Neurology Flashcards
Name 5 peripheral causes of vertigo
BPPV
Menierres disease
Acute Vestibular Neuritis
Viral or suppurative Labyrinthitis
Acoustic Neuroma
Aminoglyocside ototoxicity
Name 5 central causes of vertigo
Cerebellar CVA
Cerebellar tumour
Vertebro-basillar insufficiency
Brain stem (any posterior circulation) CVA
Multiple Sclerosis
Drug toxicity- anti epileptics, anti depressants, antimalarials
Name 5 cerebellar signs on physical examination
broad based ataxia
nystagmus
intention tremor
abnormal finger nose test (past pointing)
abnormal heel- shin test (dysmetria)
abnormal heel-toe test (fall to side of lesion)
Complete table re clinical features of vertigo
Classic symptoms of Meniere disease
Tinnitus, vertigo, sensorineural hearing loss
Usually episodic in middle aged men
Associated with vomiting, nausea and sweating
Treatment of Meniere Disease
salt restriction
HCT 25mg daily
avoid caffeine
Classic BPPV presenting symptoms
acute onset, often after waking
worse with movement of head
improves when head still
nystagmus on provocative testing- Hall pike
F>M
50-60
BPPV treatment
Prochlorperazine 12.5mg IV
Promethazine 10mg TDS
Epleys Maneuvere
Classic Acute Vestibular Neuritis presenting symptoms
Classically follows viral illness
Onset over few hours
Persistent vertigo when head is still and eyes closed
Associated with vomiting
Nystagmus at rest
Treatment of Acute Vestibular Neuritis
Prednisolone 125mg daily, decrease by 25mg every 3 days
Prochlorperazine 25mg IV
Peripheral vertigo clinical signs
able to sit or stand without assistance
no cranial nerve or cerebellar signs
unidirectional fatiguable nystagmus
unilateral abnormal head impulse test
no skew
Central vertigo clinical signs
unable to sit or mobilise without assistance
cerebellar signs
other cranial nerve signs
negative head impulse test (eyes fixed on nose)
nystagmus- vertical, torsional, non fatiguable and no latency with head movement
skew present -usually vertical
Best Imaging for vertigo
MRI
CT often not helpful- will miss small cerebellar strokes
Stroke Mimics- name 10
hypoglycaemia/ hyponatraemia
Hemiplegic Migraine
Post ictal Todds paresis
Brain tumour
Brain abscess
Meningoencephalitis
Head injury- subdural haematoma
Multiple Sclerosis
Wernickes- Korsakoffs syndrome
Drug toxicity
Bells Palsy
Name 3 non cardiac thromboembolic causes of ischaemic stroke
Carotid artery atheroma
vertebral artery atheroma
Small vessel disease- lacunar infarct
Name 5 cardiac thromboembolic causes of ischaemic stroke
AF
Atrial myxoma
Valve disease
Mural thrombosis
PFO
Name 6 non cardioembolic causes of ischaemic stroke
Cerebral vasospasm post SAH
Aortic or vertebral artery dissection
Cerebral vasospasm- pre eclampsia
Moyamoya syndome
AFE
Gas embolism
Arteritis
Cardiac arrest- low flow state
Name 5 causes of Haemorrhagic stroke
HTN ++++++
liphylanosis
AVM
Aneurysm
Bleeding diathesis- oral anticoagulation or inherited
Secondary haemorrhage into infarction or tumour
Amyloid
Indications for thrombolysis in stroke
Onset of symptoms within 4.5 hours
Significant persistent neurological deficit
CT scan which does not show SAH or bleeding risk
Does not have any absolute contraindications
No other terminal disease or severe comorbidities
What are the Absolute contraindications for thrombolysis in CVA
-Onset of symptoms > 4.5 hours
-INR >1.7
-oral anticoagulation taken in the last 12 hours
-BP > 185 systolic or 110 diastolic
-Platelets < 100
What are the relative contraindications for thrombolysis in CVA
-Pregnancy
-Known MI in the past 30 days
-known IC bleeding past 30 days
-surgery/biopsy or trauma of internal organs past 30 days
-severe comorbidities
-advanced dementia
-CPR or arterial puncture past 30 days
Name 2 thrombolysis drugs and doses
-altelpase- 0.9mg/kg max 90 mg. Give first 10% as a push and the other 90% over 60 minutes
-tenecteplase- 0.25mg/kg. Max 25 mg given as a single push
-need to be given through dedicated IV line
What are the main complications of thrombolysis treatment
-ICH
-internal bleeding-retroperitoneal, GI/GU, solid organ
-external bleeding- massive epistaxis
-angioedema (give icatabant 30 msg s/cut- don’t want to cause HTN)
-anaphylaxis
Blood pressure target in first 24 hours post thrombolysis
180 Systolic and 110 diastolic
What is the BP target in ischaemic stroke
-if receiving thrombolysis- 185/110 or less
-if infarction not receiving thrombolysis 220 max- lower by no more than 20% in first 48 hours
What is the BP target in haemorrhagic stroke
140 systolic
Name 4 drugs and does for acute treatment of HTN in setting of stroke
-Labetalol IV- 10-20 mg bolus repeat every 10 minutes as required- can start infusion 3-8 mg/hr thereafter
-Hydralazine 5mg bolus- repeat every 20 minutes
-GTN 6mg in 100ml- start 2 ml/hr and increase every 5 minute
-Sodium Nitroprusside 0.5mcg/kg/minute
Indications for clot retrieval
-Can be commenced 6 hours of onset of symptoms or up to 24 hours of onset if perfusion scan shows a favourable penumbra
-Severe persistent neurological deficit
-Anatomical location amenable to therapy- ICA, MCA, ACA, basilar, dominant vertebral artery
-combination of age, premorbid function, time since last known to be well and penumbra imagine make it non futile
Exclusion criteria for clot retrieval
-> 24 hours since onset of symptoms
-Anatomical location not amenable to therapy/ unfavourable penumbra on imaging
-significant pre morbid comorbidities/lack of independence
-suspicion for SAH or vasospasm on imaging
-INR > 1.7
-known severe hypersensitivity to contrast
What are the clinical features of MCA stroke syndrome
-contralateral motor weakness- face>legs
-contralateral sensory loss -face>legs
-homonymous hemianopia
-receptive and expressive aphasia if dominant hemisphere
-visual neglect
-gaze deviation to side of affected lesion
What are the clinical features of ACA stroke syndrome
-contralateral motor weakness- peripheral > proximal
-contralateral sensory loss- peripheral > proximal
-Urinary and faecal incontinence (paracentral lobule)
-Abulia (prefrontal cortex and anterior cingulate gyrus)
-Transcortical motor aphasia–> can repeat sentence but not come up with their own
What are the features of ICA stroke syndrome?
since it splits into ACA, MCA and ophthalmic–>
all of ACA and MCA symptoms and sudden visual loss
What are the clinical features of PCA syndrome?
homonymous hemianopia
quadrantanopia
memory loss
ipsilateral 3rd neve palsy
What are the clinical features of basilar stroke?
Locked in syndrome
Ocular palsies
What are the clinical features of cerebellar stroke?
vertigo
nausea and vomiting
ataxia
nystagmus
dysmetria
CT Brain findings in CVA
-hyperdense MCA sign on CTA (if MCA)
-loss of grey white matter differentiation
-loss of insular ribbon sign
-effacement of ventricles
-effacement of cisternes
-sulcal effacement
-midline shift
Clinical features of temporal arteritis
-F>M
->50 yo
-monocular visual loss
-scalp tenderness
-jaw claudication
-has PMR
What investigations are useful in temporal arteritis?
Blood- ESR> 50 if over 100 virtually diagnostic
CRP
Temporal artery biopsy- start steroids before, can be skip lesions
What is the treatment of temporal arteritis?
If Visual Loss- IV methylprednisolone
If no visual Loss- oral prednisolone
What are the common organisms for bacterial meningitis in adults
-streptococcus pnumoniae
-neiserria meningitides
-haemophilus inluenzae B
What are the common organisms for bacterial meningitis in kids?
1month-18 years
-streptococcus pnumoniae
-neiserria meningitides
-haemophilus inluenzae B
What are the common organisms for bacterial meningitis in neonates?
Listeria monocytogenes
Group B streptococcus
Ecoli
What are the clinical features of idiopathic intracranial hypertension?
-young, obese female
-headaches
-visual blurring
-loss of peripheral vision
-PE- diplopia and CN VI palsy
-LP opening pressure > 25 cm H20
RX weight loss, acetazolamide
Clinical features of Cerebral venus sinus thrombosis
female
OCP, pregnancy, post partum, malignancy
headache, visual change, seizure, altered mental state
PE- focal neurology, seizures, papilloedema
MRI gold standard- CT V next best- empty delta sign
CT brain findings in Cerbral Venous sinus thrombosis
Empty delta sign
Clinical features of Guillain Barre?
-recent repsiratory or GI illness
-symmetrical ascending paralysis
-loss of deep tendon reflexes
-glove and stocking distribution sensory deficit
-dysautonomia
Investigation in Guillain Barre
-Largely clinical diagnosis
-Bloods- IgG campylobacter, EBV, CMV, mycoplasma, TFTS, electrolytes
-LP- high protein, normal gluconse and cell count
-Peak flow and FVC testing
Treatment of Guillan Barre
FVC < 30% predicted–> indication for intubation
CN involvement and neck weakness and dysautonomia predict need for intubation
IVIG
plasmapheresis
supportive care- DVT prophylaxis, management of dysautonomia, nutrition, pressure care etc
Classical features of Miller fisher variant of GB syndrome
opthalmoplegia
ataxia
areflexia
What are possible complications of VP shunts?
infection- can happen anywhere
blockage-from infection or migration of catheter tip in tissues- progressive raised ICP features and neruology
fracture-mild ICP symptoms and discomfort around fracture site- most commonly near clavicle
overdrainage- waxing and waning symptoms- slit like ventricles on CT
pseudocyst formation- in abdominal site- causes blocakge
What are the clinical features of cluster headache
M>F
episodes 15-180 minutes
occur in cluster and then resolve
severe periorbital and temporal pain associated with lacrimation, conjunctival injection and rhinorrhoea
Treatment of cluster headache
100 oxygen
sumitriptan 6 mg s/cut
prevention- verapamil
