Neurology Flashcards
A 44-year-old male smoker presents with a 9-year history of recurrent headaches. Headaches occurred twice-monthly initially, always in the early hours of the morning (2 a.m. to 3 a.m.). The headaches have increased to an average of 2 episodes per day. The acute episodes can occur at any time, and last between 2 and 4 hours. He always has a nocturnal event. Attacks are triggered immediately after drinking alcohol or with the smell of strong aftershave or petrol. The pain is excruciating and focused around his right eye. The right eye reddens and tears, the right eyelid droops, and the right nostril runs. He becomes severely agitated during attacks, often pacing the room or rocking back and forth. Physical examinations, lumbar puncture, brain magnetic resonance imaging (including pituitary views), and pituitary function blood tests are normal.
Cluster headache
Migrainous features can be seen in cluster headache, including aura symptoms (14% of patients [1] ), ipsilateral photophobia and/or phonophobia (61.2%), and nausea and vomiting (27.8%). [3] During remission periods, patients may report mild pre-headache sensations or shadows in the same location as the cluster headaches. Three percent of patients fail to report autonomic features and agitation during attacks. Continuous background pain has been reported in nearly one third of patients with chronic cluster headache.
A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a working day. The pain is generalised and described as similar to wearing a tight band around her head. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen. Examination reveals tenderness of her scalp and both trapezius muscles.
Tension headache
A 32-year-old woman presents with a 13-year history of 1 to 3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding. Untreated, they last for 2 days. On 4 occasions, headaches were preceded by the gradual appearance of a shimmering, zigzag line that enlarged, moved to the peripheral visual field, and then faded away over 45 minutes. Examination is normal.
Migraine
A 40-year-old man complains of a 1-year history of twice-monthly global headache, worse on the left side in the post-auricular region. It comes on gradually and, at its most severe, the vision in his left eye becomes distorted. He often has to stop watching television as the picture becomes “blurry”. His nose becomes blocked, although sometimes he has a “runny nose”. He takes a non-steroidal anti-inflammatory drug (NSAID) that helps a little, but he feels that his head is about to explode at times. When the headache occurs, he needs to go into a dark quiet room and sleep until it resolves. He reports that the problem is “really getting him down”, and he is having difficulties with his employer due to loss of work time.
Migraine
A 56-year-old man presents with a 25-year history of constant headache. The onset was insidious and he is certain that the only time he is headache-free is when he sleeps. He states the headache is generalised and his neck and shoulders are always ‘tight’. He denies any associated autonomic symptoms including eye tearing, nasal congestion, light and sound sensitivity, nausea, or vomiting.
Tension headache
A 55-year-old woman recently diagnosed with a brain tumour in the left hemisphere has a witnessed seizure event. The seizure is initially recognised when the patient begins staring and is unresponsive to those around her. She seems to be picking at her clothes with her left hand, but the right arm and leg are not moving. After 20 seconds, she displays rapid head-turning and eye deviation to the right, with tonic extension of the right arm and flexion of the left arm. This is quickly followed by tonic extension of the left arm as well, then clonic jerking occurring in both arms synchronously. This jerking gradually slows and stops after about 30 seconds. The patient then becomes quite somnolent, and she appears to be using her arm and leg less on the right than the left.
generalised epilepsy
An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upwards through her chest. She is usually unaware for a few minutes, but others have told her that she smacks her lips, picks at her clothing, and is unable to speak during these episodes. After the event she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined. Her past medical history is notable for several febrile seizures as a young child, although she was not treated for seizures at that time. An aunt was diagnosed with seizures many years ago.
focal seizures
A middle-aged woman presents with a complaint of frequent (once or twice daily for 3 weeks), brief (lasting several seconds) episodes of intense, sharp left-sided jaw pain. She has experienced these attacks for several years, but they had previously been relatively rare (1 episode daily for several consecutive days followed by months with no attacks). She says that episodes are sometimes brought on by eating but can occur without an apparent stimulus. The patient states that even though the pain is brief, she lives in fear of repeat flares.
Trigeminal Neuralgia
Maxillary/mandibular (V2/V3) distribution symptoms occur in the majority of patients. This can present as sharp pain running from the mouth to the jaw (commonly mistaken for dental pain) or less commonly as pain from the upper lip to the orbit. Symptoms in an exclusively ophthalmia (V1) distribution are the least common, and patients typically refer to the pain as headache.
A 40 year old woman presents with a 7 month history of continuous, but fluctuating, left facial pain. It is usually dull but there can be piercing pain in the cheek. It is aggravated by chewing and diminished by relaxing or massaging facial muscles. The dentist cannot find a cause.
Facial arthromyalgia (TMJ syndrome)
An 80 year old man arrives in A&E distressed. He has had excruciating pain and tenderness over the left side of his forehead since an episode of shingles 3 months previously.
Postherpetic neuralgia
A 32 year old woman presents with a 3 year history of constant dull L facial pain. There are no aggravating or relieving factors and she has gained no benefit from tricyclics, gabapentin or opiate analgesics. The pain is dominating her life, preventing work, and making her depressed. Her GP, dentist and an ENT surgeon have not found a cause. O/E normal
Atypical facial pain
A 65-year-old woman presents with a chief complaint of dizziness. She describes it as a sudden and severe spinning sensation precipitated by rolling over in bed onto her right side. Symptoms typically last <30 seconds. They have occurred nightly over the last month and occasionally during the day when she tilts her head back to look upwards. She describes no precipitating event prior to onset and no associated hearing loss, tinnitus, or other neurological symptoms. Otological and neurological examinations are normal except for the Dix-Hallpike manoeuvre, which is negative on the left but strongly positive on the right side.
Benign paroxysmal positional vertigo
BPPV can occur as a result of a closed-head injury or vestibular neuronitis, and it can also be associated with Meniere’s disease or migraine. Most patients give the classic description of a short-lived vertigo sensation following rolling over in bed. However, many patients may not sense an actual turning sensation and may use other dizziness descriptors to describe their sensation. Because of the frightening intensity of the sensations, patients often report that the spells last for 5 or 10 minutes when in reality they typically last for no more than 20 seconds.
A 40-year-old woman presents with a 1-year history of recurrent episodes of vertigo. The vertigo spells are described as a sensation of the room spinning that lasts from 20 minutes to a few hours and may be associated with nausea and vomiting. The spells are incapacitating and are accompanied by dizziness, vertigo, and disequilibrium, which may last for days. No loss of consciousness is reported. The patient also reports aural fullness, tinnitus, and hearing loss in the right ear that is more pronounced around the time of her vertigo spells. Physical examination of the head and neck is normal. A horizontal nystagmus is noted. She is unable to maintain her position during Romberg’s testing or the Fukuda stepping test. She turns towards the right side and she is unable to walk tandem. Her cerebellar function tests are normal.
Meniere’s Disease
Patients may present with any combination of hearing loss, tinnitus, vertigo, or aural fullness.
A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain MRI are normal.
Parkinson’s
PD can present in myriad ways. The cardinal features of resting tremor, bradykinesia, rigidity, and postural instability can occur in various combinations and sequences during the course of the disease. The signs and symptoms are typically asymmetrical. Bradykinesia and rigidity often present in subtle fashion early in the disease course. For example, reduced arm swing, shuffled gait, softened voice, decreased blink rate, decreased facial expressivity, and reduced spontaneous movement are all signs of parkinsonism. The non-motor symptoms of PD, such as depression, fatigue, autonomic dysfunction (constipation, incontinence, dysphagia), and sleep disturbance may even precede the evolution of motor symptoms. Given their non-specificity, however, their relationship to PD is only made after motor symptoms/signs have been identified.
A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.
TIA
Presentation of TIA is dictated by the region of brain supplied by the obstructed vessel. Unilateral weakness or sensory deficits may result from ischaemia in the carotid distribution. This presentation represents 67% of all TIAs. [5] Aphasia from ischaemia of Wernicke’s or Broca’s area occurs in 13% of TIAs. [5] Posterior cerebral artery occlusion may give homonymous hemianopsia, whereas thrombus in the retinal artery leads to amaurosis fugax. Posterior circulation ischaemia may lead to symptoms of ataxia, vertigo, incoordination, cranial nerve deficits, or syncope, and such symptoms are described in 17% of new TIAs. [5] Isolated dizziness is rarely a symptom of TIA or stroke. [6] Lacunar symptoms tend to give isolated sensory or isolated motor deficits but also a number of less common symptom complexes.
