Neurology and Geriatrics Short Flashcards
Summary of important topics
Multiple sclerosis
Chronic, autoimmune CNS disorder, demyelination and axonal loss of neurones
Most are relapsing-remitting (80%)
Key symptoms: optic neuritis - red desaturation, loss of central vision, sensory disturbance = patchy paraesthesia, cerebellar ataxia, bladder/bowel dysfunction
Dx:
- Clinical history/examination
- MRI with contrast- white matter lesions disseminated in time and space
- Oligoclonal bands on CSF
Mx: acute = IV methylprednisolone for 3 days
Chronic: disease-modifying drugs (e.g. injectable beta-interferons or glatiramer) and symptomatic treatment (e.g. baclofen and botox for spasticity)
Migraine
Chronic, neurological disorder characterised by episodes of severe, unilateral, pulsating headache.
RFs: female, family history, obesity, stressful life event, menstruation
Features: prolonged (4-72 hrs if untreated), nausea, worse on activity, reduced functional ability
Preceding aura is only present in about 30% of patients
Triggers: CHoCLATE - chocolate, COCP, alcohol/anxiety, travel, exercise
Mx: triptans (e.g. sumatriptan), NSAIDs/paracetamol, anti-emetics high-flow O2
Prophylaxis: propranolol (contraindicated in asthma), topiramate (tetratogenic) or amitriptyline
Geriatrics: constipation
Primary - no underlying cause
Secondary - medications (e.g. opiates), diet (low fibre intake), neurological disorders (Parkinson’s, diabetic neuropathy)
Ix: history to exclude red flags, PR exam, FIT test, faecal calprotectin, FBC (anaemia), U+Es, TFTs
Refer for abdominal Xray (strictures) or colonoscopy (malignancy)
Mx: improve diet, exercise, laxatives
Bulk: ispaghula husk
Stimulant: senna
Osmotic: lactulose
Stool softener: macrogol (movicol)
Geriatrics: Mental Capacity Act key principles
- Capacity is assumed, needs to be proven otherwise
- Enable people to make their own decisions
- People can make unwise decision, does not mean they lack capacity
- Best interest - decisions made on behalf of someone who lacks capacity must be in their best interest
- Least restrictive option
Orthostatic hypotension
Systolic BP drop of 20mmHg or more or diastolic 10mmHg or more within 3 mins of standing up from sitting
Dizziness on standing, falls, syncope
Causes: medications e.g. vasodilators, diuretics, negative inotropes, dehydration, Parkinson’s disease
Mx: adequate hydration, evaluate polypharmacy, behavioural changes e.g. rising slowly
Parkinson’s disease
- Neurological condition resulting from Lewy-body formation and dopaminergic cell death in the substantia nigra
- Bradykinesia with rigidity and/or tremor
Mx: MDT, co-careldopa (levodopa with carbidopa)
Don’t prescribe metoclopramide, prescribe domperidone for nausea
Precipitating factors for delirium
PINCH ME
Pain
Infection
(Mal)Nutrition
Constipation
(De)Hydration
Medication
Environment change
Cluster headaches
Sudden onset, severe headache affecting periorbital area unilaterally - 15 mins - 3hrs
Associated symptoms: watery, bloodshot eyes, lacrimation, rhinorrhoea
Dx: brain MRI to exclude lesion
Mx: avoid triggers, prophylatic verapamil (CCB for vasodilation)
Acute Mx: 100% O2 via non-rebreather mask and subcutaneous triptan
Sudural haematoma
Accumulation of venous blood between sura and arachnoid mata
Key features: fluctuating GCS, headache, N+V, confusion
Dx: CT head -hyperdense (blood), crescent-shaped area
Motor neurone disease
Group of progressive neurological disorders that destroy motor neurons - they control voluntary muscle activity.
Amyotrophic lateral sclerosis most common
UMN: spasticity, hyperreflexia
LMN: fasciculations, muscle atrophy
Sensory neurons not affected
Mx: supportive management with: MDT, Riluzole, pain relief, discuss advanced care plans early in disease progression
Guillain-Barre syndrome
Acute, inflammatory demyelinating polyneuropathy - rapid, progressive ascending, symmetrical weakness.
Clinical features: starts in lower limbs and ascends , paraesthesia then motor symptoms e.g. symmetrical limb weakness, hypotonia, areflexia
Preceded by infection
Dx: clinical, confirm by nerve conduction studies or electromyograhy, CSF: raised opening pressure, raised protein, normal glucose, normal WCC, normal RCC
Mx: monitor FVC to check for respiratory muscle involvement = ICU
IV immunoglobins or plasmapheresis for significant disability (e.g. can’t walk)
Diabetic neuropathy
Damage to the peripheral nerves caused by chronic hyperglycaemia as a result of diabetes.
Distal symmetrical sensory neuropathy is most common
Sensory loss in a glove and stocking distribution, affecting touch, vibration and proprioception
Ix: neurological exam, nerve conduction studies, bloods including BM, HbA1c, B12, TFTs, LFTs
Mx: management of blood glucose to slow progression, gabapentin or pregabalin, tx of complications e.g. foot ulcers and autonomic disturbances
Huntingdon’s disease
Autosomal dominant neurological disorder caused by mutation on the HTT gene on chromosome 4, leading to excessive CAG repeats on the huntingtin protein (38 or more)
Key features: starts with mood and personality changes, then chorea (involuntary, random, abnormal body movements
Dx: genetic testing. CAG repeats 40 or more = positive and will develop HD. CAG repeats = 36 - 39 = intermediate results = may or may not develop HD
MRI = caudate nucleus and putamen atrophy
Mx: tetrabenazine for chorea, MDT, physio, speech and language, advanced care planning, palliative care
Transient Ischaemic Attack
Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without infarction
RFs: age, HTN, hypercholesterolaemia, smoking, diabetes, AF
Key features: sudden, brief onset (several mins) of focal deficit e.g. unilateral weakness, paralysis, dysphasia, amaurosis fugax (transient vision loss in one eye)
Ix: ECG (AF), blood glucose (hypo), FBC and platelets, lipid profile
Mx: Aspirin 300mg STAT + continue daily, referral for specialist assessment within 24 hours, MRI scan
Epilepsy
Chronic, neurological condition characterised by recurrent seizures.
Seizures are paroxysmal alterations in neurological function due to excessive, hypersynchronous firing of neurons.
Generalised, focal, focal to bilateral
Generalised seizures
- Tonic-clonic - stiffening (tonic) and rhythmic jerking of the limbs (clonic)
- Myoclonic - sudden jerking/twitching of parts of the body
- Atonic - when parts of the body or all of the body loses muscle strength
Mx: 1st line sodium valproate (teratogenic), 2nd line: lamotrigine or carbamazepine
Three key features to classify seizures
- Where the seizures began
- Level of awareness during seizure
- Other features of the seizure e.g. motor
Focal seizures
Starts in the temporal lobe and can affect hearing, speech, memory and emotions
- Hallucinations
- Deja vu
- Memory flashbacks
- Doing strange things on autopilot
Mx reverse of generalised seizures
Absence seizures
Loss of awareness of surroundings for 10 to 20 seconds - childhood. 90% stop in adulthood
Generalised
Mx = 1st line sodium valproate or ethosuximide
Infantile spasms (West syndrome)
Starts in infancy around 6 months. Clusters of full body spasms. Poor prognosis.
Mx: prednisolone, vigabatrin
Dx epilepsy
- Detailed history and examination to differentiate epilepsy from pseudo-seizures, vasovagal or febrile seizures
- Electroencephalogram after second unprovoked tonic-clonic seizure
- MRI brain for structural pathology
- ECG
- U+Es (Na, K, Ca, Mg)
- Blood glucose
- Blood cultures, urine cultures and LP if sepsis/meningitis suspected
Meningitis
Neonate: GBS - Strep agalactiae
Children and adults - Strep pneumoniae (pneumococcus), Neisseria Meningitidis
Key features: fever, neck stiffness, headache, photophobia
Dx: blood cultures, LP, CRP, FBC
Mx: do not delay antibiotics
<3m = cefotaxime + amoxicillin
>3m = ceftriaxone
Prophylaxis for close contacts = ciprofloxacin
Parkinson plus syndromes
Peripheral neuropathy
Myasthenia gravis
Autoimmune condition where auto-antibodies attack the post-synaptic nicotinic acetylcholine receptors at the neuromuscular junction
Key features: muscle weakness worse at the end of the day and improves after rest, muscle fatiguability, bilateral ptosis, facial palsy
Ice-pack test - ice pack placed for 2 - 5 mins on eye improves ptosis
Dx: anti-acetylcholine receptor antibody (anti-AChR) test, muscle-specific tyrosine kinase (anti-MusK) antibodies
Mx: MDT, regular neurology follow-up, anticholinesterase inhibitor e.g. pyridostigmine and steroids, IVIG in acute cases
Extradural haemorrhage
Bleeding into the potential between skull and dura.
Trauma is most common = rupture of middle meningeal artery
Key features: initial brief LOC followed by lucid interval > deterioration and reduced GCS
Ix: urgent non-contrast CT head - hyperdense lentiform/biconvex shape
Mx: neurosurgery, reduce ICP (head to 30 degrees, IV hypertonic saline, O2) then craniotomy
Subdural haemorrhage
Venous bleeding into potential space between dura and subarachnoid mata
Often elderly patients, reduced and fluctuating GCS
Dx: non-contrast CT - appearance depends on age
- Acute (<3 days) = crescent-shaped hyperdense
- Chronic (>3weeks) - hypodense collection
Mx: conservative if no midline shift or oedema, or surgical with craniotomy/burr hole
Subarachnoid haemorrhage
Medical emergency due to bleeding into subarachnoid space
Trauma or berry aneurysm
Key feature: thunderclap headache - sudden severe, max intensity within 5 mins
Dx: urgent non-contrast CT head, hypersense collection in subarachnoid space/basal cistern
Mx: nimodipine for vasospasm, surgical: endovascular coiling or clipping
Indications for urgent CT head < 1 hour of presentation
- GCS < 13 on initial assessment
- GCS < 15 2 hours after trauma
- Evidence of basal skull fracture (e.g. racoon eyes, mastoid bruising, rhinorrhoea)
- Seizure
- Focal neurology
> 1 episode of vomiting
