Neurology Flashcards
What are the differential diagnoses for a collapse?
Epileptic seizure
Syncope - vasovagal, postural, cardiogenic
Physiological - hypoglycaemia, sleep disorder, TIA
Psychological - non-epileptic attack/pseudo-seizure, panic attack
Give 3 features of the history to ask about for seizure
History from eyewitness Provoking factors Preceding symptoms Description of episode Recovery from episode
What risk factors may be present in the history for seizures?
Previous/family history
Birth injury, febrile convulsions, meningitis
Brain injury - stroke, surgery
History of myoclonic jerks
Give a provoking factor for seizure
Alcohol
Drugs
Sleeping tablets
Sleep deprivation
Give 2 provoking factors for syncope
HTN medication Undergoing painful medical procedure Hot environment Standing up too quickly Prolonged standing
What preceding symptoms might there be for a seizure?
Generalised - none
Focal - aura (smell, taste, deja vu, fear, unusual feeling, sensory changes)
What preceding symptoms might there be for syncope?
Darkening of vision Seeing spots Ringing in ears Hot flush Feeling dizzy Palpitations
Give 3 features of a focal seizure
Automatisms - lip smacking, stroking Head and eye deviation Limb stiffening and jerking Reduced interaction/responsiveness Frontal lobe 10-20 secs; temporal lobe 2-4 mins
Give 3 features of a generalised seizure
Body stiffening/rigidity May let out scream Rhythmical limb jerking Colour change (blue/purple) Open rolled back eyes 1-2 mins duration Heavy breathing and snoring after
Give 3 features of a vasovagal or postural episode
Fade to black Flop to ground Pale/sweaty/ashen Slow pulse Short duration Rapid recovery
What is the recovery period like after a seizure?
Non-responsive for some time Post-ictal confusion Dysphasia Todd's paresis May not recall events Headache Malaise Sleepy
What is Todd’s paresis?
Focal weakness in a part or all of the body after a seizure; usually subsides within 48 hours
What is convulsive syncope?
Common variant of syncope
May have rigidity and rhythmic jerking
May be incontinent and be briefly confused
Give 4 features of non-epileptic attack
RFs - sexual/physical abuse, anxiety, depression
Prodrome - inability to move, fear, breathlessness, dizzy
Description - prolonged, wax and wane, thrashing/flailing, back arching, tremor all over, resisting eye opening
After - confused, rapid recovery, tearful, awareness, injuries
What examinations may be considered for collapse?
Standing/lying BP
Auscultation of heart
Focused neurological exam
Fundoscopy
What investigations may be considered for collapse?
ECG
Bloods - FBC, U&Es, glucose, calcium, phosphate, magnesium
Syncope - tilt table, monitoring, echo
Seizure - MRI, EEG, video telemetry
Define seizure
Transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain
When is a diagnosis of epilepsy no longer applicable?
Patient with age dependent epilepsy syndrome who is past the applicable age
A patient who has remained seizure free for >10 years off medication
What is meant by a focal seizure?
Seizure originating within networks limited to a single hemisphere; may be localised or distributed
What is meant by a generalised seizure?
Seizure originating at some point and rapidly engaging bilaterally distributed networks; may not necessarily involve the entire cortex
What is Dravet syndrome?
Epilepsy syndrome with genetic cause
Onset in first year of life with febrile seizures, prolonged clonic seizures, often precipitated by hyperthermia
Give 3 types of non-epileptic seizures/events
Syncope Psychological/behavioural events Sleep related problems Paroxysmal movement disorders Migraine and related disorders Miscellaneous neurological and non-neurological events
Define syncope
A transient loss of consciousness resulting from an insufficient supply of oxygen to the brain
What are anoxic seizures?
The collapse, stiffening, +/- jerking that can occur as a result
of neurogenic syncope or breath holding, often due to unpleasant event/crying (children)
Give 2 clinical features used to differentiate syncope and seizure
Lateral tongue biting
Unpleasant circumstances preceding event
Define cataplexy
Sudden, brief loss of voluntary muscle tone triggered by strong emotions such as laughter
What is a TIA?
Focal neurological symptoms of acute onset which resolve within 24 hours, typically within minutes, due to underlying cerebral ischaemia
What is the ABCD2 score?
Risk factors for stroke
A- age >60 years (1)
B - BP elevation (1)
C - clinical features - unilateral weakness (2) or speech disturbance without weakness (1)
D - duration of symptoms - >60 mins (2), 10-59 mins (1)
D - diabetes (1)
Define stroke
Rapidly developing clinical signs of disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin
Give 2 signs/symptoms of stroke
Weakness - limb/face/arm/hemiparesis
Dysphasia
Visual disturbance (right homonymous hemianopia)
Light-headedness
What artery is likely to have been affected in a stroke where weakness has occurred in the leg only?
Anterior cerebral artery
What artery is likely to have been affected in a stroke where weakness has occurred in the face and arm?
Middle cerebral artery
What artery supplies Wernicke’s and Broca’s speech areas?
Middle cerebral artery
A stroke involving which artery could result in cerebellar signs?
Posterior inferior cerebral artery
Give 2 causes of ischaemic stroke
Cryptogenic (unknown)
Cardiac embolism
Small vessel disease
Atherosclerotic cerebrovasular disease
What does TACS stand for, what symptoms occur and where is the occlusion?
Total anterior circulation syndrome
Hemiperesis, higher cortical dysfunction and hemianopia
Proximal middle cerebral artery or internal carotid artery
What does PACS stand for, what symptoms occur and where is the occlusion?
Partial anterior circulation syndrome
Higher cortical dysfunction alone OR 2 of hemiparesis, HCD, hemianopia
Branch of middle cerebral artery
What does POCS stand for, what symptoms occur and where is the occlusion?
Posterior circulation syndrome
Hemianopia OR brainstem syndrome alone
Perforating arteries, posterior communicating artery or cerebellar arteries
What does LACS stand for, what symptoms occur and where is the occlusion?
Lacunar syndrome
Pure motor OR pure sensory OR sensorimotor OR ataxic hemiparesis OR clumsy hand dysarthria alone
Perforating artery or small vessel disease
Define intracerebral haemorrhage
A focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma
Give 2 causes of haemorrhagic stroke
Trauma Small vessel disease Amyloid angiopathy Blood vessel abnormalities Blood clotting deficiencies Haemorrhagic transformation of infarct Tumours Drugs (e.g. cocaine)
How does the management of ischaemic vs haemorrhagic stroke differ?
Ischaemic - IV thrombolysis +/- thrombectomy OR aspirin; stroke unit; hemicraniotomy
Haemorrhagic - BP control and reverse anticoagulation; stroke unit; neurosurgical evacuation
How is the decision between thrombolysis and thrombectomy made for managing ischaemic stroke?
Within 4.5 hours of symptoms = thrombolysis
Within 6-8 hours of symptoms = thrombectomy
Give 3 methods of secondary prevention for stroke
Smoking cessation Anti-platelets (aspirin, clopidogrel) Anti-coagulation if AF BP management (ACEI) Cholesterol management (statin) Diabetes management Surgical intervention for severe carotid stenosis
What is the most important risk factor for ischaemic stroke?
Smoking
What should a patient be prescribed if they present with a TIA episode and then meet discharge criteria?
Aspirin
oral 300 mg
once daily until seen in TIA clinic
What are the driving implications for TIA?
1 month driving ban (no need to inform DVLA)
How are headaches classified?
Primary - no underlying pathology
Secondary - underlying pathology
Name 2 types of primary headache
Migraine
Cluster
Trigeminal neuralgia
Tension
Give 3 features of a migraine
Can have aura Pounding/throbbing Lasts for hours Unilateral Nausea/vomiting Photo/phonophobia Disabling Lying still in a dark room helps
Give 3 triggers for migraine
Chocolate Cheese Red wine Aspartame Menstruation
Give 3 features of an aura
Hours/days before migraine
Lasts 5 mins - 1 hour
Visual/sensory/speech
What is a hemiplegic migraine?
Migraine with aura including motor weakness (lasts <24 hours) that usually precedes the headache
Can be autosomal dominant
How are migraines managed?
Aspirin NSAIDs Paracetamol Triptans Anti-emetics (limit to 2 days/week) Contraception
What drugs should be avoided in migraine?
Opioids
When should migraine prophylaxis be considered and what options are there?
If at least 2 attacks per month occur causing >3 days of disability
Options - propranolol, topiramate, pizotifen, amitriptyline, venlafaxine, duloxetine
6 week trial
Give 3 features of cluster headaches
Male smokers
Remission for months/years
Repeatedly occur at set times of day (up to 8x/day)
May occur during sleep
May be autosomal dominant
Unilateral pain around orbits/temporal region
Lasts 15-180 minutes
Give 2 autonomic features which can occur ipsilaterally with cluster headaches
Conjunctival injection Lacrimation Orbital oedema Nasal congestion Facial sweating Miosis/ptosis Restlessness/agitation
How are cluster headaches managed?
Acute - high flow oxygen and subcutaneous triptan
Prophylaxis - verapamil
Give 3 features of trigeminal neuralgia
Sudden, severe, shock-like facial pain
Can affect 1/2/3 branches of the nerve
Cutaneous triggers
Lasts seconds but occur in quick succession
May have a refractory period
May be due to MS/, tumour or vascular loop
How is trigeminal neuralgia managed?
Acute - none
Prophylaxis - anti-epileptics (e.g. carbamazepine), anti-depressant (e.g. amitriptyline)
Surgery - microvascular decompression
Give 3 red flag features for secondary headache
S - systemic features/risk factors (e.g. fever, weight loss, malignancy)
N - neurological signs (e.g. confusion, reduced GCS, focal neurology)
O - old (>50 years) with new headache
O - onset (thunderclap)
P - progression (change in severity)
Give 4 causes of secondary headache
Subarachnoid haemorrhage Cerebral venous sinus thombosis Temporal arteritis Meningitis Tumour Dissection Idiopathic intracranial hypertension
Give 3 features of a SAH
Thunderclap (high intensity, reaching peak in 1 minute)
Last >2 hours
Associated - meningitic signs, reduced GCS, nausea/vomiting
Usually due to burst aneurysm
Neurosurgical emergency
What investigations are helpful in SAH and why are their timings important?
CT - detection decreases with time
LP - dectection best 12 hours to 2 weeks after headache onset
Give 3 features of cerebral venous sinus thrombosis
More comon in women
Most present with headache
Sudden or insidious onset
Features of raised ICP
How is cerebral venous sinus thrombosis diagnosed and managed?
Diagnosis - CT/MR venography
Management - heparin/warfarin
Give 3 features of temporal arteritis
Diffuse headache
>50 years olds
Systemically unwell
Scalp tenderness, jaw claudication, visual disturbance
How is temporal arteritis investigated and managed?
Investigations - raised ESR, temporal artery biopsy
Managed - steroids (1mg/kg prednisolone)
Give 3 features of idiopathic intracranial hypertension
Gradual onset daily headache
Constant and diffuse
High pressure features and optic disc swelling/enlarged blind spots
May have 6th nerve palsy
How is idiopathic intracranial hypertension investigated and managed?
Investigations - LP, CT venography; diagnosis of exclusion for normal CSF and no cause for raised ICP
Management - weight management, therapeutic LPs, acetazolamide, surgery (VP shunt)
How is a medication overuse headache classified?
Medication used more than twice per week for 3 months
Headache on >15 days per month for at least 3 months
Define MS
Idiopathic inflammatory demyelinating disease of the CNS in which acute episodes of inflammation are associated with focal neurological deficits
What loss of neurological function can occur in MS and what is their timing?
Weak leg, visual loss, urinary incontinence
Develop gradually, last >24 hours, improve gradually
What are the 3 main types of MS?
Relapsing remitting
Primary progressive
Secondary profressive
Give 2 syndromes associated with/that may develop into MS
Optic neuritis
Clinically isolated syndromes
Transverse myelitis
Radiologically isolates syndromes
Give 2 features of optic neuritis
Inflammation of the optic nerve Unilateral Painful visual loss Develops over few days Often first sign of MS
Give 2 features of transverse myelitis
Inflammation of SC
Weakness
Sensory loss
Incontinence may be only symptom
What is a clinically isolated syndrome?
Single episode of neurological disability due to focal CNS inflammation
May include optic neuritis and transverse myelitis
May not be due to MS
What is required for a diagnosis of MS?
Evidence of 2 or more episodes of demyelination disseminated in space and time
What causes MS?
Unknown
Possible RFs - genetics, vitamin D, EBV, smoking
Give 5 symptoms of MS
Central - fatigue, cognitive impairment, depression
Visual - nystagmus, optic neuritis, diplopia
Speech - dysarthria
Throat - dysphagia
MSK - weakness, spasms, ataxia
Sensation - pain, paraesthesia
Bowl - incontinence, diarrhoea, constipation
Urinary - incontinence, frequency, retention
What is a radiologically isolated syndrome?
Incidental MRI finding which looks like MS
May or may not develop into MS, can cause distress
What scan is used to diagnose MS?
MRI brain and cervical spine with gadolinium contrast
What investigations should be done in suspected MS?
LP - oligoclonal bands and glucose with blood matched samples, cell counts and protein
Bloods (rule out other causes) - B12, folate, serum ACE, Lyme serology, ESR, CRP, RF, ANA, ANCA, aquaporin 4 antibodies
Visual evoked potentials
CXR (rule out sarcoidosis)
MRI
What are oligoclonal bands?
Immunoglobulin bands found in blood and CSF after protein electrophoresis
Bands in CSF but not blood is suggestive of MS but not exclusive
Why are visual evoked potentials carried out in MS?
Measure conduction of nerve signals in optic nerve to look for subclinical optic neuritis
Conduction will be slower if a patient has had optic neuritis in the past
What is the difference between a relapse and pseudo-relapse of MS?
Relapse - new neurological deficit >24 hours duration in absence of infection/pyrexia
Pseudo - re-emergence of previous neurological symptoms/signs related to old area of demyelination due to heat/infection
How are relapses managed?
1g of IV methlprednisolone for 3 days OR 500mg oral for 5 days
(Remember to give PPI)
How is alemtuzumab given for MS and what are its pros/cons?
2 short courses over 1 year, further treatment as required
Stops relapses in 40%, may improve disability
High risk of secondary autoimmune problems (e.g. ITP, thyroid, Goodpastures)
How is natalizumab given for MS and what are its pros/cons?
Monthly infusions
Very effective for relapses
Serious risk of fatal PML if infected with JC virus (can only be used for <2 years)
Name 2 oral treatments for MS and their complications
Fingolimod - daily tablet; less effective than monoclonal antibodies; risk of infection and bradycardia
Dimethyl fumerate - 2x daily tablet; less effective than fingolimod; risk of leukopenia and infection
What is cladribine, how is it given and what are its advantages?
Old chemotherapy drug which targets B cells
2 short courses of tablets over 2 years
May stop MS activity for many years
What treatment option is available for RRMS which is ongoing despite use of strong drugs?
Autologous hematopoietic cell transplantation
What drug can be used in primary progressive MS?
Ocrelizumab
What is the role of biotin in MS management?
High dose vitamin dietary supplement
May give symptomatic relief and mild improvement
