Neurology Flashcards
What are the triggers for cluster headache
Alcohol
Nitrate containing foods
Nitroglycerin
Strong odours
Acute management for cluster headache
- High flow O2
- Considers triptans
What is bridging treatment for cluster headaches
Start with maintenance therapy
Unilateral greater occipital nerve block 8-mg Methylpred with 2ml of 2% lidocaine
What is the prophylactic medication for cluster headache
*Verapamil 80mg TID (baseline ECG)
When to withdrawl cluster headache medication
4 weeks after last episode
DSM5 criteria for dementia
Decline from previous level of function in one or more cognitive domains (i.e. complex attention, learning, in memory, language, perceptual, motor, social cognition, executive function)
Area of the brain affected in Alzheimer’s
Temporal and hippocampus
Pharmacological treatment for Alzheimer’s
Donepezil
Rivastigmine
Galantamine
Pharmacological treatment for frontotemporal dementia
Focus on non-pharm measures
SSRIs
Atypical antipsychotics
Pharmacological treatment for Lewy body dementia
Rivastigmine
AVOID ANTIPSYCHOTICS
What are the rules with seizures and personal driving?
Seizures appear to have been prevented by medication AND:
You have been free from seizures for 6 months and your medication does not cause drowsiness or poor co- ordination.
You have had seizures ONLY during sleep, or immediately upon awakening, for at least five years.
You have been seizure-free for at least one year and then have a seizure after decreasing medication under your physician’s advice and supervision. You may drive once you have resumed taking your previous medication at the prescribed dosage.
What are the rules with seizures and commercial driving?
Must be seizure-free for 5 years AND not taking any anti-epileptic medication as directed by your physician.
You have had only one seizure with no indication of epilepsy, and have been seizure-free for 12 months.
You are taking anti-epileptic medications, but have been seizure free for 10 years.
What occurs in multiple sclerosis?
Immune mediated, inflammatory condition, resulting in injury to the Mylan sheath, oligodendrocyte, axon and nerve cells
Typical presentation for MS
Loss reduction of vision in one eye with painful eye movements, double vision, ascending sensory disturbance and or weakness, problems with balance, altered sensation down the back +/- limbs when bending the neck forward
What are the different patterns of MS?
Relapsing remitting, most common period. Often progresses to secondary progressive MS.
Secondary progressive MS. Drops decrease in frequency or stop completely.
Primary progressive MS. Symptoms are gradually develop over time, no relapses or remissions.
Progressive relapsing MS. Progressive with occasional attacks.
What’s the definition of a relapse in MS?
Development of new symptoms or worsening of existing symptoms period either of these occurring for more than 24 hours, with no infection, or other cause after a stable period of at least one month.
Treatment for a relapse in MS?
Methylprednisone 0.5 g daily for five days can consider IV if previous failure with oral steroids
The use of DMARDs in MS?
Often prescribed of more than one relapse in the last two years +2 or more brain lesions.
Can decrease relapses, but does not eliminate and does not improve symptoms.
What occurs in the brain in Parkinson’s disease
Degeneration of midbrain dopamine neurons and catecholamine neurons
Absolute exclusion criteria for diagnosing Parkinson’s
Cerebella signs
Supranuclear gaze palsy
Established diagnosis of behaviour variant frontal-temporal dementia
Parkinson is and restricted to lower limbs.
Treatment with an anti-dopamingeric Absence of response to levodopa Sensory cortical loss.
No evidence of dopaminergic deficiency on functional imaging.
Signs of Parkinson’s
Tremor - suppressed with initiating movement
Rigidity
Akineisa/hypokinesia (must have limb bradykinesia)
Postural instability - occurs later
Annual labs/ix if on an ergot dopamine agonist
Cr
ESR
CXR
What occurs in dopamine dysregulation syndrome
Dopaminergic medication is associated with impulse, control disorder, and normal behaviour, hypersexuality, pathological gambling
First line pharmacology for early Parkinsons
- Levodopa. Lowest dose that maintains good function. Consider in younger patients with increased risk of dyskinesia.
- Dopamine agonists (pramipexole ropinirole)
- MAOB inhibitors (rasagiline)
First line pharmacology for later Parkinsons
- Entacapone
- Rasagiline
Alternate treatments for Parkinsons
Deep brain stimulation
Requiring an antipsychotic in Parkinsons, what are the best options?
Quetiapine or clozapine
What is a lacunar stroke
Ischemic
Usually small vessel, subcortical <1.5cm without cortical infarct
What is a non-lacunar stroke
Ischemic
Caused by large artery arteriosclerosis
Cardioembolic
Causes of ischemic stroke
Cardioemboli from afib
Artheroemboli
Arterial dissection
Vasospasm
Vasculitis
Hypercoaguable state
Signs and symptoms of right hemispheric stroke
- Hemispacial neglect or inattention
- Deficit +/- neglect of left visual field
- Right gaze preference
- Impulsive or overestimation of abilities
- Contralateral face, arm, leg, weakness, or hemiparesis
- Contralateral arm +/- leg sensory loss
Signs and symptoms of left hemispheric stroke
- Aphasia, alexia, agraphia
- Slow and cautious behaviour
- Deficit in right visual field
- Legt gaze preference
- Contralateral face, arm, leg, weakness, or hemiparesis
- Contralateral arm +/- leg sensory loss
Signs and symptoms of anterior cerebral stroke
- contralateral sensomotor defect, foot and leg
- arm paresis
- gait ataxia
- bladder incontinence
- personality and behaviour changes
- flat affect, distractible
- amnesia
Signs and symptoms of middle cerebral stroke
- contralateral sensor, murder, defect face, arm, leg
- contralateral homonymous hemianopia
- contralateral, hemispatial, neglect or inattention
- aphasia, Alexia, agraphia
- gives deviation towards affected hemisphere
- dysarthria
Signs and symptoms of posterior cerebral stroke
- pure homonymous hemianopia
- nausea, vomiting, ataxia
- vertigo, weakness
- sensory loss, dysarthria
Signs and symptoms of vertebro basilar stroke
- vertigo
- limb and gait ataxia
- cranial nerve dysfunction
- coma at onset
- diplopia
- cross sensory loss
- bilateral motor deficit
- isolated field defect
- motor or sensory loss
- dysarthria, dysphasia
Signs and symptoms of thalamic stroke
- alteration and sensors except smell
- alteration in pain and crude touch
- alteration in temperature
- contralateral hemiplegia
- hypersensitivity to stimulus
- vertical and lateral gaze defect
- short-term memory loss
What are the inclusion criteria for intravenous alteplase in stroke
- Ischaemic stroke, causing disabling neurological deficit in patients 18 years and over
- onset of stroke symptom 4.5 hours or less before administration
What are the absolute exclusion criteria for alteplase
Active haemorrhage, or any condition that could increase the risk of major haemorrhage
Are the relative exclusion criteria for alteplase?
- History, intracranial haemorrhage, - - Head injury, spinal injury in the past three months
- Major surgery in the last 14 days
- Arterial puncture at non-compressible site in the last seven days
- signs and symptoms of subarachnoid haemorrhage
- refractory hypertension
What investigation should be done within 24 hours of stroke?
Ultrasound carotids
