Neurology Flashcards
1
Q
The main aims of a neurological examination. General system of examination and how to roughly do it
A
- To find the anatomical site (level) of the lesion
- Two People Cant Resist Sex
Tone:
- How stiff something is
- Increased Tone suggests UMN lesion
- Decreased Tone suggests LMN lesion
Power:
- Compare the two sides and try and compare with similiar forces
- 0-5
- 5 normal power
- 0 complete paralysis
Coordination
- Finger-nose command
- With your right hand, touch your nose, then my finger then your nose as fast as you can
Reflexes:
- Tap on knee tendon to initiate rapid muscle stretch
- Hyper-reflexia= UMN
- Hypo-reflexia= LMN
Sensation:
- Light touch: use a piece of cotton wool to compare dermatomes on both sides
- Proprioception: hold either side of finger tip then move up/down with the eyes closed
- Vibration: tuning fork on bony prominences
- Pain: use a neurotip- small disposable pin
- Temperature: metal instrument as cold and the rubber part of this as hot
2
Q
Why do all cranial nerves decussate and which CN is different
A
-Right side is controlled by the left brain and vice cersa
- Occurs because of the way light and vision works
- There needs to be an optic chiasm
- The rest of the CNS swap over so everything stays consistent
- If you saw a man on your right hand side (from left part of the brain), you would want to punch him on your right rather than your left
CNVII receives bilateral innervation from both sides of the brain
3
Q
How to rate the severity of a coma
A
- Glasgow Coma Scale assesses patient ability to open their eyes, move and speak
- Minumum score of 3 to a maximum of 15
- 8 or less is clinically defined as a coma
- Motor Response
6: Obeying commands
5: Movement localised to stimulus
2: Involuntary muscle straightening
1: None - Vertbal Response:
5: Orientated response
4: Confused response
3: Inappropriate words
2: Incomprehensible
1: None - Eye Opening
4: Spontaneous
3: To speech
2: To pain
1: None
4
Q
Assessment for dementia
A
- Abbreviated Mental Test Score (AMTS)
- Score of 7-8/10 or less suggests cognitive impairment
- Other tests are necessary to confirm a diagnosis of dementia, delirium or other causes of cognitive impairment
- What is your age
- What is the time to the nearest hour
- Give pt address and get them to repeat it at the end of the test
- What is the year
- What is the name of the hospital where the pt is situated
- Can you recognize two people (doctor and nurse)
- What is your DOB
- When did WW1 begin
- Name present prime minister
- Count backwards from 20 down to 1
5
Q
Definition of a stroke and clinical features possibilities of a patient who has suffered a stroke
A
- A focal neurological deficit that lasts longer than 24 hours
- Results from a vascular lesion
- Either ischaemic (due to lack of blood flow) or haemorrhagic
- Paraplegia- impairment of motor or sensory function of the lower extremities
- Hemiplegia- loss of motor or sensory control on one side of the body
- Tetraplagia/Quadraplegia: Paralysis by illness/injury that results in partial or total loss of use of all 4 limbs and the torso
6
Q
Increasing complexity/seriousness of strokes
A
- If there is a focal deficit and full recovery in less than 24 hours, it is known as a transient ischaemic attack
- if full recovery within a week with minimal/no deficit, then it is known as a Minor stroke
- A stroke in evolution is where the signs and symptoms are worsening
- Completed stroke is the point at which neurological deficit is at its worst
7
Q
Types of Stroke and importance of distinguishing
A
15% of strokes are wet/haemorrhagic
85% of strokes are dry/ischaemic
- First thing to do is to work out if wet or dry
- Treatment option for the wrong type can be life threatening
- If it as dry stroke, then you want to give anti coagulant drugs
- Which could be disastrous if you did this in a patient with a wet stroke
8
Q
Differential diagnosis of a stroke
A
- Can be mimicked by fast expanding space occupying lesion such as tumour or an abscess
- Hypoglycaemic patient
9
Q
Dry stroke. Different aetiopathogenesis
A
- Thrombosis at an atheroma plaque site
- Local blood clot
- Thrombi can move and form an emboli somewhere else in the body
- Embolisation of this thrombi into an end artery
- Important to work out where the embolus has come from
- Typical end arteries include the vertebral basilar/carotids
- Mural thrombi (thrombi attach in aorta) from left ventricle
- Systemic hypotension and hypoperfusion (general decrease in blood pressure and supply)
- Eg. in shock
- Sudden stop in blood pressure
- For a long period of time
- Rarely (septic) vegetations from biscuspid/aortic valves in infective endocarditis (LHS of the heart)
- If vegetations from the valve flick off, you may get a septic infarct
- SI is an area of necrosis reesulting from vascular obstruction caused by emboli consisting of clumps of bacteria or infected materials
10
Q
Which side of the heart are you more likely to get an embolus forming
A
Because as it leaves the right venticle, it is going straight to the lungs where it theoretically should get filtered
If leaving the LV, it is going around the rest of the body
So left side of the heart is where youre most likely to get an embolus
11
Q
Common Stroke symptoms
A
- Sudden numbness or weakness of face, arm or leg
- Sudden confusion, trouble speaking or understanding
- sudden trouble seeing in eyes
- Sudden trouble walking, dizziness, loss of balance
- Sudden severe headaches with no known cause
-call ambu asap
12
Q
Main risks for a dry stroke
A
- Diabetes
- Smoking
- Obesity
- Alcohol
- Oral Contraceptives (side effect of pro-coagulation)
- Polycythaemia (high concentration of RBCs)
- Atheroma (hypercholestrol/ lipid aemia)
13
Q
Aetiopathogeneis and Risks for a wet stroke
A
- Bleeding directly into the brain or into the space between the brains membranes
- May occur due to a ruptured intra-cranial micro-aneurysm (Weakness in the wall of a cerebral artery or vein causing a localised dilation or balloning of a blood vessel)
-Often a hereitable, congenital defect
Such a Circle of Willis tendency to burst
Aortic aneurysm is the most life threatening
Also secondary to hypertension
14
Q
Investigations and diagnosis of stroke
A
- History of event (trauma to the side of the head may suggest wet)
- Risk factors (IE, Rh Fever, Previous MI, Atrial Fib)
- General signs evolving (wet strokes associated with vomiting and nausea)
- Use INR to check if it is a warfarin bleed
- Use LFTs
- Use ESR to see if its vasculitis or endocarditis
- Check glucose to rule out hypoglycaemic event
- Use ECG to check AF/MI
-CT/MRI is the main differentiator to work out if it is a wet or dry stroke
Management is revolved around the diagnosis to see what type of stroke it is
15
Q
Long-Term effects of a stroke and how the features develop
A
- Most common lesion causes hemiplegia, where one side of the body is impaired
- Often due to brain tissue death from the opposing side
- Initially flaccid with reduced reflexes
- In a few days, spasticity supervenes with a ‘typical stroke walk’ in which the arm is flexed and the leg is extended
- Strength recovery takes over weeks to months
- Can lead to one sided vision loss (hemianopic)
- Or possibly apahasia (impairment of language)
16
Q
L brain damage causes what and vice versa
A
Left Brain Damage
- Paralyzed right side
- Speech/langugage deficits
- Slow, cautious behaviour
- Memory Deficits
Right Brain Damage
- Paralyzed left side
- Spatial perceptual deficits
- Quick, impulsive behavioral style
- Memory deficits
17
Q
Management of Dry stroke
A
- Initially, make sure you diagnose the correct stroke
- Use INR to check if it is a warfarin bleed
- Use LFTs
- Use ESR to see if its vasculitis or endocarditis
- Check glucose to rule out hypoglycaemic event
- Use ECG to check AF/MI
- If confirmed dry stroke then:
- Thrombolytic drugs
- Aspirin
- tPA- fibrin clot buster
- Occasional Heparin (if DVT risk)
- Slow reduction in BP- avoid a sudden crash and a second dry stroke
- Support
- Rehab, Physio
- Nasogastral feeding
- Hydration
- Chair Lifts, Aids, OH adaptations, shower etc
- Look for secondary risks
- Carotid atheromas
- Clotting screens
- Hypertension
- If appropriate, aspirin/chronic warfarin can be taken
- Can also perform endarterectomy which is a surgical procedure to remove the atheromatous plaque in the lining of the material
18
Q
Management of Wet stroke
A
- Pts may be offered meds that reduce BP and prevent further strokes
- Surgery may be required to remove any blood from the brain and repair any burst blood vessels
- Support
- Rehab, Physio
- Nasogastral feeding
- Hydration
- Chair Lifts, Aids, OH adaptations, shower etc
- Similiarly look for secondary risks
19
Q
Dental Relevance of Strokes
A
- Need to teach patients how to brush teeth one handed
- Severity and type of impairment is different for each patient so need to individualise
- ID brushing
- Getting to appointments on time
- How can we make it easier for the patient
- Dentures
- Warfarin patient
20
Q
Different types of wet strokes and explanation of each
A
Subarachnoid Haemorrhage
- Inside the structure of the brain
- Bleeding between arachnoid membrane and pia mater surrounding the brain
- Circle of Willis Aneurysm Rupture usually
- Sudden loss of conciousness
- High pressure so fast onset
- Often neurosurgery required
- clip and tie bleeder
Subdural Haemorrhage
- Collection of blood gathers between the inner layer of the dura mater and arachnoid mater
- Usually venous with a slower onset
- Lesion causes a mass effect- swells further with blood breakdown
- Typically after a milder fall
- Loss of consciousness a few hours/days later
Extradural haemorrhage
- Typically middle meningeal artery bleed after blow to the side of the head
- Typically in the temporal region
21
Q
Definition of Epilepsy
A
- Common condition that affects the brain and causes frequent seizures
- Seizures are bursts of electrical activity in the brain that temporarily affect how it works
- They can cause a wide range of symptoms
-Epilepsy means a patient may have a tendency to have seizures, but anyone can have a one-off seizure and not be epileptic
22
Q
Causes of epilepsy
A
- Not very well understood
- Electrical signals in the brain become scrambled and there are sudden bursts of electrical activity
- Often not clear why this happens
-Familial/genetic heritance: errors in genes affecting brain function
-Occasionally, epilepsy can be caused by damage to the brain, such as damage from: Stroke Brain tumour Severe Head Injury Drug/Alcohol abuse Brain infection Hypoxia during birth
23
Q
Clinical Features of Epilepsy
A
-Seizures can affect people in different ways, depending on which part of the brain is involved
- Uncontrollable jerking and shaking, called a fit
- Losing awareness and staring blankly into space
- Becoming stiff
- Strange sensations, such as a rising feeling in the tummy, unusual smells or tastes, and a tingling feeling in your arms and legs
- Collapsing/passing out
- Main symptom is repeated seizures. Sudden bursts of electrical activity in the brain that temporarily affect how it works
- Typically pass in a few seconds or minutes
- Awake or asleep
- Sometimes triggered by something, eg feeling very tired
24
Q
Different types of seizures and explanation of eahch
A
Simple partial (focal) seizures or auras:
- Strange feeling that is difficult to describe
- Feeling that events have happened before (deja vu)
- Intense feeling of fear or joy
- Rising feeling in your tummy
- Unusual smells or tastes/tingling in your arms and legs -Stiffness or twitching in part of your body, such as an arm or hand
- Remain awake and aware while this happens
- Considered warnings and may predispose to other types of seizures
Complex partial (focal) seizures:
- Lose your sense of awareness and make random body movements
- Smacking your lips
- Rubbing your hands
- Making random noises
- Moving arms around
- Picking at clothes or fiddling with objects
- Chewing or swallowing
- Pt won’t be able to respond to anyone and will not have any memory of it
Tonic-Clonic Seizures or grand mal:
- Typical epileptic seizure
- Initial tonic stage- lose conciousness, body goes stiff, and may fall to the floor
- Second clonic stage- limbs jerk, lose control of your bladder or bowel, may bite tongue or inside of cheek and may have difficulty breathing
- Typically stops after a few minutes, but some last longer
- Difficulty remembering what happened
Absences, or petit mal
- Lose awareness of surroundings for a short time
- Mainly children
- Stare blankly into space
- Daydreaming
- Flutter their eyes
- Up to 15 seconds
- Won’t be able to remember them
Myoclonic seizures
- Some or all of your body suddenly twitches or jerks, like you’ve had an electric shock
- Soon after waking up
- Only last a fraction of a second, but several can sometimes occur in a short space of time
- Normally remain awake during them
Clonic Seizures:
- Body shakes and jerks like grand mal seizures
- But you don’t go stiff at the start
- Last a few minutes and may lose consciousness
Tonic seizures:
- All muscles before very stiff
- May lose balance and fall back
Atonic seizures:
- All muscles suddenly relax
- May fall to the ground (often forward)
- Very brief
- Usually you’ll be able to get up again straight away
Status epilepticus:
- Any seizure that lasts a long time, or a series of seizures where the person doesn’t regain consciousness between
- Medical emergency and needs to be treated as soon as possible
- Call 999
25
Q
Partial and generalized seizures definition and classify all the types of seizures
A
Partial Seizure: one hemisphere or lobe which can be further split into
- Simple partial
- Complex partial
Generalized Seizure: both hemispheres of the brain are affected
- Tonic
- Atonic
- Clonic
- Tonic-Clonic
- Myoclonic
- Absence
26
Q
Significance of status epilepticus and management
A
- if seizure lasts more than 5 mins
- either ongoing or without returning to normal
- no regaining conciousness between seizures
- usually Tonic Clonic seizures
- Medical emergency
- Treated with benzodiazepines (enhance inhibitory NT GABA)
- Call 999
27
Q
Diagnosing and Investigations (along with explanation) of Epilepsy
A
- MRI/Ct scan to look for abnormalities in the brain
- eg unusual growth/brain tumour, damage to the brain, by stroke scarring in the brain
- EEG (during and between seizures) detects electrical signals in the brain
- Check for unusual electrical activity in the brain that can happen in people with epilepsy
- Small sensors attached to the scalp to pick up the electrical signals produced when brain cells send messages to each other
- Recorded by a machine and are looked at to see if unusual
- As epilepsy varies considerably, diagnosis requires tests and examination of clinical history
- Diagnosis can just be based on symptoms
28
Q
When taking a history of epilepsy, or associating the epilepsy with a syndrome, what is important information/questions
A
- Type or types of seizures
- Age at which they began
- Cause of the seizure
- Whether the seizure are inherited
- Part of the brain involved
- Factors that provoke the seizure
- How severe and how frequent
- Ever hospitalized
- ECG patterns during and between seizures
- Brain imaging findings eg. MRI or CT scans
- Genetic information
- Other associated disorders
29
Q
Triggers of epileptic seizure and how to identify the triggers
A
-Many people seizures occur randomly
- Stress
- Lack of sleep
- Waking up
- Drinking alcohol
- Meds and illegal drugs
- Monthly periods in women
- Flashing lights (uncommon trigger)
-Keep a diary of when seizures occur and what happened before to identify and avoid possible triggers
30
Q
Management of Epilepsy and aims of tx
A
- Aim is to minimize or stop seizures completely
- Take a diary everytime you have a seizure and see if you can spot a common trigger so you can avoid it. If strss is a trigger, then yoga and meditation can help
- Anti-Epileptic Drugs/ Anti-Convulsants
- Surgery to remove a small part of the brain that are causing the seizures
- Procedure to put a small electrical device in the body that can help control seizures
- Vagus nerve stimulation and deep brain stimulation
- Ketogenic diet uses fat instead of carbs for energy. Ketone bodies used as an energy source for the brain rather than glucose. But atherosclerosis, diabetes and CVS disease
- Some people may need to treatment for life, but some might be able to stop treatment if seizures disappear over time
31
Q
Anti-Epileptic Drugs how they work, type and side effects
A
- Most commonly used tx for epilepsy
- Work by changing the levels of chemicals in your brain. Don’t cure epilepsy but can stop seizures occuring
- Must be used every day. Sudden cessation can provoke a seizure so cessation is a slow withdrawal
- Phenytoin
- Sodium valproate
- Carbamazepine
- Lamotrigine
-Depends on epilepsy type, age and if female (pregnant) Sodium valproate can harm an unborn baby
- Drowsiness
- Lack of energy
- Uncontrollable shaking (tremor)
- Rashes
- Serious allergic reaction
- Headaches
- Muscle cramps
- Hair loss or unwanted hair growth
- Swollen gums- phenytoin
