Neurology Flashcards
Headache | Differentials
Neurological
Non-neurological
[Neurological]
Tension headache; bilateral, tight-band, stress
Migraine; unilateral, pulsating, photophobia/phonophobia, aura, hours, caffeine, medication-overuse, menstruation
Cluster headache; unilateral, debilitating retro-orbital pain, eye redness/watering, minutes
Raised ICP; triggered by exertion/position, learning forward
SAH; thunderclap headache
Meningitis; fever, photophobia, neck stiffness, rash
Trigeminal neuralgia; brief, stabbing pain, brushing teeth/chewing
[Non-neurological]
Sinusitis; facial pain, rhinorrhoea, nasal obstruction
AACG; painful red eye, vision loss, haloes around lights
Temporal arteritis; unilateral, scalp tenderness, jaw claudication
Neurology | History taking
Headaches Fits, faints, funny turns Memory loss Vision and hearing Speech and swallowing Numbness, tingling Weakness Balance Co-ordinaton Bladder disturbance, incontinence
CNS localisation | Syndromes
Hemisphere
Brainstem
Spinal cord syndromes; Cervical Thoracic Hemisection Transverse
CNS motor = UMN signs, weakness
Hemisphere; contralateral hemiparesis + hemisensory loss
Brainstem; ipsilateral head, contralateral below head
[Spinal cord syndromes]
Cervical; UMN UL/LL, sensory loss to neck
Thoracic; UMN LL, sensory loss to abdomen
Hemisection; ‘Brown-Séquard syndrome’ ipsilateral motor + dorsal column sensory, contralateral spinothalamic
Transverse; loss of all modalities below lesion
Guillain-Barre Syndrome | Clinical features
Motor
Sensory
Autonomic
Autoimmune inflammatory polyneuropathy
Preceding GI/URT infection; Campylobacter jejuni
Ascending symmetrical weakness UL/LL (distal to proximal)
LMN signs; areflexia
Respiratory failure; SOB
Bulbar involvement; bilateral facial palsy, slurred speech, dysphagia, diplopia, ptosis
Peripheral neuropathy
Autonomic dysfunction; tachycardia, hypotension
Guillain-Barre Syndrome | Investigations
FBC, CRP, U&Es, LFTs
Nerve conductions studies; slowed
LP; elevated CSF protein
Spirometry
Guillain-Barre Syndrome | Management
IV immunoglobulin (IVIG) Plasma exchange
Supportive Tx; BP, intubation/ventilation, neuropathic pain, rehabilitation
Facial nerve palsy | Management
Non-pharmacological
Pharmacological
RF; pregnancy
[Non-pharmacological]
Self-limiting, resolves within 3-4/12
Eye protection; glasses during the day, lubricating eye drops during the day, thicker ointment at night, tape shut
[Pharmacological]
If onset within 72hrs:
PO high-dose prednisolone
± acyclovir
Epilepsy | Management
Advice
Pharmacological
Surgical
Contraception
Pregnancy
[Advice]
Avoid putting yourself in dangerous situations where LOC could be fatal
Heights, cycling in traffic, operating heavy/dangerous machinery, bathing alone, near deep water, parents supervising children with epilepsy
[Pharmcological]
Focal; carbamazepine
Generalised; valproate, lamotrigine
[Surgical]
Lobectomy; if well-defined structural cause
[Contraception]
Carbamazepine decreases the efficacy of OCPs
Advised to use alternative method; condoms, depot, IUD, IUS
COCP reduces efficacy of lamotrigine
[Pregnancy]
Preconception counselling, ↑x folic acid, higher risk of complications
Pregnancy reduces efficacy of lamotrigine
Dose titration and serum level initially
Optimal therapy; lowest dose for best seizure control and fewest SE
Safe; levetiracetam, lamotrigine
Epilepsy | DVLA standards
Syncope
Epileptic seizure
Breakthrough seizures
Counselling
Syncope; no restrictions, no notify
Epileptic seizures; stop driving until seizure free for 1yr
Breakthrough seizures; stop driving for 6/12
[Counselling]
Persuade patient to self-report
Patient’s own safety
Safety of their own family and children
Doctor’s duty to protect members of the public
Responsible for someone else’s death
Criminal offence in the given circumstances
Invalidation of any insurance
Duty to breach confidentiality and inform the DVLA/police
Multiple sclerosis | Clinical features
Lesions; Optic nerve Cerebellum Brainstem Spinal cord
Motor
Sensory
Balance
Sphincters
Autoimmune inflammatory demyelinating disease
Episodic neurological dysfunction in ≥2x areas of CNS separated in time and space
Optic neuritis; unilateral, graying, blurred vision, impaired colour vision (red desaturation), painful EOM, RAPD
Brainstem lesion; diplopia (INO), vertigo, nystagmus, facial weakness/numbness, dysphasia, dysarthria
Spinal cord lesion; paraparesis etc.
Peculiar sensory disturbance; hemibanding, Lhermitte’s sign, patch of wetness/burning, neuropathic pain
Motor; LL weakness (often foot), UMN signs, spasticity
Ataxia; imbalance, poor coordination
Bladder/bowel dysfunction; frequency, constipation, sexual dysfunction
Multiple sclerosis | Investigations
Diagnostic criteria
FBC, CRP, ESR U&Es, LFTs TFTs Calcium, glucose Serum B12 Metabolic screen
LP and CSF analysis; OCB +ve
MR brain
MR spinal cord
Revised McDonald criteria 2010
Multiple sclerosis | Management
Acute relapse
Ongoing RR
Secondary progressive sx
Rehabilitation
Fatigue; exercise, regular sleep pattern
Vision; often resolves
[Acute relapse] High-dose corticosteroids 1. PO methylprednisolone 2. IV methylprednisolone 3. ± plasma exchange
[Ongoing RR]
Disease-modifying drugs (DMDs)
1. SC/IM beta interferon
[Secondary progressive sx] Antispasticity; baclofen Neuropathic pain; gabapentin Antidepressants; sertraline Anticholinergics/overactive bladder; oxybutinin
[Rehabilitation]
MS specialist nurse
Physiotherapy; spasticity, myalgia
OT; mobility aids, function, home adaptations
Psychotherapy, CBT; cognition, memory, depression
SALT
Multiple sclerosis | Differentials
Neurological
Non-neurological
[Neurological] Spinal cord compression Devic's syndrome; neuromyelitis optica Vitamin B12 deficiency; reversible cause Lyme disease
[Non-neurological]
Sarcoidosis; granulomas
SLE; antibodies
Investigations | CSF analysis
Herpes simplex TB GBS Myelopathy Raised ICP
Herpes simplex encephalitis; raised RBC, lymphocytosis
TB; Very high OP, very high protein, very low glucose, lymphocytosis
GBS; raised protein
Myelopathy (MS/transverse myelitis); OCB +ve
Raised ICP; high OP
Migraine | Triggers & Management
Self-help advice
Acute attack
Prophylaxis
Triggers; stress, menstruation, hormonal pills, altered sleep pattern, strenuous exercise, relaxation after stress
Food; chocolate, cheese, caffeine, alcohol
Headache diary; identity triggers
[Management] Lifestyle advice; avoid triggers Lying down in a dark room, sleeping Being sick, eating OTC painkillers; aspirin, ibuprofen, paracetamol Warn of SE medication-overuse headaches
{Acute attack}
- PO triptan + NSAID/aspirin/paracetamol; sumatriptan, or monotherapy
- antiemetic; metoclopramide, domperidone
{Prophylaxis}
- Propranolol; exacerbates asthma, preferred in women of childbearing age
- Topiramate; also 1st line, preferred in asthmatics, not in young women
Psychogenic non-epileptic attack | Clinical features
‘Pseudoseizure’
Maintains consciousness Back arching Bilateral violent shaking 'Slumping' attack Overly upset/emotional on coming around Prolonged unresponsiveness 'pseudosleep' No confusion
MND
Myasthenia gravis
Proximal fatiguable weakness
Eyes; diplopia, ptosis
Facial; dysarthria, dysphagia, facial weakness
Headache | Management
Cluster
GCA
Cluster; high-flow oxygen 100% 15L + SC sumatriptan
Prophylaxis; verapamil, prednisolone
GCA; PO high-dose prednisolone, Tx before investigation, high risk of vision loss
Transverse myelitis |
Acute onset, malaise, loss of appetite
Weakness and change in sensation below affected spinal level
But may produce UMN spasticity
Bladder/bowel/sexual dysfunction
LP + CSF analysis; OCB +ve
Epilepsy | Classification
Generalised > motor vs. non-motor
Focal > aware vs. impaired awareness
Focal may progress to bilateral tonic clonic seizures
Epileptic seizures are stereotypical taking the same form each time with the same sequence of events
Tend to cluster, may arise in sleep
Encephalitis
Fever, headache, confusion Seizures + focal neurology (speech disturbance) Meningism \+ personality change \+ reduced consciousness/coma
HSV-1 commonly
May cause raised ICP, midline shift, brain herniation
LP + CSF analysis; lymphocytosis 95%, viral PCR, MC&S
MR brain; inflammation, oedema, swelling, usually temporal lobes
[Management]
1. IV acyclovir within 6hrs
Treat before results return
2. + supportive care; ICU bed, intubation and ventilation, etc
If raised ICP; dexamethasone + mannitol
If high risk of ‘coning’ then surgery; decompressive craniectomy
Multiple sclerosis | Counselling
Affects the brain and spinal cord
Our nerve cells are covered in a protective layer like the insulation on wires, called myelin
Autoimmune condition whereby immune system (which normally fights off infection and anything foreign entering out bodies) gets confused and starts attacking our own body
In this case it attacks the myelin sheaths
This disrupts the electrical signals that travel to and from the brain, they may slow down, get distorted, or never transmit at all
Symptoms depend on where in the brain/spinal cord the attacks occur
May have vision loss, weakness, odd sensations, clumsiness
In the early stages, our myelin repairs itself which is why you can get a relapsing course
It is unknown what causes MS but is likely to be a combination of genetic and environmental factors
There appears to be a link between geographical location (northern hemisphere) and MS, ?Vit D
Must inform DVLA
Work and benefits
Exercise and diet
Complementary therapies
Everyone’s MS is different
No cure, treatment aims to control symptoms, reduce inflammation and delay the progression
Combination of therapy, physical and psychological, plus medication if you choose it
To optimise QoL
It is not a life-ending but chronic, meaning you will have it for life
Multiple sclerosis | Indications for DMDs
‘Active’ disease
If 2x relapses in 2yrs
Or CIS + MR evidence of new lesion
