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Neurology Flashcards

1
Q

Define syncope

A

Transient global cerebral hypoperfusion

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2
Q

Name 3 causes of syncope

A

Reflex/neurally mediated (happens when nervous system controlling HR and BP malfunctions in response to emotional stress), cardiogenic, orthostatic/postural hypotension

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3
Q

Name 3 types of reflex/neurally mediated syncope

A

vasovagal, situational eg. coughing/swallowing/micturition, carotid sinus hypersensitivity- on head turning/shaving

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4
Q

Name 4 risk factors for cardiogenic syncope

A

conditions that predispose to tachyarythmias = long QT, SVT (Wolff-Parkinson White), bradyarrhythmias (heart block), cardiac ischaemia, structural heart disease (AS, hypertrophic cardiomyopathy), age >60, fainting during exertion/lying down

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5
Q

What are the symptoms of vasovagal syncope

A

nausea, pallor, sweating, visual fields closing in and then fainting

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6
Q

How long does vasovagal syncope last

A

Briefly- 1 min approx

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7
Q

Is there post-ictal symptoms in vasovagal syncope

A

No

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8
Q

What investigations would you do in a patient with suspected syncope?

A

ECG, bloods- glucose, FBC, UEs, tilt table test

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9
Q

What is the treatment for reflex/neurally mediated syncope

A

Education, avoiding triggers and tilt table training- but this is not very effective

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10
Q

What is the treatment for cardiogenic syncope

A

treat the cause eg. pacemaker for bradycardia and anti-arrhythmic drugs

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11
Q

What is the treatment for orthostatic syncope

A

check any medications that might be causing eg. ACEi CCB, beta blockers , water intake and can take fludrocortisone

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12
Q

Define a seizure

A

Clinical manifestation of abnormal and excessive discharge of cerebral neurones

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13
Q

Define epilepsy

A

a recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures

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14
Q

Name 5 causes of epilepsy

A

idiopathic, cerebral haemorrhage, stroke, head injury, CNS infections eg. encephalitis, neurodegenerative disease eg. Alzheimers, metabolic disorders eg. hypoxia, hypoglycaemia, hypernatraemia, hypercalcaemia, drugs, developmental disorders

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15
Q

What is the difference between focal and generalised epileptic seizures?

A

Focal- features localised to part of one hemisphere of the brain. often caused by structural disease. Generalised- features cannot be localised to one part. causes= idiopathic, genetics/FMH, lack of sleep, alcohol, photosensitivity

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16
Q

Name and describe the two types of focal seizures?

A

Simple partial seizures - with awareness and one abnormal motor or sensory sx (depending on the lobe affected)|, complex partial seizures- loss of awareness and complex movements (commonly from temporal lobe)

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17
Q

What symptoms would occur with a simple partial seizure of the temporal lobe?

A

automatisms (e.g lip smacking, grabbing ,singing), abdominal rising sensation/pain, deja vu, dysphasia, hippocampal sx- fear, panic

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18
Q

What symptoms would occur with a simple partial seizure of the frontal lobe?

A

Motor features- posturing, leg/head movements) motor arrest, behavioural changes, dysphasia, post-ictal Todd’s palsy

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19
Q

What symptoms would occur with a simple partial seizure of the parietal lobe?

A

sensory disturbances (tingling, numbness, pain) and motor symptoms

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20
Q

What symptoms would occur with a simple partial seizure of the occipital lobe?

A

Visual symptoms- flashes, spots and lines

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21
Q

Name and describe the four types of generalised seizures?

A

generalised tonic clonic seizures (stiffening and jerking of limbs, LOC, post-ictal sx of confusion and drowsiness), myoclonic (sudden jerk of one limb), absence (spacing out) and akinetic (sudden loss of tone in limb- no LOC)

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22
Q

What are some of the post-ictal symptoms in a GTCS?

A

confusion, drowsiness, urinary incontinence, LATERAL tongue bite (tongue moves back in seizures so more to bite), injury- dislocation of the shoulder

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23
Q

What is the likely cause of a FIRST seizure in older age? (2)

A

Tumour! primary= glioblastoma, secondary= brain mets (from lung, breast, thyroid, kidney, colon, skin) or vascular- stroke, MI

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24
Q

What investigations would you do in a patient with suspected epilepsy?

A

Bloods- glucose, FBC, UE, ECG, and 24h ECG, CT, MRI, EEG (normal doesn’t exclude)

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25
What is the drug treatment for epilepsy? name the side effects of each drug
Focal seizures= carbamazepine (SE leukopenia, blurred vision) or lamotrigine (rash, fever) Generalised seizures= sodium valproate (SE teratogenic, liver failure) or lamotrigine
26
What is the surgical treatment for epilepsy?
Resection or vagal nerve stimulation (palliative)
27
Define non-epileptic seizures
Episodes of movement/sensation/experience that resemble epileptic seizures but without cerebral discharges
28
What is the cause of non-epileptic seizures?
psychological distress - trauma for example childhood sexual abuse
29
What are the symptoms of non-epileptic seizures?
Eyes closed, partially responsive, may be emotional, paralysed but conscious, may be shaking with fighting movements (remembering the trauma)
30
What are the post-ictal symptoms of non-epileptic seizures?
Very tired and worn out. Talk dramatically about the event
31
Apart from syncope, epilepsy and non-epileptic seizures , name 4 other causes of loss of consciousness
migraine, hypoglycaemia, acute hydrocephalus (tumour), orthostatic hypotension
32
How is coma measured?
on the GCS scale
33
What are the 3 components measured by the GCS?
Eye opening, motor response and visual response
34
Name 5 causes of coma?
drugs/toxins, anoxia, bleeding, infections, infarcts, hypoglycaemia, DKA, SAH, epilepsy, tumour
35
what investigations would you do in an unconscious patient?
bloods- glucose, U&E, Ca, phosphate, LFT, clotting, toxicology (alcohol level- , ECG, CT brain, MRI brain, LP (only if safe- can't do it if abscess/tumour due to high ICP), EEG
36
What are the main symptoms of CO poisoning?
Headache, altered awareness and altered behaviour
37
Patient presents with fever, cough, marked confusion. is in a coma with serial seizures. The CT shows low density and volume loss in the temporal lobe. What is the diagnosis?
Herpes simplex encephalitis. (acute deterioriation in conscious level= think of encephalitis)
38
Define status epilepticus
Non self- limiting manifestation of an epileptic seizure
39
Name the 4 types of status epilepticus and describe
GTCS (seizure lasts 90s, then unresponsive and then another seizure), myoclonic, absence (confused, slow, lasting >5s and doesnt stop), focal- unusual
40
Name 5 causes of status epilepticus
ALCOHOL (no.1 cause of status epilepticus in those without epilepsy), NON-COMPLIANCE (no.1 cause in epileptics), stroke (haemorrhage/ischaemic), malignancy, infections- meningitis, encephalitis, , drugs, trauma, metabolic- hypogylcaemia, hypocalcemia, hyponatraemia, hypokalaemia, thiamine deficiency (leading to Wernicke's encephopathy and Korsakoff's syndrome)
41
What investigations would you do in suspected status epilepticus?
Bloods- FBC, WBC (infection?), U&Es, glucose, Ca, toxins- drug and alcohol levels, EEG, CT/MRI if suspecting stroke/haemorrhage
42
How do you treat status epilepticus? (1st and 2nd line drugs)
Initially- check airway is clear and give O2 if necessary. 1st line: BENZOs (lorazepam IV in hospital, midazolam buccal if at home). 2nd line: phenytoin infusion (anti-seizure, Na channel blocker stopping the repeated action potentials)
43
How do benzodiazepines work to treat status epilepticus?
They bind to GABA receptors, enhancing the effect of GABA in producing sedative, anti-convulsive, muscle relaxant and anti-anxiety effects
44
What is the definition of a stroke?
Sudden onset of focal neurological signs lasting longer than 24h , of presumed vascular origin
45
Name 5 causes of stroke
small vessel thrombosis, cardiac emboli (MI, AF, endocarditis), atherothrombolism (from carotids eg), haemorrhage (trauma, increased BP, aneurysm rupture, anticoagulation), subarachnoid haemorrhage, carotid artery dissection
46
What are the risk factors for stroke? modifiable and non-modifiable
non-modifiable: age, sex, FMH of vascular disease, ethnicity (afro-carribean and asian). modifiable: HTN, smoking, AF, excess alcohol intake, hyperlipidaemia, diabetes, obesity, carotid artery disease, recreational drugs . in younger people= ASD/VSD in heart, AF, sickle cell disease, aortic dissection, OCP
47
What arteries does an anterior circulation stroke affect and what symptoms would this produce?
involves the carotid system (ACA, MCA). symptoms= unilateral contralateral weakness of arm and face, sensory loss, dysphasia, homonymous hemianopia, amarausis fugax
48
what arteries does a posterior circulation stroke affect and what symptoms would this produce?
basilar and vertebral arteries. symptoms: bilateral symptoms- dysarthria, dysphagia, diplopia, dizziness, ataxia, diplegia (paralysis)
49
What symptoms would a brainstem infarct produce?
quadriplegia, locked in syndrome, eye movement abnormalities
50
What are the 5 stroke syndromes produced by a lacunar infarct?
ataxic hemiparesis, pure motor, pure sensory, sensorimotor and dysarthria
51
where does a lacunar infarct occur most commonly?
in basal ganglia, thalamus, pons and internal capsule
52
What investigations would you do in a patient with stroke?
CT! bloods- FBC, ESR, clotting (looking for thrombophilia/thrombocytopaenia), U&Es, LFTs, glucose (hyper/hypo), cholesterol (dyslipidaemia-> ischaemia), carotid duplex (US), Echo (if pt <55 and previous cardiac disease to see thrombus)
53
What are the indications for an immediate CT scan in a patient with stroke?
* less than 4.5 hours from onset and considering thrombolysis (so if ischaemic stroke) * indications for early anticoagulation eg. if have AF * on anticoagulation * known bleeding tendency * decreasing GCS * unexplained/progressive sx * Papilloedema * Severe headache at onset of stroke (SAH)
54
Name 6 differential diagnosis of stroke
Seizure (and Todds paresisis- post ictal paralysis), migraines, metabolic eg. hypoglycaemia, subdural haemorrhage, tumours, head injury
55
What is the treatment for ischaemic stroke?
Thrombolysis, anticoagulation (if AF), antiplatelets- aspirin for 2 weeks, then clopidogrel, statin (if cholesterol >4) and rehab- OT, physio, speech and language therapists. Secondary treatment: statins, check blood glucose, antihypertensives if necessary, dysphagia screen
56
What drug and method of administration is used in the main treatment of ischaemic stroke (thrombolysis) and what is the importance of the time of administration
IV alteplase (tissue plasminogen activator). MUST be administered within 4.5 hours of stroke onset.
57
What is the treatment for haemorrhagic stroke?
surgery. supportive treatments
58
What are 5 causes of haemorrhagic stroke?
HTN, tumour, vascular malformations (AV malformations), aneurysms, trauma
59
What is the most likely cause of a DEEPER bleed in a haemorrhagic stroke?
HTN
60
What is the most likely cause of a CORTICAL/SUPERFICIAL bleed in a haemorrhagic stroke?
AV malformations, aneurysms
61
How does hydrocephalus occur in a stroke and what is the treatment?
Haemorrhage occurs and a clot blocks the aqueduct obstructing CSF flow through the ventricles causing a build up = hydrocephalus. Tx= clot evacuation
62
Define a TIA
The sudden onset of focal CNS symptoms due to temporary occlusion of part of the cerebral circulation- usually by emoli. Sx <24h
63
How does amaurosis fugax occur in a TIA?
Emboli in retinal artery
64
Name 4 causes of TIA
Atherothrombolism (from carotid- gives carotid bruit), cardiothrombolism (from MI), AF, valve disease
65
What investigations would you do in a patient with a suspected TIA?
FBC, U&E, ESR, glucose, lipids, CXR, ECG, carotid doppler, MRI - for previous infarcts
66
What is the acute treatment of a stroke?
ABCDE- aspirin, treat BP, order CT and do ABCD2
67
What is ABCD2 in a TIA and what is the clinical significance?
Age >60, BP: systolic >140, diastolic >90, clinical features: unilateral weakness, speech disturbance only, duration of TIA >60 mins, 10-60 mins, diabetes. An ABCD2 score >4= assessment within 24h
68
What is the treatment of a TIA (not acute)?
Aspirin for 2 weeks then change to clopidogrel, treat risk factors (high BP, alcohol intake, hyperlipidaemia)
69
What is the surgical treatment option for TIA when the cause is atherothrombolism from carotid
Carotid endarterectomy and stenting - for symptomatic carotid stenosis
70
Define SAH- subarachnoid haemorrhage
spontaneous bleeding into the subarachnoid space
71
What are the causes of SAH?
Main- rupture of saccular aneurysms (Berry aneurysms|), AVM, arterial dissection, tumour
72
Name the 3 common sites for a Berry aneurysms
* Junction of posterior communicating artery within internal carotid. * junction of anterior communicating with anterior cerebral artery. * Bifurcation of MCA
73
What conditions are associated with Berry aneurysms? (3)
Polycystic kidneys, coarctation of the aorta, Ehlers- Danlos syndrome (hypermobile joints with increased skin elasticity)
74
Name 5 symptoms of SAH
Thunderclap headache- sudden, very painful), depressed GCS, meningisim (neck stiffness, nausea, photophobia), seizures, sentinel headache (previously- from small warning bleed)
75
What are the signs of SAH?
neck stiffness, Kernig's sign, focal neurology
76
What is the big condition associated with SAH?
Polycystic kidney disease
77
What would you find on examination of a patient with SAH?
Neck stiffness, reduced GCS, 3rd nerve palsy (eye- down and out), extensor plantar reflex/ Babinski, pain on eye movement
78
What investigations would you do in a patient with suspected SAH?
CT head, MRI, LP (if CT is negative) = find yellow pigment xanthocromia- due to bilirubin present from breakdown of Hb
79
What is the treatment of a SAH? and what drug is helpful in reducing morbidity?
surgical clipping of aneurysms or endovascular coiling. Nimodipine- Ca antagonist- reduces vasospasm and morbidity from bleeding.
80
Name 3 complications of SAH
Rebleeding, cerebral ischaemia, hydrocephalus

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