lip smacking = (Oral) automatisms
Investigations: 3Hz generalized spike wave activity EEG but ask the child to hyperventilate (induces seizure)
Treatment: Sodium Valproate
What are the features of Childhood absence epilepsy?
dozens of frequent, short (10-15s) absence seizures “zoning out”/staring
Onset and termination are sudden with no recollection or awareness
No post-ictal phase
Associated with Automatisms (e.g. lip smacking, swallowing)
Induced via hyperventilation
School performance often affected by frequency of occurrence
What is meant by clustering in epilepsy?
What syndrome is it associated with?
Multiple seizures of the same type occurring one consecutively within a short span of time
Infantile spasms (West Syndrome)
8 month old infant makes repeated sets of jerks and spasms such as head nodding, arm extension, and leg flexion. They occur multiple times after each other and then stop for a few hours.
What is your most likely diagnosis?
What do you expect to find on examination?
You conduct a developmental assessment. What are your expected findings?
Under what circumstances do these seizures usually occur?
What is the post-ictal phase?
Infantile spasms/West Syndrome
Hypotonia on examination
Significant developmental delay
These seizures typically occur when the infant is going to bed or waking up
Post-ictal sleepiness or crying
What are the main features of an infantile spasm?
How would you diagnose this?
What is the triad for West Syndrome?
What are the most common causes (2)?
How would you treat?
What is the prognosis of this syndrome?
Clusters!!! of jerks and spasms
Occurs when going to bed or waking up
Post-ictal sleepiness/crying
Diagnosed via EEG showing Hypsarrythmia (chaotic EEG)
Triad is Infantile spasms + developmental delay + Hypsarrhythmia on EEG
Causes: Trisomy 21 and Tuberous sclerosis (AD)
Treat: Corticosteroids, Prednisolone
Prognosis: Often limited to first 2 years of life before progressing to another epilepsy syndrome. Most commonly Lennox-Gastaut syndrome
