Neurology Flashcards
Name 5 causes of cerebellar lesions
VITAMIN C Vascular Inflammatory - MS Trauma Alcohol Metabolic Iatrogenic - Phenytoin and carbamazepine Neoplastic Congenital - Friedrichs ataxia
What is Fredrich’s ataxia
AR trinucleotide repeat disorder
GAA - chromosome 9
Name 3 presentations of Fredrich’s ataxia
kyphoscoliosis Spinocerebellar tract degeneration HOCM DM Cerebellar ataxia optic atrophy High arched palette
How does a lesion of the cerebellar vermis present
Truncal ataxia
gait instability
How does a lesion of cerebellar hemisphere present
Ipsilateral limb signs
Name 5 risk factors for an ischaemic stroke
Male FHx of stroke - < 60 Old age smoking AF Hypercholesterolaemia DM Alcohol
Name 4 causes of ischaemic stroke
Cardiac emboli - AF / IE
Atherothromboembolism - Carotid artery
Systemic hypoperfusion - cardiac arrest
Describe the investigations in an acute suspected stroke
1st line - CT scan
Others
- MRI with DWI
- Carotid artery USS
- Echo
- ECG +/- 72 hr tape
- Bloods
Describe the management of acute stroke <4.5 hours
< 4.5 hours
IV Alteplase
repeat CT 24 hrs after
300 mg Aspirin
Describe the management of acute stroke > 4.5 hrs
> 4.5 hrs 300mg Aspirin (2 weeks) 75 mg Clopidogrel (lifelong)
When is mechanical thrombectomy offered
Patient with Anterior circulation stroke within 6hrs
Name 4 CI to IV alteplase in stroke
Haemorrhagic stroke Unstable BP INR - High Recent head trauma GI bleed Recent surgery Platelet count
Describe secondary prevention for strokes
HALTSS
HTN - Anti-hypertensives
Antiplatelet - Clopidogrel 75mg
Lipids - Atorvastatin
Tobacco - smoking cessation
Sugar - DM screen
Surgery - >50% Ipsilateral carotid artery stenosis –> carotid endarterectomy
How should a patient diagnosed with AF following a stroke be treated differently in secondary prevention
HALTSS - A is different
Initiate Warfarin or DOAC 2 weeks post stroke
STROKE PRESENTATION
TACI
ACA + MCA
ALL 3 REQUIRED
contralateral weakness +/- sensory deficits of face / arm / legs \+ contralateral homonymous hemianopia \+ Higher cerebral dysfunction - aphasia - neglect
STROKE PRESENTATION
PACI
ACA OR MCA
2 REQUIRED
contralateral weakness +/- sensory deficits of face / arm / legs
+
contralateral homonymous hemianopia
OR - This alone
Higher cerebral dysfunction alone
STROKE PRESENTATION
Lacunar stroke
Pure: - motor - sensory - sensorimotor OR Ataxic hemiparesis
STROKE PRESENTATION
Posterior circulation infarct
Cerebellar dysfunction OR Conjugate eye movement disorder OR Bilateral motor/sensory deficit OR Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit OR Cortical blindness/isolated hemianopia.
What are the rules following a stroke and driving
No driving for 1 month
Don’t have to inform DVLA
HAEMORRHAGIC STROKE
Name 4 risk factors
older age FHx Malignancy Anti-coagulants cocaine Haemophilia vasculitis
HAEMORRHAGIC STROKE
Name 3 causes of a haemorrhagic stroke
ruptured cerebral artery
trauma
AV malformation
reperfusion injury - ischaemic stroke
HAEMORRHAGIC STROKE
Describe the management
conservative
- BP
- lifestyle advice
Medical
- Stop anti-coag and anti-platelet
- Factor 7 concentrate
- Antihypertensive (Beta blocker / CCB)
- Nimodipine (vasospasm)
Surgical
- Clipping
- Coiling
HAEMORRHAGIC STROKE
Name the reversal agents for
- warfarin
- heparin
- LMWH
- Apixaban
warfarin
- Beri plex
- vitamin K
Heparin
- protamine
LMWH
- Protamine
Apixaban
- Beri plex
Describe the ABCD2 risk score
A > 60
B - BP >140/80
Clinical features
Unilateral weakness(2)
speech impairment without weakness (1)
Duration
> 60 mins (2)
<59 mins (1)
D - Diabetes (1)
Describe how raised ICP presents
Headache - worse on lying down/bending/coughing papilledema seizures reduced consciousness - GCS N+V - relieves headache Cushigs triad
What is Cushing’s triad and what presentation is it commonly found in
Raised ICP
Raised BP
Reduced HR
Irregular breathing
Name 2 causes of raised ICP
Meningitis
haemorrhages
SOL
Hydrocephalus
What is the management of raised ICP
Bed rest and head elevation
IV mannitol
Name 4 risk factors for SAH
Family hx previous aneurysmal SAH Smoking alcohol PCKD Increased BP
Name 4 causes of a SAH
Aneurysmal
- ADPCK
- Rupture of berry aneurysm
- atherosclerosis
- HTN
Non aneurysmal
- Trauma
- AVM
- Coagulopathies
How does a SAH present
Thunderclap headache N+V Reduced GCS Double vision Meningism - photophobia / neck stiffness / pain on flexion Seizure Kernig's sign 3rd CN palsy - PCA aneurysm
Describe the investigations for a SAH
Non contrast CT head
Serial LP - If CT -ve but clinical signs present
- 12 hrs post sx onset
- Xanthochromia
Name 4 SAH complications
re-bleeding hydrocephalus Vasospasm Hyponatraemia seizures
What is the management of a SAH
ABCDE
Analgesia and anti-emetics
Nimodipine
Clipping / coiling
Describe the flow of CSF
Lateral ventricles Foramen of monro 3rd ventricle cerebral aqueduct 4th ventricle - central spinal canal - SA cisterns
GCS
Describe the scoring system for eye opening
Spontaneous - 4
To sound - 3
To pain - 2
No response - 1
Not testable
GCS
Describe the scoring system for verbal response
Can you tell me your name
Do you know where you are
Do you know the date today
Orientated response - 5
confused conversation- 4
Inappropriate / random words - 3
Incomprehensible - 2
No response - 1
GCS
Describe the scoring system for motor response
Obeys commands- 6
- 2 part command
Localises to pain - 5
- trapezius squeeze
- supraorbital notch
Withdraws to pain - 4
- flexion response
Abnormal flexion response to pain - 3
- decorticate posturing
Abnormal extension response - 2
- Decerebrate posturing
No response - 1
GCS
Describe decorticate posturing
Adduction of arm + Internal rotation of shoulder + pronation of the forearm + wrist flexion
GCS
Describe decerebrate posturing
Head extended + arms and legs extended and internally rotated
Name 4 differentials for transient LOC
Seizure
NEAD
Hypoglycaemia
Postural hypotension
What is cardiogenic syncope
L.V outflow obstruction leading to to syncope on exertion
Name 5 causes of cardiogenic syncope
Aortic stenosis
HCOM
Name 5 causes of orthostatic hypotension
Drugs
- Antihypertensive
- TCA
Hypovolaemia
Primary autonomic failure
- Parkinson’s
Secondary autonomic failure
- Diabetes
-
Hydrocephalus - Name 3 causes of a communicating hydrocephalus
Damage to arachnoid granulations
- Intracranial haemorrhage
- Meningitis
- Venous thrombosis
Name the 3 different categories of syncope
Vasovagal
- reflex bradycardia and peripheral vasodilation
Situational - Post:
- cough
- micturition
carotid hypersensitivity
- tight collar / shaving
Name 8 causes of a seizure
Children
- inherited syndromes
- Birth hypoxia
- Infections (meningitis)
Metabolic
- Hypoglycaemia
- Hyponatraemia
- Hypoxia
- Delirium tremens
Other
- Head trauma
- stroke
Name 4 factors that reduce seizure threshold
Alcohol Anti-depressants SOL Lack of sleep Hyponatraemia Stroke
How do you diagnose epilepsy
2 unprovoked seizures occuring >24 hours apart
OR
1 unprovoked seizure and a >60% probability of increased predisposition to further seizures In next 10 years
(eg: MRI - SOL/ Stroke or on EEG)
Name and describe the 4 stages of a seizure
Prodrome - not part of seizure
- change in mood
Aura
- deja-vu
- strange smells
Ictal phase
Post ictal
- headache
- confusion
Name investigations required following a seizure
Bloods - glucose / Ca2+ / Na+
ECG - R/O other conditions
EEG
CT/MRI
Name the 5 classifications of a generalised seizure
GTC
- tongue biting
- incontinence
- eyes closed
- confusion
Tonic
Atonic
- No LOC
- Falls to floor
Absence
- 3Hz spike in EEG
Myoclonic
- thrown to floor
Name the 5 classifications of a generalised seizure
GTC
- tongue biting
- incontinence
- eyes closed
- confusion
Tonic
Atonic
- No LOC
- Falls to floor
Absence
- 3Hz spike in EEG
Myoclonic
- thrown to floor
What is the management of generalised seizure
1st - sodium valproate
2nd - Carbamazepine / Lamotrigine
Describe the differences between a simple and complex focal seizure
Simple
- No LOC
- No post ictal confusion
Complex
- LOC
- Post ictal confusion
- common from temporal and frontal lobes
Describe the presentation of a frontal lobe focal seizure
pedalling leg movements posturing changes jacksonian march motor arrest post ictal - Todd's palsy
Describe the presentation of a temporal lobe focal seizure
Deja - vu
hallucination - smell / taste / sound
Automatisms - lip smacking / pulling
Describe the presentation of a parietal and occipital lobe focal seizure
Parietal
- sensory changes (tingling / paresthesia)
Occipital
- Visual disturbance
What is the management in status epilepticus
1st line - IV 4mg lorazepam
Buccal midazolam
rectal diazepam
2nd line - Repeat if no response after 10 mins
3rd line - IV phenytoin
What are the risks / complications if status epilepticus is not managed
death
rhabdomyolysis
AKI
Metabolic acidosis
What are the driving requirements following a seizure and in epilpesy
Must inform DVLA
- Can’t drive for 6m following a seizure
- If established epilepsy must be seizure free for 1 year
What is required when administering phenytoin
cardiac monitoring - risk of arrhythmias
Name 4 side effects of sodium valporate
teratogenic
weight gain
hair loss
pancreatitis
name 4 side effects of lamogitrine
rashes
aggression
steven-johnson syndrome
Name 4 side effects of carbamazepine
Teratogenic
Hyponatraemia - SIADH
Rashes
Agranulocytosis
Name 4 side effects of phenytoin
gum hypertrophy
cerebellar atrophy
arrhythmias
What is the driving advice following a NEAD
No driving unless seizure free for 3m
Describe NEAD
Physical manifestation of trauma
- Common after childhood sexual abuse
- no EEG changes
Presents with other MUS
- IBS / Fibromyalgia / chronic fatigue
Mx - Psychotherapy and explanation
Describe the presentation of Wernicke’s syndrome
Triad: - ataxia - encephalopathy - Ocular abnormalities Ophthalmoplegia gaze paresis ptosis nystagmus
Peripheral neuropathy
Name 3 causes of Wernicke’s syndrome
Hyperemesis
Alcohol dependence
Malnutrition / Anorexia
Where is vitamin B1 - thiamine absorbed and stored
Absorbed - duodenum
stored - liver
What is the Mx of wernicke’s syndrome
IV Pabrinex
IV glucose - prevent metabolic acidosis
How does Korsakoff syndrome present
Sx of Wernicke’s +
- Anterograde and retrograde amnesia
- Confandibulation
What is the pathophysiology behind Korsakoff syndrome
Chronic lack of thiamine damages mamillary bodies in limbic system - Degradation visible on MRI
CLUSTER
- Timings
- RF
- Causes
- Presentation
- Mx
- Prophylaxis
5 - 180 mins
Smoking is a risk factor
Alcohol
Unilateral orbital pain - rhinorrhoea - lacrimation - bloodshot - ptosis Vomiting
Mx - 100 O2 + Sumatriptan
Prophylaxis - Verapamil
TRIGEMINAL NEURALGIA
- Timings
- RF
- Causes
- Presentation
- Ix
- Mx
Seconds
> 55 year old female
Compression of trigeminal nerve - Aggravated by: Shaving / smiling / talking / wind
Unilateral - electryfying stabbing pain
Ix - MRI to R/O other conditions
Mx:
Medical
- 1st: Carbamazepine
- 2nd: Phenytoin / Gabapentin
Surgical
- Surgical decompression
What drugs commonly cause medication overuse headache
opioids
triptans
NSAIDs
Name 3 risk factors for GCA
Female
PMR
Family hx
What is found on temporal artery biopsy in GCA
Multinucleated giant cells
Name the investigations required in GCA
Bloods
- ESR
- ALP - raised
- CRP
- FBC - normochromic normocytic anaemia
Duplez USS - hypoechoic halo sign
What is the presentation of GCA
Unilateral temporal headache scalp tenderness jaw claudication blurred / double vision vision loss fever weight loss fatigue
What is the management of GCA
Prednisolone - 40/60mg
Decrease stroke and vison loss risk
75mg Aspirin
Gastric protection whilst on steroids
PPI
Bisphosphonates + Coleclacifarol
Name 2 risk factors for glaucoma
family hx
High BP
Describe the pathophysiology in Glaucoma
Increased intraocular pressure damages optic nerve
Describe the presentation of glaucoma
Unilateral orbital pain
swollen eye
visual blurring
Halos in vision
What investigations are required in glaucoma
Vision testing
Measure IO pressure - Tonometer
What is the medical and surgical management of glaucoma
Medical
- Iatanoprost (PG analgoues)
Surgical
- Trabeculoplasty
- Trabeulotomy
Name 4 causes meningitis
Strep pneumonia Neisseria meningitidis H.influenza Strep agalactiae Listeria monocytogenes
What is the prophylaxis for menignitis for close contacts
Oral ciprofloxacin
Name 3 causes of encephalitis
HSV - 1
VZV
CMV
EBV
Describe the presentation of encephalitis
Sudden onset behavioural change Headache New onset seizures Decreased GCS Confusion Focal neurology Fever
Describe the investigations required in suspected encephalitis
1st line - Bloods and blood culture
- Viral PCR
2nd line - LP
- Viral PCR
Contrast enhanced CT scan / MRI scan
- Bitemporal and inferior changes
What is the infectivity period of shingles
infective 1/2 days before rash onset and 5 days post rash
Name 2 complications of shingles
Ramsey hunt syndrome
Post herpetic neuralgia
- burning intractable pain
- poor response to analgesics
What is the management of post herpetic neuralgia
Amitriptyline
