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
» sodium valproate causes weight gain - 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
caused by excessive sympathetic response below level of injury without coordinated parasympathetic counter response
can only occur if spinal cord injury is above T6
features
- severe hypertension
- flushing and sweating above level of injury
- reflex bradycardia
causes
- urinary retention / catheter blockage
- faecal impaction / loading
complications: stroke
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 weakness
- cranial nerve involvement: diplopia, bilateral facial nerve palsy, oropharyngeal weakness
- autonomic involvement: urinary retention, diarrhoea
investigations
- LP: rise in CSF protein with normal WCC
> gold-standard investigation
- anti-ganglioside antibodies
- 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
- Todd’s paralysis
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
SCD: spinocerebellar tract, corticospinal tract, dorsal columns
causes
- vitamin B12 & E deficiency
- can result from replacing folate before b12 if b12 deficient (BeFore)
- 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
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
describe the features, investigations and management of a TIA
brief period of neurological deficit due to a vascular cause, typically lasting less than an hour (always <24h)
Clinical features
- unilateral weakness or sensory loss
- aphasia or dysarthria
- ataxia, vertigo, or loss of balance
- visual problems
- sudden transient loss of vision in one eye (amaurosis fugax)
- diplopia
- homonymous hemianopia
ABCD2: prognostic score to risk stratify patients
Management
- immediate antithrombotic therapy: > aspirin 300 mg immediately
unless:
1. bleeding disorder / anticoagulated (needs immediate admission for imaging to exclude a haemorrhage)
2. already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team
Advise the person not to drive until they have been seen by a specialist
Investigations
- diffusion-weighted MRI first-line
- Carotid imaging
> all patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy
Further management
> Secondary prevention
- clopidogrel is recommended first-line (as for patients who’ve had a stroke)
- aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel
- lipid modification
- high-intensity statin (such as atorvastatin 20–80 mg daily)
carotid artery endarterectomy if carotid stenosis > 70%
Describe the symptoms of stroke depending on the affected vessel
ACA
> contralateral hemiparesis and sensory loss
> lower extremity > upper
MCA
> contralateral hemiparesis and sensory loss
> upper extremity > lower extremity
> aphasia
> contralateral homonymous hemianopia
PCA
> Contralateral homonymous hemianopia with macular sparing
> Visual agnosia
Weber’s syndrome (branches of PCA supplying midbrain)
> contralateral upper and lower limb weakness
> ipsilateral CN III palsy
PICA (lateral medullary syndrome, Wallenberg syndrome)
> ipsilateral facial pain and temperature loss
> contralateral limb/torso pain and temperature loss
> ataxia, nystagmus
> ipsilateral Horner’s syndrome
AICA (lateral pontine syndrome)
> similar to Wallenberg’s but ipsilateral facial paralysis and deafness also
> reduced GCS, paralysis, bilateral pinpoint pupils
Retinal/ophthalmic artery: amaurosis fugax
Basilar artery: locked in syndrome
Lacunar strokes present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
> strong association with hypertension
> common sites include the basal ganglia, thalamus and internal capsule
Describe bacterial meningitis and its management
Clinical features
- meningism: neck stiffness, photophobia
- nausea / vomiting
- reduced GCS
- non-blanching rash
- fever
- tachycardia, tachypnoea, hypotension
- Brudzinski / kernig’s sign +ve
attempt LP unless
- severe sepsis / rapidly evolving rash
- severe respiratory / cardiac compromise
- significant bleeding risk
- signs of raised ICP (focal neurological signs, papilloedema, continuous/uncontrolled seizures)
CT head prior to LP ONLY if risk of evolving SOL / signs of increased ICP
Management
- IV antibiotics
> <3 months: IV cefotaxime + amoxicillin
> 3 months-50 years: cefotaxime or ceftriaxone
> >50 years: cefotaxime (or ceftriaxone) + amoxicillin (increased risk of Listeria meningitis)
- IV dexamethasone 0.15mg/kg QDS for 4 days
> avoid in septic shock, meningococcal septicaemia, immunocompromised or meningitis following surgery - if allergic to penicillin / cephalosporins, use chloramphenicol
- if Listeria monocytogenes: IV amoxicillin + gentamicin
Describe a post-LP headache and its management
Low pressure headache
can occur up to a week later from when the LP was taken
alleviated by lying down
> if headache lasts more than 3 days, consider subdural haematoma
management
- supportive analgesia - analgesia, rest
- consider blood patch, epidural saline and IV caffeine
Describe the diagnostic criteria for migraine
- headache attacks lasting 4-72h
- at least 2 of the following characteristics
> unilateral location but may be bilateral
> pulsating quality
> moderate or severe pain
> aggravation by routine physical activity - during headache at least one of the following
> nausea or vomiting
> photophobia, phonophobia - not attributed to another disorder
in children, attacks may be shorter-lasting, headache is bilateral and GI disturbance is more prominent
migraine with aura
> aura is progressive in nature and occurs hours prior to headache
> typical aura: transient hemianopic disturbance / spreading scintillating scotoma (jagged crescent)
> sensory symptom
auras may occur with/without headache and are fully reversible, develop over at least 5 minutes and last 5-60 minutes
atypical symptoms
> motor weakness
> double vision
> visual symptoms affecting only one eye
> poor balance / decreased GCS
Name the most common cause of
- bacterial meningitis <60
- viral meningitis
- viral encephalitis
bacterial meningitis <60: Neisseria meningitidis, streptococcus pneumoniae
Viral meningitis: enterovirus
> Coxsackie, Echovirus
Viral encephalitis: HSV
Describe viral meningitis and its management
Presents similarly to bacterial meningitis
> less likely to have a non-blanching purpuric rash
> less severe than bacterial meningitis
management
- supportive, usually self-limiting course of 7-14 days
- aciclovir if thought to be caused by HSV
- IV aciclovir if concern regarding encephalitis
in the context of meningitis, under which circumstances should LP be delayed?
- signs of severe sepsis
- rapidly evolving rash
- severe respiratory / cardiac compromise
- significant bleeding risk
- signs of increased ICP
> focal neurology
> GCS <=12
> Papilloedema
> seizures
describe CSF results depending on the cause of meningitis
bacterial
- appearance: cloudy
- glucose: low (<1/2 plasma)
- protein: high (>1g/l)
- WCC: 10-5000 polymorphs/mm3
viral
- appearance: clear/cloudy
- glucose: 60-80% of plasma glucose
- protein: normal/raised
- WCC: 15-1000 lymphocytes/mm3
TB
- appearance: slight cloudy, fibrin web
- glucose: low (<1/2 plasma)
- protein: high (>1 g/l)
- WCC: 30-300 lymphocytes/mm3
fungal
- appearance: cloudy
- glucose: low
- protein: high
- WCC: 20-200 lymphocytes/mm3
describe the management of status epilepticus
- ABCDE assessment
- airway: lateral decubitus, nasal trumpets, O2, suction
- IV access
0-5 mins (give benzos at 5 mins)
> lorazepam 0.1mg/kg IV, max 4mg, repeat once in 4min
> OR midazolam 10mg IM once
10-15 mins
> levetiracetam 60mg/kg IV
> OR fosphenytoin or phenytoin 20mg/kg IV
> OR valproate 40mg/kg IV
> advanced airway management
> RSI
> Preoxygenation
> Induction: propofol or ketofol
> paralytics: rocuronium, succinylcholine
15-20 mins: refractory medications
- propofol
- midazolam
- ketamine
- lacosamide
- phenobarbital
describe herpes simplex encephalitis
infection of brain parenchyma
features
- fever
- headache
- psychiatric symptoms
- seizures
- vomiting
- focal features e.g. aphasia, weakness, limping
investigations
- LP
> elevated protein
> lymphocytosis
> PCR for HSV, VZV, enterovirus
- CT head: temporal lobe changes e.g. asymmetrical low density areas
- EEG
management
- start aciclovir promptly in all suspected cases of viral encephalitis
> treats HSV and VZV
> ganciclovir is needed for CMV
how would you check if fluid is truly CSF?
check a glucose level: bedside test
beta-2-transferrin level: gold standard
describe the different types of aphasia
Wernicke’s (receptive) aphasia
> lesion of superior temporal gyrus
> usually supplied by inferior division of left MCA
> features
- sentences that make no sense
- word substitution
- neologism
- speech remains fluent
- “word salad”
- comprehension is impaired
Broca’s (expressive) aphasia
> lesion of inferior frontal gyrus
> usually supplied by superior division of left MCA
> speech is non-fluent, laboured and halting
> repetition is impaired
> comprehension is normal
Conduction aphasia
> usually due to stroke affecting arcuate fasciculus
> speech is fluent but repetition is poor
> aware of errors being made
> comprehension is normal
Global aphasia
> severe expressive and receptive aphasia
> may still be able to communicate using gestures
describe chronic fatigue syndrome
aka myalgic encephalomyelitis (ME)
diagnosed after at least 3 months of disabling fatigue affecting mental and physical function >50% of the time in the absence of other disease which can explain symptoms
features
- fatigue
- sleep problems
- muscle/joint pains
- headaches
- painful lymph nodes
- cognitive dysfunction
- physical or mental exertion makes symptoms worse
management
- energy management
- CBT
What is the mechanism of controlled hyperventilation in raised ICP?
Reduced blood carbon dioxide to induce cerebral vasoconstriction
describe the Barthel index
measure of disability or dependence in activities of daily living in stroke patients
describe neurogenic shock
causes
- trauma e.g. spinal cord transection
features
- bradycardia
- hypotension
management
- vasopressors
Describe the management of migraines
Acute:
- analgesia
NSAIDs or paracetamol + triptans
> avoid opioids - antiemetic: metoclopramide
> prokinetic agent that helps to relieve gastric stasis that occurs during acute migraine attack
> consider even in cases without nausea
Prophylaxis:
- topiramate (teratogenic) or propranolol
What are the antibiotics of choice for contacts of patients with meningococcal meningitis
PO ciprofloxacin or rifampicin
> one dose for close contacts within last 7 days
Describe idiopathic intracranial hypertension
classically seen in young overweight females
features
- headache
- blurred vision
- papilloedema
- enlarged blind spot
- sixth nerve palsy
- high pressure features: worse on coughing/sneezing/lying flat/leaning forwards
associated with tetracycline antibiotics
investigations
- lumbar puncture: opening pressure values >25 cmH2O
- CT brain: enlarged arachnoid outpouchings, prominent perivascular spaces
management
- weight loss - semaglutide and topiramate
- carbonic anhydrase inhibitors e.g. acetazolamide
- repeated LP - temporary measure
- surgery:
> optic nerve sheath decompression and fenestration
> lumboperitoneal / ventriculoperitoneal shunt
Describe an Arnold-Chiari malformation
downward displacement or herniation of cerebellar tonsils through foramen magnum
malformation may be congenital or acquired through trauma
features
- non-communicating hydrocephalus may occur as a result of obstruction of CSF flow
- headache
- syringomyelia
describe essential tremor
autosomal dominant condition which usually affects both upper limbs
Features
- postural tremor: worse if arms outstretched
- improved by alcohol and rest
- most common cause of titubation (head tremor)
Management
- propranolol is first-line
- primidone is sometimes used
describe a myasthenic crisis and its management
myasthenic crisis
- acute respiratory failure characterised by FVC <1L
- accessory muscle use
Management
> plasmapheresis
> intravenous immunoglobulins
> ventilatory support: low threshold for intubation
