Neurology Flashcards

1
Q

What are the differential diagnoses for a collapse?

A

Epileptic seizure
Syncope - vasovagal, postural, cardiogenic
Physiological - hypoglycaemia, sleep disorder, TIA
Psychological - non-epileptic attack/pseudo-seizure, panic attack

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2
Q

Give 3 features of the history to ask about for seizure

A
History from eyewitness
Provoking factors 
Preceding symptoms 
Description of episode 
Recovery from episode
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3
Q

What risk factors may be present in the history for seizures?

A

Previous/family history
Birth injury, febrile convulsions, meningitis
Brain injury - stroke, surgery
History of myoclonic jerks

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4
Q

Give a provoking factor for seizure

A

Alcohol
Drugs
Sleeping tablets
Sleep deprivation

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5
Q

Give 2 provoking factors for syncope

A
HTN medication 
Undergoing painful medical procedure 
Hot environment 
Standing up too quickly
Prolonged standing
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6
Q

What preceding symptoms might there be for a seizure?

A

Generalised - none

Focal - aura (smell, taste, deja vu, fear, unusual feeling, sensory changes)

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7
Q

What preceding symptoms might there be for syncope?

A
Darkening of vision
Seeing spots 
Ringing in ears 
Hot flush 
Feeling dizzy
Palpitations
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8
Q

Give 3 features of a focal seizure

A
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
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9
Q

Give 3 features of a generalised seizure

A
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
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10
Q

Give 3 features of a vasovagal or postural episode

A
Fade to black 
Flop to ground 
Pale/sweaty/ashen
Slow pulse
Short duration
Rapid recovery
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11
Q

What is the recovery period like after a seizure?

A
Non-responsive for some time 
Post-ictal confusion 
Dysphasia
Todd's paresis 
May not recall events 
Headache 
Malaise 
Sleepy
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12
Q

What is Todd’s paresis?

A

Focal weakness in a part or all of the body after a seizure; usually subsides within 48 hours

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13
Q

What is convulsive syncope?

A

Common variant of syncope
May have rigidity and rhythmic jerking
May be incontinent and be briefly confused

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14
Q

Give 4 features of non-epileptic attack

A

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

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15
Q

What examinations may be considered for collapse?

A

Standing/lying BP
Auscultation of heart
Focused neurological exam
Fundoscopy

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16
Q

What investigations may be considered for collapse?

A

ECG
Bloods - FBC, U&Es, glucose, calcium, phosphate, magnesium
Syncope - tilt table, monitoring, echo
Seizure - MRI, EEG, video telemetry

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17
Q

Define seizure

A

Transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain

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18
Q

When is a diagnosis of epilepsy no longer applicable?

A

Patient with age dependent epilepsy syndrome who is past the applicable age
A patient who has remained seizure free for >10 years off medication

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19
Q

What is meant by a focal seizure?

A

Seizure originating within networks limited to a single hemisphere; may be localised or distributed

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20
Q

What is meant by a generalised seizure?

A

Seizure originating at some point and rapidly engaging bilaterally distributed networks; may not necessarily involve the entire cortex

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21
Q

What is Dravet syndrome?

A

Epilepsy syndrome with genetic cause

Onset in first year of life with febrile seizures, prolonged clonic seizures, often precipitated by hyperthermia

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22
Q

Give 3 types of non-epileptic seizures/events

A
Syncope
Psychological/behavioural events 
Sleep related problems 
Paroxysmal movement disorders
Migraine and related disorders
Miscellaneous neurological and non-neurological events
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23
Q

Define syncope

A

A transient loss of consciousness resulting from an insufficient supply of oxygen to the brain

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24
Q

What are anoxic seizures?

A

The collapse, stiffening, +/- jerking that can occur as a result
of neurogenic syncope or breath holding, often due to unpleasant event/crying (children)

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25
Q

Give 2 clinical features used to differentiate syncope and seizure

A

Lateral tongue biting

Unpleasant circumstances preceding event

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26
Q

Define cataplexy

A

Sudden, brief loss of voluntary muscle tone triggered by strong emotions such as laughter

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27
Q

What is a TIA?

A

Focal neurological symptoms of acute onset which resolve within 24 hours, typically within minutes, due to underlying cerebral ischaemia

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28
Q

What is the ABCD2 score?

A

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)

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29
Q

Define stroke

A

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

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30
Q

Give 2 signs/symptoms of stroke

A

Weakness - limb/face/arm/hemiparesis
Dysphasia
Visual disturbance (right homonymous hemianopia)
Light-headedness

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31
Q

What artery is likely to have been affected in a stroke where weakness has occurred in the leg only?

A

Anterior cerebral artery

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32
Q

What artery is likely to have been affected in a stroke where weakness has occurred in the face and arm?

A

Middle cerebral artery

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33
Q

What artery supplies Wernicke’s and Broca’s speech areas?

A

Middle cerebral artery

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34
Q

A stroke involving which artery could result in cerebellar signs?

A

Posterior inferior cerebral artery

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35
Q

Give 2 causes of ischaemic stroke

A

Cryptogenic (unknown)
Cardiac embolism
Small vessel disease
Atherosclerotic cerebrovasular disease

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36
Q

What does TACS stand for, what symptoms occur and where is the occlusion?

A

Total anterior circulation syndrome
Hemiperesis, higher cortical dysfunction and hemianopia
Proximal middle cerebral artery or internal carotid artery

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37
Q

What does PACS stand for, what symptoms occur and where is the occlusion?

A

Partial anterior circulation syndrome
Higher cortical dysfunction alone OR 2 of hemiparesis, HCD, hemianopia
Branch of middle cerebral artery

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38
Q

What does POCS stand for, what symptoms occur and where is the occlusion?

A

Posterior circulation syndrome
Hemianopia OR brainstem syndrome alone
Perforating arteries, posterior communicating artery or cerebellar arteries

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39
Q

What does LACS stand for, what symptoms occur and where is the occlusion?

A

Lacunar syndrome
Pure motor OR pure sensory OR sensorimotor OR ataxic hemiparesis OR clumsy hand dysarthria alone
Perforating artery or small vessel disease

40
Q

Define intracerebral haemorrhage

A

A focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma

41
Q

Give 2 causes of haemorrhagic stroke

A
Trauma 
Small vessel disease
Amyloid angiopathy
Blood vessel abnormalities
Blood clotting deficiencies 
Haemorrhagic transformation of infarct 
Tumours 
Drugs (e.g. cocaine)
42
Q

How does the management of ischaemic vs haemorrhagic stroke differ?

A

Ischaemic - IV thrombolysis +/- thrombectomy OR aspirin; stroke unit; hemicraniotomy
Haemorrhagic - BP control and reverse anticoagulation; stroke unit; neurosurgical evacuation

43
Q

How is the decision between thrombolysis and thrombectomy made for managing ischaemic stroke?

A

Within 4.5 hours of symptoms = thrombolysis

Within 6-8 hours of symptoms = thrombectomy

44
Q

Give 3 methods of secondary prevention for stroke

A
Smoking cessation 
Anti-platelets (aspirin, clopidogrel)
Anti-coagulation if AF
BP management (ACEI)
Cholesterol management (statin)
Diabetes management 
Surgical intervention for severe carotid stenosis
45
Q

What is the most important risk factor for ischaemic stroke?

A

Smoking

46
Q

What should a patient be prescribed if they present with a TIA episode and then meet discharge criteria?

A

Aspirin
oral 300 mg
once daily until seen in TIA clinic

47
Q

What are the driving implications for TIA?

A

1 month driving ban (no need to inform DVLA)

48
Q

How are headaches classified?

A

Primary - no underlying pathology

Secondary - underlying pathology

49
Q

Name 2 types of primary headache

A

Migraine
Cluster
Trigeminal neuralgia
Tension

50
Q

Give 3 features of a migraine

A
Can have aura 
Pounding/throbbing 
Lasts for hours 
Unilateral 
Nausea/vomiting 
Photo/phonophobia
Disabling 
Lying still in a dark room helps
51
Q

Give 3 triggers for migraine

A
Chocolate 
Cheese
Red wine 
Aspartame
Menstruation
52
Q

Give 3 features of an aura

A

Hours/days before migraine
Lasts 5 mins - 1 hour
Visual/sensory/speech

53
Q

What is a hemiplegic migraine?

A

Migraine with aura including motor weakness (lasts <24 hours) that usually precedes the headache
Can be autosomal dominant

54
Q

How are migraines managed?

A
Aspirin 
NSAIDs
Paracetamol
Triptans
Anti-emetics 
(limit to 2 days/week)
Contraception
55
Q

What drugs should be avoided in migraine?

A

Opioids

56
Q

When should migraine prophylaxis be considered and what options are there?

A

If at least 2 attacks per month occur causing >3 days of disability
Options - propranolol, topiramate, pizotifen, amitriptyline, venlafaxine, duloxetine
6 week trial

57
Q

Give 3 features of cluster headaches

A

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

58
Q

Give 2 autonomic features which can occur ipsilaterally with cluster headaches

A
Conjunctival injection 
Lacrimation 
Orbital oedema
Nasal congestion
Facial sweating 
Miosis/ptosis 
Restlessness/agitation
59
Q

How are cluster headaches managed?

A

Acute - high flow oxygen and subcutaneous triptan

Prophylaxis - verapamil

60
Q

Give 3 features of trigeminal neuralgia

A

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

61
Q

How is trigeminal neuralgia managed?

A

Acute - none
Prophylaxis - anti-epileptics (e.g. carbamazepine), anti-depressant (e.g. amitriptyline)
Surgery - microvascular decompression

62
Q

Give 3 red flag features for secondary headache

A

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)

63
Q

Give 4 causes of secondary headache

A
Subarachnoid haemorrhage
Cerebral venous sinus thombosis
Temporal arteritis 
Meningitis
Tumour 
Dissection 
Idiopathic intracranial hypertension
64
Q

Give 3 features of a SAH

A

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

65
Q

What investigations are helpful in SAH and why are their timings important?

A

CT - detection decreases with time

LP - dectection best 12 hours to 2 weeks after headache onset

66
Q

Give 3 features of cerebral venous sinus thrombosis

A

More comon in women
Most present with headache
Sudden or insidious onset
Features of raised ICP

67
Q

How is cerebral venous sinus thrombosis diagnosed and managed?

A

Diagnosis - CT/MR venography

Management - heparin/warfarin

68
Q

Give 3 features of temporal arteritis

A

Diffuse headache
>50 years olds
Systemically unwell
Scalp tenderness, jaw claudication, visual disturbance

69
Q

How is temporal arteritis investigated and managed?

A

Investigations - raised ESR, temporal artery biopsy

Managed - steroids (1mg/kg prednisolone)

70
Q

Give 3 features of idiopathic intracranial hypertension

A

Gradual onset daily headache
Constant and diffuse
High pressure features and optic disc swelling/enlarged blind spots
May have 6th nerve palsy

71
Q

How is idiopathic intracranial hypertension investigated and managed?

A

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)

72
Q

How is a medication overuse headache classified?

A

Medication used more than twice per week for 3 months

Headache on >15 days per month for at least 3 months

73
Q

Define MS

A

Idiopathic inflammatory demyelinating disease of the CNS in which acute episodes of inflammation are associated with focal neurological deficits

74
Q

What loss of neurological function can occur in MS and what is their timing?

A

Weak leg, visual loss, urinary incontinence

Develop gradually, last >24 hours, improve gradually

75
Q

What are the 3 main types of MS?

A

Relapsing remitting
Primary progressive
Secondary profressive

76
Q

Give 2 syndromes associated with/that may develop into MS

A

Optic neuritis
Clinically isolated syndromes
Transverse myelitis
Radiologically isolates syndromes

77
Q

Give 2 features of optic neuritis

A
Inflammation of the optic nerve 
Unilateral 
Painful visual loss
Develops over few days
Often first sign of MS
78
Q

Give 2 features of transverse myelitis

A

Inflammation of SC
Weakness
Sensory loss
Incontinence may be only symptom

79
Q

What is a clinically isolated syndrome?

A

Single episode of neurological disability due to focal CNS inflammation
May include optic neuritis and transverse myelitis
May not be due to MS

80
Q

What is required for a diagnosis of MS?

A

Evidence of 2 or more episodes of demyelination disseminated in space and time

81
Q

What causes MS?

A

Unknown

Possible RFs - genetics, vitamin D, EBV, smoking

82
Q

Give 5 symptoms of MS

A

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

83
Q

What is a radiologically isolated syndrome?

A

Incidental MRI finding which looks like MS

May or may not develop into MS, can cause distress

84
Q

What scan is used to diagnose MS?

A

MRI brain and cervical spine with gadolinium contrast

85
Q

What investigations should be done in suspected MS?

A

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

86
Q

What are oligoclonal bands?

A

Immunoglobulin bands found in blood and CSF after protein electrophoresis
Bands in CSF but not blood is suggestive of MS but not exclusive

87
Q

Why are visual evoked potentials carried out in MS?

A

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

88
Q

What is the difference between a relapse and pseudo-relapse of MS?

A

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

89
Q

How are relapses managed?

A

1g of IV methlprednisolone for 3 days OR 500mg oral for 5 days
(Remember to give PPI)

90
Q

How is alemtuzumab given for MS and what are its pros/cons?

A

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)

91
Q

How is natalizumab given for MS and what are its pros/cons?

A

Monthly infusions
Very effective for relapses
Serious risk of fatal PML if infected with JC virus (can only be used for <2 years)

92
Q

Name 2 oral treatments for MS and their complications

A

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

93
Q

What is cladribine, how is it given and what are its advantages?

A

Old chemotherapy drug which targets B cells
2 short courses of tablets over 2 years
May stop MS activity for many years

94
Q

What treatment option is available for RRMS which is ongoing despite use of strong drugs?

A

Autologous hematopoietic cell transplantation

95
Q

What drug can be used in primary progressive MS?

A

Ocrelizumab

96
Q

What is the role of biotin in MS management?

A

High dose vitamin dietary supplement

May give symptomatic relief and mild improvement