neurology Flashcards
raised ICP presentation: (7)
Cushing’s triad:
1. bradycardia
2. wide pulse pressure
3. irregular respirations
+ raised BP
vomiting
papilloedema
reduced GCS
CN III palsy
CN most commonly affected by raised ICP
CN III
CN III (opthalmic n.) palsy signs
eye deviated “down & out”
ptosis
pupillary dilation (mydriasis)
internuclear ophthalmoplegia
what is it?
occular movement disorder caused from a lesion in the medical longitudinal fasciculus (MLF)
internuclear ophthalmoplegia presentation:
failure to ADDUCT eye on affected side
CONTRALATERAL NYSTAGMUS
EDH
i. blood vessel most commonly affected
middle meningeal a.
EDH typical hx
acceleration/ deceleration trauma
or trauma to side of head
LOC followed by lucid interval
SDH
i. vessels most commonly affected
i. bridging veins
SDH
ii. RF
iii. presentation
ii. alcoholism
old age
anticoagulation
iii. fluctuating confusion/ consciosness especially for chronic
SAH non-traumatic causes
- ruptured berry aneurysms
^^ most commonly on posterior communicating artery
arteriovenoius malformations
arterial dissection
diffuse axonal injury
i. what causes it
ii. 2 components
i. rapid head acceleration/ deceleration
ii.
1. mulitple haemorrhages
2. diffuse axonal damage in white matter
triptan CI:
IHD/ cerebrovascular disease
triptans adverse effects:
“triptan sensations”
–> tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
generalised tonic clonic seizures
mgt in males
sodium valproate
generalised tonic clonic seizures
mgt in females
lamotrigene or leviteracetam
may also offer sodium valproate if <10 and unlikely require rx when child bearing age
focal seizures:
i. 1st line mgt
ii. 2nd line
i. lamotrigine/ leviteracetam
ii. carbamazepine, oxcabapazepine or zonisamide
absence seizures:
i. 1st line
ii. 2nd line
i. ethosuximide
ii. in M: sodium valproate
in F: lamotrigene/ leviteracetam
which anti-epileptic can exacerbate absence seizures?
carbemazapine
myoclonic seizures mgt
in M: Na valproate
in F: levetiracetam
tonic/ atonic seizures mgt
in M: sodium valproate
in F: lamotrigene
sodium valproate SE:
Valproate SE:
Appetite increase & weight gain
Liver failure
Pancreatitis
Reversible alopecia
Oedema
Ataxia
Teratogenic, tremor, thrombocytopenia
Encephalopathy (due to increased Na+)
p450 INHIBITOR
phenytoin SE:
dizziness, diplopia, slurred speech, nystagmus, ataxia
confusion, seizures
gingical hyperplasia
megaloblastic anaemia
peripheral neuropathy
carbamazepine SE:
SIADH
Agranulocytosis
Dizziness
Diplopia
Drowsiness
lamotrigine SE:
SJS
cyctochrome p450
enzyme inducers
reduce concentration of drugs i.e. make drug work less
CRAP GPS
Carbamazepine
Rifampicin
Alcohol (chronic)
Phenytoin
Grisefu;uin (antifungal)
Phenobarbitones
Sulphonylureas
cyctochrome p450
enzyme inhibitors
increase concentration of drugs (i.e. increase risk of toxicity)
SICK FACES.COM
Sodium valpraite
Izoniazid
Cimetidine
Ketokonazole
Fluconazole
Alcohol (acute)
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
common drugs affected by enzyme inducers/ inhibitors:
COCP
warfarin
theophyline
steroids
TCAs
pethidine
statins
status mgt:
PR diazepam: -
5mg if 1 month-1yr
10mg 12+yrs
features of temporal lobe seizure:
with or without impairment of consciousness or awareness
aura:
- epigastric rising
- dejà vu / jamais vu
- less commonly hallucinations (auditory/gustatory/olfactory)
typically last approx 1 min
- automatisms
features of frontal lobe seizure:
MOTOR
Head/leg movements
posturing
post-ictal weakness
Jacksonian march
features of parietal lobe seizure:
SENSORY
paraesthesia
features of occipital lobe seizure:
floaters/ flashes
GCS
Mo6 V5 E4
motor response:
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture)
- Extending to pain
- None
verbal response:
- Orientated
- Confused
- Words
- Sounds
- None
eye opening:
- Spontaneous
- To speech
- To pain
- None
anti-hypertensives are required for stroke mgt if BP > what?
> 185/110
essential tremor features:
postural tremor: worse if arms outstretched
improved by alcohol and rest
most common cause of titubation (head tremor)
AD inheritance
essential tremor mgt
propranolol is first-line
primidone is sometimes used
myasthenia gravis: exacerbating factors
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
TACI
i. vessels involved
ii. features
i. middle and anterior cerebral arteries
ii. all 3 of:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
PACI
i. vessels involved
ii. features
i. smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
ii. 2 of:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
lacunar infarcts (LACI, c. 25%)
i. vessels involved
ii. features
i. perforating arteries around the internal capsule, thalamus and basal ganglia
ii.presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
posterior circulation infarct (POCI):
i. vessels involved
ii. features
i. vertebrobasilar arteries
ii. presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
Lateral medullary syndrome (posterior inferior cerebellar artery)/ Wallenberg’s syndrome
features:
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Weber’s syndrome features:
ipsilateral CN III palsy
contralateral weakness
cluster headache mgt:
i. acute
ii. prophylaxis
i. oxygen
s/c triptan
ii. verapamil
some evidence for tapering dose of prednisolone
migraine mgt:
i. acute
ii. prophylaxis
i. triptan, NSAID, paracetamol
[or amitriptyline]
ii. topiramate or propranolol
[or valproate]
if age 12-17 consider nasal triptan
iii. pizotifen
topiramate associated with risk of cleft palate so propranolol is preferred in women of child bearing age
trigeminal neuralgia mgt:
carbamazepine
if fails to respond or atypical features –> refer to neuro
hsv encephalitis CT head fetaures
temporal lobe changes
mgt of spasticity in MS
gabapentin and baclofen
Bell’s palsy mgt
PO prednisolone within 72 hrs of sx onset
idiopathic intracranial HTN mgt:
weight loss
carbonic anhydrase inhibitors e.g. acetazolamide
repeated LP (temporary measure only)
neuroleptic malignant syndrome features:
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
neuropathic pain:
1st line:
amitryptiline/ duloxetine/ gabapentin/ pregabalin
monotherapy i.e. if one does not work try another
tramadol as ‘rescue therapy’
Miller-Fisher syndrome vs GBS:
anti- GQ1B antibodies in Miller-Fisher
Miller - Fisher - starts proximally i.e. with eyes
Miller Fisher triad:
ataxia
areflexia
ophthalmoplegia
Lambert Eaton syndrome
i. what is it?
ii. association?
i. autoimmune disorder characterised by the production of autoantibodies that target pre-synaptic voltage-gated calcium channels, leading to impaired neurotransmission at the neuromuscular junction
ii. small cell lung cancer
Lambert Eaton syndrome presentation:
- limb weakness, PROXIMAL and SYMMETRICAL
- autonomic features: - xerostomia, orthostatic hypotension, impotence
- reduced/ absent tendon reflexes which can be potentiated by brief muscle contraction
IMPROVED with repeated movements/ repetitive contractions (unlike myaesthenia gravis which = fatiguable weakness)
lower brachial plexus (Klumpke’s)injury association:
Horner’s syndrome (ipsilateral)
if T1 involvement
criteria for CT head within 1 hour of injury:
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
>1x vomiting
criteria for CT head within 8 hrs of head injury:
any of following RF:
age 65+
hx bleeding/ clotting disorders/ anticoagulants
dangerous mechanism of injury
PD mgt
- levodopa
dopamine agonists e.g. roplinirole, rotigotine, apomorphine
MOA-B inhibitors e.g. selegiline, rasagaline (used + levodopa)
COMT inhibitors e.g. entacapone, tolcapone
amantadine
anti-cholinergics e.g. prochyclidine (not used that often irl)
PD ddx:
Lewy body dementia
progressive supranuclear palsy
multiple system atrophy
corticoobasal degeneration
Wilson’s
drug induced Parkinsonism
demenuta pugillistica
vascular parkinsonism
progressive supranuclear palsy features
early instability + frequent falls
vertical gaze impairment
Parkinsonism
multiple system atrophy
early autonomic dysfunction
poor response to levodopa
corticobasal degeneration
alien limb phenomenon
apraxia
cortical sensory loss (cannot recognise objects despite normal sensory input)
