Neurology 2 Flashcards
What is a sudden onset headache likely to be?
SAH - sudden onset worst ever thunderclap occipital headache and neck stiffness
Migraine - more gradual onset, history of migraines
Venous sinus thrombosis
What is a subdural haematoma?
Bleeding between the arachnoid and dura mater
What are the risk factors of subdural haematoma?
More common in patients with smaller brains e.g. alcoholics, elderly
What causes a subdural haematoma?
Often head injury – can be minor/from a long time ago, sometimes the patient doesn’t remember/notice the injury
What is the site of the bleed in a subdural haematoma?
Bridging veins between the dura and arachnoid mater
How does a subdural haematoma present?
Confusion/drowsiness
Fluctuating consciousness
Signs of raised ICP
Focal neurological signs e.g. hemiparesis.
What is the difference in presentation between an acute and chronic subdural haematoma?
Acute presents like an extradural, chronic presents more gradually with fluctuating consciousness
How do you investigate subdural and extradural haematomas?
1st line = IMMEDIATE CT HEAD – remember blood is white on CT
What is an extradural haematoma?
Bleeding between the dura mater and skull bone
What causes an extradural haematoma?
Traumatic head injury! Usually associated with skull fracture
Where is the site of the bleed in an extradural haematoma?
Middle meningeal artery
How does an extradural haematoma present?
- Head injury
- Brief loss of consciousness/drowsiness
- Lucid period
- Rapid decline in consciousness as it compresses other structures.
- Signs of raised ICP.
How do you treat subdural and extradural haematomas?
Surgery
Craniotomy/decompressive craniectomy/burr hole
IV mannitol to reduce ICP
What can happen if a haematoma keeps growing?
Compress local structures + raises ICP > cerebellar herniation/coning + brainstem death
What are the signs of a growing haematoma?
Severe headache N+V Confusion Seizures Papilloedema Eventually start to get signs of brainstem compression (RAISED ICP)
What is the body’s response to raised ICP?
Cushing’s triad > bradycardia + HTN + deep irregular breathing
What are the common causes of raised ICP?
Haemorrhages
Tumours
Hydrocephalus
What are the less common causes of raised ICP?
Infections e.g abscess
Metabolic stuff – hypercalcaemia, hyponatraemia
What does a subdural haematoma look like on a CT scan?
Crescent shaped haematoma in 1 hemisphere
On CT blood gets darker over time so chronic ones are usually hypodense (dark)
Look for midline shift
What does an extradural haematoma look like on a CT scan?
Biconvex/lemon shaped haematoma adjacent to skull
What is an intracerebral haemorrhage?
Bleeding into the brain tissue
What causes an intracerebral haemorrhage?
HTN
Where is the site of bleeding in an intracerebral haemorrhage?
Can be anywhere - intraventricular, cerebellar, lobar
What is the most common site of an intracerebral bleed?
Basal ganglia
How does an intracerebral haemorrhage present?
Signs of raised ICP, rapid loss of consciousness, focal neurological signs
How do you investigate an intracerebral haemorrhage?
CT head - shows irregularly shaped, high density area
How do you manage an intracerebral haemorrhage?
Clot evacuation
What can cause loss of consciousness?
Epileptic seizure
Syncope
Psychogenic non-epileptic seizure
What are the 2 types of syncope?
Vasovagal and cardiogenic
What causes cardiogenic syncope?
Due to an arrhythmia
What is the cause of blackouts during exercise until proven otherwise?
Cardiogenic syncope
What are the key investigations after loss of consciousness?
Vital signs including BP
Bloods - glucose, FBC, U+Es
Same day ECG then 24hr ECG
EEG if they have another event
How does a non-epileptic seizure present?
Often stay a normal colour/normal vital signs
Eyes closed
Retained consciousness - may be able to respond
Pelvic thrusting, arching back, erratic movements
How are non-epileptic seizures treated?
No treatment
How does timing of seizures compare with syncope?
Seizures - anytime, commonly during activity
Syncope - day or after prolonged standing
How does prodome of seizures compare with syncope?
Seizures - brief (twitching, hallucinations)
Syncope - longer (light-headedness, dizziness, confusion, tunnel vision, vertigo, N+V, headache, sweating, palpitations)
How does the duration of seizures compare with syncope?
Seizures - variable
Syncope - <5 mins
How do tonic-clonic movements of seizures compare with syncope?
Seizures - common with tongue biting and head turning
Syncope - rare
How does colour change in seizures compare with syncope?
Seizures - may be cyanosed
Syncope - pallor
How does injury in seizures compare with syncope?
Seizures - common
Syncope - rare
How does urine incontinence in seizures compare with syncope?
Seizures - common
Syncope - rare
How does recovery from seizures compare with syncope?
Seizures - post-ictal symptoms: drowsiness, confusion, headache, myalgia, sore tongue
Syncope - quick
How many seizures are required for an epilepsy diagnosis?
At least 2 unprovoked seizures >24 hours apart
What are the stages of an epileptic seizure?
- Prodome
- Aura
- Ictus
- Post-ictal period
How long do seizures normally last?
30-120 seconds
What happens in the prodome stage of an epileptic seizure?
Change of mood/behaviour before attack
What happens in the aura stage of an epileptic seizure?
Part of the seizure where the patient is aware, symptoms just before attack e.g. déjà vu
What happens in the ictus stage of an epileptic seizure?
Attack itself, usually positive symptoms e.g. jerking
What happens in the post-ictal stage of an epileptic seizure?
Negative symptoms e.g. weakness, drowsiness, myalgia
What are the different types of epilepsy?
Primary generalised
Partial/focal seizures
What is the pathology of primary generalised epilepsy?
Electrical discharge throughout whole cortex
What are the features of primary generalised epilepsy?
No localising features
Bilateral symmetrical manifestations
Loss of consciousness/awareness
What is the pathology of partial/focal seizures?
Features restricted to limited part of the cortex of one hemisphere
What are the features of partial/focal seizures?
May remain conscious
May later become generalised + spread to both hemispheres (secondary generalised tonic-clonic seizure)
What are the different types of primary generalised seizures?
Generalised tonic clonic (grand mal)
Absence (petit mal)
Myotonic
Atonic
What are the classic features of a generalised tonic clonic seizure?
Epileptic cry at onset Tonic then clonic phase Eyes remain open Lose consciousness May be cyanosed Post-ictal drowsiness/confusion
What happens in the tonic phase of a seizure?
Sudden rigid limbs
What happens in the clonic phase of a seizure?
Bilateral muscle jerking +/- tongue biting, incontinence
What are the classic features of an absence seizure?
Sudden cessation of activity
No aura
No post-ictal period
Who is commonly affected by absence seizures?
Usually in children, likely to develop tonic-clonics as an adult
How does a patient appear when they are having an absence seizure?
Often stop talking mid-sentence and stare blankly/pale for a few seconds/stay still then continue where they left off and don’t realise it happened
How long do absence seizures last?
<30 seconds
What are the classical features of a myoclonic seizure?
Repetitive but isolated shock-like symmetrical jerks of limb/face/trunk
What are the classical features of an atonic seizure?
Sudden loss of muscle tone > drop attack (fall to ground). Usually remain conscious
What are the 2 types of focal seizures?
Simple and complex
What is a simple focal seizure?
Does not affect consciousness / memory
No post-ictal signs
Motor, sensory, autonomic, psychic signs
How long do simple focal seizures last?
10-20 seconds
What are complex focal seizures?
Memory affected before during or after
Temporal lobe so post-ictal confusion + automatisms common
Where do complex focal seizures usually occur?
Temporal lobe
How do seizures in the temporal lobe present?
Aura
Automatisms
Post-ictal confusion & headache
What symptoms are experienced in the aura phase of a seizure?
Déjà vu, auditory hallucinations, strange smells, fear, vertigo
Give some examples of automatisms.
Lip smacking, chewing, fiddling etc.
What is the main cause of temporal lobe epilepsy?
Hippocampal sclerosis
How does a parietal lobe seizure present?
Sensory disturbances e.g. tingling, skin crawling
How does an occipital lobe seizure present?
Visual phenomena
How does a frontal lobe seizure present?
Motor features - posturing/peddling legs
Jacksonian march
Post-ictal Todd’s paralysis
No post-ictal confusion
What is Jacksonian march?
Motor symptoms spread from distal limb to face on ipsilateral side
What is post-ictal Todd’s paralysis?
Paralysis of limbs involved for a few hours
How is a diagnosis of epilepsy made?
Clinically with description of attacks - eyewitnesses
What investigations are done for epilepsy?
EEG during next seizure, almost always abnormal during epilepsy
MRI/CT to exclude underlying cause e.g. space occupying lesion
Bloods
ECG
What is classed as an emergency in epileptic patients?
Seizure lasting >3 mins
How is an epileptic emergency treated?
ABCDE management + IV diazepam/lorazepam. Repeat twice until it stops. IV phenytoin if still fitting after this.
What is the long-term management of epilepsy?
Primary generalised - sodium valproate (CI in pregnancy - use lamotrigine)
Partial seizure - carbamazepine
Inform DVLA - can’t drive until seizure free for >1 year
When should drugs be prescribed for epilepsy?
After 2nd seizure of after 1st if high risk of recurrence
What is the main complication of epilepsy?
Status epilepticus
What is status epilepticus?
Continuous seizure (>30 mins or 2+ seizures without recovery)
How is status epilepticus managed?
2 doses of benzodiazepine e.g. lorazepam then anti-epileptic drugs e.g. IV valproate
Find and treat underlying cause
What could be the underlying cause to status epilepticus?
Non-adherence to medication, alcohol, acute brain problem
What is the risk posed by status epilepticus?
Hypoxic brain injury
What should you aim for when treating epilepsy?
Monotherapy
