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.
