Neurology: Clinical - MS, headache, epilepsy Flashcards
1
Q
What is Uthoff’s phenomenon?
A
Heat slowing nerve conduction and so worsening signs of MS on hot days
2
Q
What is Lehrmitte’s sign?
A
Sudden sensation resembling electric shock that passes down the back of the neck and into spine, may radiate in arms and legs (can be a symptom of MS)
3
Q
What is the pathology of multiple sclerosis?
A
Demyelination occurring at multiple CNS sites, caused by T-cell mediated immune response
4
Q
Why does MS often have relapsing and remitting symptoms?
A
Demyelination heals poorly
5
Q
What does prolonged demyelination in MS cause?
A
Axonal loss and progressive symptoms
6
Q
How does the demyelination occur in MS?
A
Activated T cels cross the BBB causing demyelination and acute inflammation of the myelin sheath
7
Q
How does MS present on MRI?
A
Lesions or plaques on MRI = white areas on scan
8
Q
What are the MS plaques seen on MRI due to?
A
Conduction block/axonal loss
9
Q
What is benign MS?
A
When people have 1 (or small number of) attacks of the disease
10
Q
What are the four mains patterns of disease for MS?
A
Progressive-relapsing MS
Secondary progressive MS
Primary progressive MS
Relapsing-remitting MS
11
Q
What is the most common pattern of disease seen in MS?
A
Relapsing-remitting MS
12
Q
What is the relapsing-remitting pattern of disease seen in MS?
A
Unpredictable attacks which may or may not leave permanent deficits followed by periods of remission
13
Q
What is the primary progressive pattern of disease seen in MS?
A
Steady increase in disability without attacks
14
Q
What is the secondary progressive pattern of disease seen in MS?
A
Initial relapsing-remitting MS, that suddenly begins to have decline without periods of remission
15
Q
What is the progressive-relapsing pattern of disease seen in MS?
A
Steady decline since onset with super-imposed attacks
16
Q
What is the aetiology of MS?
A
Complex genetic inheritance Association with autoimmune disease Females more than males Commoner in temperate climates ?Vitamin D exposure Young age of onset
17
Q
What are some of the symptoms of MS?
A
Fatigue, sexual dysfunction (erectile dysfunction), incontinence, constipation, facial numbness/weakness, speech difficulties, dysphagia
18
Q
What are some of the signs of MS?
A
Optic neuritis Sensory symptoms: numbness and paraesthesia (pins and needles) Limb weakness Tremor Diplopia/vertigo/ataxia (brainstem) Bladder weakness (spinal cord bilateral) UMN signs: spasticity, weakness, brisk reflexes Scotoma = dark spot in centre of vision
19
Q
What are some of the symptoms of optic neuritis?
A
Subacute visual loss in one eye, pain on moving eye, colour vision disturbed, visual field loss, flashing lights
20
Q
What are some of the signs of optic neuritis?
A
Initial swelling optic disc, optic atrophy seen later, relative afferent pupillary defect
21
Q
What is internuclear opthalmoplegia (INO)?
A
Disorder of conjugate lateral gaze:
Affected eye shows impairment of adduction
22
Q
What is internuclear ophthalmoplegia (INO) a disorder of?
A
Brainstem (medial longitudinal fascicles (MLF))
23
Q
What symptoms might a patient have if the cerebellum is damaged?
A
Vertigo, nystagmus, ataxia
24
Q
How does myelitis normally present?
A
Muscle weakness or paralysis
25
What examinations would you perform is you suspect MS?
```
Afferent pupillary defect
Nystagmus or abnormal eye movements
Cerebellar signs
Sensory signs
Weakness
Spasticity
Hyperreflexia
Plantars extensor
```
26
What are lesions or plaques on MRI scan?
Areas of demyelination
27
For 10 lesions, approximately how many relapses will the patient experience?
1
28
What are some differential diagnoses for MS?
```
Acute disseminated encephalomyelitis (ADEM)
Other auto immune conditions e.g. SLE
Sarcoidosis
Vasculitis
Infection
```
29
When does primary progressive MS usually present?
5th/6th decade
30
What are the symptoms for primary progressive MS like?
Spinal and bladder symptoms
31
What is prognosis for primary progressive MS?
Poor
32
What is the other name for Devic's disease?
Neuromyelitis optica
33
What is the other name for neuromyelitis optica?
Devic's disease
34
What type of hypersensitivity reaction is MS?
Type IV hypersensitivity reaction (cell-mediated)
35
What is Charcot's triad in relation to MS?
Dysarthria - unclear/difficult speech
Nystagmus
Intention tremor
36
What are primary headaches?
Migraine
Tension type headache
Cluster headache
37
What are secondary headaches?
Caused by structural or biochemical cause e.g tumour, meningitis, vascular disorders, systemic infection, head injury, drug induced
38
What does ETTH stand for?
Episodic tension type headache
39
What does CTTH stand for?
Chronic tension type headache
40
How many headaches per month for infrequent ETTH?
<1 day/month
41
How many headaches per month for frequent ETTH?
1-14days/month
42
How many headaches per month for CTTH?
>15days/month
43
What is the treatment for tension type headaches (TTH)?
Abortive e.g. aspirin/paracetamol, NSAIDs
| Preventative e.g. tricyclic antidepressants (amitriptyline)
44
What can happen if you have too much abortive treatment for TTH?
Develop medication overuse headaches
45
What should you limit abortive treatment to for TTH?
Limit to 10 days/month (2/wk)
46
What are the triggers for migraine?
Diet, dehydration, hunger, stress, sleep disturbances, oestrogen levels in women, environmental stimuli
47
What are the symptoms of migraine?
Headache which is unilateral, pulsating with moderate/severe pain, photophobia, phonophobia, nausea, functional disability (can't do activities)
48
What is migraine?
Chronic disorder of episodic attacks of complex changes in the brain
49
What symptoms are there in the premonitory phase of migraine?
Mood changes, fatigue, cognitive changes, muscle pain, food craving
50
What symptoms are there in the early headache phase of migraine?
Dull headache, nasal congestion, muscle pain
51
What percentage of migraineurs experience aura?
33%
52
What can aura symptoms be confused for?
TIA
53
What is the most common aura symptom in migraines?
Visual aura - loss of vision, blind spot that progresses or enlarges
54
What does sensory aura include?
Parasthesia in one hand, spreading to arm, elbow, face, lips and tongue
55
What is aura (migraine)?
Transient neurological symptoms resulting from cortical or brainstem dysfunction e.g. visual, sensory, motor or speech symptoms
56
How does aura typically move from one symptom to the next?
Vision -> sensory -> speech
57
How long can aura last (migraine)?
15-60 minutes
58
What duration is classed as chronic migraine?
Headache >15days/month with >8 days as migraine for more than 3 months
59
What is a transformed migraine?
History of episodic migraine and increasing frequency of headaches but migrainous symptoms have become less frequent and less severe
More headaches = less severe
60
What is duration is classed as a medication overuse headache (MOH)?
Headache present on >15days/month which has developed or worsened whilst taking regular symptomatic medication
61
What is the treatment for migraines?
Abortive: aspirin/NSAIDs, triptans
Preventative: propranolol, Cadesartan, anti-epileptics (valproate), tricyclic antidepressants (amitriptyline), venlafaxine
62
What gets better with pregnancy: migraine with aura or migraine without aura?
Migraine without aura gets better in pregnancy
63
Which drug is contraindicated in active migraine with aura?
Oral contraceptive pill
64
What is the treatment for migraine during pregnancy?
Acute attack: paracetamol
| Preventative: propanolol or amitriptyline
65
What are trigeminal autonomic cephalalgias (TACs)?
A group of headache disorders characterised by attack of moderate to severe unilateral pain in the head/face with associated ipsilateral cranial autonomic features e.g. lacrimation, conjunctival infection, nasal congestion, oedema, ptosis
66
What headaches are included in TACs?
Cluster headache
Paroxysmal hemicrania
Short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT)
Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)
Long-lasting autonomic symptoms with hemicranial (LASH)
67
Where is the pain focussed usually for cluster headaches?
Oribital and temporal regions
68
Are attacks unilateral or bilateral for cluster headaches?
Unilateral
69
What is typical duration of a cluster headache?
15 mins - 3 hours
70
Where is the pain focussed usually for paroxysmal hemicrania?
Orbital and temporal regions
71
Are attacks unilateral or bilateral for paroxysmal hemicrania?
Unilateral
72
What is the typical duration for paroxysmal hemicrania?
2-30mins
73
What are 10% of paroxysmal hemicrania attacks precipitated by?
Bending or rotating the head
74
Approximately, how many attacks per day for paroxysmal hemicrania?
2-40 per day
75
Where is the pain focussed usually for SUNCT?
Unilateral orbital, supraorbital or temporal pain
76
What is the character of pain for SUNCT?
Stabbing or pulsating
77
What is the duration of an episode of SUNCT?
10-240 seconds
78
What are the triggers for SUNCT?
Cutaneous triggers - cold, touch, chewing
79
What is the frequency of attacks for SUNCT?
3-200/day
80
What is pain accompanied by with SUNCT?
Conjunctival inaction and lacrimation
81
What are red flags for headaches?
New onset headache
New or change in headache - over 50, cancer, immunosuppresion
Change in freq, characteristics or associated symptoms
Focal neurological symptoms
Non-focal neurological symptoms
Abnormal neurological examination
Neck stiffness/fever
High pressure - worse lying down/wakening patient/precipitated by exercise/valsalva manoeuvre
Low pressure - precipitated by sitting/standing
GCA - jaw claudication/visual disturbance/prominent/beaded temporal arteries
82
What is a thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
83
What are the differential diagnoses for thunderclap headache?
```
Primary (migraine)
Subarachnoid haemorrhage (SAH)
Intracerebral haemorrhage
TIA/stroke
Carotid/vertebral dissection
Cerebral venous sinus thrombosis
Meningitis/encephalitis
Pituitary apoplexy
Spontaneous intracranial hypotension
```
84
What percentage of patients with a thunderclap headache will have a SAH?
10%
85
What are the investigations for a suspected SAH?
CT brain and LP same day
86
What are some symptoms of meningitis?
Nausea, vomiting, photo/phono-phobia, stiff neck, headache, fever, rash
87
What CNS infections should be considered with any patient presenting with headache or fever?
Meningitis and encephalitis
88
What are the symptoms of encephalitis?
Altered mental state/consciousness, focal symptoms/signs, seizures, headache, fever, rash
89
What are some causes of raised intracranial pressure?
```
Glioblastoma multiforme
Cerebral abscess
Venous infarct with focal area of haemorrhage
Meningioma
Hydrocephalus
Papilloedema
```
90
What are the features suggestive of a space occupying lesion and/or raised intracranial pressure?
Progressive headache with associated symptoms/signs
Headache worse in morning/wakes from sleep
Headache worse lying flat or brought on by Valsalva
Focal symptoms or signs
Non-focal symptoms - cognitive/personality change, drowsiness
Seizures
Visual obscurations and pulsatile tinnitus
91
What are the causes of intracranial hypotension?
Dural CSF leak - either spontaneous or iatrogenic (LP)
92
What are the features of a headache of a patient with intracranial hypotension?
Headache develops/worsens soon with upright posture and lessens/resolves with lying down
93
What are the investigations for intracranial hypotension?
MRI brain and spine
94
What is the treatment for intracranial hypotension?
Bed rest, fluids, analgesia, caffeine
IV caffeine
Epidural blood patch
95
What is giant cell arteritis?
Arteritis of large arteries
96
Which patient group should giant cell arteritis be considered in?
Over 50s with new headache
97
What are the signs and symptoms of giant cell arteritis?
Headache: diffuse, persistent, severe
Systemically unwell
Scalp tenderness, jaw claudication, visual disturbance
Prominent, beaded or enlarged temporal arteries
98
What markers support a diagnosis of giant cell arteritis?
Elevated ESR
| Raised CRP and platelet count
99
What is the treatment is giant cell arteritis is suspected?
High dose prednisolone
| Temporal artery biopsy
100
When considering epilepsy, what history do you want from the patient?
History of preceding events
History of event itself - warning symptoms/level of awareness/recollection
Afterwards - first recollection, seizure markers e.g. prolonged disorientation, tongue biting, incontinence, muscle pains
101
When considering epilepsy, what history do you want from a witness?
How were they before?
Description of episode: eyes open/closed, description of abnormal movements, pallor, alteration in breathing pattern, pulses, duration of LOC, time to recovery
102
What are the three categories of syncope?
Reflex (neuro-cardiogenic)
Orthostatic
Cardiogenic
103
How is reflex (neuropathy-cardiogenic/vasovagal) syncope caused?
Taking blood/medical situations
| Cough, micturation
104
How is orthostatic syncope caused?
Dehydration
Medication related (antii-hypertensive)
Endocrine
ANS
105
How is cardiogenic syncope caused?
Arrhythmia
| Aortic stenosis
106
What is the recovery like for normal syncope?
Very brief LOC
Fully orientated quickly
Rapid recovery
107
What investigations would you do for syncope?
Examination: heart sounds, pulse, postural BPs
ECG: look at QT ratio, for heart block
24hr ECG
Tilt table test
108
What is the usual patient account for signs/symptoms for cardiogenic syncope?
On exertion
Chest pain, palpitations, SOB
Came round fairly quickly
Clammy/sweaty
109
What is the usual witness account for signs/symptoms for cardiogenic syncope?
```
Suddenly went floppy
Looked grey/ashen white
Seemed to stop breathing
Unable to feel pulse
Few brief jerks
Rapid recovery
```
110
What investigations would you do for cardiogenic syncope?
```
Family history
Examinations: heart sounds, pulse
ECG: look at QT ratio, for heart block
Refer to cardiology urgently/admission for telemetry
24hr ECG/ECHO/prolonged monitoring
```
111
What triggers can result in provoked seizures?
```
Alcohol withdrawal
Drug withdrawal
Within few days of head injury
Within 24hrs of stroke
Within 24hrs neurosurgery
With severe electrolyte disturbance
Eclampsia
```
112
What are the two main categories of seizure?
Generalised seizures
| Focal seizures
113
Where do the electrical disturbances occur in generalised seizures?
Across whole brain at once
114
Where do the electrical disturbances occur in focal seizures?
In one particular part of the brain
115
What types of seizures are included in the classification generalised seizures?
```
Absence seizures
Generalised tonic-clonic seizures
Myoclonic seizures
Juvenile myoclonic epilepsy
Atonic seizures
```
116
What types of seizures are included in the classification focal seizures?
Simple partial seizures
Complex partial seizures
Secondary generalised
Or by localisation of onset e.g. temporal lobe
117
What are the features of primary generalised epilepsy?
```
No warning
<25 years
May have history of absences and myoclonic jerks as well as GTCS
Generalised abnormality of EEG
Family history
```
118
What are the features of focal/partial epilepsy?
```
May get an 'aura'
Any age
Simple partial and complex partial seizures can become secondary generalised
Focal abnormality on EEG
MRI may show cause
```
119
What is the usual patient account for a generalised tonic clonic seizure (GTCS)?
```
Unpredictable - tend to cluster
PMH - trauma, brain injury, meningitis
Irritability before event
May have vague warning
Tongue biting
Incontinence
First recollection a lot later - hospital/ambulance
Muscle pain
```
120
What is the usual witness account for a generalised tonic clonic seizure (GTCS)?
```
Groaning sound
Tonic (rigid phase) - generalised jerking in all four limbs
Eyes open - staring/roll upwards
Foaming at mouth
Jerking for few minutes
Groggy for 15-30mins - poor recollection until later
Agitated after
Clusters of episodes
```
121
Who are prone to getting absence seizures?
Children
122
What are absence seizures often provoked by?
Hyperventilation
| Photic stimulation
123
What happens in an absence seizure?
Brief staring
Eye-lid fluttering
Re-start what they were doing
124
Who are prone to getting juvenile myoclonic epilepsy?
Adolescents/early adulthood
125
What is juvenile myoclonic epilepsy often provoked by?
Alcohol
| Sleep deprivation
126
What other seizures can juvenile myoclonic epilepsy get?
Absence seizures
| GTCS
127
Which type of epilepsy will often have early morning myoclonus, meaning they will drop things and have brief jerks in the limbs?
Juvenile myoclonic epilepsy
128
What is the usual patient account for complex partial seizures?
Rising feeling in stomach before, funny smell/taste
Deja vu
No recollection of event itself
Disorientated afterwards
129
What is the usual witness account for complex partial seizures?
Sudden arrest in activity
Staring blankly into space
Automatisms: lip smacking/repetitive picking at clothes
Disorientated
130
What is the routine clinical assessment for seizures?
```
Refer to first seizure clinic
ECG, routine bloods (Glc)
CT
Neurology clinic:
MRI for focal lesion
EEG
Discuss anti-epileptic drugs
Discuss driving
```
131
What investigations would you do for both generalised and focal seizures?
Generalised: EEG if hyperventilation/photic stimulation
Focal: MRI/CT
Video-telemetry
132
What are factors influencing seizure risk?
```
Missed medications (most common)
Sleep disturbance/fatigue
Hormonal changes
Drug/alcohol use, drug interactions
Stress/anxiety
Photosensitivity
```
133
What is the first line treatment for epilepsy for generalised epilepsies?
Sodium valproate
Lamotrigine
Levetiracetam
134
What is the first line treatment for epilepsy for focal and secondary generalised epilepsies?
Lamotrigine
Carbamazepine
Levetiracetam
135
What is the first line treatment for epilepsy for absence seizures?
Ethosuzimide
136
What is the first line treatment for status epilepticus?
Lorazepam/midazolam first line
| Valproate or phenytoin second line
137
What are some second line treatment for epilepsy for generalised epilepsies?
Topiramate
Zonisamide
Clobazam
138
What are some second line treatment for epilepsy for partial seizures?
Sodium valproate
Topiramate
Gabapentin
139
What are the side effects of phenytoin?
Arrhythmia
Hepatitis
Medication interactions
140
What are the side effects of sodium valproate?
```
Tremor
Weight gain
Ataxia
Nausea
Drowsiness
Hepatitis
(Avoid in women of childbearing age)
```
141
What are the side effects of carbamazepine?
```
Ataxia
Drowsiness
Nystagmus
Blurred vision
Low serum sodium levels
Skin rash
```
142
What are the side effects of lamotrigine?
Skin rash
| Difficulty sleeping
143
What are the side effects of levetiracetam?
Irritability
| Depression
144
What are the DVLA regulations about epilepsy?
After 1 seizure, patient may drive a car after 6 months if investigations are normal and no further events
(HGV after 5 years)
Patients with epilepsy can drive a car once they have been seizure-free for a year or have only have sleep seizures for a year
145
What is status epilepticus?
Prolonged or recurrent tonic-clonic seizures persisting for 30mins+ with no recovery period between seizures
146
Who does status epilepticus usually affect?
Patients with no previous history of epilepsy e.g. stroke, tumour, alcohol
147
What is non-convulsive status epilepticus?
Prolonged unresponsiveness following a seizure
148
What is the first line treatment of status epilepticus?
Midazolam
Lorazepam
Diazepam
149
What are the second and third line treatments of status epilepticus?
Second: phenytoin, valproate
Third: anaesthesia with propofol or thiopentone
150
What is the usual patient account for a non-epileptic attack/pseudoseizure?
Events may occur at time of stress/at rest
Lots of details about other reaction, little of events themselves
May recall what people said during episode
May be prolonged episode
May describe dissociation
Remembers others reactions
151
What is the witness account for a non-epileptic attack/pseudoseizure?
May recognise stress as trigger
May report signs of patient retaining awareness
Tracking eye movements, some verbalization
Movements not typical of seizures: pelvic thrusting, asynchronous movements, tremor, episodes waxing and waning
