Neurology Flashcards
What are the common causes of a migraine?
C- chocolate and certain foods H - hormones e.g. menstrual cycle O- oral contraceptive pill C- caffeine O- obesity L- lie ins - too much or too little sleep A- alcohol T- trauma, head injury E- exercise S - stress
What are common triggers for a migraine?
too little/ too much sleep stress hormonal e.g. menstrual migraine, menopause eating e.g. skipping meals minor head injuries
How long does a migraine commonly last?
4 hours - 72 hours
What is the diagnostic criteria of a migraine?
AT LEAST 2 OF: unilateral pain throbbing/ pulsating pain moderate-severe intensity motion sensitivity
AT LEAST 1 OF:
nausea/ vomiting
photophobia/ photophobia
normal examination
What is a migraine with an aura?
aura precedes the migraine, with symptoms changing as wave of spreading neuronal depression moves across cortex and focal neurological deficit
e.g. visual aura (loss of vision, shimmering, zig zag lines), motor aura (pins and needles, dysarthria, ataxia, hemiparesis), somatosensory
How are acute attacks of migraines managed?
- simple analgesics e.g. NSAIDs, paracetamol
- triptans + paracetamol e.g. sumatriptan
- avoid trigger
- anti emetics (even if not feeling nausea) e.g. prochloroperazine, metachlorpramide
How can migraines be managed long term if they are frequent and affecting quality of life?
- beta blockers e.g. propanolol
2. anti convulsants e.g. topiramate
Which group of people tend to get cluster headaches?
high alcohol intake
smoking
men 20-40 y/o
If a patient presents with a unilateral headache around one eye that has become watery/ bloodshot and has been several months without a headache, what is the most likely diagnosis?
cluster headache
What is the typical pattern of frequency of a cluster headache?
once/ twice daily headaches for 4-12 weeks and then non headaches for several months
What symptoms other than unilateral headache around one eye is associated with cluster headaches?
rhinorrhoea vomiting Horners syndrome agitation, pacing around congestion of sinuses
eye symptoms: watery, blood shot, lid oedema, lacrimation
What is the acute management of a cluster headache?
subcut sumatriptan + high flow oxygen (12-15L per min via non breathe mask for 15 mins)
What are the risk factors for getting tension headaches?
stress noise concentration/ visual effort fumes/ smells depression
If a patient presents with a bilateral headache that lasts for hours-days and is dull/diffuse and non pulsatile, what is your diagnosis and what other symptoms would you ask about?
TENSION HEADACHE
chronic tight banding pain scalp tenderness pressure behind eyes worse at the end of the day spreads to neck
How are tension headaches managed?
avoid causative factors
analgesics e.g. paracetamol, NSAIDs, aspirin (avoid opioids)
supportive care e.g. massage, ice packs
preventative measures - acupuncture, low dose amitriptyline
What is temporal arteritis?
CHRONIC VASCULITIS OF LARGE/ MEDIUM VESSELS: granulomatous inflammation affecting the branches of external carotid artery, including the superficial temporal artery
What are the main clinical features of temporal arteritis?
- unilateral headache/ pain over non pulsatile temporal arteries, thickened skin
- visual loss - amaurosis fugax
- jaw claudication
- scalp tenderness e.g. brushing hair causes pain
+ fever, fatigue, weight loss, polymyalgia rheumatic
How is temporal arteritis diagnosed?
- raised ESR
2. temporal artery biopsy - granulomatous inflammation, skip lesions
How is temporal arteritis managed?
high dose corticosteroids 60mg e.g. prednisolone + urgent referral to ophthalmology (if eye symptoms)
(give gastric and bone protection e.g. PPI, bisphosphonates)
steroids gradually reduced over time
How is Huntingtons disease inherited?
autosomal dominant disorder
complete penetrance - all gene carriers have the disease
What is the underlying pathology of Huntingtons disease?
expanded trinucleatide repeat (CAG= huntingtin gene) on chromosome 4
each generation, the repeat increases in length causing a younger age of onset and worse phenotype
causes a loss of GABA and cholinergic neurones in the striatum of the basal ganglia
How does Huntingtons disease first present “prodrome”?
personality change and lack of coordination
What are the main symptoms of Huntingtons disease?
presents usually > 35 y/o
personality/behavioural change = irritable, depression, antisocial
chorea (jerky involuntary movements) = affects face/trunk/limbs, dystonia, grimacing, gait problems
dementia - late
How is Huntington’s disease diagnosed?
genetic testing - CAG repeats
How is Huntington’s managed?
no treatment prevents progression or cures
- dopamine blocking drugs e.g. tetrabenazine for chorea
- MDT approach - counsel family, SALT, physiotherapists, OT, palliative care
List the MDT members that are involved in managing a patient with Huntington’s disease
speech and language therapists physiotherapists dieticians occupational therapists psychologists palliative care team counsellors for family
List the causes of parkinsonian symptoms
Lewy body dementia
side effects of drugs e.g anti-psychotics, metaclopramide
vascular disease
tumour in basal ganglia
parkinsons plus syndrome e.g. young onset Huntingtons, spinal cerebellar ataxia, progressive supra-nuclear palsy, normal pressure hydrocephalus
What is the pathology behind parkinsons disease?
degeneration of dopaminergic neurones in the substantial nigra
lewy bodies found in brain stem which contain alpha synuclein and ubiquitin
What are the cardinal features of parkinsons disease?
T- tremor
R- rigidity
A- akinesia/ bradykinesia
P - postural instability
List the clinical symptoms and signs of parkinsons disease
TREMOR - unilateral, pill rolling, resting
RIGIDITY - cogwheel, increased muscle tone
BRADYKINESIA- slow to initiate movements
SPEECH- slow, monotone, quiet, slurred
GAIT- reduced arm swing, shuffling, apraxic, slow to initiate movement
PSYCHIATRIC- depression, dementia, psychosis
REM SLEEP DISTURBANCE
AUTONOMIC SYMPTOMS- urinary frequency, constipated, drooling, postural hypotension, falls are late sign
How is parkinsons disease diagnosed?
clinical examination
dopamine transporter imaging - use radioactive labelled ligand binding to assess extent of nigrastriatal loss
How is Parkinson’s managed with medication?
1st line if have motor symptoms = levodopa e.g. L-dopa + decarboxylase inhibitor (carbidopa)
1st line if no motor symptoms= dopamine agonist e.g. ropinirole, bromocriptine or MAO-I e.g. seligilene
How does levodopa work?
levodopa crossed the blood brain barrier and enters nigrostriatal neurones and converted to dopamine
combined with decarboxylase inhibitor to reduce peripheral adverse effects and prolong half life
What are the side effects of levodopa?
chorea, dyskinesia, reduced efficacy over time, dry mouth, palpiatations, postural hypotension
Name some examples of dopamine agonists and what are their possible side effects?
e.g. ropinirole, pramipipexone, bromocriptine, cabergoline
psychosis, compulsive/addictive behaviour, gambling, risky behaviour, postural hypotension, excessive day time sleeping
if Ergot derived, then at risk of cardiac, pulmonary and retroperitoneal fibrosis
Describe an astrocytoma?
type of glioma
most common primary brain tumour
arise from astrocytes
Describe glioblastoma multiforme and what is the prognosis with this tumour?
highly malignant
no cell differentiation
life expectancy is <1 year
Describe an ependyoma?
derived from ependymal cells and chord plexus
better survival rate than other gliomas
List the different types of intracranial tumours
- gliomas
- meningiomas
- primary central nervous system lymphoma
- neurofibromas and schwannomas
- haemangioblastomas
- metastasis
Describe meningiomas
mostly benign tumours
arise from arachnoid membrane and granulations
compress adjacent brain structures
Who are primary central nervous system lymphomas most common in?
males
>60 y/o
immunocompromised patients
What are the most common types of pituitary tumours?
prolactinomas
growth hormone secreting adenomas
ACTH secreting adenomas
Which tumour might you suspect if a patient presents with visual symptoms e.g. bitemporal hemianopia
pituitary tumour - they comprises on the chiasma to cause visual symptoms
Describe haemangioblastomas
derived from blood vessels
occur in cerebellar parenchyma or spinal cord
associated with von hippie lindau disease, tumours in retina
Describe the classic triad of symptoms of raised intracranial pressure
- headache
worse on waking, coughing, bending forward, wake up at night - vomiting
- papilloedema
What is a colloid cyst?
cyst in 3rd ventricle that obstructs CSF flow out of the ventricle -> increases ICP -> rapidly fatal in hours
If a patient presents with a headache worse on bending forwards, what tumour might you suspect?
colloid cyst
Describe “cushings triad” of signs of raised intracranial pressure
- irregular respiratory rate
- bradycardia
- hypertension
What symptoms does herniation cause?
impaired consciousness
respiratory depression
bradycardia
death
Define coning
compression of medulla by herniation of the cerebellar tonsils through the foramen magnum
Describe “false localising signs” and why are these important?
important as indicate increase in brain pressure with brain shift and urgent surgery is required
6th nerve palsy
3rd nerve palsy
hemiparesis on same side as tumour
How do intracranial tumours present?
- effects of raised intracranial pressure
= classic triad (headache, papilloedema, vomiting), herniation, false localising signs - focal neurological signs
= caused by direct effects of tumour and effects depend on site of tumour - diffuse cereal symptoms
e. g. seizures, cognitive symptoms - tiredness
What are the risk factors for developing MS?
first degree relatives
viral infections can precipitate e.g. EBV, HHV
low levels of vitamin D and lack of sunlight - living further away from equator
women
smoking
Describe the pathology behind MS
- autoimmune T cell mediated demyelination of oligodendrocytes (white matter)
- gliosis (scarring)
- axonal loss
- conduction loss and progressive disability
What are the core symptoms of MS?
VISUAL- optic neuritis (painful eye on movement, reduce visual acuity over days, difficulty distinguishing colour, worse on heat exposure, eye pain at rest )
SENSORY - numbness, tingling, Lhermittes sign (electrical impulse down back when bend head), Uhtoffs phenomenon (symptoms worse in hot bath)
MOTOR - spastic weakness, tremor, ataxia, clumsy
OTHER SYMPTOMS - urinary incontience, neuropathic pain, fatigue, depression, sexual dysfunction
What are the later signs of MS?
spastic tetra paresis nystagmus urinary incontinence pseudo bulbar palsy cognitive impairment
What are the 4 different clinical patterns of MS presentation?
- relapsing remitting (80%)
- primary progressive (10-20%)
- secondary progressive
- progressive relapsing
Describe the relapsing remitting MS presentation?
most common type
symptoms occur in attacks with a characteristic time course
unpredictable onset of attacks over days, recovery over weeks
steady increase in disability
Describe primary progressive MS presentation
gradually worsening disability without relapses or remission
usually presents later
10-20% of cases
Describe secondary progressive MS presentation
gradually worsening disability progressing over years
75% of relapsing remitting evolve to this after 30 years of onset
Describe progressive relapsing MS clinical pattern
steady decline since onset with super imposed attacks
<10%
How is MS diagnosed?
MRI - multiple lesions/ plaques across brain
CSF lumbar puncture- oligoclonal IgG bands
evoked potential testing
What is clinically isolated syndrome?
an example of one of the MS disease courses
it is the 1st episode of neurological symptoms lasting for 24 hours
in 70% of patients, they have lesions across brain in MRI and can develop MS
How are acute relapses of MS managed?
short course of steroids
IV methylprednisiolone 0.5g/day for 5 days
steroids can only be used twice a year
Which drugs are indicated for reducing relapse of relapsing remitting MS?
disease modifying drugs - beta interferon or glatiramer acetate
reduce relapse by 1/3 and reduce development of new MRI lesions
SE: flu like symptoms
Which drugs are used to treat more aggressive forms of MS?
MONOCLONAL ANTIBODIES e.g. alemtuzumab, natalizumab
prevents relapses and reduces disability
used in very agressive disease or when disease modifying drugs not working
What are the adverse side effects of monoclonal antibodies treating MS?
progressive multifocal leukoencephalopathy **
fatigue
autoimmune disorders
cardiotoxicity
Other than medical treatment, how should MS patients be managed?
MDT approach - physiotherapy, occupational therapy, psychological therapy , reviewed annually by specialist
Spasticity treated with baclofen
urinary incontinence treated with anti-muscarinics or botulinum toxin injection
fatigue treated with amantadine
Define Guillain Barre syndrome
acute inflammatory (immune mediated) demyelinating polyradiculopathy
How is GBS caused?
several weeks after an infection, for example:
food poisoning e.g. campylobacter jejuni **
HIV
vaccination
respiratory infection
How does GBS present?
distal paraesthesia** that ascends up lower limbs and body over days-weeks
symmetrical proximal weakness**
tingling, numbness
asymmetrical facial weakness
autonomic dysfunction - urinary retention, diarrhoea
What is a major concern with GBS?
if have cranial nerve involvement, at risk of intercostal muscle and diaphragmatic weakness -> RESPIRATORY FAILURE
What is Miller Fishers syndrome?
variant of GBS
symptoms include: ophthalmoplegia, ataxia, areflexia, descending paralysis ***
How is GBS diagnosed?
clinical history and examination
nerve conduction studies - slow
lumber puncture - CSF protein raised, normal cell count, mild lymphocytosis
How is GBS managed?
EMERGENCY!
IV immunoglobulin for 5 days
plasma exchange
+ continuous heart monitoring, regular vital capacity, refer to ITU for ventilation
What is meningitis?
inflammation and infection of the meninges
What are the main bacterial infectious causes of meningitis?
neisseria meningitidis
streptococcus pneumoniae
listeria monocytogenes
What are the main viral infectious causes of meningitis?
enteroviruses e.g. coxsackie*
mumps
herpes simplex
what is the difference between bacterial and viral meningitis?
bacterial meningitis is lethal and sudden onset -> need urgent treatment!
viral meningitis is self limiting lasting 4-10 days
What is the classic meningitic syndrome triad?
- headache
- neck stiffness
- fever
How does meningitis present?
headache neck stiffness fever + rigors intense malaise and muscle aches photophobia vomiting kernigs sign - pain and resistance on knee extension
What are the later signs of meningitis?
seizures
decreased consciousness
signs of septicaemic shock
petechial rash - non blanching
What are the signs of meningococcal meningitis?
petechial rash ** - non blanching
fever
headache
neck stiffness
EMERGENCY!!!
How is meningitis diagnosed?
blood cultures and septic screen
lumbar puncture
If a mass lesion is suspected, why can’t you perform a lumbar puncture?
at risk of coning of the cerebellar tonsils
high ICP = no lumbar puncture
do a CT scan first to exclude
What would you expect to see in both a viral and bacterial meningitis CSF sample?
VIRAL
+ lymphocytes, 10-2000 white cell count, colourless, normal glucose and protein
BACTERIAL
+++ polymorphs/neutrophils, 1000-5000 white cell count, turbid colour, low glucose, raised protein, +ve gram statin
How is meningococcal meningitis treated?
slow IV benzylpenicillin - given ASAP + notify public health
How is unknown meningitis treated?
IV cefotaxime = broad spectrum
+ ciprofloxacin to close contacts
Define encephalitis
inflammation of the brain parenchyma caused by a viral infection
Which viruses are likely to cause encephalitis?
herpes simplex enterovirus adenovirus HIV mumps and measles rabies
How does encephalitis commonly present?
- personality and behavioural change
- progressive reduced level of consciousness
- seizures
- fever
How is encephalitis investigated?
- MRI - inflammation, cerebral oedema and swelling
- EEG - periodic sharp and slow wave complexes
- CSF - viral detection, elevated lymphocytes and protein, reduced glucose
How is encephalitis managed?
IV acyclovir - EMERGENCY - for 14-21 days
early treatment reduces mortality
How is trigeminal neuralgia caused primarily and secondarily?
trigeminal neuralgia is caused by compression of the trigeminal nerve root by blood vessels e.g. superior cerebellar (primary)
secondary (15%) causes: aneurysms of intracranial vessels, tumour, MS, trauma, meningeal inflammation (should do MRI and referral to neuro if suspect)
How does trigeminal neuralgia present?
FACIAL PAIN WITH NO OTHER SYMPTOMS
unilateral, sudden, short stabbing, intense, affects mandibular and maxillary divisions of trigeminal nerve, precipitated by light touch, 10/10 pain, can occur up to 100x/day
How is trigeminal neuralgia treated medically?
carbamazepine - 200mg TDS
What is an extradural haemorrhage?
blood collects between the dura mater and bone of skull
How is an extradural haemorrhage usually caused?
there is a traumatic tear in the middle meningeal artery, usually caused by a fracture to the temporal and parietal skull
How does an extradural haemorrhage commonly present?
patient has had head injury with few hours of a lucid period
after the lucid period, patient develops focal signs, deteriorating consciousness, confusion, vomiting, severe headache
How is an extradural haemorrhage diagnosed?
CT HEAD - biconvex/lens shaped haematoma
how is an extradural haemorrhage treated?
urger referral to neurosurgeons for clot evacuation
What is a subdural haemorrhage?
accumulation of blood in the subdural space (between dura mater and arachnoid mater) following rupture of the cortical vein
How does a subdural haemorrhage commonly occur?
caused by trauma to the head in a patient with a shrunken brain e.g. alcoholics, elderly
What is the common history of a patient with a subdural haemorrhage?
- INJURY - minor
- LATENT INTERVAL - days-months
- SYMPTOMS START - fluctuating, drowsiness, headache, confusion, personality change, focal deficits
What is the classic sign of a subdural haemorrhage on the CT?
crescent/ sickle shape
midline shift
How is a subdural haemorrhage managed?
refer to neurosurgeons
irrigation/ evacuation via burr hole to relieve high ICP
What are the likely causes of a subarachnoid haemorrhage?
- TRAUMA - most common
- SPONTANEOUS
saccular berry aneurysms in circle of willis (80%) - associated with Polycystic kidney disease, Ehlers danlos
arteriovenous malformation (15%)
Other rarer causes (<5%) - acute bacterial meningitis, tumours, coarction of the aorta
What are the risk factors for a subarachnoid haemorrhage?
family history
smoking
hypertension
polycystic kidney disease
How does a subarachnoid haemorrhage commonly present?
sudden severe thunderclap headache - often occipital, warning sentinel headache previous
transient loss of consciousness/ seizure
nausea and vomiting after headache
meningism symptoms: neck stiffness, papilloedema, neck stiffness
What is a sentinel headache?
a generalised headache in the weeks before a subarachnoid haemorrhage due to a small leak before rupture of berry aneurysm
What are the complications of a subarachnoid haemorrhage?
rebreeding (>10%) cerebral ischaemia hydrocephalus hyponatraemia seizure coma
How is a subarachnoid haemorrhage diagnosed?
CT HEAD - star shaped lesion
LUMBAR PUNCTURE - 12 hours after onset of symptoms, if CT -ve but high suspicion,
CSF= xanthochromic (yellow) due to bilirubin breakdown of haemoglobin (do not do if high ICP)
How is a subarachnoid haemorrhage managed?
EMERGENCY
refer to neurosurgeons
surgery = endovascular coiling within 24 hrs, whilst waiting bed rest, monitoring of BP, no exertion
medical= nimodipine for 3 weeks to control hypertension
What are the two types of common presentation of myasthenia gravis?
young women (20-35 y/o) -> acute, severely fluctuating older men (60-75 y/o) -> oculobulbar presentation
What is the pathology behind myasthenia gravis?
autoimmune disorder where antibodies are directed against postsynaptic acetylcholine receptor at neuromuscular junctions -> decreased neurotransmission -> weakness and fatiguability
What are the main symptoms of myasthenia gravis?
muscle fatiguability and fluctuating weakness :
- extraocular muscles - diplopia
- proximal muscle weakness
- dysphagia
- ptosis
When is weakness worse in myasthenia gravis?
exercise end of day infection change of climate emotion drugs e.g. opiates, tetracycline, beta blockers pregnancy
What are the commonly affected muscles in myasthenia gravis and what are their presentations?
OCULAR **
cognans lid twitch, ptosis, diplopia
BULBAR**
dysphagia, dysphonia
PROXIMAL LIMB*
fatigue on repeated movements
RESPIRATORY MUSCLES
shortness of breath
NECK WEAKNESS
difficulty lifting head up
CRANIAL MUSCLE WEAKNESS
weak face and jaw, dysarthria
How is myasthenia gravis diagnosed?
- TENSILON TEST**
IV bolus of edrophonium (anti cholinesterase) and will improve fatiguability within seconds for 2-3 mins - serum acetylcholine receptor antibody (85% of patients) or MUSK antibodies (50% of patients)
- thymus imaging - hyper plasmic thymus as a cause
How is myasthenia graves managed long term?
oral acetylcholinesterase inhibitor e.g. PYRIDOSTIGMINE
- prevents destruction of acetylcholine in the synaptic space so more ACh for transmission
What are the side effects of pyridostigmine?
increased salivation
sweats
lacrimation
cholinergic crisis - severe weakness, colic, diarrhoea
How are myasthenic crises managed?
- plasmapheresis
2. IV immunoglobulin
What is hydrocephalus?
excessive volume of CSF within the ventricular system of the brain and is caused by an imbalance between CSF production and absorption
How does hydrocephalus present?
present with symptoms due to raised intracranial pressure including…
headache
nausea and vomiting
papilloedma
coma - severe
how is hydrocephalus classified?
- OBSTRUCTIVE HYDROCEPHALUS = non communicating
due to a structural pathology blocking the flow of CSF, dilatation of ventricular system is superior to site of obstruction - NON OBSTRUCTIVE HYDROCEPHALUS= communicating
due to imbalance of CSF production absorption
What are the causes of obstructive hydrocephalus?
tumours
acute haemorrhage
developmental abnormalities e.g. aqueduct stenosis
What are the causes of non-obstructive hydrocephalus?
increased production of CSF caused by choroid plexus tumour
failure of reabsorption e.g. meningitis, post haemorrhagic
how is hydrocephalus diagnosed?
- lumbar puncture
2. CT head
What is normal pressure hydrocephalus?
ventricular dilatation in the absence of raised CSF pressure on lumbar puncture
What is the classic triad of features of normal pressure hydrocephalus?
- urinary incontinence
- dementia - reversible cause of dementia in elderly!
- gait abnormality
How is normal pressure hydrocephalus diagnosed?
lumbar puncture - CSF pressure normal
Neuroimaging (MRI/CT) - hydrocephalus with an enlarged 4th ventricle
How is normal pressure hydrocephalus managed?
Medical - carbonic anhydrase inhibitors e.g. acetazolamide
Surgical - ventriculoperitoneal shunting
What are the most common sites for an atheromatous plaque?
origin of internal carotid artery
within carotid syphon
origin of vertebral arteries
What areas of the brain does the middle cerebral artery supply?
largest branch of the internal carotid artery and supplies largest area of cerebral cortex:
- motor cortex
- sensory cortex
- wernickes area (comprehension of speech)
- Brocas area (expression of speech)
Which areas of the brain does the posterior cerebral artery supply?
terminal branches of basilar artery which supply... medial inferior temporal lobes occipital lobe visual cortex midbrain thalamus
Which structure is involved if a patient has locked in syndrome?
bilateral infarction in ventral pons
If a patient presents with ataxia, dysarthria and hiccoughs, which area is affected in their brain?
cerebellum
When is thrombolysis contraindicated for ischaemic strokes?
major infarct recent surgery birth severe liver disease INR >1.7 on anticoagulants
What is an epileptic seizure?
sudden synchronous discharge of cerebral neurones causing symptoms or signs that are apparent either to patient or witness
What is epilepsy?
recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain causing seizures
What are the possible causes of seizures?
genetic epilepsy hippocampal sclerosis * trauma e.g. depressed skull fracture, intracranial haemorrhage surgery brain tumours vascular disorders neurodegenerative disorders alcohol and drugs inflammatory conditions e.g. encephalitis, cerebral abscesses, chronic meningitis
What is the difference between partial and generalised seizures?
partial/ focal seizures = caused by electrical discharge restricted to a limited part of the cortex of one cerebral hemisphere
Generalised seizures= simultaneous involvement of both hemispheres
What are the types of partial seizures?
simple partial
complex partial
partial seizures with secondary generalisation
What are the types of generalised seizures?
total absence (petit mal)
tonic clonic (grand mal)
myoclonic
atonic
Describe a simple partial seizure
conscious
isolated limb jerking on one side
Todd paralysis can follow (local temporary paralysis of limbs)
Describe a complex partial seizures
loss of consciousness and awareness for 1-2 mins
preceding aura
speech arrest, lip smacking, dystonic limb posturing
post ictal confusion
Describe a partial seizure with secondary generalisation
spread of electrical activity to both sides of the brain
remember initial part of seizure before losing consciousness
Describe total absence seizures
begin in childhood
loss of awareness
vacant expression for <10s before return to normal like nothing happened
Describe tonic clonic seizures and its stages
Prodrome: no warning or aura
Tonic clonic phase: stiffening (tonic) followed by synchronous jerking of limbs (clonic) + tongue biting, eyes open, incontinence
Post ictal phase: period of placid unresponsiveness, confusion, drowsiness, headache
Describe myoclonic seizures
sudden limb/trunk/face jerking
only clonic symptoms
eye rolling
Describe atonic seizures
sudden collapse with loss of muscle tone
loss of consciousness
How is epilepsy diagnosed?
Clinically based * - history of seizure, eye witness, triggers
EEG - categorise seizures and understand cause
What is status epilepticus?
continuous seizures for >30 mins or 2 or more seizures without recovery of consciousness between them
mortality of 10-15%
How is status epilepticus managed?
- lorazepam IV 4mg bolus
- oxygen
- monitor BP
- ECG
- bloods
How is a prolonged seizure (>5 mins) managed or repeated seizures?
emergency!
rectal diazepam or buccal midazolam
monitor airway
What is 1st line treatment for generalised seizures?
sodium valproate
increases GABA concentration and inhibits Na+ channel and inhibits glutamate decarboxylase at synapse
What is 2nd line treatment for generalised seizures?
lamotrigine
carbamazepine
(choose these if women at childbearing age/ pregnant as sodium valproate is tetragenic)
What is 1st line treatment for focal partial seizures?
carbamazepine
= inhibits sodium channels so decrease number of action potentials
What are the possible causes of syncope?
hypoglycaemia vertigo migraine pseudo-seizure TIA panic attacks postural hypotension cardiac causes
How does syncope present?
prodrome = brief, dizziness, light headed, sweating, nausea
blackout = lie still but can twitch, pale, incontinence?
recovery= quick, general fatigue
List the types of syncope
cardiac syncope e.g. arrhythmias, heart attack
micturition syncope
neurogenic= inappropriate activation fo cardio inhibitory and vasodepressor reflex leading to hypotension
cough syncope
orthostatic = autonomic failure
carotid sinus syncope
convulsive syncope
What are the causes of carpal tunnel syndrome?
"MEDIAN TRAPS" M- myxoedema E- enforced flexion D- diabetic neuropathy I- idiopathic A- acromegaly N- Neoplasm
T- thyroid (hypo) R- rheumatoid arthritis A- amyloidosis P- pregnancy S- sarcoidosis
What are the muscles that the median nerve controls?
muscles of precision grip "LOAF" L- lumbricals O- opponens pollicis A- abductor pollicis brevis F- flexor pollicis brevis
Which nerves roots are the median nerve supplied by?
C6
C7
C8
T1
How does carpal tunnel present?
tingling, pain and numbness in hand - wakes patient from sleep or in the morning, relieved by shaking of arm/hand
weakness of thenar muscles esp abductor pollicis brevis
sensory loss affects palm and maternal 3 1/2 digits
Which 2 tests are used to diagnose carpal tunnel syndrome?
Tinels sign- tapping on carpal tunnel reproduces tingling and pain
Phalanx test - forced wrist flexion causes similar sensory symptoms
How is carpal tunnel managed?
splint: worn at night , avoid repetitive strain at work
carpal tunnel steroid injection
surgical decompression
What causes ulnar nerve compression?
fracture of the ulna **
prolonged/ recurrent pressure at ulnar e.f. screwdrivers, crutches, cycle handlebars
How does ulnar nerve compression present?
tingling or numbness in the little finger/ ring finger/ ulnar side of hand distal to wrist
sensory loss
wasting of hypothenar muscles
“ulnar claw hand”
Which muscles does the ulnar nerve supply?
adductor pollicis
abductor digiti minimi
interossi
Which muscles/ areas does the radial nerve supply?
triceps brachioradialis supinator wrist and finger extensors long thumb abductor
How does a radial nerve compression present?
wrist drop
weakness of finger extension
sensation loss in anatomical snuff box
Which nerve roots is the common peroneal nerve supplied by?
L4, L5, S1, S2 nerve roots
How does compression of the common peroneal nerve present?
foot drop
weakness of eversion and dorsiflexion
sensory loss on the anterolateral border of shin and dorsum of foot
How can spinal cord compression be caused?
trauma
degenerative disease e.g. spinal canal stenosis, spondolysis
spinal cord temps
infective lesions e.g. epidural abscess, HIV, tuberculoma
epidural haemorrhage
How can spinal cord compression present depending on site of lesion?
lesions above C5 = legs and arms UMN
lesions C5- T1 = involves arms (LMN and UMN signs) and legs (UMN signs)
lesions below T1 = do not involve arms
pain limb weakness sensory loss below lesion sphincter disturbance - bladder hesitancy, frequency, painless retention, constipation spastic paraparesis
Which diagnostic test is most appropriate if suspect spinal cord compression
MRI
What is caudal equina?
compression of caudal equina
What are the causes of cauda equina?
disc herniation* metastasis * spinal infection or inflammation lumbar spondylosis lumbrosacral nerve lesions
How does caudal equina present?
sudden onset and quick progression
lower back pain and radicular pain down legs
loss of sphincter tone - post void incontinence, urinary retention, constipation
saddle anaesthesia
LMN signs in lower limbs
How is caudal equina diagnosed?
MRI
How is caudal equina managed?
SURGICAL EMERGENCY
surgical decompression
What are the causes of peripheral neuropathy?
“DAVID”
DIABETIC NEUROPATHY
“walking on cotton wool/ cobblestones”
use monofilament to assess sensation
loss of deep tendon reflexes, muscle weakness, neuropathic ulcer, callus
ALCOHOL NEUROPATHY
EMG, nerve conduction studies, LFT
VITAMIN B12 DEFICIENCY
transient, decreased vibratory and joint position sense + other signs e.g. lemon tinge, splenomegaly, pallor
INFECTIVE / INHERITED
Gullain barre syndrome: symmetrical proximal weakness and distal ascending paraesthesia
Charcot Marie tooth: glove and stocking distribution, “champagne bottle” legs
DRUGS
isoniazid, amiodarone, nitrofurantoin, metronidazole
what is motor neurone disease?
progressive degeneration of motor neurones in the motor cortex and in the anterior horns of the spinal cord
What are the 4 different presentations of motor neurone disease and do they have LMN/UMN signs?
amyotrophic lateral sclerosis * - UMN + LMN
progressive muscular atrophy - LMN
progressive bulbar and pseudo bulbar palsy - UMN + LMN
primary lateral sclerosis - UMN
What is the pathology behind ALS?
damage to the lateral corticospinal tracts
loss of motor neurones in the motor cortex and anterior horn of cord
How does ALS present?
UMN and LMN signs: progresses from one limb to another, asymmetrical
50% have cognitive impairment
10% develop fronto temporal dementia
What is the pathology behind progressive muscular atrophy and what are the signs?
anterior horn cell lesion so only LMN affected
asymmetrical in small muscles of hands and feet
hands have atrophy, weakness and cramps
What is the pathology behind progressive bulbar palsy and its prognosis?
degeneration of motor neurones in cranial nerves IX-XII
worse prognosis due to increased risk of aspiration
How does bulbar palsy present?
prominent fasciculations in tongue and wasting - weak tongue weak palate dysphagia nasal regurgitation and nasal voice dysarthria / slurred speech disturbed emotional state
How does pseudo-bulbar palsy present?
UMN bilaterally
spastic dysarthria
dysphagia
emotional lability
How does primary lateral sclerosis present and what is its prognosis?
slower progression and better prognosis
onset in legs and progresses to arms and bulbar muscles
respiratory muscles involved
spastic tetra paresis
sensory symptoms
What upper motor neurone signs are seen in MND?
spastic paralysis brisk reflexes clonus extensor plantar response = babinski no wasting or fasciculations
What lower motor neurone signs are seen in MND?
flaccid paralysis muscle wasting fasciculations reduced or absent reflexes plantar responses flexor or absent no clonus
How is MND diagnosed?
electromyography - presence of denervation in muscles supplied by more than one spinal region
nerve conduction studies
MRI - to exclude skull base lesions
How is MND managed medically?
Riluzole = glutamate receptor antagonist
increases survival by 2-3 months but no effect on disability
check liver enzymes regularly
How are MND symptoms and signs managed? (conservative treatment)
speech therapy and communication aids alter food consistency for safe swallowing baclofen for spasticity physiotherapy, walking aids non invasive respiratory support palliative care
What is the diagnostic criteria for neurofibromatosis (NF1)?
2 out of 7 criteria: >6 cafe au last spots axillary or inguinal freckles >2 neurofibromas optic nerve glioma >2 iris haematomas sphenoid dysplasia 1st degree relative
What are the features of neurofibromatosis NF2?
bilateral acoustic neuromas
multiple intracranial schwannomas
fewer cafe au last spots
How does cerebellar syndrome present?
"DANISH" D- dysdiadochokinesia A- ataxia N- nystagmus I- intention tremor S- slurred speech H- hypotonia
What are the signs and symptom of progressive supra nuclear palsy?
impairment of vertical gaze parkinsonism falls slurred speech POOR RESPONSE TO L-DOPA
What are the signs and symptoms of multi system atrophy?
poor response to l-dopa parkinsonism impotence urinary retention younger onset
Describe the 2 pyramidal motor tracts and their function
- lateral corticospinal
- anterior corticospinal
controls voluntary control of musculature
Describe the 4 extrapyramidal motor tracts and their functions
extrapyramidal = involuntary and autonomic control of musculature
- rubrospinal - fine control of hand
- reticulospinal - enhance and inhibit voluntary movements
- olivospinal - vision
- vestibulospinal - balance and posture
What are the sensory ascending spinal tracts
- DORSAL COLUMN MEDICAL LEMNISCUS =fine touch, vibration and proprioception
(cuneate fasciculus, gracile fasciculus) - SPINOCEREBELLAR TRACTS = proprioception from lower limbs to ipsilateral cerebellum
- ANTEROLATERAL SYSTEM
lateral spinothalamic = pain and temp
anterior spinothalamic = crude touch and pressure
What are the differentials for a painful red eye?
- optic neuritis
- conjunctivitis
- glaucoma
What are the symptoms of optic neuritis?
worse over 1 week unilateral visual loss blurred and cloudy vision pain on eye movement poor discrimination of colours exacerbated by heat or exercise
How is visual acuity assessed?
cover one eye with palm and test each eye using Snellen chart
test distant, near and colour vision
What are the differentials for decreased visual acuity?
CONDITIONS AFFECTING THE EYE ITSELF - glaucoma, macular degeneration, cataracts, diabetic retinopathy
CONDITIONS AFFECTING OPTIC NERVE/ TRACT - trauma, tumour, infarction
How are visual fields assessed?
patient sat in front of you, they cover one eye with palm and you close eye on same side
then bring in pin from periphery and test the 4 quadrants of visual fields and ask when they can see it
What are the differentials for visual field loss?
- mononuclear field loss = retinal damage, ipsilateral optic nerve lesion
- bitemporal hemianopia = optic chiasma compression = pituitary tumour
- L/R homonymous hemianopia = contralateral optic tract lesion e.g. tumour, haemorrhage
How are reflexes assessed in eyes?
- accommodation reflex - focus on distant object and move finger close to face and pupils constrict
- direct and consensual papillary reflex - shine light in each pupil and observe for pupil constriction
- swinging light reflex
What are the differentials for loss of red reflexes in eyes?
retinal blastoma
cataracts
corneal scarring
What are the signs of a CN3 (oculomotor) lesion?
“down and out” eye
ptosis
dilated fixed pupil
what are the signs of a CN4 (trochlear) lesion?
defective downward glaze = vertical diplopia
What are the signs of a CN6 (abducens) lesion?
defective abduction = horizontal diplopia
What does a complete optic nerve lesion caused?
blindness in that eye
List possible transient causes of unilateral visual loss
central retinal vein occlusion thromboembolism uveitis amaurosis fugax - stroke, temporal arteritis migraine prodrome
List possible persistent causes of unilateral visual loss
trauma glaucoma optic neuritis - MS tumour retinal detachment
List possible causes of bilateral visual loss
diabetic maculopathy
papilloedema
What are the possible causes of optic neuritis?
= inflammation and damage to myelin of optic nerve
MS infections e.g. lyme disease, measles, mumps, meningitis sarcoidosis B12 deficiency drugs - quinine neuromyelitis optica
How is optic neuritis managed?
methylprednisolone IV
immunoglobulin IV
How are EEGs useful in investigating recurrent blackouts?
performed within 24-48 hours of first seizure and can help determine a diagnosis of epilepsy and seizure type
What are they types of EEGs available?
sleep deprived
prolonged EEG
video telemetry
interictal EEF
What are the primary prevention measures for a stroke?
Risk assessment tools - Q risk, CHADS2VASC
Lifestyle modifications - dietary advice, weight loss, physical activity, decrease alcohol, smoking cessation
What are the secondary prevention measures for a stroke?
regular review and treatment of vascular disease risk factors
aspiring
statin
anti hypertensive medication
What is the difference between CT and MRI for a patient with a stroke?
CT * - more commonly available and can easily differentiate between ischaemic and haemorrhage stroke
MRI - considered if clinical signs localise to posterior fossa or small as this might not be picked up on CT
Who is involved in the rehabilitation of stroke patients?
consultant physicians nurses physiotherapists occupational therapists SALT psychologists social workers
What are the side effects of triptans?
warm sensation tingling tightness flushing heaviness in face/ limbs/ chest
(contraindicated in ischaemic heart disease)
how are cluster headaches managed long term?
verapamil
avoid analgesics as don’t work e.g. paracetamol, NSAIDs, oral triptans, opioids
What are the possible complication of giant cell arteritis that is largely prevented by administering corticosteroids?
permanent visual loss large artery complications e.g. aortic aneurysm, aortic dissection depression deafness CVD peripheral neuropathy
What are the red flags for Parkinsonism plus syndromes?
early falls
unresponsive to L-dopa
symmetrical
What are the features of progressive supra nuclear palsy?
Parkinsonism impairment of vertical gaze pseudo bulbar palsy dementia falls
What are the features of multi system atrophy?
parkinsonism urinary retention impotence ataxia postural hypotension cerebellar signs
How is horners syndrome caused?
1st order: MS *, trauma, spinal cord tumours
2nd order: apical lung tumour, lymphadenopathy, neuroblastoma
3rd order: cluster headache, herpes zoster infection, temporal arteritis
What are the features of horners syndrome?
compression of the faces sympathetic nerve supply
- ptosis - drooping of eyelid
- anhidrosis - loss of sweating
- miosis - pupil constriction
+/- enopthalmos (sunken eye)
What are the features of Bells palsy?
LMN unilateral facial nerve plasy
sudden onset
post auricular pain, altered taste, dry eyes
How is bells palsy managed?
- prednisolone for 10 days
2. eye care: eye drops, artificial tears
Define TIA
transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischameia, without acute infarction
How is a TIA caused?
atherothromboembolism
cardio embolism e.g. post MI, AF, valve disease
hyperviscocity e.g. polycythaemia, sickle cell anaemia
What are the clinical features of TIA?
sudden onset where symptoms improve within 24 hours numbness weakness slurred speech visual disturbance
which features are seen in a TIA in the anterior circulation?
dysphagia
contralateral hemiparesis
contralateral homonymous visual field loss
amaurosis fugax
which features are seen in a TIA in the posterior circulation?
dysphagia diplopia vertigo dysarthria ataxia LOC
Which risk stratifying score if used after TIA to assess the risk of stroke?
ABCD2 Age >50 y/o Blood pressure >140/90 mmHg Clinical features e.g. unilateral weakness, speech difficulties Diabetes Duration of symptoms >60 mins
How do you interrupt ABCD2 scores?
>4 = assessment by specialist within 24 hours >6 = strong risk of stroke
If see a person who has had a TIA, how should they be managed?
- aspirin 300mg immediately
- if suspected tIA in last 7 days, urgent specialist referral within 24 hours
- do not drive for 1 month
How should person who has had a TIA be managed long term?
- clopidogrel 1st line
- carotid endarterectomy if carotid stenosis >70% (often regional anaesthetic so can see if pt experience neurological symptoms during surgery)
Define stroke
clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death
What are the 2 types of stroke?
- ischaemic stroke **
2. hemorrhagic stroke
How are ischaemic strokes caused?
= neurological dysfunction due to ischaemia and death of brain, spinal cord or retinal tissue following vascular occlusion or stenosis
- thrombosis due to atherosclerosis
- embolus due to fatty material from an atherosclerotic plaque/clot
List the possible risk factors for an ischaemic stroke?
hypertension ** smoking ** alcohol misuse/ drug misuse hyperlipidaemia elderly diabetes mellitus physical inactivity infective endocarditis valvulvar disease sickle cell disease anti phospholipid syndrome CKD obstructive sleep apnoea
How are haemorrhage strokes caused?
= neurological dysfunction caused by a local collection of blood from rupture of a blood vessel either:
- within the brain = intracerebral
- subarachnoid haemorrhage
list the risk factors for a haemorrhage stroke?
age
hypertension
anti coagulants
arteriovenous malformation
List the general features of a stroke
motor weakness speech problems swallowing difficulties visual field defects balance problems
list the features of a cerebral hemisphere infarct?
contralateral hemiplegia: flaccid -> paralysis
contralateral sensory loss
contralateral homonymous hemianopia
dysphagia
List the features of posterior cerebral artery occlusion?
dysphagia
diplopia
dysarthria
List the features of brainstem infarct
quadriplegia
lock in syndrome
horners syndrome
nystagmus
List the features of a haemorrhage stroke?
decrease LOC
vomiting
headache
seizures
what are the possible early complications of a stroke?
cerebral oedema
haemorrhage transformation to ischaemic stroke
seizures
venous thromboembolism
cardiac complications e.g. MI, AF
infection risk e.g. aspiration pneumonia, UTI, cellulitis from pressure sore
List the possible late complications of stroke?
- mobility problems- hemiparesis/ hemiplegia, ataxia, falls, spasticity
- communication problems - dysphasia, dysarthria
- fatigue - disturbed sleep
- pain - neuropathic or MSK
- continence issues
- depression, anxiety
- swallowing difficulties - poor nutrition, poor oral hygiene, dysphagia
- cognitive - dyspraxia, impairment of attention and spatial awareness
which system is used to classify strokes?
Oxford stroke classification “Bamford”
should assess:
1. unilateral hemiparesis +/- hemisensory loss
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
What is the FAST test?
Face Arm Speech Test - used for rapid assessment of someone if suspect having a stroke
what should first be done when someone presents with a stroke?
CT scan - differentiate between haemorrhage or ischaemic stroke
If an ischaemic stroke and no contraindications, how are they managed?
IV recombinant tissue plasminogen activator e.g. alteplase given within 4.5 hours
List the secondary prevention lifestyle advice given to stroke patients?
- encourage physical activity
- smoking cessation
- diet optimisation
- alcohol consumption under limits <1 units/week
- control diabetes
- arrange pre winter influenza vaccinations
- treat heart failure
How are stroke patients managed with medical management?
- anti platelet therapy with clopidogrel 75mg daily + aspirin for first 3 months (+ warfarin if AF)
- statin e.g. atorvastatin 20-80mg daily
- anti hypertensives and aim for systolic <130mmHg
what are the risks of a carotid endarterectomy?
stroke risk MI death wound haematoma at risk of damaging: hypoglossal nerve, vagus nerve
