Neurology Flashcards
Describe the management of epilepsy
Most neurologists now start antiepileptics following a second epileptic seizure.
NICE guidelines suggest starting antiepileptics after the first seizure if:
> neurological deficit
> brain imaging: structural abnormality
> EEG: unequivocal epileptic activity
> patient / family / carers seizure risk unacceptable
Drug treatment
- Generalised tonic-clonic seizures
> males: sodium valproate
> females: lamotrigine or levetiracetam
» sodium valproate if under 10 or women unable to have children - Focal seizures
> first line: lamotrigine or levetiracetam
> second line: carbamazepine, oxcarbazepine or zonisamide - Absence seizures (Petit mal)
> first line: ethosuximide
> second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures - Myoclonic seizures
> males: sodium valproate
> females: levetiracetam - Tonic or atonic seizures
> males: sodium valproate
> females: lamotrigine
describe autonomic dysreflexia
can only occur if spinal cord injury is above T6
features
- severe hypertension
- flushing and sweating above level of injury
- reflex bradycardia
causes
- spinal cord injury
- catheter blockage
- faecal loading
caused by excessive sympathetic response below level of injury without coordinated parasympathetic counter response
describe Guillain-Barré syndrome
immune-mediated demyelination of peripheral nervous system usually post-diarrhoeal illness e.g. Campylobacter jejuni
clinical features
- back/leg pain
- progressive symmetrical ascending weakness (starting in legs)
- reflexes are reduced or absent
- sensory symptoms usually mild
other features
- respiratory muscle gastroenteritis
- respiratory muscle weakness
- cranial nerve involvement: diplopia, bilateral facial nerve palsy, oropharyngeal weakness
- autonomic involvement: urinary retention, diarrhoea
investigations
- LP: rise in protein with normal WCC
- Nerve conduction studies: decreased motor nerve conduction velocity
treatment - plasma exchange, IV immunoglobulins
Which medications can be given for the following problems in MS?
- fatigue
- spasticity
- oscillopsia
- bladder dysfunction
fatigue: amantadine
spasticity: baclofen, gabapentin
oscillopsia: gabapentin
bladder dysfunction: anticholinergics
which medications can be given to reduce the risk of relapse in MS?
indications
> relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)
medications
- natalizumab: first-line
- ocrelizumab: another first-line option
- fingolimod
- beta-interferon: less effective
- glatiramer acetate: less effective
describe hereditary sensorimotor neuropathy (HSMN) aka Charcot-Marie-Tooth
encompasses Charcot-Marie-Tooth disease (aka peroneal muscular atrophy)
2 common types in clinical practice
- type I: demyelinating
- type II: axonal pathology
HSMN type I
- Autosomal dominant
- due to defect in myelin-coding gene
- features start at puberty
- motor symptoms predominate
- distal muscle wasting, pes cavus, clawed toes
- foot drop and leg weakness often first features
when can anti-epileptic drugs (AED) be stopped?
can be considered if seizure free for >2 years with AEDs being stopped over 2-3 months
describe localising features of focal seizures
temporal lobe
- with/without impairment of consciousness or awareness
- aura
> rising epigastric sensation
> psychic/experiential phenomena e.g. deja vu, jamais vu - less commonly hallucinations (auditory/gustatory/olfactory)
- seizures typically last around one minute
- automatisms (lip smacking/grabbing/plucking of clothes)
- post-ictal dysphasia
frontal lobe (motor)
- head/leg movements
- posturing
- post-ictal weakness
- Jacksonian march
parietal lobe (sensory)
- paraesthesia
occipital lobe (visual)
- floaters/flashes
describe subacute combined degeneration of the cord
subacute combined degeneration of the cord
causes
- vitamin B12 & E deficiency
- can result from replacing folate before b12 if b12 deficient
- nitrous oxide inhalation
features
- bilateral spastic paresis: weakness, spasticity
- bilateral loss of proprioception and vibration: distal tingling, burning and/or sensory loss
- bilateral limb ataxia
- hyperreflexia
- positive Babinski sign
positive Romberg’s test due to sensory ataxia
list driving restrictions for individuals with epilepsy
first unprovoked/isolated seizure: 6 months off if no structural brain abnormalities on imaging or epileptiform activity on EEG
established epilepsy / multiple unprovoked seizures:
> qualify for driving license if they have been seizure free for 12 months
> if no seizures for 5 years, a til 70 license is restored
withdrawal of epilepsy medication: cannot drive whilst being withdrawn and for 6 months after zass
describe spinal muscular atrophy (SMA)
rare autosomal recessive condition which causes a progressive loss of lower motor neurones leading to progressive muscular weakness
features
- fasciculations
- reduced muscle bulk
- reduced tone
- reduced power
- reduced / absent reflexes
management: supportive
describe myotonic dystrophy
genetic disorder usually presenting in adulthood
features
- progressive muscle weakness
- prolonged muscle contractions
- cataracts
- cardiac arrhythmias
