Neurology 5 Flashcards
What is the most common cause of a SAH?
Trauma
Other causes are spontaneous
- Berry Aneurysm
- AVM
- Arterial dissection
- Pituitary apoplexy
What changes may you see on ECG with a SAH?
ST elevation
What are some of the complications that can occur with SAH?
Re-bleeding
Cerebral ischemia
- vasospastic action *Nimodipine given to counter act
Hydrocephalus
- arachnoid granulation and blood obstruction
SIADH
Which system is involved causing pain in a migraine?
Trigeminovascular system
- spreading cortical depression
- Release of CGRP
What are some triggers for migraines?
Sleep (too much to little)
Hormone changes
- menstrual cycle
Stress
- includes a let down period after intense stress
Eating
- alcohol
Weather changes
What features can help differentiate a Aura migraine from a TIA?
Positive symptoms
- scotoma
- tingling
- TIA tend to have complete vision loss as oppossed to distorted vision
Onset time
- migraines tend to build up
Migraine typically has pain associated
What are the duration of times of antibiotic therapy for meningitis?
N. meningitides: 5 days
S. Pneumonia: 10-14 days
L. Monocytogenes: 21 days
What are some poor prognostic indicators in meningitis?
> 60 years old
S. Pneumonia infection
Low GCS
Focal neurology
Bleeding
What is the ABCD2 score?
Score used to assess if a patient needs to be managed as in patient (seen within 24 hours) or outpatient Due to risk of further risk of stroke.
>4 need to be admitted and seen within 24 hours
A- Age >60 B - Blood pressure >140 C - Clinical condition (weakness?) D - Duration of symptoms D - Diabetes
When is the best time to give Alteplase?
within first 90mins is best but can be given within 4.5 hour window
What scoring system can be used to assess severity of strokes?
NIH Stroke Scale
Why is an extensive stroke not treated with thrombolysis even if within the 4.5hours?
Extensive stroke demonstrates large necrosis which is a big risk factor for haemorrhage
When treated with thrombolysis how many will benefit and how many will ?
1/3rd will improve
1% will have worse outcomes
What is the criteria for endarterectomy following a stroke?
Males: >50% stenosis
Females: >70% stenosis
- has to be symptomatic (i.e. had a stroke)
- done within 2 weeks of the event
Why is anti-coagulation not started straight away in patients with an embolic stroke?
Anti-coagulation increases the risk of bleeding
- in a similar way thrombolysis increases risk
If someone has signs of a posterior circulatory stroke but no findings on CT what should be done next?
MRI scan
CT scan can’t rule out posterior stroke
**any Brainstem signs you need an MRI
What type of nystagmus is suggestive of a central cause?
Bidirectional nystagmus
- beats to both sides
RTC and patient presents with Horner’s syndrome, what has occurred?
Carotid dissection
How is a carotid dissection treated?
Anti-coagulation
In terms of onset of weakness - if a patient describe s a progressive weakness over 24-72 hours what is the likely underlying pathology?
Inflammatory
If you have a lesion in the internal capsule what kind of symptoms can you expect?
Dense hemiparesis of the face and body on contralateral side
- all the motor fibres pass through there
If you have a lesion in the thalamus what symptoms can you expect?
Hemisensory loss
If you have a lesion within the medulla what symptoms can you expect?
Dysphagia Dysarthria Dysphonia Wasting of tongue Lack of soft palate risen when saying "ahh"
*this is because cranial nerves 9,10,11 exit from the medulla.
What is a prognostic indicator on how well someone will do following a spinal transection?
Their ability to use truncal muscles.
What is a positive Romberg’s sign indicative of?
Sensory neuro-ataxia
- they’ve lost proprioception input
Give some differentials for length dependent polyneuropathy:
Diabetes
Alcohol
Multiple myeloma
B12 deficiency
Autoimmune:
- RA
- Lupus
Drugs:
- Isoniazid
- Amiodarone
Kidney disease
Hypothyroidism
What are some of the risk factors for a SAH?
Female Smoking HTN Polycystic kidney disease Ehlor Danlos Family history Coarctation of aorta
What is a sign seen in the eyes which is very characteristic of a SAH?
Subhyaloid haemorrhage causing vitreous detachment
Once a SAH has been established what tests should then be conducted to establish the cause?
CT angiogram
- assess for aneurysms
- digital subtraction to view the vessels can also be done.
- assess eGFR
- a digital subtraction graph can be done if CT not appropriate
What investigations other than a CT Scan do you want to order in a SAH?
Bloods:
- U&Es - hyponatraemia
- Troponin levels
X-rays:
- Echocardiogram (Takusubo)
- pulmonary oedema
ECG
- non-specific ST elevation
What are the complications of a SAH and some treatments used:
Re-haemorrohage
- 10% within the first 72 hours
- immediate repair can help
Delayed Ischemia
- peaks around day 7
- nimodipine is used to reduce
- Inotropic may be needed
- microvascular dilation
Hydrocephalus
- due to arachnoid granulation irritation
- needs shunted
SIADH
- can become fluid depleted by passing lots of water
- hypertonic saline
Takotsubo cardiomyopathy
- large catecholamine release
Troponin rise
- due to catecholamine release
DVTs
- Mechanical compression
- use of LMWH is controversial and should be with held 24 hours between surgeries
What is the mortality rate in SAH?
50%
1/3rd who survive will require dependent care
What are the pathological processes behind cervical myelopathy?
Disc prolapse
Facet joint degeneration
Osteophyte formation
Cervical stenosis
Malignancy
What kind of symptoms occur in radiculopathy?
Lower motor sign
Pain is the biggest sign first.
How does an UMN lesion affect the bladder and sphincter complex?
Spastic bladder
- urgency
- strangury
- incontinence
Bowel:
- constipation
- unable to open
What condition will inhibit an approach from the front to treat cervical myelopathy? and what is the surgery called that is conducted from the front?
Posterior longitudinal calcification
Anterior cervical discectomy with fusion
Name three operation which can be conducted to fix a cervical myelopathy and what would help you decide to take an anterior or posterior view?
Anterior cervical discectomy with fusion
Posterior laminectomy
Cervical foraminotomy
Decision:
- Where the most amount of compression is
i. e. if anterior then anterior approach
What are the red flags of lumbosacral radiculopathy?
Foot drop
Bilateral leg pain
Bladder/ bowel dysfunction
Saddle anaesthesia
Known cancer
What are the treatment options for lumbosacral radiculopathy?
Physiotherapy
Analgesia
- Duloxetine
- Gabapentin
- TCAs
Nerve root blocks
Surgical:
- Lumbar microdiscectomy ** definitive management
Contrast a LMN bladder and an UMN bladder and list one condition it is seen with:
UMN:
- hyperactive
- inability to fill and relax
- Strangulation
- Urgency
- cervical myelopathy
LMN: - Atonic - Drippling Progresses to retention and incontinence *cauda equina syndrome
What test can you do to establish if there is bladder dysfunction in cauda equina syndrome?
Post- void ultrasound scan
Residual of >100mls is suggestive of dysfunction
What is the definitive management for cauda equina?
Lumbar microdiscectomy
+/-
Laminectomy (done if unsure its decompressed)
*should be conducted with 24 hours - as soon as possible
What criteria can be used to help establish which patients are likely to benefit from surgical surgery who have a spinal tumour?
Patchel criteria
What are the two types of haemorrhagic transformation?
Petechial
- not of much clinical significance
- usually antiplatelet therapy is withheld for one day following this
Intraparenchymal
- carries worse prognosis
**this is why a repeat CT is done following thrombolysis therapy 19-24 hours later
What are the two main types of primary intracerebral bleeds?
Hypertension
- this is centrally located bleeds
Cerebral amyloid angiopathy
- seen with susceptibility weighted MRI
- there are peripherally located
Where is the most common place for a SAH to occur?
Anterior communicating Artery
What imaging modality should be utilised for follow up of a coil in SAH?
MRI
in CT there is too much artefact
On imaging how do you differentiate between atrophy and hydrocephalus?
In hydrocephalus the sulci are squished as well
Low density is found around the ventricles
- this is CSF leaking out into the parenchymal
In atrophy the sulci are equally enlarged
What are the layers of the scalp and what is the vein that passes through from the scalp to the superior sagital sinus?
SCALP
- Skin
- Connective tissue
- Aponeurosis
- Loose aorola tissue
- Peritoneum
Emissary vein
- source of infection
**above the aponeurosis it will not be influenced by the pull of the frontalis muscle thus can be fixed with glue
List some signs of myasthenia gravis:
Diplopia Proximal muscle weakness (neck, limb girdle) Dysphonia Dysphagia Ptosis
- pernicious anaemia
- Thyroid disease
What are the core symptoms of Parkinson’s disease?
Tremor at rest
Rigidity
Bradykinesia
Postural instability - due to poor postural reflexes
What tests do you want to order to help diagnose Myasthenia Gravis?
Bloods:
- ACh receptor antibodies
- Anti- Muscle specific Kinase receptor (MuSK)
- Low Density lipoprotein receptor - 4
X-rays:
- CXR (thyoma)
Special tests:
- Pulmonary function - Spirometry looking at FVC
- single fibre EMG
What are some triggers to a myasthenia crisis and how is it treated?
Drug
- gentamicin
- beta blockers
- over dose of Acetylcholinesterase inhibitors
- pregnancy
Treatment: - Ventilator support or BiPAP - plasmapheresis or - IV immunoglobulin
What drug is given in an overdose of an Acetylcholinesterase inhibitor?
Glycopyrronium
What symptoms would point away from Parkinson’s disease and to one of the Parkinson plus syndromes?
Early onset dementia
- fluctuation in consciousness
- Hallucinations
Early postural instability and postural hypotension
- Multisystem atrophy
Multiple early falls
Symmetrical presentation
`Levodopa non-responsiveness
What drug can be given as a rescue medicine for sudden “off” freezing in Parkinson’s? and how is it delivered?
Apomorphine
- Sub cut
What are the two common dopamine agonists used in Parkinson’s disease? why are these preferred over other dopamine agonists and what are some side effects to them?
Ropinirole
Pramipexol
Typically used initially in young persons with Parkinson’s due to reduced efficacy of L-DOPA as time goes on.
Preferred over other domapine agonists as they can cause fibrotic reaction of the heart
Side effects:
- N&V
- Postural hypotension
- Increased compulsivity
- Hypersexuality
- Psychotic features
When a patient is admitted with Parkinson’s disease - what important question should you ask them? and list some consequences of not:
Establish when they take their medication
- it is important this is given at the same time of day each day.
Missing dosages or changing dosages can result in:
- neuroleptic malignancy syndrome
What are COMT inhibitors used for and name two:
Help reduce the on-off effects of levadopa
*typically used in late disease
- Entacapone
- Tolcapone
What are some side effects of levadopa?
Dyskinesia
On-off affect
Psychosis
Hallucinations
What anti-emetic can be given for Parkinson’s?
Domperidone (even though it is a dopamine antagonist - it doesn’t cross the BBB)
What features would suggest a Psychogenic non-epileptic seizure?
Gradual onset
Hip thrusting
Crying after seizure
Rarely occurs alone
How do posterior circulating strokes present?
Brainstem signs or Cerebellar signs or Unconsciousness or Isolated homologous hemianopia
Outline the pathological mechanisms of traumatic brain injury:
Diffuse neural exonal injury
- can be opposite side of injury (contrecoup)
Neuronal and axonal damage directly from blow
Brain hypoxia
Oedema build up afterwards
What are some long term consequences of trauma to the brain?
Incomplete recovery
- cognitive impairment
Post-traumatic epilepsy
Post-traumatic syndrome
- recurring headaches
- dizziness
Hydrocephalus
BPPV
What is the treatment for idiopathic intracranial hypertension?
Acetazolamide
Which class of antibiotics can lower the seizure threshold in epileptics?
Quinolones
What is the management for an extra-dural haemorrhage and give some differentials:
Differentials:
- epilepsy
- Carbon monoxide poisoning
- Carotid artery dissection
Management:
- ABCDE (early intubation is needed)
- Clot evacuation
- Ligation of bleeding vessel
- control if ICP
- Ventilation
- Mannitol
What is conduction aphasia?
Where speach is fluent but they have difficulty repeating what is said to them
- comphrension is present
What investigations would you consider in someone presenting with a seizure?
Blood glucose ECG - rule out cardiac FBC - infection? U&Es/ Toxicology Head CT
Later on:
- EEG
- EEG doesn’t diagnose unless it is occurring but can help with prognosis i.e. to look at normal activity
Following one seizure how likely is a person to have another?
40%
*if there is abnormal EEG this rises to 60%
What are some risk factors for a epilepsy?
Family history
Birthing injury/ preterm
Meningitis
Febrile convulsions
- especially if out-with normal ages
Head injuries
When asking about seizures at night - what kind of things do you want to think about?
If they wake up with muscle aches
Tongue biting through the night
When treating cauda equina - what initial things are done?
Dexamethasone
Urinary catheter ***
Whole spinal MRI