Neurology Flashcards by Elisabeth Feord

classification of causes of headaches

structures: trigeminovascular system, meninges, CSF containing structures, muscle, nerves
processes: “neurogenic” inflammation, inflammation, infection, pressure, obstruction

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papilloedema: def, appearance and cause

swelling of optic disc

appearance: disc pinkness, with blurring and heaping up of disc margins. small haemorrhages surround disc
cause: raised intracranial pressure

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prevalence of migraines

1/5 women

1/12 men

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what is an aura and symptoms

+diagnostic criteria for it

neurological features preceding headache: visual disturbances (one eye, or one visual file, scintillating scotoma) and sensory symptoms (unilateral parasthesia, ascending numbness of hand, arm, face, lips and tongue)

Symptoms:

fully reversible
develop over at least 5 minutes
lasts for 5-60minutes

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what is cortical spreading depression

slow wave of neuronal and glial depolarisation followed by depression of spontaneous neuronal activity spreading from occipital lobe anteriorly across cerebral cortex
look more into this
+ suppression occurs alongside changes in brain blood flow

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how does cortical spreading depression cause migraine?

activates trigeminal nerve afferents, causing inflammatory changes in pain-sensitive meninges (causing migraine through peripheral and central reflex mechanism) (can also happen in areas where depolarisation is not consciously perceived)

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triggers for migraines

stress or relaxing after stress
jet lag/change in sleep/lack of sleep
tyramine rich foods (i.e. cheese)
contraceptive pills
menstruation (fall of oestrogen)
bright lights, loud sounds, smoky rooms
eating/Alcohol
physical exertion
changes in weather patterns

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migraine treatment

-acute: oral triptan + NSAID/paracetamol
-prophylaxis: propranolol or topiramate (consider amitriptyline, acupuncture, sodium valproate if topiramate or propranolol ineffective)
+ oestrogen patches when menstruation precedes it
+ ACEi, ARB, Ca channel blockers may be helpful

can also
-anti-emetics (for nausea and vomiting): domperidone, prochlorperazine and metoclopramide
(-triptans (5-HT receptor agonist): act of pre and post synaptic receptors in midbrain and trigeminal nucleus caudalis + cause vasoconstriction of vasodilated vessels

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which medical conditions are contraindicated to treatment with triptans?

(the have peripheral vasoconstrictor action on arterioles)

ischemic heart disease (including MI)
transient ischemic attack
cerebrovascular accident
mild uncontrolled hypertension
peripheral vascular disease
Prinzmetal’s angina

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criteria for preventative treatment of migraine

quality of life/ business duties/ school attendance severely affected
2+ attacks/month
migraine attacks do not respond to acute drug treatment
frequent, very uncomfortable aura occurs

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meningitis symptoms

headache
neck stiffness
fever
photophobia
vomiting

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bacteria infections leading to meningitis

neisseria meningitidis
streptococcus pneumoniae
haemophilus influenza
listeria monocytogenes
staphylococcus aureus
gram neg bacilli
mycobacterium tuberculosis

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viral infections leading to meningitis

enterovirus
herpes simplex
varicella zoster
cytomegalovirus
epstein-barr virus
adenovirus

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fungal infections leading to meningitis

cryptococcus neoformans

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differential diagnoses of meningitis

encephalitis (inflammation of brain)
non-infective causes of meningeal irritation
subdural empyema (collection of pockets of pus)

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risk factors of meningitis

extremes of age
living in close proximity
absence of vaccination
immune suppression/deficiency

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if meningococcal meningitis what particular sign would there be?

rash or purpura (non blanching)

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examination for suspected meningitis

-purpuric rash
-signs of sepsis, shock (+record GCS)
-stiff neck: ask paint to touch chest with neck
-Kernig’s sign
-fundoscopy (for papilloedema)
-full neuro exam
(-cognitive assessment if worried about encephalitis)

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investigations for meningitis

CSF collection (opening pressure, microscopy/culture/sensitivity, protein, glucose, lactate, meningococcal and pneumococcal PCR)
blood cultures
urine pneumococcal antigen
serology for viruses causing meaningo-encephalitis
throat swab for meningococcus pneumonie and neisseria meningitides

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contra-indications of lumbar punctures

signs of raised intracranial pressure (papillodema or focal neurological signs)
coagulation defects
signs of infection at site of needle insertion)

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treatment of meningitis

bacterial: empirical therapy with an IV 3rd generation cephalosporin OR IM benzylpenicillin (in GP) + dexamethasone
- if patient over 60: amoxicillin added
- if Listeria suspected: ampicillin added
- if patients travelled to countries with high rate of pneumococcal penicillin resistance, seek advice (vancomycin or rifampicin)

difference between CT and MRI

CT: X ray based
MRI: magnetic waves (better spatial resolution of soft tissue lesions + greater resolution of portico-medullary patterns)

Headache red flag examination

Papilloedema (raised intracranial pressure)
Peripheral visual loss, enlarged ind spots (raised intracranial pressure)
Eye abduction inhibition (raised intracranial pressure or nerve infarction)
Extensor plantar
Pronator drift (pyramidal tract dysfunction due to raised intracranial pressure)
New onset ataxia
Oral hairy leukoplakia (EBV)
Non blanching/purpura rash
Livedo reticularis (risk of venous clots)

emergency/red flag symptoms headaches

Thunderclap onset
New onset neurological deficit/cognitive dysfunction
head trauma (w/in last 3 months)
photophobia + nuchal rigidity + fever +/- rash
reduced consciousness
acute red eye/acute angle closure glaucoma
new onset in third trimester pregnancy/early postpartum
change in personality
headache triggered couch, sneeze or valsa
Headache triggered by exercise
Symptoms suggestive giant cell arthritis
Substantial change in character of headache

When do you refer and/or further investigations with headache

Emergency/red flag symptoms OR if present with new onset headache: - immunocompromised (drugs/HIV) - <20 yo and history of malignancy - history of malignancy that metastasise to brain - vomiting without other obvious cause

What should be recorded in headache diary

``` Frequency, duration and severity of headache Associated symptoms Medications taken to relieve headache Possible précipitants Relationship headaches and menstruation ```

Migraine symptoms

Unilateral or bilateral Pulsing (throbbing/banging) Moderate or severe intensity of pain Unusual sensitivity to light and/or sound or nausea/vomiting Aura (symptoms are reversible, develop over 5 minutes and lasts 5-60 minutes)

quick onset symptoms points towards what type of meningitis

bacterial

``` CSF interpretation: clear, colourless WCC count: 0.5 Glucose > 2/3 blood glucose Protein (g/L): 0.15-0.4 ```

normal

``` CSF interpretation: turbid appearance WCC count: 500-10000 polymorphs Glucose: v low Protein (g/L): high ```

bacterial meningitis

CSF interpretation - appearance: turbid, viscous, straw - WCC count: <500 lymphocytes/polymorphs - glucose: low - protein: v high

tuberculosis meningitis:

CSF interpretation: - appearance: viscous, clear - WCC count <500 lymphocytes/polymorphs - glucose: low - protein: v high

fungal meningitis

when do you offer antimicrobial (rifampicin) to household who has come into contact with meningitis

``` haemophilus influenzae (esp non vaccine types) Neisseria meningitis ```

CSF interpretation: - appearance: clear - WCC count <1000 lymphocytes - glucose: normal - protein: raised

viral meningitis

types of intracranial space occupying lesions

- tumours (primary/secondary) - infections (brain abscess, subdural empyema, granuloma, parasitic) - vascular (haemorrhages, vascular malformations, infarction) - hydrocephalus (obstructive, communicating, overproduction)

signs/symptoms of raised intracranial pressure

symptoms: headache, vomiting, blurred vision, decrease in consciousness level signs: late in the process: bradycardia, hypertension, papilloedema, respiratory depression

space occupying lesions effect by location

- frontal lobe: weakness, dysphagia, personality changes, dementia - parietal lobe: sensory symptoms, Dressing apraxia, visual field defects - temporal lobe: dysphagia, visual field defects - posterior fossa: dysmetria, in-coordination gait ataxia, CN palsy, tremors, nystagmus etc - brain irritation: seizures

sites of origin of secondary metastases of brain

bronchus, breast, stomach, prostate, thyroid, kidney

primary malignant brain tumours

- astrocytes: glioblastoma multiforme, anaplasie astrocytoma - oligodendrocytes: oligodendroglioma - mixed malignant glioma (can arise from glial and oligodendrocytes) - ependydmal cells: ependymoma - cerebellum: medulloblastoma

benign brain tumours

- meninges: meningioma - myelin: nerve sheath tumour - pituitary gland: pituitary tumour, craniopharyngioma - astrocytes: astroctyoma

diagnosis of brain tumours

neuro exam scans (CSF studies bloods)

WHO grading of glioma

grade 1: pilocytic astrocytoma grade 2: low grade astrocytoma grade 3: anaplastic astrocytoma grade 4: glioblastoma multiforme (high grades can arise de novo or from malignant changes of low grade)

normal intracranial pressure value

<15 mmHg in adults | lower in children and negative in newborns

pathological ICP

persistent pressure >20 mmHg

Monro-Kellie doctrine

changes in one of the intracranial components (blood, CSF or brain parenchyma) causes displacement or replacement of another (usually CSF) = compliance

causes of raised ICP

- increase in brain/tissue/mass volume (cerebral oedema, SOL) - increase in CSF volume (obstruction of CSF circulate, reduced CSF absorption, increased CSF production) - increase in blood volume (raised arterial PCO2, venous obstruction, raised T°)

cerebral perfusion pressure formula

arterial BP - ICP

why is it important to know ICP in head injury

auto regulation of cerebral perfusion pressure in impaired: | if you know ICP, you can adapt ABP

how do you measure ICP

- EVD with strain-gauge pressure transducer (GOLD standard) - fibre optic intra-parenchymal transducer - air-pouch balloon - combined with temperature and micro dialysis

management of ICP

- promote venous outflow: 30-45° head tilt up, neck straight, no tight ETT tapes - maintain cerebral blood flow: avoid hypotension, maintain normal PCO2 - reduce cerebral oedema: maintain euvolaemia and norm-hyper osmolar state - reduce metabolic demands: maintain adequate sedation If this isn't enough: - CSF drainage - mannitol (osmotic therapy) - hyperventilation - barbituates - decompressive craniectomy - removal of space occupying lesion

symptoms of giant cell arthritis?

- head pain and tenderness (usually affecting both temples) - scalp tenderness - jaw pain when you chew or open mouth - fever - fatigue - unintended weight loss - vision loss or double vision - sudden permanent loss of vision in one eye

diagnosis of giant cell arthritis

- bloods: CRP, erythrocyte sedimentation rate (f RBC drop quickly, can indicate inflame) - biopsy of temporal artery