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Medicine > Neurology > Flashcards

Neurology Flashcards

1
Q

Define epileptic seizure

A

Sudden synchronous discharge of cerebral neurons causing symptoms or signs that are apparent either to patient or observer.

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2
Q

Classification of seizures

A

General:
- Absence seizures with 3Hz spike-and-wave discharge (petit mal)
- Generalised tonic-clonic seizures (grand mal)
- Myoclonic seizures
- Tonic and Atonic seizures
Partial seizures or Focal seizures (location related epilepsy)
- Simple partial seizures (without impaired awareness e.g. Jacksonian seizures)
- Complex partial seizures (with impaired awareness e.g. temporal lobe seizures)
- Partial seizures with secondary generalisation
Unclassified seizures: any that don’t fit in the above categories.

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3
Q

What is syncope?

A

Transient loss of consciousness due to transient global cerebral hypoperfusion. Rapid onset, short duration and spontaneous complete recovery.

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4
Q

Causes of syncope

A
  1. Neurally mediated: vasovagal, carotid sinus, situational
  2. Orthostatic: drug induced, ANS failure
  3. Cardiac Arrhythmia: Brady(sick sinus) tachy(VT/SVT) Long QT
  4. Structural cardio-pulmonary: aortic stenosis, HOCUM
  5. Non-cardiovascular: psychogenic, metabolic, neurological
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5
Q

Red flag signs for pathological cause of syncope

A

ECG abnormalities
Heart failure or previous MI
TLoC during exercise
Family history of sudden cardiac death

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6
Q

Dangerous ECG signs

A 
Long or short QTc
Pre-excited QRS complex
Brugada syndrome: RBBB with ST elevation V1-V3
Abnormal T wave inversion
Negative T waves in right precordial leads, epsilon waves suggest ARVC
Pathological Q waves
Conduction abnormality
Inappropriate persistent bradycardia
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7
Q

What is an epsilon wave on ECG?

A

Small positive deflection ‘blip’ buried in end of QRS
Characteristic of ARVD- arrhythmogenic right ventricular dysplasia. (Seen often with T wave inversion in ; prolonged S wave upstroke (55ms); local QRS widening 110ms; all in V1-V3)

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8
Q

Classification of cardiovascular causes of syncope

A

Vascular
Obstructive
Arrhythmias

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9
Q

Vascular causes of syncope

A

AKA neurally mediated reflex syncope (NMS)
Neurocardiogenic (vasovagal: if no features of other diagnosis and features suggesting uncomplicated faint)
Postural hypotension
Postprandial hypotension
Micturition syncope
Carotid sinus syndrome
Situational syncope

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10
Q

Structural cardiovascular causes of syncope

A 
Ventricular arrhythmia 2a to structural disease
- HCM
- DCM
- ARVD (arrhythmogenic right ventricular cardiomyopathy)
- Ischaemic cardiomyopathy
Obstructive
- HOCM (hypertrophic obstructive cardiomyopathy)
- Severe AS (aortic stenosis)
- Atrial myxoma or thrombus
- Pulmonary hypertension/emboli
- defective prosthetic valve
- Pulmonary stenosis
- Tetralogy of Fallot
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11
Q

Arrhythmic causes of syncope

A

Brady:
- sinus arrest, exit block (significant pauses)
- high grade or acute complete AV block e.g. Stoke-Adams attacks
- artificial pacemaker failure
Tachy (rarely due to SVT)
- ventricular: VT and VF

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12
Q

How useful is EEG to investigate seizures

A

Single awake EEG -> 29-56% show changes

Repeat inc sleep EEG -> 59-92% show changes

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13
Q

Types of epilepsy

A

Provoked seizure

Unprovoked seizure: generalised or focal… Etc

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14
Q

Provocation of seizures

A

In those not prone to epilepsy: drug OD, hypoglycaemia

In epileptics: sleep deprivation; stress; alcohol; TV/strobe lighting; menstruation.

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15
Q

Common types of epilepsy in childhood

A

Absence seizures ‘petit mal’
Febrile convulsions
Infantile spasms
Juvenile myoclonic epilepsy

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16
Q

Common causes of epilepsy in neonates and childhood

A

Neonatal:
- hypoxia: perinatal hypoxic ischaemic encephalopathy (HIE)
- vascular insufficiency (or intracranial haemorrhage)
- birth trauma;
- acute infection
- metabolic
- congenital malformation
- genetic
Childhood: (most idiopathic)
- acute infection
- trauma
- febrile convulsion
OR: congenital abnormality; tuberous sclerosis; metabolic storage disorders
Any age: Metabolic; infection; tumour; AVM; Inflammation.

17
Q

Secondary causes of epilepsy in adulthood/elderly

A

Any age: metabolic, infection, tumour, AVM, inflammation.
Adult:
- head injury
- drug and/or alcohol intoxication/withdrawal
Elderly:
- cerebrovascular disease
- degenerative disease e.g. Alzheimer’s, huntington’s

18
Q

Secondary causes of epilepsy in any age

A
  • Metabolic e.g. Hypoglycaemia, hypocalcaemia, hyponatraemia
  • Cerebral infection e.g. Meningitis, encephalitis, abscess
  • cerebral tumour or AVM
  • Inflammation e.g. Vasculitis, SLE, rarely demyelination.
19
Q

Differential diagnoses for epilepsy

A
  • syncope e.g. Vasovagal, micturition, cough
  • cerebrovascular disease e.g. Transient ischaemic attack; critical carotid artery stenosis; vertebrobasilar ischaemia
  • vestibular disorders
  • low cardiac output states
  • metabolic e.g. Hypoglycaemia
  • postural hypotension
  • narcolepsy
  • psychiatric disorders e.g. Conversion hysteria
20
Q

Characteristics of infantile spasms

A
  • brief shock-like spasms, flexion of arms, head and neck, drawing up knees
  • asn with progressive learning difficulties
  • causes: perinatal asphyxia/metabolic disorders/encephalitis/cerebral malformations
21
Q

Prognosis of absence seizures and febrile convulsions

A

Absence seizures: (4-10y, F>M) no post-ictal period; few continue after puberty, 5-10% have adult seizures

Febrile convulsions (

22
Q

Common causes of adolescent seizures

A 
Teenage:
- Idiopathic
- Trauma
- drug/EtOH withdrawal
- Arteriovenous malformation
Young adult 18-35
- trauma
- alcoholism
- brain tumour
23
Q

Common causes of seizure in >35

A
  • tumour
  • stroke
  • Metabolic: ureamia; liver failure; electrolyte disturbance; hypoglycaemia
  • alcohol
24
Q

Teenage onset infrequent general seizure and daytime absences

A

=juvenile myoclonic epilepsy

- asn with myoclonus

25
Q

Common Types of epilepsy seen in adults

A
  1. Primary generalised epilepsy (tonic-clonic/grand mal)
    Prodrome/aura of dizziness/irritable/etc -> LoC
    ->tonic phase (generalised muscle spasms clonic phase (sharp repetitive muscular jerks in all limbs)
    ->unconscious for about 30min and Post-ictal for hours
    Asn with tongue biting/involuntary micturition
  2. Temporal lobe epilepsy
    Typical aura of fear/deja-vu/hallucinations(visual/olfactory/gustatory)/rising sensation in epigastrium
    Confusion and anxiety (+automatism/organised stereotyped movements e.g. Chew/lip smacking)
  3. Jacksonian (focal) epilepsy (parallel to sensory epilepsy)
    From 1 area of motor cortex= 1 body part-> entire side->whole body
    Temporary paresis of originally affected limb post-attack (Todd’s paresis)
26
Q

Define status epilepticus and management

A

Recurring or continuous seizures without regaining consciousness between attacks. Medical emergency.
- basic life support/resus
- seizure control
- ID and correct predisposing cause
Nursed in HDU/ICU (+restart anticonvulsant meds ASAP if known epilepsy)

27
Q

Drugs used for partial seizures (+/- secondary generalisation)

A 
1st line: 
Carbamazepine 
Lamotrigine
Oxcarbazepine
Sodium valproate
2nd line
Clobazam
Gabapentin
Levetiracetam
Pregabalin
Topiramate
28
Q

Drugs for generalised tonic-clonic epilepsy

A 
1st line
Carbamazepine 
Lamotrigine
Sodium valproate
2nd line
Clobazam
Levetiracetam
Phenytoin
Topiramate
29
Q

Drugs for absence seizure epilepsy

A 
1st line:
Ethosuximide
Sodium valproate
Alternatives:
Clonazepam
Lamotrigine
30
Q

Drugs used for myoclonic epilepsy

A

1st line: sodium valproate

2nd line: clonazepam, levetiracetam, Topiramate

31
Q

Drugs used for status epilepticus

A
  • IV lorazepam 4mg (or clonazepam, diazepam). Can repeat dose after 10mins if seizures recur/continue
  • IV phenytoin 15mg/kg, max: 50mg/min (or fosphenytoin- prodrug). Both need ECG monitoring. OR phenobarbitone 10mg/kg, max 100mg/min, when established status epilepticus
  • IV thiopentone, bolus then infusion, AND ventilation/NMJ block = if seizures >30-60min. OR midazolam and propofol. EEG monitoring to confirm termination of seizure.
32
Q

Problems of epilepsy in pregnancy

A

Uncontrolled seizures: risk to mother and foetus
Sodium valproate/carbamazepine: screen for neural tube defects and folic acid supplements (preconception and pregnancy)
Carbamazepine/phenobarbitone/phenytoin- Vit K before delivery and for newborn (due to enzyme induction- hepatic microsomal enzymes increasing metabolism of oestrogens/progestagens = OC pill ineffective!)

33
Q

Signs of optic neuropathy?

A 
Pale disc
Loss of visual acuity
Loss of red colour vision
Central Scotsman
Afferent pupillary defect: pupil dilates to light in swinging torch test (Marcus Gunn pupil)
34
Q

Signs of background diabetic retinopathy

A

Microaneurysms and hard exudates

35
Q

What is maculopathy? Differentials? Causes?

A

Reduction in visual acuity either due to cataracts or maculopathy. Check visual acuity. Commonly due to diabetes (macular oedema

36
Q

Features of pre-proliferative diabetic retinopathy?

A

Cotton wool spots (infarct of nerve cell layer on retina); venous beeding and looping; intra-retinal microvascular abnormalities

37
Q

Features of proliferative diabetic retinopathy?

A

New vessels

38
Q

Features of end stage diabetic retinopathy?

A

Scarring with white bands of scar tissue and retinal traction

39
Q

Management of status?

A 
Oh My Lord Fetch the Anaesthetist!
Oxygen
Midazolam buccal
Lorazepam IV
Phenytoin
Get the anaesthetist for Rapid sequence induction

Medicine (16 decks)

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