Neurology Flashcards
What are the features of motor neuron disease?
Can present with both UMN and LMN signs Fasciculations Absence of sensory signs/sx Wasting of small hand muscles/tibialis anterior No cerebellar/external ocular muscle effects Sphincter dysfunction late feature
What is the commonest presentation of MS?
Optic neuritis
What are the features of MS?
Visual: Optic neuritis Optic atrophy Internuclear ophthalmoplegia Sensory: Pins and needles Numbness Trigeminal neuralgia Lhermitte’s (paraesthesiae in limbs on neck flexion) Motor: Spastic weakness (most commonly legs) Cerebellar: Ataxia Tremor Other: Urinary incontinence Sexual dysfunction Intellectual deterioration
What are risk factors for MS?
EBV Low Vit D Smoking Obesity in adolescence Female gender
If you suspect MS what should you do?
Refer to neurology Bloods incl. FBC, inflammatory markers, LFTs, U&Es, Ca, glucose, TFTs, B12, HIV
What is the treatment for a relapse of MS?
Oral methylprednisolone 0.5g daily for 5 days
What is an essential tremor?
Autosomal dominant Postural tremor Worse if arms outstretched
What improves essential tremor?
Alcohol and rest
What is the management of essential tremor?
Propanolol 1st line Primidone sometimes used
What are the features of Wernicke’s encephalopathy?
Confusion Ataxia Nystagmus Opthalmoplegia PEripheral Neuropathy
What causes Wernicke’s encephalopathy?
Thiamine deficiency Persistent vomiting Stomach Ca Dietary deficiency
What can occur if Wernicke’s encephalopathy is not treated?
Korsakoff syndrome
What is korsakoff syndrome?
Nystagmus Opthalmoplegia Ataxia + Amnesia + Confabulation
What is the management of cluster headaches
Sumatriptan subcut (6mg) or nasal (10-20mg) 100% O2 for 15-20mins
What are the features of Bells palsy?
LMN facial nerve palsy Affects forehead May have pain, altered taste, dry eyes, hyperacusis
What is the management of Bells palsy?
Pred 1m/kg for 10d if seen within 72hr of onset of symptoms Consider eye lubricants/artificial tears
What causes Brown-Sequard syndrome?
Lateral hemisection of the spinal cord
What does ipsilateral weakness, ipsilateral loss of proprioception and vibration sensation, and contralateral loss of pain and temp sensation suggest?
Brown-Sequard syndrome
Definition of encephalitis
Inflammation of brain parenchyma
Triad for acute encephalitis
Fever Headache Altered mental status
Causes of encephalitis
Vacterial Bacterial Toxins Autoimmune disorders
Features of viral encephalitis
Symptoms of meningitis (fever, headache, neck stiffness, vomiting) followed by altered consciousness, confusion, drowsiness, seizures and coma May have features of increased intracranial pressure
What is CIDP
Chronic inflammatory demyelinating polyneuropathy cause of peripheral neuropathy antibody mediated inflammation results in segmental demyelination of peripheral nerves
Features of CIDP
Males more commonly affected than females Similar to Guillain-Barre syndrome (GBS), with motor features predominating Insidious onset, over weeks to months - often thought of as the chronic version of GBS
High protein content in CSF suggests
CIDP
Treatment of CIDP
High dose steroids
Migraine features
- Headache- usually unilateral, pulsating or throbbing, lasts 4-72hrs
- Worsened by routine activity
- Photophobia
- Phonophobia
- Nausea
- Vomiting
- Can occur with or without aura (transient focal neurological symptoms e.g. zigzag lines, scotoma, pins and needles).
Management of migraines
Conservative
- Headache diary
- Avoid triggers
- Lifestyle - good sleep hygiene, stress management, hydration, exercise, regular meals, healthy weight
- If medication overuse headache, restrict acute medication
Medical
- Simple analgesia- ibuprofen, aspirin or paracetamol
- Triptan alone or with paracetamol/NSAID e.g. sumatriptan 50-100mg
- Consider anti-emetic e.g. metoclopramide 10mg or prochlorperazine 10mg
- Avoid COCP in migraine with aura
Indications for preventative treatment in migraine?
- Migraine attacks are having a significant impact on QOL/daily function, or are prolonged and severe despite optimal treatment
- Acute treatments contraindicated/ineffective
- Patient at risk of medication overuse headache
Preventative treatments for migraine
- Propanolol 80-160mg daily
- Topiramate 50-100mg daily
- Amitriptyline 25-75mg at night
Features of tension-type headache
- Generalised headache usually described as a pressure or tightness around the head which often spreads into or arises from the neck
- Mild-moderate intensity, can last minutes to days
- Not aggravated by routine physical activity e.g. walking
- Pericranial tenderness which may be elicited on manual palpation
Management of tension-type headache
- Simple analgesia e.g. paracetamol, aspirin, NSAIDs
- Avoid opioids
- Identify and manage comorbidities e.g. mood disorder, chronic pain, sleep disorders
- Avoid medication overuse
- Preventative treatment- chronic tension headaches. Acupuncture or low dose amitriptyline.
Features suggestive of a serious cause of headache
-
New severe or unexpected headache:
- Sudden onset severe headache reaching max intensity withing 5mins- intracranial haemorrhage, venous sinus thrombosis, hypertensive encephalopathy, verterbral artery dissection.
- New onset headache and ages >50yrs- GCA/SOL
- Progressive or persistent headache/headache that has changed dramatically- consider mass lesion/subdural haematoma
- Fever, impaired consciousness, seizure, neck pain/stiffness, photophobia- consider meningitis/encephalitis
- Papilloedema- consider SOL, cerebral venous sinus thrombosis, benign intracranial HTN
- New-onset neurological deficit, change in personality and new-onset cognitive dysfunction- consider cerebrovascular event, malignancy or SOL e.g. haematoma
- Atypical aura or aura in patient on COCP- consider cerebrovascular event
- Dizziness- ischaemic/haemorrhagic stroke
- Visual disturbance- migraine, acute closure glaucoma, temporal arteritis
- Vomiting- migraine, mass lesion, brain abscess, carbon monoxide poisoning
- Headache worse on standing- CSF leak
- Headache worse on lying down- SOL or cerebral venous sinus thrombosis
- Recent trauma- subacute or chronic subdural haematoma
Cause of shingles
Reactivation of varicella-zoster virus causing viral infection of nerve cells
Complications of shingles
Post-herpetic neuralgia
Secondary infection
Scarring
Ocular complications
Features of shingles
Prodrome- including abnormal sensation in affected skin and sometimes headache, malaise and fever.
Rash- usually unilateral. Macules and papules develop into vesicular lesions in dermatomal distribution which burst and form ulcers and crusts.
Pain- intense neuralgic pain over affected area
Healing within 2-4 weeks, lesions typically crust over within 7-10d
Management of shingles
- Paracetamol/codeine/ibuprofen for pain
- Amitriptyline/gabapentin/pregabalin/duloxetine if severe pain
- Aciclovir within72 hrs of rash onset if >50yrs, non-truncal involvement, moderate/severe pain or rash
Shingles is infectious until…
All vesicles have crusted over (usually 5-7d after rash onset)
Shingles vaccine is offered to…
All people aged 70-75, 78, or 79 years
Causes of blackouts (transient spontaneous LOC followed by complete recovery)
Neurally mediated reflex syncope (incl. vasovagal, carotid sinus syndrome, situational syncope)
Orthostatic hypotension
Cardiac abnormalities
Epilepsy
Vasovagal syncope is suggested by absence of (?) and presence of (?)
Absence of features to suggest an alternative diagnosis
AND
Presence of the 3 P’s:
Posture- blackout occured after prolonged standing
Provoking factors- such as pain/medical procedure
Prodromal symptoms- such as sweating or feeling warm/hot
Features of orthostatic hypotension
Light-headedness
Dizziness
Weakness
Tunnel vision
Symptoms worse on standing
Relieved by sitting/lying down
Features suggestive of epilepsy as cause of blackout
Bitten tongue
Head-turning to one side during blackout
Loss of bowel and bladder control
Unusual posturing
Prolonged limb-jerking
Confusion following event
Prodromal deja vu or jamais vu
Features suggesting cardiac cause of blackout
ECG abnormality
Evidence of heart failure
Blackouts occuring during exertion
Palpitations
FHx of sudden cardiac death in people <40yrs
Inherited heart condition
New/unexplained breathlessess
Heart murmur
Features suggesting a non-epileptic seizure
Duration over two minutes
Gradual onset, fluctuating course
Violent thrashing movements
Dide-to-side head movement
Asynchronous movements
Eyes closed
Recall for period of unresponsiveness.
Types of psychogenic seizures (3)
- Dissociative seizures are involuntary and happen unconsciously. This is the most common type of NES and the person has no control over the seizures.
- Associated with psychiatric conditions that cause seizures - eg, panic attacks.
- Factitious seizures - eg, Münchhausen’s syndrome, fabricated or induced illness by carers.
What are reflex anoxic seizures?
Paroxysmal, spontaneously-reversing brief episodes of asystole triggered by pain, fear or anxiety.
Anoxic seizures are non-epileptic events caused by a reflex asystole due to increased vagal responsiveness.
They are often misdiagnosed as epilepsy.
Typical presentation of reflex anoxic seizures
- During the episode, the child becomes suddenly pale and limp, will fall if standing and loses consciousness.
- This is followed by stiffening and clonic jerking of the limbs.
- The episode is usually brief (30-60 seconds) and recovery is rapid.
- There may also be upward eye deviation and urinary incontinence.
- On recovery, the child may feel tired and washed-out for some time.
- Reflex anoxic seizures do not cause tongue-biting and this may be useful in the differentiation from epilepsy.
Definition of epileptic seizure
An epileptic seizure is the transient occurrence of signs or symptoms due to abnormal electrical activity in the brain, leading to a disturbance of consciousness, behaviour, emotion, motor function or sensation.
Epileptic seizure classification
Focal seizures:
- Simple focal
- Focal dyscognitive
- Focal seizure evolving to generalised tonic-clonic convulsions
Generalised seizures:
- Abscence
- Myoclonic
- Clonic
- Tonic
- Tonic-clonic
- Atonic
Unclassified
Investigations in someone presenting with a seizure
Bloods- glucose, electrolytes, calcium, renal function, LFTs, urine biochemistry
EEG- if seizure likely epileptic
MRI- to identify structural abnormalities
Types of generalised seizure
- Tonic seizures that cause impairment of consciousness and stiffening; the trunk may be either straight or flexed at the waist.
- Clonic seizures that cause jerking and impairment of consciousness.
- Tonic–clonic seizures that cause stiffening and jerking and impairment of consciousness.
- Typical absence seizures, which begin in childhood.There is a sharp onset and offset with no residual symptoms. Normal activity is interrupted and the child stares for a few seconds. The eyelids may twitch and some very small jerking movements of the fingers may occur (but these are usually not noticed). The duration is typically 5–10 seconds and usually less than 30 seconds; absence seizures may occur dozens or even hundreds of times daily in some children.
- Myoclonic seizures that cause brief, shock-like contraction of the limbs, without apparent impairment of consciousness.
- Atonic seizures that cause sudden brief attacks of loss of tone, associated with falls and impairment of consciousness.
Features of focal seizures
- Focal motor seizures that cause a jerking movement, typically beginning in the face or one hand, and spreading to involve the limbs. They may also present with apparently purposeful movements such as turning the head, eye movements, lip smacking and mouth movements, drooling, or rhythmic muscle contractions. Limb weakness may occur for several hours after the seizure.
- Focal sensory seizures, including temporal lobe seizures that may cause sensory, autonomic, emotional, cognitive, or other changes. Consciousness may be fully retained (simple partial seizures) or impaired (complex partial seizures) during an attack.
- Secondarily generalized seizures start with a focal seizure before spreading to cause a generalized seizure.
Primary care management of suspected seizure
Urgent referral to neurology
Advise family/carers how to recognise and manage seizures
Advise them to stop driving until have seen specialist
Keep a seizure diary
Avoid swimming, take care when bathing
Management of epileptic seizure
(in primary care/community)
For people having a tonic-clonic seizure, note the time, and if it lasts less than 5 minutes:
- Look for an epilepsy identity card or jewellery.
-
Protect them from injury by:
- Cushioning their head with your hands or soft material.
- Removing harmful objects from nearby, or if this is not possible, moving the person away from immediate danger.
- Do not restrain them or put anything in their mouth.
- When the seizure stops, check their airway and place them in the recovery position.
- Observe them until they have recovered.
- Examine for, and manage, any injuries.
- Arrange emergency admission if it is their first seizure.
For people having a tonic-clonic seizure lasting more than 5 minutes, or who have more than three seizures in an hour, in addition to the above measures:
Treat with one of the following:
- Buccal midazolam as first-line treatment in the community.
- Rectal diazepam if preferred, or if buccal midazolam is not available.
- Intravenous lorazepam if intravenous access is already established and resuscitation facilities are available.
- Call for an ambulance if seizures not responding or are prolonged/recurrent.
When should antiepileptics be started?
- Following a second epileptic seizure
- After the first seizure if:
- Patient has neurological deficit
- Brain imaging shows structural abnormality
- EEG shows unequivocal epileptic activity
- Patient/family/carers consider risk of further seizure unacceptable
What are the first line AEDs for generalised and focal seizures?
Generalised seizures:
Sodium valproate
Focal seizures:
Carbamazepine or lamotrigine
What is carotid sinus hypersensitivity?
An exaggerated response to carotid baroreceptor stimulation
Defined by response to gentle carotid sinus massage for 5-10 seconds:
- At least 3 second asystole (cardio-inhibition)-70-75% of cases
- Lowering of BP by at least 50mmHg (vasodepression)- 5-10%
- A combination of the above- 20-25%
Triggers for carotid sinus hypersensitivity?
- Shaving
- Head turning
- Neck extension
- Tight collars
