Neurology Flashcards
Two types of stroke? Percentage of each?
Main way to differentiate between each?
Ischaemic - 80%
Haemorrhagic - 20%
Head CT
Two mechanisms of ischaemic stroke?
Where does each occur?
1: comes from? other example?
2: mechanism? which vessels?
Will have a core and a ____?
- Embolism (away from brain) - clot form the heart (A-fib), cholesterol
- Thrombotic (within brain vessel) - atherosclerosis, generally in larger vessels (IC, BA, MCA)
Penumbra - preserved by collateral circulation, may survive
Two mechanisms of haemorrhagic?
1: often occurs at?
Increased ______ pressures increases risk of ___?
Tissue ischaemic is because of two reasons?
- Berry (saccular) aneurysms: often at ACA, PCA, MCA at junctions
- Arteriovenous malformations (rare defect)
Increased intracranial pressures increases risk of brain herniation
Tissue ischaemia - lack of flow & leaked blood irriates other vessels
Lacunar strokes: mechanism? aneurysms? which vessels? vessels feed what?
chronic HTN causes hyaline arteriolosclerosis (protein thickening)
Charcot-Bouchard
Lenticulostriate - occur on branch of MCA
Feed internal capsule and basal ganglia
When would a watershed strokes occur?
SHOCK - or other general decreased blood flow
What are the risk factors for forming Berry aneurysms? (3)
Chronic HTN, PKD, connective tissue disorders
How would different arteries affected by stroke present clinically? MCA (3) ACA (1) PCA (1) Basilar (1)
What is the 4 letter pneumonic?
MCA - face, upper body, Broca’s (speech)
ACA - lower body
PCA - vision: homonymous hemianopia
Basilar artery - locked-in syndrome (bilateral loss of corticospinal tracts)
Face, Arms, Speech, Time (FAST)
Risk factors for ischaemic stroke:
Major heart problem?
2 basic others?
Atrial fibrillation
Metabolic syndrome - diabetes, obesity, HTN, low HDL cholesterol, high triglyceride
Smoking
Acute treatment for ischaemic stroke (2) vs haemorrhagic stroke (3)
Surgery? (2 x 2)
ISCHAEMIC - Aspirin (stops further clots), Thrombolytics (eg, tPA)
Surgery: MERCI or suction
HAEMORRHAGIC - Anti-hypertensives, Elevate head, Anti-convulsant
Surgery: clips, coil embolisation
What defines a TIA over a stroke?
______ long term problems
______ risk of ______
TIA - resolves in 24 hours
Minimal long term problems
Large increase risk of stroke occuring
Prevention of further strokes:
Lifestyle - 3 points
Medications - 3 points
Surgery - 1 point
Lifestyle - blood pressure (exercise, salt, alcohol), smoking, medical conditions
Medications - blood pressure, statins, anti-platelet or anti-coagulants
Surgery - carotid endarterectomy
EPIDURAL HAEMATOMA: Occurs where? Normal mechanism? 4 symptoms? Clinical point to differentiate from subdural? Diagnosis - scan? shows what? Management - 3 key points?
Occurs in epidural space - between skull and periosteal dural mater
Damage to middle meningeal arteries - temporal bone fracture
Headache, N/V, High BP, Focal neural symptoms
Lucid interval present - good period followed by deterioration
CT scan - lens shape haematoma not crossing suture lines
SUBDURAL HAEMATOMA:
Occurs where?
Mechanism - what vessel? situation? 2 risky populations? baby?
Symptoms? (4- classic)
Diagnosis - scan, shows what?
Management: if there is a ______, then evacuate the haematoma
Occurs in sub-dural space - between dural and arachnoid maters
Bridging vessels
Trauama, Falls, MVC
Elderley (brain atrophy), Alcoholics (vein damage)
Shaken baby syndrome
CT-head: Concave (crescent) that can cross suture lines
Hyperdense (acute) Hypodense (chronic)
Midline shift >5mm, then evacuate
SUBARACHNOID HAEMATOMA: Occurs where? Mechanism? Symptoms - classic? meningitis like (2)? Diagnosis - scan? if positive, then what? Management - two strategies?
Occurs in subarachnoid space - in between arachnoid mater and pia mater
Berry (saccular) aneurysm ruptures in circle of Willis
“thunderclap” headache - severe, sudden
Neck stiffness, photophobia
CT-Head, positive, 4-vessel angiography
Supportive - bed rest, lower BP
Surgery - coil embolisation (preferred) or clips (out of date)
INTRACEREBRAL HAEMATOMA:
Occurs in where? (4)
3 example arteries supplying these areas?
3 causes of these arteries being damaged?
Sudden neurological defecits like hemiparesis? hemiplegia?
Management - increased _____ needs to be controlled. If there is _____ evacuation needed
Occurs in various places - thalamus, basal ganglia, cerebellum, PONS
Lenticulostriate, thalamo-geniculate, pontine branches
Hypertension, AV malformations, Amyloidosis
Hemiparesis - half side weakness
Hemiplegia - half side paralysis
Increased INTRACRANIAL PRESSURE needs to be controlled
If MASS EFFECT is present, evacuate
What is amaurosis fugax? What condition does it often occur in?
Emboli in retinal artery
Cannot see - “curtain descending over my vision”
Association with TIAs
What does the ABCD2 score predict? What does each letter represent?
Risk of stroke after a TIA has occured
Age
Blood pressure
Clincial features of the TIA
Duration & Diabetes
What specifically is inflamed in meningitis?
Two types of spread, that can cause the infection
LEPTOMENINGES - pia mater and arachnoid mater
DIRECT - skin, nose, fracture, spina bifida
HAEMATOGENOUS - blood
Bactaeria in meningitis:
Newborns (4)
Children & young adults (2)
Elderly and immunocomprimised (2)
• Newborns -
Group B streptococci,
E. Coli,
Listeria monocytogenes, Haemophilus influenzae
- Children & young adults - Neisseria meningitidis, Streptococcus pneumoniae
- Older adults & elderly - Streptococcus pneumoniae, Listeria monocytogenes
3 viral causes of meningitis?
3 other categories of causes (non-bacterial)
What is different in these presentations?
Enterovirus (coxsackie)
HSV
HIV
FUNGAL - Cryptococcus genuses, Coccidioides genuses (chronic)
TUBERCULAR - Mycobacterium tuberculosis (chronic)
PARASITIC - Plasmodium falciparum (chronic)
Classic triad of MENINGITIS symptoms?
Other symptoms?
What are the two signs that will be positive in meningitis?
Classic triad - headaches, photophobia, neck stiffness
Fever often present
Two tests:
Kernig’s sign - knee at 90, straightened at knee, causes back pain
Brudzinski’s sign - neck flexed, causes knees to be flexed
CSF in bacterial meningitis: Colour? WBC? Protein? Pressure? Glucose?
Noted differences in VIRAL and FUNGAL/TB
Signs of infection: CSF - cloudy (should be gin clear) WBC - increased (bacterial = neutrophils, lymphocytes = viral) Protein - increased Pressure - increased Glucose - decreased
Viral - normal proteins, normal gram-staine, normal pressure, clear (not cloudy), massive WBC increases
Fungal/TB - fibrin web
Neisseria meningitis: Microscopy vs S. pneumoniae Causes a skin \_\_\_\_, looks like? Notifiable to? Why is it common in university students?
GRAM -VE, DIPLOCOCCI
Streptococcus pneumoniae is POSITIVE
Capillary damage and/or DIC
- non-blanching, purpuric, petechiae rash
Family carriers - move to a new house
Tell Public Health England
Treatment of meningitis: In community? Two classic broad spectrum? Other antibiotic used in cover? What is used other than antibiotics?
IN COMMUNITY - IM Benzylpenicillin, send to hospital
Commonly 3rd generation
cephalosporins:
Ceftriaxone, Cefotaxime
Amoxicillin covers Listeria
Steroids used - reduces brain swelling (inflammation)
Important differential of meningitis?
How is viral meningitis treated?
Subarachnoid haemorrhage
Supportive w/ acyclovir
Encephalitis is inflammation of \_\_\_\_? Normal cause (2)? + a rarer cause?
of the BRAIN PARENCHYMA Often viral (HSV, sometimes Varicella Zoster), sometimes bacterial
Symptoms of encephalitis:
Early symptoms (4)
Late symptoms: (3)
Can still have _____ signs and symptoms, but ______ is often altered
Early symptoms - fever, headache, lethargy, behaviour changes
Late symptoms - focal signs, seizures, coma
Can still have MENINGITIS signs and symptoms, but CEREBRAL FUNCTION is often altered
Normal treatment for encephalitis? (2)
What would the lumbar puncture show in this condition?
Supportive
Often IV acyclovir (anti-viral)
Would show raised lymphocytes
What organism cause tetanus? Found where? Mechanism of the disease? What to do if there is a risk injury? Two classic presentation points?
Clostridium tetani
Found in soil
Bacteria produce toxins - travel along axons and interfere with neurotransmitter release
Vaccintion if there is a risk injury
Risus sardonicus (satanic smile)
Complete muscle spasm
Could be localised?
Rabies is what type of infection?
Cause by?
“Travels ____”
Has a varaible ______
Treatment: 2 options?
If it becomes _____
Viral infection
Inoculation throguh skin with saliva of rabid animal
Travels retrogradely along nerve
Pre or Post-exposure prophylaxis
If symptomatic - it’s fatal
Name the 3 primary headaches?
Name 4 secondary headaches?
What is the name of the painful cranial neuropathy?
Primary -
migraine,
cluster,
tension type
Secondary -
meningitis,
subarachnoid haemorrhage, GCA,
chronic medication overuse (aspirin, paracetamol, NSAIDs, triptans, etc)
Painful cranial neuropathy - trigeminal neuralgia
MIGRAINE: What side? Severity? Character of pain? Onset? How long? 4 associated symptoms? Worsens with?
Often unilateral, Moderate/severe,
Throbbing,
Gradual onset
Duration: 4-72 hours
N/V, Photophobia, Phonophobia
Worsens with activity
Migraine treatment: Normal (3 - 2 drugs and 1) Severe (1 - drug) Preventative? (2 - drugs) Reduce \_\_\_\_\_? Examples of this?
NSAIDs/Aspirin, Antiemetic, Hydration
Severe - oral triptan (eg, Sumatriptan) is given. Has come contraindications - vascular diseases
Preventive - topiramate (anti-convulsant) or propranolol (beta-blocker)
Reduce triggers:
Chocolate, Hangovers, Orgasms, Cheese, OCP, Lie-ins, Alcohol, Tumult (loud noises), Exercise
TENSION TYPE: What side? Severity? Character of pain? How long? Associated symptoms?
Bilateral
Mild to moderate
Waxes and wanes
Pressure or tightness band
Massive variable time - 30 minutes to 7 days
Little associated - sometimes photophobia or phonophobia
Triggers - missed meals, stress, overexertion, lack of sleep, depression
Can you name some triggers of TENSION TYPE headache? (5)
What is the go to medication?
_____ relief?
Triggers: missed meals, stress, overexertion, lack of sleep, depression
Paracetamol or NSAIDs
Stress relief
CLUSTER: What side? Where? Severity? Character of pain? Onset? How long? Point about activity? Associated points (3) - trigeminal autonomic features
Unilateral - around eye Severe Deep continous pain Begins quickly Short (15-180 minutes) Often causes restlessness and agitation
Horner’s syndrome (ptosis + miosis)
Lacrimation
Nasal charge
What is the main medicatino for CLUSTER headache?
2 preventative drugs?
Treatment: SC SUMATRIPTAN
Preventive - topiramate or propranolol
RAISED ICP: Headache is worse when (1) Headache is worse when (1) Headache is worse when (3) Association with _/_ What is papilloedema?
Worse on waking
Worse on coughing, sneezing, straining
Postural - worse lying down
Nausea/Vomiting
Papilloedema (may be absent if acute): swollen optic disks
Type of pain in trigeminal neuralgia? Lasting how long?
What is the main medication of trigeminal neuralgia? Next step?
Electrifying/Lightning/Stabbing pain - lasting a few seconds
Medication - CARBAMAZEPINE (anti-convulsant)
Phenytoin, Gabapentin (neuropathic pain analgesia)
Surgery is a final option
Can have what before a migraine? What percentage of migraines?
3 points about it
Episodic migraines
Aura: 20% without, 80% with
Visual symptoms - flashing lights, zigzags
Sensory disturbances - tingling in hands and feet
Language aura and motor aura
What would you see in a biopsy of someone with GCA?
Which vessels does GCA affect?
Why is it difficult to biopsy?
Giant cells in the elastic lamina
Branches of the carotid - eg, TEMPORAL, opthalmic, facial, occipital…
Segmental - need a long piece, and may not be present
How would someone with GCA present: 3 general symptoms Temporal specific? Opthalmic specific? Facial specific? Occipital specific?
3 signs related to the temporal arteries?
Malaise, fever, anaemia
Temporal - headache (often localised)
Opthalmic - visual disturbances (amaurosis fugax)
Facial - jaw claudication
Occipital - scalp tenderness
PALPABLE, TENDER and REDUCED PULSATION of temporal arteries
3 points on epidemiology of GCA?
What is major lab result that would be seen in GCA?
Women > Men, Almost always >50, Common in Scandinavia
Increased ESR!! (also CRP)
What is the go to treatment of GCA? Why does this need to be done quickly?
Corticosteroids
Eg - prednisolone
Because of the complication:
BLINDNESS (important to treat quick - don’t wait for biopsy)
What is the definition of an epileptic seizure?
Too much ____?
Too little ____ ?
neurons synchronously active (paroxysmal discharge of cerebral neurons)
Too much excitation - lots of glutamate
Too little inhibition - too little GABA
What is the other name for a partial seizure? What does it effect? What are the two subtypes? Basic characteristics of each subtype? What is a Jacksonian March?
Focal seizure
Effects ONE hemisphere or ONE area
Simple - remain conscious (small area, strange sensations and jerking)
Complex - impaired consciousness (imapired awareness, may not remember)
A simple partial seizure spreads from the distal part of the limb toward the ipsilateral face
What can a generalised seizure progress from? Definitions of the following? TONIC ATONIC CLONIC TONIC-CLONIC MYOCLONIC ABSENCE Which of these is most common?
Can progress from a PARTIAL SEIZURE
- TONIC - flexed, fall backwards
- ATONIC - relaxed, fall forwards
- CLONIC - convulsions
- TONIC-CLONIC - sudden tense muscle, followed by convulsions
- MYOCLONIC - short muscle twitches
- ABSENCE - lose and regain consciousness, “space out”, commonly presents in childhood
Tonic-Clonic is most common
If seizures last greater than 5 minutes what are these called?
What is the usually type of seizure?
What is the emergency treatment used? How does this work?
If seizures last greater than 5 minutes - STATUS EPILEPTICUS
Usually TONIC-CLONIC
Medical emergency - treated with BENZODIAZEPINES (enhances GABA)
What are the three diagnostic tests that can be done in epilepsy?
What are the two symptoms that could occur after seizures?
MRI & CT - brain scan for abnormalities
EEG - detect electrical signals
Postical confusion
Todd’s Paralysis (paresis in arms or legs for around 15 hours after seizure)
Management of epilepsy: Focal/partial medication? Generalised medication? Nerve \_\_\_\_\_? Epilepsy \_\_\_\_\_? Diet \_\_\_\_? Avoid \_\_\_\_? eg \_\_\_\_
- Focal - CARBAMAZEPINE
- Generalised - SODIUM VALPORATE (teratogenic)
Nerve Stimulation
Epilepsy surgery
Ketone diet
Avoid triggers - eg flashing lights
Differential of seizures: EPILEPTIC - Time \_\_\_\_ symptoms 3 more
30-120 seconds Positive symptoms - tingling and movement Tongue biting Head turning Muscle pain
Differential of seizures:
NON-EPILEPTIC -
Time
4 more
1-20 minutes in duration (longer than epileptic) Eyes closed Crying or speaking Pelvic thrusting History of psychiatric illness
Differential of seizures:
Syncope
Time
4 more
5-30 seconds Sweating Nausea Pallor Dehydration
