Neurology Flashcards
What are primary headaches and some examples of them?
Headaches with no underlying cause
- Migraine
- Cluster
- Tension
- (Trigeminal neuralgia)
What are red flag features for headaches?
- Sudden onset for longer than 5 minuets
- New onset over 50
- Progressive or persistent
What are red flag precipitating factors for headaches?
- Recent head trauma
- Headache worse lying down (raised ICP)
- Headache worse on standing (CSF leak)
- Household contacts with similar symptoms (CO poisoning)
What are red flag associated symptoms of headaches?
- Fever, photophobia or neck stiffness
- New neurological defect (stroke/raised ICP)
- Visual disturbance
- Vomiting (raised ICP, brain abscess and CO poisoning)
What is an important investigation to carry out for a headache?
fundoscopy which will look for papilledema which indicates raised ICP
What are some risk factors for migraines?
- FH
- Female
- Obesity
What are some triggers of migraines
CH- Chocolate
OC- Oral contraceptive
OL- alcohOL
A- anxiety
T- travel
E- exercise
CHOCOLATE
Other triggers can be red wine, bright lights and menstruation
What are some different types of migraine/
- Migraine without aura
- Migraine with aura
- Silent migraine (just the aura without the headache
- Hemiplegic migraine
What are the headache symptoms of a migraine?
Lasts between 4-72 hours
- Pounding or throbbing in nature
- Usually unilateral
- Photophobia
- Phonophobia
- Aura
- Nausea and vomiting
What is aura/
Aura is the term used to describe the visual changes associated with migraines symptoms can be:
- Sparks in vision
- Blurring vision
- Line across vision
- Loss of different visual fields
What is a hemiplegic migraine?
They can mimic a stroke need to rule out if patient has symptoms:
- Typical migraine
- Sudden onset
- Hemiplegia
- Ataxia
- Change in consciousness
What are the 5 stages of a migraine/
- Prodromal
- Aura
- Headache
- Resolution
- Prodromal
What is the diagnostic criteria for migraines with aura?
At least two headaches filling criteria
What is the diagnostic criteria for migraines without aura?
At least five headaches filling criteria
What is the management for migraines?
- Analgesia
- Oral triptan (500mg sumatriptan) as the headache starts (can also use aspirin)
- Antiemetics metoclopramide
What are triptans?
They are serotonin agonists and they cause
- Smooth muscle contraction in arteries
- Peripheral pain receptors to inhibit activation of pain
- Reduce neuronal activity in the central nervous system
What medications are used for migraine prophylaxis?
- Propranolol
- Topiramate (is teratogenic)
- Amitriptyline
What should not be given to a female who experiences migraines with aura?
The combined pill it increases the risk of a stroke
What are the non-pharmacological treatments for migraines?
- Acupuncture: if both propranolol and topiramate are ineffective or unsuitable
- Riboflavin (vitamin B2): **may be effective in some people, but avoid in pregnancy
What is amaurosis faugax?
A classical syndrome of painless short-lived monocular blindness. Is mainly caused by transient obstruction e.g. an emboli but can be caused by GCA
- Often described as a black curtain coming across the vision.
What is a tension headache?
Most common primary headache
Can be episodic (<15 days/month) or chronic (>15 days a month for at least 3 months)
What are the causes of tension headaches?
- Missed meals
- Stress
- Overexertion
- Lack of sleep
- Depression
What are the symptoms of a tension headache/
- Bilateral with a pressing/tight sensation of mild-moderate intensity
- Nausea or vomiting
- Photophobia
- Phonophobia
What is the main risk factor for a tension headache?
STRESS
What are cluster headaches?
Severe unilateral headaches often periorbital that come in clusters of attack
What is the typical presentation for cluster headaches?
A 0-50 year old male smoker. Attacks can be triggered by alcohol, strong smells and exercise
How long can cluster headaches last?
3-4 attacks a fay for weeks or months followed by a pain free period
Attacks can last for 15 minuets to 3 hours
What are the symptoms of a cluster headache?
- Severe intolerable pain
- Unilateral
- Red swollen watering eye
- Pupil constriction
- Eyelid dropping
- Nasal discharge
- Facial swelling
What is the acute management of cluster headaches?
- Triptans
- High flow oxygen
What are the prophylaxis for cluster headaches?
- Verapamil
- Lithium
- Prednisolone
What are the risk factors for trigeminal neuralgia?
- Female
- 50-60
- Increases with age
- Unilateral
- MS
What are the causes of trigeminal neuralgia?
Normally due to compression of the trigeminal nerve by a vascular loop often superior cerebellar artery
What are triggers for TGN?
- Light touch
- Washing
- Shaving
- Talking
- Cold weather
What is the headache like in trigeminal neuralgia?
Electric Shock Pain that lasts for seconds to minutes across the face
90% unilateral
10% bilateral
What is the diagnostic criteria for trigeminal neurlagia?
Clinical Dx
3 or more attacks with characteristic unilateral facial pain and symptoms
MRI- exclude secondary causes/other pathology
What is the treatment for TGM?
- First line: carbamazepine
- Second line: microvascular decompression
What is an acoustic neuroma?
A benign tumour of the Schwann cells surrounding the auditory nerve that innervates the inner ear
Are acoustic neuromas usually unilateral or bilateral?
Unilateral
Bilateral acoustic neuromas are almost always due to neurofibromatosis type II
What is the presentation of a acoustic neuroma?
40-60 year old patient with gradual onset of:
- Unilateral sensorineural hearing loss
- Unilateral tinnitus
- Dizziness
- A sensation of fullness in the ear
Can also be associated with a facial nerve palsy
What is the management of an acoustic neuroma?
Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate
Surgery to remove the tumour (partial or total removal)
Radiotherapy to reduce the growth
What is used to asses the hearing loss in an acoustic neuroma?
Audiometry
Heating will be more affected with loud sounds
What does the spinothalamic tract convey?
- Anterior tract is responsible for crude touch/or pressure
- Lateral tract is responsible for pain and temperature
What is the pathway of the spinothalamic tract, and what will a lesion present as?
- These pathways decussate within the spinal cord and travel up to the brain
So the lesion of the spinal cord will cause a of pain, crude touch, sensation
As nerve entering the Anterior lateral pathways tend to travel up 1 or 2 vertebral levels before Decussating
Spinothalamic and Dorsal Column medial lemniscal pathway synapses in the ventral posterio-lateral division (VPL) of the nucleus of thalamus.
What does the DCML tract convey?
- Fine touch and tactile sensation, vibration and proprioception
- Signals from lower limbs travel up ** fasciculus gracillis**
Signals from the upper limb (above T6) tend to travel in the Fasciculus Cuneatus
graciLis = L for Leg of Lower Limb
Outline the pathway of the DCML tract
What will a lesion in the DCML tract present as?
- Afferent signals are carried along first order neurons to and up the dorsal columns then synapse in the medulla
- 2nd order neurones decussate at the medulla and travel to the thalamus where they synapse again
- 3rd order neurones the order neurones then travel through the internal capsule to the somatosensory cortex in the Parietal mode (postcentral gyrus)
THESE TRACTS RUN IPSILATERALLY THROUGH THE SPINAL CORD AND DECUSSATE IN THE MEDULLA OF THE BRAINSTEM = so damage to spinal cord here would lead to loss of Ipsilateral fine touch, tactile sensation, proprioception etc.
What does the cortical spinal tract convey?
Carry brain signals for voluntary movemnts
Outline the pathway of the corticospinal tract?
After originating from the cortex, the neurones converge, and descend through the internal capsule
- this is particularly susceptible to compression from haemorrhagic bleeds
The fibres within the lateral corticospinal tract decussate
The anterior corticospinal tract remains ipsilateral, descending into the spinal cord.
From the ventral horn, the lower motor neurones go on to supply the muscles of the body.
What things can damage the spinal tracts/causes sign?
Corticospinal damage - UPPER MOTOR NEURONE SIGN, AS SPINAL NERVES ARE UMN
Trauma
MS
Tumour/growth
Vascular supply of the spinal cord/spinal cord stroke?? - ANTERIOR SPINAL ARTERY STROKE INFARCTS CAN AFFECT TRACTS, —> can cause back pain as spine has pain receptors
Acute spinal chord and strokes can cause lower MN signs (spinal shock)
Syringomyelia - affects CRTS and STHAM - think this if see cape like distribution of weakness
What is Bell’s palsy?
It presents as a unilateral lower motor neurone facial nerve palsy.
The majority of patients fully recover over several week but recovery may take up to 12 moths
What is the treatment of Bell’s palsy?
prednisolone as treatment, either:
50mg for 10 days
60mg for 5 days followed by a 5-day reducing regime of 10mg a day
Patients also require lubricating eye drops
What is a brain abscess?
A pus-filled pocket of infected material in the brain
What are some bacterial causes of a brain abscess?
Streptococcus pyogenes/Strep milleri
Staph Aureus
Klebsiella pneumoniae,
Neisseria meningitides
What are some fungal causes of brain absces?
Aspergillus fumigates, Candida albicans
What are some parasitic causes of brain abscess?
Toxoplasma gondii,
What are the symptoms of a brain abscess?
Fever
Headache
Changes to mental state
Focal neurological deficits
Gradual mal seizures
Nausea
Vomiting
Neck stifness
What are the symptoms associated with a ruptured brain abscess/
suddenly worsening headache, followed by emerging signs of meningism
What are some investigations for a brain abscess?
FBC
ESR and CRP raised
Blood culture
MRI
CT scan: appears as a radiolucent space-occupying lesion
What is the management of a brain abscess?
Vancomycin+ metronidazole+ Ceftriaxone
drain intracranial collection
administer effective antibiotic therapy (early treatment is essential)
Steroids
What are the most common cancers that spread to the brain?
Lung cancer, 48%
Breast cancer, 15%
Genitourinary tract cancers, 11%
Osteosarcoma, 10%
Melanoma, 9%
What is bulbar palsy/
Refers to signs and symptoms linked to the impairment of the glossopharyngeal nerve (CN IX), the vagus nerve (CN X), the accessory nerve (CN XI), and the hypoglossal nerve (CN XII).
What conditions cause a bulbar palsy?
MND
GBS
Polio
Brainstem tumours
MG
Myotonic dystrophy
Toxic: Botulism
What are some signs and symptoms of bulbar palsy?
- Dysphagia
- Chewing difficulty
- Dysphonia
- Nasal speech
- Flaccid paralysis
The ocular muscles are spared and this differentiates it from myasthenia gravis.
What are the investigations for bulbar palsy?
electromagnetic articulography (EMA)
electropalatography (EPG)
pressure sensing EPG
routine bloods, brain/brainstem imaging, electromyography
What is the difference between bulbar and pseudobulbar palsy?
PSEUDO – affects the upper motor neurones
BULBAR – affects the lower motor neurones (of CN 9,10,11,12)
In contrast, pseudobulbar palsy is a clinical syndrome similar to bulbar palsy but in which the damage is located in upper motor neurons of the corticobulbar tracts in the mid-pons (i.e., in the cranial nerves IX-XII), that is the nerve cells coming down from the cerebral cortex innervating the motor nuclei in the medulla. This is usually caused by stroke.
What are the symptoms of cerebellar dysfunction?
D Dysdiadochokinesia
A Ataxia (gait and posture)
N Nystagmus
I Intention tremor
S Slurred, staccato speech
H Hypotonia/heel-shin test
What is ataxia?
A neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormalities, speech changes and abnormalities in eye movements
What can cause ataxia?
- Cerebellar problems
- Issues with proprioception
What test helps you distinguish between proprioceptive and cerebellar causes of ataxic gait?
If they can walk normally with their eyes open but bad with their eyes closed then it is a proprioception problem
If the problem is there all the time then it is a cerebellar cause
What are some general features of ataxia?
Wide based gait
Falls
Cannot walk hell-to-toe
Often worse in the dark or with eyes closed
Gait abnormalities
nystagmus/
intention tremors
Heart problems
Decreased tone/reflexes
What are some cerebellar causes of ataxia?
MS
Posterior fossa tumour
Alcohol
Direct injury
Gluten ataxia autoimmunity to purkinje cells or other neural cells
CNS vasculitis, multiple sclerosis, infection, bleeding, infarction, tumors, direct injury, toxins (e.g., alcohol), genetic disorders and neurodegenerative diseases
What side is affected in a cerebellar lesion?
Deficit is Ipsilateral If they are ataxic on the right, the problem is with the right side of the cerebellum) - UNLIKE IN CEREBAL LESIONS
What are some proprioceptive causes of an ataxic gait?
Sensory neuropathies- Low B12
Inner ear problems- affecting the vestibular system
What is Fredrich’s ataxia?
Genetic, progressive, neurogenerative movement disorder which typically presents at age 10-15 years
- Autosomal recessive on chromosome 9
What happens in Fredrich’s ataxia?
It can lead to peripheral neuropathy, due to the atrophy of the dorsal root ganglia and thinning of the dorsal roots
What blood tests are used in ataxia diagnosis?
- FBC, U&E, extended LFT’s
- HbA1c, B12, folate, TSH
- ESR, CRP
- gluten related serology* (can only be requested in Sheffield)
What is cerebral palsy?
- Permanent neurological problems resulting from damage to the brain around the time of birth
- It is not a progressive conditions however problems may change over time during growth and development
What are some causes of CP?
Antenatal:
Maternal infections
Trauma during pregnancy
Perinatal:
Birth asphyxia
Pre-term birth
Postnatal:
Meningitis
Severe neonatal jaundice
Head injury
What is spastic hypertonia CP?
Increased tone and reduced function resulting from damage to upper motor neurones
What is Dyskinetic CP?
- Problems controlling muscle tone with hypertonia and hypotonia
- It causes athetoid movements Twisting, turning, squirming, twitching, jerking, repeated motions, tremors, poor posture, unsteadiness, and grimacing
- It also causes oro-motor problems
Due to damage of the BASAL GANGLIA
What are some other types of CP?
Ataxic: problems with coordinated movement resulting from damage to the cerebellum
Mixed: a mix of spastic, Dyskinetic and/or ataxic features
What is the presentation of CP?
- Failure to meet milestones
- Increased or decreased tone
- Hand preference below 18 months
- Problems with coordination
- Feeding or swallowing problems
- Learning difficulties
What can be affected in cerebral palsy?
Monoplegia: one limb affected
Hemiplegia: one side of the body affected
Diplegia: four limbs are affects, but mostly the legs
Quadriplegia: four limbs are affected more severely, often with seizures, speech disturbance and other impairments
What gaits will indicate CP?
- Hemiplegic gait: it is caused by increased muscle tone and spasticity in the legs
- The leg will be extended with plantar flexion of the feet and toes
- This means they have to swing the leg around in a large semicircle when moving their leg from behind them to in front. There is not enough space to swing the extended leg in a straight line below them.
What are some complications associated with CP?
Learning disability
Epilepsy
Kyphoscoliosis
Muscle contractures
Hearing and visual impairment
Gastro-oesophageal reflux
What is the management of CP?
Physiotherapy is used to stretch and strengthen muscles, maximise function and prevent muscle contractures.
Occupational therapy is used to help patients manage their everyday activities, such as getting dressed and using the bathroom. That can involve techniques to perform tasks despite disability. They can also make adaptations and supply equipment, such as rails for assistance or fitting a hoist for a patient who is entirely wheelchair bound.
Speech and language therapy can help with speech and swallowing. When swallowing difficultly prevents them meeting their nutritional requirements they may require an NG tube or PEG tube to be fitted.
Dieticians can help ensure they meet nutritional requirements. Some children may require PEG feeding through a port on their abdomen that gives direct access to the stomach.
Orthopaedic surgeons can perform procedures to release contractures or lengthen tendons (tenotomy).
What medications can be used to manage the side effects of CP?
Muscle relaxants (e.g. baclofen) for muscle spasticity and contractures and Botox
Anti-epileptic drugs for seizures
Glycopyrronium bromide for excessive drooling
What is chronic fatigue syndrome?
A complex, chronic medical condition affecting multiple body systems and of unknown cause which has many different presentations
Known as myalgic encephalomyelitis
What can cause ME?
- 50-80% of people start suddenly with a flu-like illness
- Often found after infection
- Strong genetic disposition
- Life stressors
What are some key presentations of ME?
Onset is usually abrupt, often following a stressful event
viral-like illness with swollen lymph nodes, extreme fatigue, fever, and upper respiratory symptoms
Debilitating fatigue
Post-exertional malaise
Unrefreshing sleep or sleep disturbance
‘Brain fog’
Generalized pain
Significantly reduced ability to engage in occupational, educational, social or personal activities
What are some investigations for ME?
The diagnosis of CFS is made by the characteristic history combined with a normal physical examination and normal laboratory test results
normal FBC, U+Es, Creatine, ESR, TFTs
What is the management for ME?
Lifestyle advice - pace yourself, rest as needed, maintain health diet, work adjustments
CBT
No medicine treatment
What is diabetic neuropathy? What are some symptoms?
peripheral nerve damage as a result of diabetes mellitus
Commonly results in weakness; sensory symptoms such as numbness, tingling, or pain; or autonomic changes such as urinary symptoms.
These changes are thought to result from a microvascular injury involving small blood vessels that supply nerves (vasa nervorum).
What is benign essential tremor?
- A fine tremor affecting all the voluntary muscles it is most common in the hands
- Can also affect the head, jaw and vocal cords
What are the features of a benign essential tremor?
- Fine tremor
- Symmetrical
- More prominent with voluntary movement
- Worse when tired, stressed or after caffeine
- Improved by alcohol
- Absent during sleep
What are some differentials of a BET?
Parkinson’s disease
Multiple sclerosis
Huntington’s chorea
Hyperthyroidism
Fever
Dopamine antagonists
What is the management of a BET?
Propranolol (a non-selective beta blocker)
Primidone (a barbiturate anti-epileptic medication)
What is Parkinson’s disease?
A neurodegenerative disorder characterised by the loss of dopaminergic neurons within the substantia nigra pars compacta of the basal ganglia
What are the risk factors for developing PD?
Age
Gender: more common in men
Family history
Describe the pathophysiology of PD?
- There is a progressive loss of dopamine-producing neurons meaning there is a reduction in the amount produced
- This leads to a reduction in action of the direct pathway and an increase in the antagonistic indirect pathway which restricts movements
- This leads to the symptoms of bradykinesia and rigidity
- There is also formation of protein clumps Lewy bodies
What are the 3 key symptoms of PD?
- Bradykinesia
- Tremor
- Rigidity
Symptoms usually start unilateral and then become bilateral later in the disease course
What symptoms are not present in the early stages of PD?
- Incontinence
- Dementia
- Falls
- Symmetry
Can be a sign of normal pressure hydrocephalus
What are the effects of bradykinesia in PD?
- Small handwriting
- Shuffling gait
- Difficulty initiating movement
- Difficulty turning around when standing
- Reduced facial movements and expressions
What is the presentation of the tremor in PD?
- Unilateral resting tremor
- Described as a pill rolling tremor
- Worse when resting and distracted using other hand
Frequency of 4-6 times a second
What is the rigidity like in PD?
- If you take their hand and passively flex and extend their arm at the elbow you will feel tension in their arm that gives way to movement in small increments (little jerks)
- Described as cogwheel
What are some other symptoms of PD?
- Depression
- Sleep disturbance
- Loss of smell
- Postural instability
- Cognitive impairment
What are some differences between BET and PD?
- PD= asymmetrical BET= symmetrical
- PD= frequency= 4-6 BET= 5-8
- PD= worse at rest BET= better at rest
- PD= improves with intentional movement BET= worse
- PD= no change with alcohol/worse BET= better with alcohol
What is used to diagnose PD?
a clinical diagnosis that showed be suspected in a patient with bradykinesia and at leas tone of:
- Tremor
- Rigidity
- Postural instability
What is the treatment for PD?
Motor symptoms not affecting quality of life:
A choice of one of the following:
Dopamine agonist(non-ergot derived)
- Pramipexole, ropinirole
Monoamine oxidase B inhibitor (MOA-B)
- Selegiline, rasagiline
- Stop breakdown of circulating dopamine
Motor symptoms affecting the quality of life:
- Synthetic dopamine levodopa given with a drug that stops it being broken down
- Peripheral decarboxylase inhibitors
Co-benyldopa (levodopa and benserazide)
Co-careldopa (levodopa and carbidopa)
What is Huntington’s disease?
An Autosomal dominant condition that is neurodegenerative and causes a deterioration in the nervous system
What causes HD?
- It is a trinucleotide repeat disorder
- There is a repeat of CAG which codes for glutamine 36 times in a row so patients have 6 glutamine in a row on the Huntington protein
- These mutated proteins aggregate within neuronal cells of the caudate. This leads to decreased ACh and GABA synthesis
- This leads to an increase in dopamine production
What is anticipation and how is it linked to HD?
- A feature of trinucleotide repeat disorders. When coping the HTT gene DNA polymerase can lose track of which CAG it’s on and add an extra CAG.
- This leads to successive generations having more repeats in the gene resulting in:
- Early age of onset
- Increased severity of the disease
What are the symptoms of HD?
Patients asymptomatic until 30-50
- Begin with cognitive, psychiatric or mood problems
- Chorea
- Eye movement disorders
- Dysarthria: speech difficulties
- Dysphagia: swallowing difficulties
- Dementia
What medications are given for symptoms relief in HD?
- Life expectancy is 15-20 years after the onset of symptoms
- Antipsychotics (e.g. olanzapine)
- Benzodiazepines (e.g. diazepam)
- Dopamine-depleting agents (e.g. tetrabenazine)
What is GCA?
A vasculitis affecting the medium and large arteries it is the most common cause of systemic vasculitis
It usually affects branches of the carotid artery
What are the risk factors for GCA?
- Age usually over 50
- Female
- Caucasians
- Polymyalgia rheumatica associated in 50% of cases
What causes GCA and which arteries are affected?
It is a granulomatous vasculitis. Arteries become inflamed and thickened and there is a narrowed lumen which prevents blood flow
Cerebral arteries are affected:
Superficial temporal: headache and scalp tenderness
Mandibular: Jaw claudication
Ophthalmic artery: visual loss due to retinal ischaemia
What are the signs of GCA?
- Superficial temporal artery tenderness
- Absent temporal pulse
- Reduced visual activity
What are the symptoms of GCA?
- Main symptom is headache that us unilateral and around forehead and temple.
- Irreversible painless complete sight loss
- Jaw claudication
- Scalp tenderness may be noticed when brushing hair
What are some systemic symptoms of GCA?
- Fever
- Muscle aches
- Fatigue
- Weight loss
- Loss of appetite
- Peripheral oedema
What are the investigations for GCA?
- ESR a value of greater than 50
- A temporal artery biopsy is gold standard and will show multinucleated giant cells negative results don’t rule out as there can be skip lesions
What is the treatment of GCA?
- Corticosteroids 40-60mg IV methylprednisolone
- Oral aspirin to prevent ischaemic cranial complications
What are the complications of GCA?
- Aortic aneurysms
- Glucocorticoid toxicity
- Vision loss
- Cerebrovascular accident
What is the ongoing management for GCA?
Once the diagnosis is confirmed they will need to continue high dose steroids (40-60mg) until the symptoms have resolved. They then need to slowly wean off the steroids. This can take several years. This is a similar process to managing polymyalgia rheumatica.