Neurology Flashcards
What is bells palsy?
- Acute unilateral facial nerve weakness or paralysis of rapid onset <72 hours w unknown cause.
- Causes –> HSV, VSV
- Sudden onset <72 hours
- RF –> ages 15-45, previous stroke, brain tumour, pregnancy (x3 as likely)
What is the typical presentation of bells palsy?
- Sudden onset <72 hours
- Unilateral facial muscle weakness of whole face including forehead
- Reduction movement of affected side
- Drooping of eye, nasolabial fold, mouth
- Numbness/tingling side of face - cheek, mouth
- Dry eyes and mouth
- Change in taste, hyperacusis
- Pain in ear and post auricular region
- Unable to completely close affected eye
- Bells phenomenem –> can’t close eye and pupil goes upwards and outwards
What are the investigations for bells palsy?
What are the differentials?
-Typically clinical diagnosis –> etc CN exam
DDx –> stroke (forehead sparing), brain tumour (mental state changes, usually other neurological findings),
What is the management for bells palsy?
- If present w/i 72 hours onset of symptoms
- High dose prednisolone –> 50mg OD for 10 days or
- 60mg prednisolone for 5 days w 10mg reduction daily for 5 days.
- Eye lubrication, microporous tape at night
- Referral to CN7 specialist when –> no improvement in symptoms w/i 3 weeks or incomplete recovery w/i 3 months
- Refer to opthalmologist when eye symps –> pain
- Urgent referral –> worsening of existing neurological findings. Features suggest CNS cause. ?cancer, trauma, systemic or severe local infection
What is meningitis?
What are the most common bacterial causes by age?
- Inflamm of the meninges –> the lining of the brain and spinal cord
- Bacterial or viral causes
- Transmission through close contact, droplets or direct contact w respiratory secretions.
< 3 months - group B strep +cocci
3 months - 45 years - Neisseria meningitidis -ve diplococci
>50 years - strep pneumoniae +ve diplococci
- Bacterial - life threatening emergency
- Meningococcal septicaemia –> infection w/I the blood stream
What is the typical presentation of bacterial meningitis?
What can be the presentation in children?
What are two signs you can check?
- Fever, nausea and vomiting, neck stiffness, altered mental state e.g confusion, drowsiness. Headaches, photophobia.
- Lethargy, off food, bulging fontanelle < 2 years
- Meninococcal septicaemia –> non blanching rash
Kernig –> flex knee and hip. Then straighten knee –> panfuls stretching meninges
Brudinski –> neck to chest causes flexion in knees and hips
What are the investigations for meningitis?
How quickly should the most important investigation be done?
- LP w culture –> should be done w/I 1 hour
- Ideally LP before Ab but can’t delay Ab
- Bloods –> PCR, culture
What are the CI for LP?
- Meningococcal septicaemia –> don’t want to contaminate
- Signs raised ICP –> papilloedema, cerebral herniation, significant bulging fontanelle
Describe the results of LP for meningitis depending on cause?
Bacterial Viral
Cloudy Clear/cloudy
GlucoseLow (< 1/2 plasma) 60-80% of plasma glucose*
Protein - High (> 1 g/l) Normal/raised
10 - 5,000 polymorphs/mm³ 15 - 1,000 lymphocytes/mm³
What is the management for meningitis?
- Immediate transfer
- Meninocoocal septiacamia –> IM benzylpenicillin prior to admission as long as won’t delay admission
-<3 months and >50 –> ceftaxime and amoxicillin.
amoxicillin to cover listeria.
> 3 months - 50 years –> ceftriaxone
-Recent travel abroad or prolonged ab exposure –> add vancomycin incase pneumoccal penicillin resistant
-Anaphylaxis to penicillin –> chlormaphenicol
- IV dexamethasone –> reduce risk complications e.g severity of hearing loss
- Fluids
- Cerebral monitoring, e.g intubation
-Inform PHE - all close contact w/I last 7 days should be treat –> ciprofloxacin.
What are the main causes of viral meningitis?
How is it investigated?
How should it be treated?
-Most common causes herpes simplex virus (HSV), enterovirus and varicella zoster virus (VZV).
- Headache, nick stiffness, photophobia (milder than that in bacterial).
- Confusion, fevers, may have focal neurological (less frequently than in bacterial.
- Significant change in behaviour, disorientation or marked deterioration in mental satte –> suggest meningoencephalitis (spread of infection to encephalon).
- A sample of the CSF from the lumbar puncture should be sent for viral PCR testing.
- Viral meningitis tends to be milder than bacterial and self limiting, often only requires supportive treatment we symptoms improving over 7-14 days.
- Aciclovir can be used to treat suspected or confirmed HSV meningitis.
- Any question of bacterial or encephalitis –> broad spec Ab w CNS penetration e.g ceftriaxone and aciclovir.
What is a migraine and the common risk factors?
- Primary headache.
- x3 common women than men
- 20% have aura
- CHOCOLATES –> chocolate, hangover, orgasm, cheese/caffeine, OCP, lie ins, alcohol/anxiety, travel, exercise. Stress/tiredness can be a trigger.
What is the typical features of a migraine?
- A severe, unilateral (can be bilat), throbbing headache
- Lasts 4-72 hours.
- Nausea and vomiting
- Photophobia and phonophobia.
- Patients characteristically go to a darkened, quiet room during an attack –> avoidance of routine physical activity
What can occur during aura?
- ‘Classic’ migraine attacks are precipitated by an aura. 1/3 migraines
- Typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma
- Visual zig zags, dots, flashing lights, chaotic distorting.
- Sensory numbness, tingling.
- Dysphasia
How is a migraine diagnosed?
-Clinical
What is the management of an acute migraine?
What should be 1st line management in pregnancy?
- 1ST line –> Oral triptan w NSAID or paracetomal.
- WHEN PREGNANT 00> paracetomal 1g 1st line. NSAIDS can be used 2nd line in 1st/2nd trimester. Avoid aspirin or opioids.
- Aged 12-17 consider nasal triptan rather than oral.
- Above measures not effective tolerated consider anti emetics –> e.g non oral metoclopramide or prochlorperazine and consider non oral triptan.
What is the prophylaxis for migraine?
1st line
2nd line
When is prophylaxis indicated?
Should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients.
- 1st line –> propranolol (BB) or topiramate (depends on preference, comorbidities etc). AVOID topiramate in women child bearing age as tetraogenic and reduce effectiveness of oral contraceptives.
- 2nd line –> Acupuncture up to 10 sessions over 5-8 weeks.
- NICE –> riboflavin 400mg OD may help to reduce freq and severity.
- Women with predicatble menstrual migraines consider frovatriptan or zolmitrptan as ‘mini prophylaxis.
