Neurology Flashcards

1
Q

What are cluster headaches?

A

Unbearable unilateral headaches, centred around eye
Come in clusters and disappear for extended periods

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2
Q

What are the symptoms of cluster headaches?

A

3-4 episodes/d for wks/mths, then pain-free period lasting several yrs
Attacks last between 15mins and 3hrs
Unilateral

Red, swollen and watering eye
Pupil constriction
Eyelid drooping
Nasal discharge
Facial sweating

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3
Q

Outline acute management of cluster headaches

A

Triptans (eg: Sumitriptan)
High-flow 100% O2

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4
Q

Outline prophylactic management of cluster headaches

A

1st line: Verapamil
Occipital nerve block
Prednisolone- Given short course to break the cycle
Lithium

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5
Q

What are the 4 types of migraine?

A

Migraine w/o aura
Migraine with aura
Silent migraine (aura but no headache)
Hemiplegic migraine

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6
Q

What are the 5 stages of migraine?

A
  • Premonitory/prodromal- Several days before headache
  • Aura (lasts up to 60mins)
  • Headache- Lasts 4 to 72h
  • Resolution- Headache fades/relieved abruptly by vomiting or sleeping
  • Postdromal/recovery phase
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7
Q

What are the typical features of a migraine headache?

A

Lasts between 4 and 72h
Usually unilateral
Moderate-severe intensity
Pounding or throbbing
Photophobia
Phonophobia
Osmophobia (discomfort with smells)
Aura (visual changes)
N&V

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8
Q

What are the common features of an aura?

A

Affects vision/sensation/language
Sparks in vision
Blurred vision
Lines across vision
Loss of visual fields (eg: Scotoma)
Tingling/numbness
Dysphagia

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9
Q

What is a hemiplegic migraine?

A

Unilateral limb weakness
Ataxia (loss of coordination)
Impaired consciousness
Familial hemiplegic migraine- Autosomal dominant
Can mimic stroke or TIA

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10
Q

List some of the triggers of migraines

A

Stress
Bright lights
Strong smells
Certain foods (eg: Chocolate, cheese, caffeine)
Dehydration
Menstruation
Disrupted sleep
Trauma

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11
Q

Outline acute management of migraines

A

NSAIDs
Paracetamol
Triptans (eg: Sumitriptan)
Antiemetics (eg: Metoclopramide or prochlorperazine)

Opiates can make migraine worse

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12
Q

Outline triptans

A

5-HT receptor agonists (bind to serotonin receptors

MoA:
Cranial vasoconstriction
Inhibit transmission of pain signals
Inhibit release of inflammatory neuropeptides

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13
Q

What are the CIs of triptans?

A

Associated with vasoconstriction:
HTN
Coronary artery disease
Previous stroke
TIA
MI

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14
Q

Outline prophylaxis of migraines

A

Headache diary and avoid triggers
Propanolol
Amitriptyline
Topiramate (teratogenic)

Specialist:
Pizotifen
Candesartan
Sodium valproate
MA- Erenumab or fremanezumab

CBT
Mindfulness and meditation
Acupuncture
Vit B2 (riboflavin)

Menstrual migraines- Prophylactic triptans (eg: Frovatriptan or zolmitriptan)

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15
Q

Which type of headache is the COCP CI in and why?

A

Migraine with aura
Associated with increased risk of stroke

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16
Q

What are the red flags of headaches?

A

Fever, photophobia, neck stiffness- Meningitis, encephalitis, brain abscess
New neuro symptoms- Haemorrhage, tumours
Visual disturbance- Giant cell arteritis, glaucoma, tumours
Sub-onset occipital headache- SAH
Worse on coughing or straining- Raised ICP
Postural, worse on standing/lying/bending over- Raised ICP
Vomiting- Raised ICP or CO poisoning
History trauma- ICH
History of cancer- Brain metastasis
Pregnancy- Pre-eclampsia

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17
Q

What is an important investigation in papilloedema?

A

Fundoscopy
Suggests raised ICP- Brain tumour, benign intracranial HTN, intracranial bleed

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18
Q

Outline tension headaches

A

Common
Mild ache or pressure in band-like pattern around head
Develop and resolve gradually
No visual changes

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19
Q

What are some of the associations of tension headaches?

A

Stress
Depression
Alcohol
Skipping meals
Dehydration

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20
Q

Outline management of tension headaches

A

Reassurance
Ibuprofen or paracetamol
Amitriptyline for chronic/frequent tension headaches

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21
Q

What are secondary headaches?

A

Similar presentation to tension headache, but with a clear cause

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22
Q

List some of the causes of secondary headaches

A

Infections- Viral URTI
OSA
Pre-eclampsia
Head injury
CO poisoning

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23
Q

Outline sinusitis

A

Inflammation of paranasal sinuses
Typically causes pain and pressure following recent viral URTI
Tenderness and swelling on palpation of affected areas
Resolve within 2-3wks

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24
Q

What is the management of sinusitis?

A

Usually spontaneously resolves within 10d
Steroid nasal spray
Antibiotics- Pen V

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25
What is a medication overuse headache?
Analgesic headache caused by frequent analgesia use Similar non-specific features as tension headache
26
Outline hormonal headaches
Related to low oestrogen Similar to migraine features Occur: 2d before and 1st 3d menstruation Perimenopause Early pregnancy
27
Outline management of hormonal headaches
Triptans NSAIDs- Mefenamic acid
28
Outline cervical spondylosis
Caused by degenerative changes in cervical spine Causes neck pain, worse with movement Often presents with headaches
29
Outline trigeminal neuralgia
Intense facial pain in distribution of trigeminal nerve 90% unilateral More common in MS
30
Outline presentation of trigeminal neuralgia
Pain comes on suddenly and lasts secs to hrs Electricity-like, shooting, stabbing or burning pain May be triggered by touch, talking, eating, shaving or cold Attacks may worsen over time
30
Outline management of trigeminal neuralgia
Carbamazepine
31
What is tuberous sclerosus?
Autosomal dominant genetic condition that affects multiple systems Characteristic feature- Hamartomas (benign tissue growths)
32
What are the common locations of hamartomas in tuberous sclerosus?
Skin Brain Lungs Heart Kidneys Eyes
32
What are the common mutations causing tuberous sclerosus?
TSC1 gene on Chr 9- Hamartin TSC2 gene on Chr16- Tuberin Hamartin and tuberin interact to control size and growth of cells- Abnormality leads to abnormal cell size and growth
33
Outline skin features of tuberous sclerosus
Ash leaf spots- Depigmented areas of skin shaped like ash leaf Shagreen patches- Thickened, dimpled, pigmented patches of skin Angiofibromas- Small skin-coloured/pigmented papules that occur over nose and cheeks Ungual fibromas- Circular painless lumps that grow from nail bed and displace nail Cafe-au-lait spots Poliosis- Isolated patch of white hair on head/eyebrows/eyelashes/beard
34
List neurological features of tuberous sclerosis
Epilepsy LD Brain tumours
35
Outline other features of tuberous sclerosus
Rhabdomyolysis in heart Angiomyolipoma in kidneys Lymphangioleiomyomatosis in lungs Subependymal giant cell astrocytoma in brain Retinal hamartomas in eyes
36
Outline management of tuberous sclerosus
No treatment for underlying gene defect Supportive- Monitor and treat complications mTOR inhibitors may be used to suppress growth of brain/lung/kidney tumours
37
What is neurofibromatosis?
Genetic condition causing nerve tumours (neuromas) to develop throughout nervous system Benign but can cause neuro and structural problems
38
Outline NFT1
More common than type 2 Chr 17- Codes for neurofibromin- Tumour suppressor protein Autosomal dominant
39
Outline features of NFT1
C- Cafe au lait spots R- Relative with NF1 A- Axillary or inguinal freckling BB- Bony dysplasia, such as Bowing of long bone or sphenoid wing dysplasia I- Iris hamartomas- Yellow-brown spots on iris N- Neurofibromas G- Glioma of optic pathway
40
What do neurofibromas look like on the skin?
Skin-coloured, raised nodules or papules with smooth, regular surface
41
Outline management of NF1
Diagnosis based on presentation No treatment Manage complications
42
List complications of NF1
Migraines Epilepsy Renal artery stenosis, causing HTN LD ADHD Scoliosis of spine Vision loss (2ndary to optic nerve glioma) *Malignant peripheral nerve sheath tumours *GI stromal tumour Brain tumour Spinal cord tumour Increased risk cancer
43
Outline neurofibromatosis type 2
Chr 22- Codes for Merlin (tumour suppressor protein in Schwann cells (PNS)) Mutations lead to Schwannomas Autosomal dominant Acoustic neuromas (tumours of auditory nerve)
44
What is the key characteristic of NF2?
Bilateral acoustic neuromas
45
What is Guillain-Barre syndrome?
Acute paralytic polyneuropathy affecting PNS Acute symmetrical ascending weakness and sensory symptoms Triggered by infection- Campylobacter jejuni, CMV, EBV
46
Outline presentation of Guillain-Barre syndrome
Symptoms start within 4wks of triggering infection Symmetrical ascending weakness Reduced reflexes Recovery period- Mths to yrs May have peripheral loss sensation or neuropathic pain May progress to CNs and cause facial weakness Autonomic dysfunction- Urinary retention, ileus or heart arrhythmias
47
Outline diagnosis of Guillain-Barre syndrome
Clinically Nerve conduction studies- Reduced signal through nerves Lumbar puncture- Raised protein, normal cell count and glucose
48
Outline management of Guillain-Barre syndrome
Supportive care VTE prophylaxis- PE leading cause of death IVIG 1st line Plasmapheresis- Alternative to IVIG
49
Outline prognosis of Guillain-Barre syndrome
Recovery mths-yrs 5% mortality due to respiratory or CV complications
50
What is Charcot-Marie-Tooth disease?
Inherited disease that affects peripheral motor and sensory neurones Myelin or axon dysfunction Autosomal dominant Symptoms usually present <10y
51
Outline features of Charcot-Marie-Tooth disease
High foot arches (pes cavus) Distal muscle wasting- Inverted champagne bottle legs Lower leg weakness- Loss of ankle dorsiflexion (high stepping gait due to foot drop) Weakness in hands Reduced tendon reflexes Reduced muscle tone Peripheral sensory loss
52
List causes of peripheral neuropathy
Alcohol B12 deficiency Cancer and CKD Diabetes and Drugs (isoniazid, amiodarone, leflunomide, cisplatin) Every vasculitis Charcot-Marie-Tooth disease
53
Outline management of Charcot-Marie-Tooth disease
Physio Podiatrists Analgesia (amitriptyline)
54
What is Myasthenia gravis?
AI condition affecting NMJ Muscle weakness that progressively worsens with activity and improves with rest
55
Which condition has a strong link to myasthenia gravis?
Thymomas (thymus gland tumours)
56
Outline presentation of myasthenia gravis
Affects women <40y and men >60y Associated with thymoma Affects proximal muscles of limbs and small muscles of head and neck Weakness worsens with muscle use and improves with rest Difficulty climbing stairs, standing from a seat, raising hands above head Extraocular muscle weakness- Diplopia Eyelid weakness- Ptosis Weak facial muscles Difficulty swallowing Fatigue in jaw when chewing Slurred speech
57
How can you test muscles for fatiguability indicating myasthenia gravis?
Repeated blinking- Ptosis Prolonged upward gazing- Diplopia Repeated abduction of 1 arm 20 times- Unilateral weakness
58
Outline pathophysiology of myasthenia gravis
ACh receptor antibodies produced- Bind to postsynaptic ACh receptors- Blocked More receptors used in activity= More blocked Clear at rest
59
How do NMJ work?
Way for motor neurones to communicate with muscles Axons release ACh from presynaptic membrane- Travels across synapse and attaches to receptors on postsynaptic membrane stimulating muscle contraction
60
Which antibodies can cause myasthenia gravis?
AChR antibodies MuSK antibodies LRP4 antibodies
61
Outline investigations in myasthenia gravis
Antibody tests CT/MRI of thymus gland- Thymoma Edrophonium test if doubt
62
Outline management of myasthenia gravis
Pyridostigmine- Cholinesterase inhibitor Immunosuppression (eg: Prednisolone or azathioprine) Thymectomy- Can improve symptoms even w/o thymoma Rituximab
63
What is Myasthenic crisis?
Potentially life-threatening complication of myasthenia gravis Acute worsening of symptoms- Often triggered by RTI Respiratory muscles weaken- Can lead to respiratory failure
64
How is a myasthenic crisis managed?
NIV or mechanical ventilation IVIGs Plasmapheresis
65
What is Lambert-Eaton Myasthenic syndrome?
AI condition affecting NMJ Symptoms less insidious/pronounced Mostly paraneoplastic and occurs alongside SCLC
66
Outline pathophysiology of Lambert-Eaton Myasthenic syndrome
Antibodies against voltage-gated calcium channels in presynaptic membrane Less ACh released- Weaker signal- Reduced muscle contraction
67
What is the role of voltage-gated calcium channels in muscle contraction?
Responsible for assisting release of ACh into synapse of NMJ
68
Outline presentation of Lambert-Eaton myasthenic syndrome
Proximal muscle weakness Autonomic dysfunction- Dry mouth, blurred vision, impotence, dizziness Reduced/absent tendon reflexes *Signs and symptoms improve after periods of muscle contraction
69
Outline management of Lambert-Eaton Myasthenic syndrome
Exclude malignancy- SCLC Amifampridine Pyridostigmine Immunosuppressants (eg: Prednisolone or azathioprine) IVIGs Plasmapheresis
70
What is Huntington's Chorea?
Autosomal dominant- Trinucleotide repeat disorder Progressive neurological dysfunction Has anticipation
71
Outline presentation of Huntington's Chorea
Symptoms begin 30-50y Begins with cognitive/pschiatric/mood problems Chorea Dystonia Rigidity Eye movement disorders Dysarthria Dysphagia
72
What is chorea?
Involuntary, random, irregular and abnormal body movements
73
What is dystonia?
Abnormal muscle tone, leading to abnormal postures
74
What is rigidity?
Increased resistance to passive movement of joint
75
What is dysarthria?
Speech difficulties
76
What is dysphagia?
Swallowing difficulties
77
What is anticipation?
Huntington's chorea Feature of trinucleotide repeat disorders- Successive generations have more repeats Earlier age of onset Increased severity of disease
78
Give examples of trinucleotide repeat disorders
Huntington's Chorea Fragile X syndrome
79
Outline management of Huntington's chorea
Diagnosis- Genetic testing Genetic counselling Physiotherapy Speech and language therapy Tetrabenazine- Chorea symptoms SSRIs Advanced directives and end-of-life care
80
Outline prognosis of Huntington's disease
Progressive Life expectancy- 10-20y after onset of symptoms Death often due to aspiration pneumonia Suicide also common
81
Outline presentation of brain tumours
As grow- Progressive focal neurological symptoms Raised ICP symptoms: Constant headache Nocturnal Worse on waking Worse on coughing/straining Vomiting Papilloedema (fundoscopy) Altered mental state Visual field defects Seizures (partial) Unilateral ptosis 3rd and 6th nerve palsies
82
What are the causes of increased ICP?
Brain tumours ICH Idiopathic intracranial HTN Abscess or infection
83
Outline papilloedema
Sign of raised ICP Swelling of optic disc 2ndary to raised ICP Paton's lines on fundoscopy
84
Outline gliomas
Tumours of glial cells in brain/SC Glial cells surround and support neurones- Astrocytes, oligodendrocytes, ependymal cells Most common and aggressive form- Glioblastoma
85
Outline meningiomas
Tumour growing from meninges Usually benign Take up space- Mass effect
86
What are the most common cancers to spread to the brain?
Lung Breast Renal cell carcinoma Melanoma
87
Outline management of brain tumours
MRI 1st line Biopsy during surgery Options- Surgery/chemotherapy/radiotherapy/palliative care
88
Outline pituitary tumours
Tend to be benign Press on optic chiasm- Bitemporal hemianopia
89
Outline presentation of pituitary tumour
Bitemporal hemianopia Acromegaly (excessive GH) Hyperprolactinaemia (excessive prolactin) Cushing's disease (excessive ACTH and cortisol) Thyrotoxicosis (excessive TSH and TH)
90
How can pituitary tumours be managed?
Trans-sphenoidal surgery Radiotherapy Bromocriptine- Blocks excess prolactin Somatostatin analogues (eg: Octreotide)- Block excess GH
91
Outline acoustic neuromas
Benign tumours of Schwann cells that surround vestibulocochlear nerve Occur at cerebellopontine angle Bilateral= NF2
92
Outline presentation of acoustic neuroma
40-60y Gradual onset: Unilateral sensorineural hearing loss Unilateral tinnitus Dizziness or imbalance Sensation of fullness in ear Facial nerve palsy
93
Outline management of acoustic neuroma
Conservative- Monitor if no symptoms Surgery Radiotherapy
94
What are the infectious causes of LMN FN palsy?
Otitis media Otitis externa HIV Lyme disease
95
What are the systemic disease causes of LMN FN palsy?
Diabetes Sarcoidosis Leukaemia MS Guillain-Barre
96
What are the tumour causes of LMN FN palsy?
Acoustic neuroma Parotid tumour Cholesteatoma
97
What are the trauma causes of LMN FN palsy?
Direct nerve trauma Surgery BoS fractures
98
What is the pathway of the facial nerve?
Exits brainstem at cerebellopontine angle Passes through temporal bone and parotid gland
99
What are the 5 branches of the facial nerve?
Temporal Zygomatic Buccal Marginal mandibular Cervical
100
What is the motor function of the facial nerve?
Facial expression Stapedius inner ear Posterior digastric, stylohyoid and platysma muscles
101
What is the sensory function of the facial nerve?
Taste from ant. 2/3 of tongue
102
What is the parasympathetic supply of the facial nerve?
Submandibular and sublingual salivary glands Lacrimal gland (tear production)
103
What are the features of UMN FN palsy?
Urgent Forehead sparing on affected side- Can move forehead Can be unilateral or bilateral
104
What are the features of LMN FN lesion?
Less urgent Forehead not spared- Paralysis
105
Give examples of unilateral UMN lesions
Stroke Tumours
106
Give examples of bilateral UMN lesions
Rare Pseudobulbar palsies MND
107
What is Bell's palsy?
Idiopathic Unilateral LMN FN palsy Recover over 12mths
108
Outline management of Bell's palsy
Prednisolone: 50mg for 10d 60mg for 5d, then 5d reducing regime Lubricating eyedrops- Help prevent exposure keratopathy
109
Outline Ramsay-Hunt Syndrome
VZV Unilateral LMN FN palsy Painful and tender rash in ear canal, pinna and around ear on affected side- Can extend to anterior tongue and hard palate
110
Outline management of Ramsay-Hunt syndrome
Aciclovir and prednisolone Lubricating eye drops
111
What are the SEs of NSAIDs?
Gastritis with dyspepsia Stomach ulcers Exacerbation of asthma HTN Renal impairment Coronary artery disease, HF, stroke- Rare
112
What are the CIs of NSAIDs?
Asthma Renal impairment Heart disease Uncontrolled HTN Stomach ulcers
113
What is often prescribed alongside NSAIDs and why?
PPI- Omeprazole or lansoprazole Reduce risk of GI SEs
114
What are the key SEs of opioids?
Constipation Skin itching Nausea Altered mental state (sedation, cognitive impairment, confusion) Respiratory depression
115
What is the antidote to opioids?
Naloxone
116
What are the options for opioid regimes in palliative care?
Background opiates- eg: 12hrly MR oral morphine or opioid patches Rescue doses- For breakthrough pain, eg: Immediate-release oral morphine solution Rescue dose is usually 1/6 of background 24h dose
117
Give examples of opioid patches
Buprenorphine patches- 5mcg/h patches Fentanyl patches- 12mcg/h patches
118
What is complex regional pain syndrome?
Areas of abnormal nerve functioning, causing neuropathic pain, abnormal sensations and skin changes Often triggered by an injury and isolated to one limb
119
What are the features of complex regional pain syndrome?
Hypersensitive Allodynia- Pain associated with normal sensations Intermittent swelling/colour changes/skin flushing/abnormal sweating Abnormal hair growth
120
What are the 4 1st line treatments of neuropathic pain?
Amitriptyline- TCA Duloxetine- SNRI Gabapentin- Anticonvulsant Pregabalin- Anticonvulsant Tramadol- Only used as short-term rescue for flares
121
What is the 1st line medication for trigeminal neuralgia?
Carbamazepine
122
List common causes of neuropathic pain
Post-herpetic neuralgia from shingles in dermatome distribution on trunk Nerve damage from surgery MS Diabetic neuralgia Trigeminal neuralgia Complex regional pain syndrome
123
What is the difference between chronic primary and chronic secondary pain?
Primary- No underlying condition Secondary- As a result of an underlying condition
124
What are the options for managing chronic primary pain?
Supervised group exercises Acceptance and commitment therapy ABT Acupuncture Antidepressants (eg: Amitriptyline, duloxetine, SSRI)
125
What should patients with chronic primary pain not be started on?
Paracetamol NSAIDs Opiates Anti-epileptics (eg: Pregabalin or gabapentin)
126
Outline a generalised tonic-clonic seizure
Tonic- Muscle tensing Clonic- Muscle jerking Associated with complete LOC (also called Grand mal) May have aura Prolonged post-ictal phase
127
Outline partial seizures
(focal seizures) Often in temporal lobe Affect hearing, speech, memory and emotions Patient awake Simple partial seizures- Aware Complex partial seizures- Lose awareness
128
What are some of the symptoms of partial seizures?
Deja vu Strange smells, tastes, sight or sound Unusual emotions Abnormal behaviours
129
Outline myoclonic seizures
Sudden, brief muscle contractions- Abrupt jump/jolt Remain awake
130
Outline tonic seizures
Sudden onset of increased muscle tone- Entire body stiffens Usually results in fall if standing Last seconds
131
Outline atonic seizures
Drop attacks Sudden loss of muscle tone resulting in fall Usually aware May be indicative of Lennox-Gastaut syndrome
132
Outline absence seizures
Blank, stares into space, abruptly returns to normal During episode- Unaware of surroundings, no response Tend to stop as gets older
133
Outline infantile spasms
West syndrome Rare Starts at 6mths age Clusters of full body spasms Developmental regression and poor prognosis
134
What is a characteristic finding on EEG in West syndrome?
Hypsarrhythmia
135
Outline management of West syndrome
ACTH Vigabatrin
136
Outline febrile convulsions
Tonic-clonic seizures occur during high fever Not caused by epilepsy Between 6mths and 5yrs Don't usually cause lasting damage 1/3 have more than one Slight increased risk of developing epilepsy
137
Outline investigations of seizures
EEG MRI brain ECG Serum electrolytes Blood glucose- Hypoglycaemia and diabetes Blood cultures, urine cultures, lumbar puncture- If sepsis/encephalitis/meningitis suspected
138
What is the criteria for driving with seizures?
No driving if had seizures within past yr
139
What is the management of generalised tonic-clonic seizures?
1st line- Sodium valproate 2nd line- Lamotrigine or levetiracetam
140
What is the management of partial/focal seizures?
Lamotrigine or levetiracetam
141
Outline management of myoclonic seizures
1st line- Sodium valproate 2nd line- Levetiracetam
142
Outline management of tonic and atonic seizures
1st line- Sodium valproate 2nd line- Lamotrigine
143
Outline management of absence seizures
Ethosuximide
144
What are the SEs of sodium valproate?
Teratogenic Liver damage and hepatitis Hair loss Tremor Reduce fertility
145
What is the effect of using sodium valproate in pregnancy?
Neural tube defects Developmental delay
146
What is status epilepticus?
Sezure lasting >5mins Multiple seizures w/o regaining consciousness
147
Outline management of status epilepticus
Secure airway High-conc. O2 Check blood glucose levels IV access
148
Outline the medical management of status epilepticus
1st line- Benzo, repeat after 5-10mins if seizure continues 2nd line- IV levetiracetam, phenytoin or sodium valproate 3rd line- Phenobarbital or general anaesthesia
149
List options for use of benzos in status epilepticus
Buccal midazolam Rectal diazepam IV lorazepam
150
What are the acute complications of status epilepticus?
Hyperthermia Pulmonary oedema Cardiac arrhythmia CV collapse
151
What are the long term complications of status epilepticus?
Epilepsy Encephalopathy Focal neurological defects
152
What is a benign essential tremor?
Fine tremor affecting all voluntary muscles
153
Outline features of benign essential tremor
Fine tremor (6-12Hz) Symmetrical More prominent with voluntary movement Worse when tired/stressed/caffeine Improved by alcohol Absent during sleep
154
What are the differential diagnoses of tremor?
Parkinson's MS Huntington's chorea Hyperthyroidism Fever Dopamine antagonists (eg: Antipsychotics)
155
Outline management of benign essential tremor
Propranolol Primidone (barbiturate anti-epileptic)
156
Outline Parkinson's disease
Progressive reduction in dopamine in basal ganglia leading to disordered movement
157
What is the classic triad of features in Parkinson's disease?
Resting tremor Rigidity Bradykinesia
158
Outline features of Parkinson's disease
Symptoms asymmetrical (one side of body affected more) Gradual onset Tremor 4-6Hz (pill-rolling) Resting tremor (improves with movement)- Gets worse when patient distracted Rigidity- Resistance to passive movement of joint- Cogwheel rigidity Bradykinesia: Handwriting smaller Shuffling gait Difficulty initiating movement Difficulty turning (take lots of little steps) Hypomimia (reduced facial movement/expression) Depression Sleep disturbance and insomnia Anosmia Postural instability Cognitive impairment and memory problems
159
What are Parkinson's-Plus syndromes?
Multiple system atrophy Dementia with Lewy bodies
160
What is multiple system atrophy?
Parkinson's-Plus syndrome Rare Neurones of various systems in brain degenerate Basal ganglia- Leads to Parkinson's presentation Other areas- Autonomic dysfunction and cerebellar dysfunction
161
What are signs of autonomic dysfunction?
Postural hypotension Constipation Abnormal sweating Sexual dysfunction
162
What are the signs of cerebellar dysfunction?
Ataxia
163
Outline dementia with Lewy bodies
Dementia with features of Parkinsonism Progressive cognitive decline Associated symptoms- Hallucinations, delusion, REM sleep disorders, fluctuating consciousness
164
Outline diagnosis of Parkinson's disease
Diagnosed clinically
165
Outline management of Parkinson's disease
Levodopa COMT inhibitors Dopamine agonists MAOB inhibitors
166
Outline levodopa
Synthetic dopamine Normally combined (eg: Co-careldopa or Co-beneldopa)- Stops it being metabolised in body before reaches brain Most effective for treatment of Parkinson's but declines over time
167
What is the main SE of levodopa?
Dyskinesia- Abnormal movements associated with excessive motor activity: Dystonia Chorea Athetosis
168
What is dystonia?
Excessive muscle contraction leads to abnormal postures or exaggerated movement
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What is athetosis?
Involuntary twisting or writhing movements, usually in fingers/hands/feet
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What is an option for managing dyskinesia caused by levodopa?
Amantadine (glutamate antagonist)
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Outline COMT inhibitors
Eg: Entacapone Slows breakdown of levodopa in body and brain Extends effective duration of levodopa
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Outline Dopamine agonists
Mimic action of dopamine in basal ganglia, stimulate dopamine receptors Less effective than levodopa in reducing symptoms Eg: Bromocriptine, pergolide, cabergoline
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What is the most notable SE of dopamine agonists?
Pulmonary fibrosis
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Outline MAO-B inhibitors
Increase circulating dopamine Eg: Selegiline, rasagiline
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What is motor neurone disease?
Variety of diseases affecting motor nerves Progressive, eventually fatal condition where motor neurones stop functioning
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What are the types of MND?
Amyotrophic lateral sclerosis (ALS)- Most common Progressive bulbar palsy- Affects muscles of talking and swallowing
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Outline pathophysiology of MND
Progressive degeneration of upper and lower motor neurones Increased risk with smoking, FHx, exposure to heavy metals, and certain pesticides
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Outline presentation of MND
Late middle-aged man Insidious, progressive weakness of muscles throughout body Weakness first noticed in upper limbs May be increased fatigue when exercising May complain of clumsiness/dropping things more often Can develop dysarthria (Slurred speech)
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What are the signs of lower MND?
Muscle wasting Reduced tone Fasciculations Reduced reflexes
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What are the signs of upper MND?
Increased tone or spasticity Brisk reflexes Upgoing plantar reflex
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Outline diagnosis of MND
Clinical presentation Diagnosis of exclusion
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Outline management of MND
Riluzole can slow progression and extend survival by several months in ALS NIV- Support breathing when respiratory muscles weaken Baclofen- For muscle spasticity Benzos- Help breathlessness caused by anxiety
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Outline pathophysiology of Parkinson's disease
Basal ganglia- Coordinates habitual movement (walking/voluntary movement) Dopamine- Essential for basal ganglia function Slow progressive drop in dopamine production
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What is MS?
Chronic and progressive AI condition Demyelination in CNS Immune system attacks myelin sheath of myelinated neurones
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Outline pathophysiology of MS
Myelin covers axons of neurones to help electrical impulses travel faster Ms affects CNS (oligodendrocytes)
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What are the different cells in myelin?
Oligodendrocytes- CNS Schwann cells- PNS
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What is the characteristic feature of MS?
Disseminated in time and space: Vary in location and symptoms change over time
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List causes of MS
Multiple genes EBV Low vit D Smoking Obesity
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Outline onset of MS
Symptoms progress over >24h and last days to weeks at 1st presentation then improve
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Outline optic neuritis and MS
Most common presentation of MS Demyelination of optic nerve Unilateral reduced vision
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What are the key features of optic neuritis?
Central scotoma (enlarged central blind spot) Pain with eye movement Impaired colour vision RAPD
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What is RAPD?
Relative afferent pupillary defect Pupil in affected eye constricts more when shining light in contralateral eye than when shining it in affected eye
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List causes of optic neuritis
MS Sarcoidosis SLE Syphilis Measles or mumps Neuromyelitis optica Lyme disease
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Outline symptomatic treatments of MS
Exercise Fatigue- Amantadine, modafinil or SSRIs Neuro pain- Amitriptyline or gabapentin Depression- SSRIs Urge incontinence- Solifenacin Spasticity- Baclofen or gabapentin Oscillopsia- Gabapentin or memantine
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How are MS relapses treated?
Steroids: 500mg orally daily for 5d 1g IV daily 3-5d if severe
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Outline diagnosis of MS
Clinical picture and symptoms MRI scans Lumbar puncture- Oligoclonal bands
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What is found on MS LP?
Oligoclonal bands
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Outline disease patterns of MS
Clinically isolated syndrome- 1st episode of demyelination and neuro signs/symptoms- Lesions on MRI suggest more likely to occur again Relapsing-remitting- Most common Secondary progressive- Was relapsing-remitting, now progressive worsening with incomplete remission Primary progressive- Worsening disease from point of diagnosis, w/o relapses or remissions
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Outline ataxia and MS
Problem with coordinated movement Sensory- Loss of proprioception- Positive Romberg's and pseudoathetocis (involuntary writhing movement)- Lesion in dorsal column Cerebellar ataxia- Problems with cerebellum coordinating movement- Cerebellar lesion
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Outline focal weakness in MS
Incontinence Horner syndrome Facial nerve palsy Limb paralysis Transverse myelitis
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Outline focal sensory symptoms in MS
Trigeminal neuralgia Numbness Paraesthesia Lhermitte's sign Transverse myelitis
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What is Lhermitte's sign?
Electric shock sensation travelling down spine and into limbs when flexing neck Indicates disease in cervical spinal cord in dorsal column
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Outline management of complications in SAH
Hydrocephalus: LP External ventricular drain VP shunt Seizures: Anti-epileptics
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Which eye movement abnormalities can occur in MS?
Oscillopsia- Visual sensation of environment moving, can't create stable image CN III/IV/VI- Diplopia and nystagmus Internuclear ophthaloplegia- Lesion in medial longitudinal fasciculus- Impaired adduction in same eye as lesion, nystagmus in contralateral abducting eye CN VI- Conjugate lateral gaze disorder- If lesion in L eye, look left, R eye adducts, L eye stays central
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What is a subarachnoid haemorrhage?
Bleeding in subarachnoid space Between pia mater and arachnoid membrane Cerebral aneurysms High mortality- Approx. 30%
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List RFs for subarachnoid haemorrhage
45-70y Women Black ethnic origin HTN Smoking Excessive alcohol intake FHx Cocaine use SCA Marfans or Ehlers-Danlos Neurofibromatosis ADPKD
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Outline presentation of subarachnoid haemorrhage
Sudden-onset occipital headache During strenuous activity- Heavy lifting/sex Thunderclap headache
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Outline investigations of subarachnoid haemorrhage
1st line- CT head- Hyper-attenuation in subarachnoid space Lumbar puncture in normal CT head- Wait at least 12h after symptoms start (takes time for bilirubin to accumulate in CSF) CT angiography- After confirmed diagnosis- Locates source of bleeding
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What will an LP of subarachnoid haemorrhage show?
Raised cell count Xanthochromia- Yellow CSF due to bilirubin
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Outline management of SAH
Surgical intervention for aneurysms- Coils or clipping Nimodipine- CCB- Prevents vasospasm (common complication following SAH- Causes brain ischaemia)
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What is an extradural haemorrhage?
Bleeding between skull and dura mater Rupture of MMA in temporoparietal region Bi-convex on CT, don't cross suture lines Lucid period
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Outline subdural haemorrhage
Between dura mater and arachnoid mater Rupture of bridging veins Crescent shape on CT, cross suture lines Occur in elderly and alcoholics
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Outline intracerebral haemorrhage
Bleeding in brain tissue Presents similar to ischaemic stroke with sudden-onset focal neuro symptoms Occur spontaneously or secondary to ischaemic stroke/tumour/aneurysm rupture
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Outline management of intracranial haemorrhage
Immediate CT head FBC (platelets) and coagulation screen Avoid hypotension Small bleed: Conservative management Close monitoring, repeat imaging Surgical (extradural or subdural): Craniotomy Burr holes
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What are the two types of cerebrovascular accident?
Ischaemia or infarction (ischaemic stroke) Intracranial haemorrhage (haemorrhagic stroke)
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What is the difference between ischaemia and infarction?
Ischaemia- Inadequate blood supply Infarction- Tissue death
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What is a TIA?
Temporary neuro dysfunction (lasts <24h) caused by ischaemia w/o infarction Rapid onset and resolve quickly
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What are crescendo TIAs?
2+ TIAs within 1wk Indicate high risk of stroke
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Outline presentation of stroke
Limb weakness Facial weakness Dysphasia (speech disturbance) Visual field defects Sensory loss Ataxia and vertigo (post. circulation infarction)
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List RFs for stroke
Previous stroke/TIA AF Carotid artery stenosis HTN Diabetes Raised cholesterol FHx Smoking Obesity Vasculitis Thrombophilia COCP
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Outline management of TIA
Aspirin 300mg daily Refer within 24h for specialist assessment Diffusion-weighted MRI scan
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Outline management of stroke
Exclude hypoglycaemia Immediate CT brain Aspirin 300mg daily for 2wks after scan Thrombolysis with alteplase- Consider once haemorrhage excluded- Give within 4.5h symptoms onset
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What is the difference between management of BP in haemorrhagic stroke and ischaemic stroke?
Ischaemic- Low BP can worsen ischaemia Haemorrhagic- Aggressively treated to lower and reduce ICP
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How are the underlying causes of stroke assessed?
Carotid imaging- Carotid artery stenosis ECG- AF Start anticoagulation following stroke due to AF after finishing course of aspirin
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What are the top risk factors for stroke?
AF Carotid artery stenosis
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Outline secondary prevention of stroke
Clopidogrel- 75mg OD Atorvastatin- 20-80mg- Delay at least 48h BP and diabetes control Stop smoking, lose weight, exercise as required
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