Neurology Conditions A Flashcards
1
Q
Ischaemic Stroke - Description
A
rapid onset focal neurological deficit lasting more than 24 hours due to arterial stenosis or occlusion
2
Q
Ischaemic Stroke - Causes (7)
A
1) small vessel occlusion
2) large vessel atherothromboembolism
3) cardioembolism (AF, MI, IE)
4) vasculitis
5) sickle cell disease
6) polycythaemia
7) hypoperfusion (inc. caused by sepsis)
3
Q
Ischaemic Stroke - Risk Factors (13)
A
1) older age
2) male
3) family history
4) Afro-Caribbean
5) transient ischaemic attack
6) atrial fibrillation
7) diabetes mellitus
8) hypertension
9) dyslipidaemia
10) hypercoagubility
11) oral contraceptive pill
12) smoking
13) alcohol
4
Q
Ischaemic Stroke - Symptoms (General) (4)
A
FAST
1) facial drooping
2) arm weakness
3) slurred speech
4) time (sudden onset)
5
Q
Ischaemic Stroke - Symptoms (Anterior Cerebral Artery) (6)
A
1) contralateral numbness (esp. leg)
2) contralateral weakness (esp. leg)
3) truncal ataxia
4) gait ataxia
5) incontinence
6) drowsiness
6
Q
Ischaemic Stroke - Symptoms (Middle Cerebral Artery) (4)
A
1) contralateral numbness (arm+leg)
2) contralateral weakness (arm+leg)
3) dysphasia —> aphasia
4) visuospatial disturbances
7
Q
Ischaemic Stroke - Symptoms (Posterior Cerebral Artery) (5)
A
1) contralateral homonymous hemianopia
2) cortical blindness
3) visual agnosia
4) prosopagnosia
5) unilateral headache (esp. haemorrhagic)
8
Q
Ischaemic Stroke - Symptoms (Vertebrobasilar Artery) (5)
A
1) quadriplegia
2) dysarthria
3) dysphasia
4) visual disturbances
5) locked in syndrome
9
Q
Ischaemic Stroke - Complications (5)
A
1) haemorrhage
2) deep vein thrombosis
3) seizure
4) aspiration pneumonia
5) depression
10
Q
Ischaemic Stroke - Investigations (5/1)
A
initial
1) urgent head CT (brain parenchyma hypoattenuation, dark)
2) brain diffusion weighted imaging MRI (infarct hyperattenuation, bright)
3) serum glucose (exclude hypoglycaemia/hyperglycaemia)
4) ECG + BP
5) FBC
consider
1) CT/MRI angiogram (identify stenosis/occlusion)
11
Q
Ischaemic Stroke - Management (5/4/1)
A
conservative
1) nil by mouth until swallowing assessment (aspiration pneumonia)
2) maintain oxygen (>95%)
3) maintain hydration
4) head CT post thrombolysis (24 hours later)
5) CVS risk factor control
medical
1) thrombolysis (IV alteplase) (<4.5 hours of onset)
2) aspirin (24 hours after IV alteplase) (2 weeks)
3) clopidogrel (unknown onset or >4.5 hours of onset) (lifelong)
4) prophylactic anticoagulant (DVT)
surgery
1) thrombectomy (large artery occlusion)
12
Q
Haemorrhagic Stroke - Description
A
rapid onset focal neurological deficit lasting more than 24 hours due to an intracerebral haemorrhage
13
Q
Haemorrhagic Stroke - Causes (7)
A
1) cerebral amyloid angiopathy
2) hypertension (Charcot Bouchard aneurysm)
3) aneurysm rupture
4) ateriovenous malformation
5) anticoagulants
6) trauma —> carotid artery dissection
7) subarachnoid haemorrhage
14
Q
Haemorrhagic Stroke - Risk Factors (7)
A
1) older age
2) male
3) Afro-Caribbean
4) family history
5) hypertension
6) haemophilia
7) anticoagulants
15
Q
Haemorrhagic Stroke - Symptoms (General) (7)
A
FAST 1) facial drooping 2) arm weakness 3) slurred speech 4) time (sudden onset) other 5) neck stiffness 6) severe headache 7) impaired consciousness
16
Q
Haemorrhagic Stroke - Symptoms (Anterior Cerebral Artery) (6)
A
1) contralateral numbness (esp. leg)
2) contralateral weakness (esp. leg)
3) truncal ataxia
4) gait ataxia
5) incontinence
6) drowsiness
17
Q
Haemorrhagic Stroke - Symptoms (Middle Cerebral Artery) (4)
A
1) contralateral numbness (arm+leg)
2) contralateral weakness (arm+leg)
3) dysphasia —> aphasia
4) visuospatial disturbances
18
Q
Haemorrhagic Stroke - Symptoms (Posterior Cerebral Artery) (5)
A
1) contralateral homonymous hemianopia
2) cortical blindness
3) visual agnosia
4) prosopagnosia
5) unilateral headache (esp. haemorrhagic)
19
Q
Haemorrhagic Stroke - Symptoms (Vertebrobasilar Artery) (5)
A
1) quadriplegia
2) dysarthria
3) dysphasia
4) visual disturbances
5) locked in syndrome
20
Q
Haemorrhagic Stroke - Complications (5)
A
1) hydrocephalus
2) deep vein thrombosis
3) seizure
4) aspiration pneumonia
5) depression
21
Q
Haemorrhagic Stroke - Investigations (4/1)
A
initial
1) urgent head CT (brain parenchyma hyperattenuation, bright)
2) serum glucose (exclude hypoglycaemia/hyperglycaemia)
3) ECG + BP
4) FBC
consider
1) CT/MRI angiogram (identify aneurysm, arteriovenous malformation)
22
Q
Haemorrhagic Stroke - Management (5/3/2)
A
conservative 1) monitor GCS 2) nil by mouth until swallowing assessment (aspiration pneumonia) 3) maintain oxygen (>95%) 4) maintain hydration 5) CVS risk factor control medical 1) IV prothrombin complex concentrate + vitamin K (anticoagulant reversal) 2) diuretic (mannitol) (lower ICP) 3) prophylactic anticoagulant (DVT) (once haemorrhage controlled) surgery 1) craniotomy + drainage (severe) 2) cerebral shunt (hydrocephalus)
23
Q
Transient Ischaemic Attack - Description
A
rapid onset reversible focal neurological deficit lasting less than 24 hours due to arterial stenosis or occlusion
24
Q
Transient Ischaemic Attack - Causes (7)
A
1) small vessel occlusion
2) large vessel atherothromboembolism* (esp. carotid)
3) cardioembolism (AF, MI, IE)
4) vasculitis
5) sickle cell disease
6) polycythaemia
7) hypoperfusion (inc. caused by sepsis)
25
Transient Ischaemic Attack - Risk Factors (13)
1) older age
2) male
3) family history
4) Afro-Caribbean
5) transient ischaemic attack
6) hypertension
7) atrial fibrillation
8) diabetes mellitus
9) dyslipidaemia
10) hypercoagubility
11) oral contraceptive pill
12) smoking
13) alcohol
26
Transient Ischaemic Attack - Symptoms (Anterior Circulation) (5)
90%
1) dysphasia —> aphasia
2) contralateral numbness
3) contralateral weakness
4) contralateral hemianopia
5) amaurosis fugax (sudden loss of vision in one eye)
27
Transient Ischaemic Attack - Symptoms (Posterior Circulation) (6)
10%
1) dysarthria —> choking
2) contralateral numbness
3) contralateral hemianopia
4) diplopia
5) vertigo
6) transient global amnesia (episode of amnesia/confusion that resolves within 24 hours)
28
Transient Ischaemic Attack - Complications (2)
1) stroke (30% in 5 years)
| 2) myocardial infarction (15% in 5 years)
29
Transient Ischaemic Attack - Investigations (5/2)
initial
1) brain diffusion weighted imaging MRI (exclude haemorrhage)
2) serum glucose (exclude hypoglycaemia/hyperglycaemia)
3) ECG + BP
4) FBC
5) carotid artery Doppler ultrasound (stenosis)
consider
1) carotid CT/MRI angiogram (if stenosis)
2) echocardiogram (cardioembolism)
30
Transient Ischaemic Attack - Stroke Risk (ABCD2) (5)
>6 - immediate specialist referral; >4 - <24 hour specialist referral
A) age >60 years old (1)
B) BP >140/90 (1)
C) clinical features: unilateral weakness (2); speech disturbances without weakness (1)
D) duration: <1 hour (1); >1 hour (2)
D) diabetes mellitus (1)
31
Transient Ischaemic Attack - Management (3/3/1)
```
conservative
1) specialist referral (<1 week minimum)
2) no driving (4 weeks)
3) CVS risk factor control
medical
1) aspirin (first 2 weeks)
2) clopidogrel (after 2 weeks)
3) anticoagulant (if cardioembolism)
surgery
1) carotid endarterectomy or stent (>50% stenosis)
```
32
Subarachnoid Haemorrhage - Description
spontaneous bleeding into subarachnoid space (in between arachnoid and pia)
33
Subarachnoid Haemorrhage - Causes (4)
1) berry aneurysm rupture (80%)
2) arteriovenous malformation (15%)
3) vasculitis
4) idiopathic
34
Subarachnoid Haemorrhage - Risk Factors (10)
1) >50 years old (esp. 50-55)
2) female
3) family history
4) Afro-Caribbean
5) hypertension
6) smoking
7) polycystic kidney disease
8) Ehlers-Danlos syndrome
9) Marfan syndrome
10) aorta coarctation
35
Subarachnoid Haemorrhage - Symptoms (7)
1) sudden severe occipital headache (thunderclap)
2) neck stiffness
3) vomiting
4) collapse
5) seizure
6) coma
7) photophobia
36
Subarachnoid Haemorrhage - Signs (3)
1) Kernig’s sign (inability to extend knee when hip is flexed) (6 hour later)
2) Brudzinski’s sign (when neck is flexed, hip and knee also flex)
3) papilloedema
37
Subarachnoid Haemorrhage - Complications (7)
1) rebleeding (20%)
2) vasospasm —> cerebral ischaemia
3) hydrocephalus
4) cerebral oedema
5) hyponatraemia
6) coma
7) death
38
Subarachnoid Haemorrhage - Investigations (1/2)
initial
1) head CT* (star shaped lesion)
consider
1) lumbar puncture (if CT negative) (xanthochromic - yellow)
2) CT angiogram (number/extent of aneurysms)
39
Subarachnoid Haemorrhage - Management (0/3/2)
medical
1) IV fluids (maintain cerebral perfusion)
2) nimpdipine (CCB) (reduce vasospasm —> cerebral ischaemia risk)
3) dexamethasone (corticosteroid) (reduce cerebral oedema)
surgery
1) endovascular coiling*
2) surgical clipping
40
Subdural Haematoma - Description
accumulation of clotted blood in subdural space (in between dura and arachnoid)
41
Subdural Haematoma - Risk Factors (5)
1) traumatic head injury (esp. decelerating injuries)
2) aging —> cerebral atrophy
3) alcohol —> cerebral atrophy
4) anticoagulation
5) coagulopathy
42
Subdural Haematoma - Pathophysiology (2)
1) rupture of bridging vein between cortex and venous sinus
| 2) accumulation of clotted blood in subdural space
43
Subdural Haematoma - Symptoms (Acute) (7)
1) headache
2) fluctuating consciousness
3) nausea
4) vomiting
5) seizure
6) coma
7) focal neurological deficit (e.g. hemiparesis)
44
Subdural Haematoma - Symptoms (Chronic) (4)
1) headache
2) fluctuating consciousness
3) cognitive decline
4) personality change
45
Subdural Haematoma - Complications (5)
1) epilepsy
2) stroke
3) cerebral oedema
4) coma
5) death
46
Subdural Haematoma - Investigations (1/0)
initial
| 1) head CT (diffuse hyperdense crescent shaped mass, shifting of midline structures)
47
Subdural Haematoma - Management (1/2/1)
```
conservative
1) anticoagulant/antiplatelet cessation
medical
1) IV mannitol (high ICP)
2) IV prothrombin complex concentrate + vitamin K (anticoagulation reversal)
surgery
1) craniotomy (haematoma evacuation)
```
48
Extradural Haematoma - Description
accumulation of clotted blood in extradural space (in between skull and dura)
49
Extradural Haematoma - Risk Factors (1)
1) traumatic head injury (temporal/parietal fracture)
50
Extradural Haematoma - Pathophysiology (3)
1) fracture of temporal or parietal bone
2) laceration of middle meningeal artery
3) accumulation of clotted blood in extradural space
51
Extradural Haematoma - Symptoms (6)
```
1) post traumatic loss of consciousness —> lucid interval (hours/days) —> decrease in consciousness
high ICP
2) headache
3) nausea
4) vomiting
5) coma
```
52
Extradural Haematoma - Investigations (2/0)
initial
1) head CT* (hyperdense lemon shaped mass adjacent to skull)
2) skull x-ray
53
Extradural Haematoma - Management (1/2/1)
```
conservative
1) anticoagulant/antiplatelet cessation
medical
1) intubation + ventilation
2) IV mannitol (high ICP)
surgery
1) craniotomy (haemotoma evacuation ± blood vessel ligation)
```
54
Depression - Description
disorders characterised by persistent low mood and anhedonia
55
Depression - Risk Factors (8)
1) >65 years
2) female (2x)
3) family history
4) chronic disease (1/3)
5) postpartum (20%)
6) oral contraceptive pill
7) corticosteroids
8) propranolol
56
Depression - Symptoms (10)
1) low mood*
2) anhedonia* (decreased interest and/or pleasure in all activities)
3) functional impairment
4) sleep disturbances (insomina/hypersomnia)
5) fatigue
6) guilt (inc. worthlessness)
7) weight change
8) libido change
9) poor concentration
10) suicidal intention
57
Depression - Diagnosis (DSM-5 Criteria) (2/8)
```
2 week period, ≥5 symptoms nearly everyday, ≥1 major criteria
major criteria
1) low mood
2) anhedonia (decreased interested and/or pleasure in all activities)
minor criteria
1) functional impairment
2) sleep disturbances (insomnia/hyperosomnia)
3) fatigue
4) guilt (inc. worthlessness)
5) weight change
6) libido change
7) poor concentration
8) suicidal intention
```
58
Depression - Management (5/3/0)
```
conservative
1) watchful waiting (2 week GP follow-up)
2) regular exercise (inc. yoga)
3) self-help books
4) psychotherapy
5) cognitive behavioural therapy (inc. computer based)
medical
1) SSRI (e.g. fluoxetine)
2) TCA (e.g. amitriptyline)
3) St. John’s wort
```
59
Epilepsy - Description
recurrent spontaneous, intermittent, abnormal electrical brain activity manifesting as seizures
60
Epilepsy - Causes (5)
1) idiopathic (2/3)
2) cortical scarring (head injury, cerebrovascular disease, CNS infection)
3) tumour
4) tuberous sclerosis
5) dementia
61
Epilepsy - Risk Factors (9)
1) family history
2) premature birth
3) febrile seizure
4) dementia
5) drugs (e.g. cocaine)
6) head trauma
7) cerebrovascular disease (e.g. stroke)
8) CNS infection (e.g. meningitis)
9) tumour
62
Epilepsy - Types (7)
```
focal (57%)
1) simple
2) complex
3) with secondary generalised (2/3 of focal)
generalised (40%)
4) absence (petit-mal)
5) myoclonic
6) tonic-clonic (grand-mal)
7) atonic
```
63
Epilepsy - Pathophysiology (Focal) (1)
1) electrical discharge limited to one part of the cortex (80% in temporal lobe)
64
Epilepsy - Pathophysiology (Generalised) (1)
1) electrical discharge simultaneously throughout whole cortex
65
Epilepsy - Phases (4)
1) prodromi
2) aura
3) ictus (i.e. seizure
4) post-ictus
66
Epilepsy - Symptoms (Focal - Temporal) (5)
80% of focal
1) deja vu (feeling of unfamiliar feeling familiar)
2) jamais vu (feeling of familiar feeling unfamiliar)
3) auditory hallucinations
4) olfactory hallucinations
5) anxiety —> fear
67
Epilepsy - Symptoms (Focal - Frontal) (1)
1) motor features
68
Epilepsy - Symptoms (Focal - Parietal) (1)
1) sensory features
69
Epilepsy - Symptoms (Focal - Occipital) (1)
1) visual features (e.g. visual hallucinations, visual loss)
70
Epilepsy - Symptoms (Generalised - Absence) (2)
1) <10 second pause in activity (e.g. stops talking mid-sentence)
2) unaware of attack
71
Epilepsy - Symptoms (Generalised - Myoclonic) (1)
1) sudden jerk of limb, face, trunk (e.g. thrown to ground or violently disobedient limb)
72
Epilepsy - Symptoms (Generalised - Tonic-Clonic) (4)
1) loss of consciousness
2) still limbs —> jerking limbs (tonic —> clonic)
3) drowsiness (post-ictus)
4) confusion (post-ictus)
73
Epilepsy - Symptoms (Generalised - Atonic) (1)
1) sudden loss of muscle tone —> fall
74
Epilepsy - Complications (4)
1) head trauma
2) fractures
3) memory loss
4) sudden, unexpected death in epilepsy (SUDEP)
75
Epilepsy - Investigations (3/2)
```
initial
1) head CT
2) electroencephalogram (not diagnostic)
3) serum glucose (exclude hypoglycaemia/hyperglycaemia)
consider
1) head MRI (identify causative lesion)
2) genetic testing
```
76
Epilepsy - Diagnosis (1)
1) history of >2 unprovoked seizures >24 hours apart
77
Epilepsy - Management (4/4/2)
conservative
1) ABCDE (esp. maintain airways)
2) protect from injury
3) check glucose
4) inform DVLA
medical
1) IV diazepam or IV lorazepam x2 (1st line, during seizure)
2) IV phenytoin (2nd line, during seizure)
3) carbamazepine (focal)
4) sodium valproate (generalised)
surgery
1) surgical resection (hippocampal sclerosis or tumour) (70% resolution)
2) neurostimulation system (e.g. vagal nerve stimulation or deep brain stimulation)
78
Parkinson’s Disease - Description
progressive neurodegenerative movement disorder due to decreased DA in substantia nigra
79
Parkinson’s Disease - Causes (1)
1) unknown
80
Parkinson’s Disease - Risk Factors (6)
1) age* (peak onset 55-65 years old)
2) male
3) family history
4) GBA gene mutation (Gaucher’s disease) (5x)
5) MPTP exposure (e.g. cocaine)
6) insecticide/herbicide exposure
81
Parkinson’s Disease - Pathophysiology (6)
1) mitochondrial dysfunction and oxidative stress on substantia nigra
2) progressive degeneration of dopaminergic neurones of substantia nigra
3) decreased DA synthesis in the striatum
4) decreased DA release
5) decreased thalamus activity
6) decreased movement
82
Parkinson’s Disease - Symptoms (Non-Motor Prodrome) (3)
up to 7 years prior to motor symptoms
1) anosmia
2) urgency
3) constipation
83
Parkinson’s Disease - Symptoms (Parkinson’s Triad) (3)
1) tremor (esp. at rest, in hand)
2) rigidity
3) bradykinesia
84
Parkinson’s Disease - Symptoms (Rigidity) (2)
1) leadpipe rigidity (sustained resistance to passive movements)
2) cogwheel rigidity (jerky resistance to passive movements)
85
Parkinson’s Disease - Symptoms (Bradykinesia) (5)
1) slow movement initiation
2) slow repetition (e.g. blinking)
3) decreased amplitude in action repetition (e.g. micrographia (small handwriting))
4) hypophonia (decreased voice volume)
5) hypomimesis (expressionless face)
86
Parkinson’s Disease - Symptoms (Other) (2)
1) fine motor skill difficulty (e.g. buttons)
| 2) gait (stooped posture, small shuffling steps, narrow base, reduce arm swing, difficulty turning)
87
Parkinson’s Disease - Complications (7)
1) aspiration pneumonia
2) depression
3) anxiety
4) REM sleep disorders
5) postural hypotension
6) Lewy body depression
7) dyskinesia
88
Parkinson’s Disease - Investigations (0/2)
consider
1) levodopa trial (symptoms improve) (if unclear clinical diagnosis, confirmation)
2) MRI brain
89
Parkinson’s Disease - Management (3/2/1)
```
conservative
1) SALT (speech and language therapy)
2) physiotherapy (balance, gait)
3) physical activity
medical
1) levodopa* (>70 years old or severe)
2) decarboxylase inhibitor (e.g. co-careldopa) (decreases levodopa SEs, increases levodopa efficacy)
surgery
1) deep brain stimulation (refractory, party DA responsive)
```
90
Parkinson’s Disease - Management (Delay Levodopa) (3)
1) dopamine agonist (e.g. ropinirole)
2) monomanie oxidase b inhibitors (e.g. selegiline)
3) catechol-o-methyl transferase inhibitors (e.g. tolcapone)
91
Migraine - Description
recurrent unilateral pulsatile headache
92
Migraine - Risk Factors (3)
1) <40 years old (90%)
2) female
3) family history
93
Migraine - Triggers (9)
```
CHOCOLATE
C) chocolate
H) hangovers
O) orgasm
C) caffeine/cheese
O) oral contraceptive
L) lie-ins
A) alcohol
T) travel
E) exercise
```
94
Migraine - Symptoms (Aura) (4)
15-30%
1) visual hallucinations (e.g. visual sparkles)
2) scotoma (black hole in visual field)
3) hemianopia
4) paraesthesia (fingers to face)
95
Migraine - Symptoms (6)
1) unilateral pulsatile headache (moderate —> severe)
2) photophobia
3) phonophobia
4) nausea
5) vomiting
6) motion sensitivity
96
Migraine - Complications (5)
1) status migrainosus (>72 hours)
2) migrainous infarction
3) persistent aura
4) seizure
5) depression
97
Migraine - Investigations (0/2)
consider
1) lumbar puncture (exclude subarachnoid haemorrhage, meningitis, altered ICP)
2) brain MRI (red flags)
98
Migraine - Diagnosis (5)
1) ≥5 headaches lasting 4-72 hours
2) photophobia/phonophobia or nausea/vomiting
+ 2 of
3) unilateral
4) pulsatile
5) impairs or worsened by routine activity
99
Migraine - Management (1/5/0)
conservative
1) avoid triggers (CHOCOLATE)
medical
1) NSAID (e.g. aspirin) (moderate)
2) serotonin agonist (e.g. sumitriptan) (severe)
3) antiemetic
4) propranolol or topiramate (anticonvulsant) (prevention, >2 a week) (1st line)
5) amitriptyline (prevention, >2 a week) (2nd line)
100
Tension Headache - Description
most common primary headache
101
Tension Headache - Triggers (7)
1) stress
2) anxiety
3) noise
4) eyestrain
5) hunger
6) sleep deprivation
7) fatigue
102
Tension Headache - Types (2)
1) acute - <15 days/month
| 2) chronic - >15 days/month for 3 months
103
Tension Headache - Symptoms (2)
1) bilateral tight non-pulsatile headache (mild to moderate) (esp. frontal or occipital)
2) scalp muscle tenderness
104
Tension Headache - Management (4/3/0)
```
conservative
1) reassurance
2) avoid triggers
3) regular exercise
4) stress relief (e.g. massage)
medical
1) paracetamol
2) NSAID (e.g. ibuprofen, aspirin)
3) TCA (amitriptyline) (chronic)
```
105
Cluster Headache - Description
most disabling primary headache
106
Cluster Headache - Risk Factors (5)
1) male
2) family history
3) smoking
4) alcohol
5) head trauma
107
Cluster Headache - Types (2)
1) episodic - 4-12 week clusters, months-years remission
| 2) chronic - >1 year, without remission
108
Cluster Headache - Symptoms (7)
```
1) excruciating unilateral headache (rapid onset)
ipsilateral cranial autonomic symptoms
2) lacrimation (flow of tears)
3) swollen eyelid
4) facial flushing
5) rhinorrhoea
6) miosis (excessive pupil constriction)
7) ptosis (drooping upper eyelid)
```
109
Cluster Headache - Symptoms (Headache Sites) (4)
1) orbital
2) retro- orbital
3) temporal
4) mandibular
110
Cluster Headache - Complications (1)
1) depression
111
Cluster Headache - Diagnosis (1)
1) >5 cluster headaches
112
Cluster Headache - Management (2/3)
conservative
1) smoking cessation
2) avoid alcohol (in cluster)
medical
1) serotonin agonist (sumatriptan) (attack)
2) oxygen (15L 100% for 15 minutes via non-breathable mask) (attack)
3) CCB (verapamil) (prophylaxis)
113
Dementia - Description
syndrome characterised by memory loss, and decline of thinking, language, daily living activity
114
Dementia - Causes (5)
1) Alzheimer’s disease (50%)
2) vascular dementia (25%) (i.e. stroke)
3) Lewy-body (15%) (Parkinson’s associated)
4) frontotemporal (MND associated)
5) Huntington’s disease
115
Dementia - Symptoms (General) (4)
1) amnesia
2) disorientation
3) personality change (inc. mood changes)
4) daily living activities decline
116
Dementia - Symptoms (Lewy Body Triad) (3)
1) Parkinsonism
2) visual hallucinations
3) fluctuating course
117
Dementia - Complications (3)
1) Parkinson’s disease (25%)
2) pneumonia
3) urinary tract infection
118
Dementia - Investigations (General) (8/3)
```
initial
1) FBC
2) U+E
3) LFT
4) TFT
5) serum glucose
6) serum vitamin B12
7) urine drug screen
8) brain MRI
consider
1) FDG-PET
2) single photon emission CT
3) electroencephalogram
```
119
Alzheimer’s Disease - Description
chronic neurodegenerative disorder characterised by memory loss, and decline of thinking, language, daily living activities
120
Alzheimer’s Disease - Risk Factors (9)
1) >55 years old
2) female
3) family history
4) genetics (PICALM, CL1, CLU)
5) Down’s syndrome
6) cerebrovascular disease
7) hyperlipidaemia
8) obesity
9) smoking
121
Alzheimer’s Disease - Pathophysiology (6)
1) increased production / decreased clearance of β amyloid peptide
2) accumulation of β amyloid peptide
3) formation of dense amyloid oligomer plaques
4) inflammation of plaques forming neuritic plaques
5) synaptic damage and cell death
6) decreased ACh signalling
122
Alzheimer’s Disease - Symptoms (8)
1) amnesia
2) disorientation
3) personality change (inc. mood changes)
4) daily living activities decline
5) apathy
6) nominal dysphasia
7) prosopagnosia (late)
8) autoprosopagnosia (late)
123
Alzheimer’s Disease - Complications (2)
1) pneumonia
| 2) urinary tract infection
124
Alzheimer’s Disease - Investigations (8/3)
```
initial
1) FBC
2) U+E
3) LFT
4) TFT
5) serum glucose
6) serum vitamin B12
7) urine drug screen
8) brain MRI
consider
1) FDG-PET
2) single photon emission CT
3) electroencephalogram
```
125
Alzheimer’s Disease - Management (4/5/0)
```
conservative
1) identification bracelet
2) specialist memory service
3) home safety evaluation
4) occupational therapy
medical
1) vitamin E supplement
2) AChEi (e.g. donepezil, rivastigmine, galatamine)
3) antidepressants (e.g. SSRI, TCA)
4) antiglutaminergic (late)
5) antipsychotic (severe)
```
126
Multiple Sclerosis - Description
CNS oligodendrocyte demyelination due to chronic autoimmune inflammation
127
Multiple Sclerosis - Causes (1)
1) unknown
128
Multiple Sclerosis - Risk Factors (7)
1) 20-40 years old (presentation)
2) female
3) Caucasian
4) vitamin D deficiency (e.g. low sunlight exposure)
5) viral infection (EBV, MMR)
6) autoimmunity
7) smoking
129
Multiple Sclerosis - Types (3)
1) primary progressive - worsening disability with no relapses/remissions (10-15%)
2) relapsing remitting - worsening disability with relapses/remissions (80%)
3) secondary progressive - worsening disability with fewer relapses/remissions (2nd to 75% of RRMS)
130
Multiple Sclerosis - Pathophysiology (7)
1) unknown cause
2) T cells activate B cells to produce oligodendrocyte (CNS) autoantibodies
3) autoimmune demyelination of oligodendrocytes (CNS)
4) perivenular demyelination plaques form
5) myelin sheath regenerates but is less efficient and temperature dependant
6) repeated autoimmune demyelination of oligodendrocytes (CNS)
7) axonal loss
131
Multiple Sclerosis - Symptoms (8)
1) unilateral optic neuritis (eye movement pain and rapid decrease of central vision)
2) dysaesthesia
3) parasaesthesia
4) hypertonia (spasticity) (esp. legs, e.g. leg cramps)
5) bowel dysfunction (urgency, incontinence) (esp. constipation)
6) bladder dysfunction (urgency, incontinence, frequency)
7) erectile dysfunction
8) amnesia
132
Multiple Sclerosis - Symptoms (Brainstem/Cerebellum) (5)
1) diplopia
2) vertigo
3) ataxia
4) dysphagia
5) dysarthria
133
Multiple Sclerosis - Signs (2)
1) Lhermitte’s sign (neck flexion causes ‘electric shocks’ in trunk and limbs)
2) Uhthoff’s sign (symptoms worsen with heat)
134
Multiple Sclerosis - Complications (6)
1) depression
2) mobility impairment
3) osteopenia —> osteoporosis
4) aspiration pneumonia
5) urinary tract infections
6) erectile dysfunction
135
Multiple Sclerosis - Investigations (6/2)
initial
1) brain MRI* (perivenular demyelination plaques)
2) spinal MRI* (perivenular demyelination plaques)
3) FBC (normal)
4) TFT (normal)
5) metabolic panel (normal)
6) serum vitamin B12 (normal)
consider
1) lumbar puncture + CSF electrophoresis (oligoclonal IgG bands)
2) evoked potential (delayed visual, auditory, somatosensory)
136
Multiple Sclerosis - Diagnosis (McDonald Criteria) (2)
without investigation
1) ≥2 relapses
2) ≥2 objective clinical lesions
137
Multiple Sclerosis - Management (5/5/0)
conservative
1) regular exercise
2) physiotherapy
3) smoking cessation
4) avoid stress
5) self-catheterisation
medical
1) PO methylprednisolone (relapse) (IV if severe) (avoid >3/year)
2) dimethyl fumarate (1st disease modifying)
3) alemtuzumab or natalizumab (2nd disease modifying)
4) gabapentin (spasticity, pain, dysaesthesia)
5) tolterodine (urinary frequency)
138
Motor Neurone Disease - Description
group of progressive neurodegenerative disorders that affect motor neurones
139
Motor Neurone Disease - Risk Factors (3)
1) >40 years old (peak 60)
2) male (1.5x)
3) family history (5-10%)
140
Motor Neurone Disease - Types (4)
1) amyotrophic lateral sclerosis (<80%) (UMN+LMN)
2) progressive bulbar palsy (10-20%) (LMN IX-XII)
3) progressive muscular atrophy (<10%) (LMN)
4) primary lateral sclerosis (rare) (UMN)
141
Motor Neurone Disease - Onset Patterns (3)
1) limb (most common)
2) bulbar (20%)
3) respiratory (least common)
142
Motor Neurone Disease - Symptoms (Amyotrophic Lateral Sclerosis) (5)
UMN+LMN
1) weakness
2) hypertonia (spasticity) (inc. unsteady gait)
3) hyperreflexia
4) clonus (series of involuntary rhythmic muscular contractions and relaxations)
5) cramps
143
Motor Neurone Disease - Symptoms (Progressive Bulbar Palsy) (4)
LMN IX-XII
1) pseudobulbar palsy (inc. dysarthria, dysphagia, hypomimesis)
2) dysphonia
3) hypophonia
4) tongue fasciculation (tongue twitching, like a sack of worms)
144
Motor Neurone Disease - Symptoms (Primary Muscular Atrophy) (4)
LMN
1) weakness
2) hypotonia (flaccid)
3) hyporeflexia —> areflexia
4) fasciculation (brief spontaneous muscular contraction)
145
Motor Neurone Disease - Symptoms (Primary Lateral Sclerosis) (5)
UMN
1) weakness (inc. stumbling, foot drop) (esp. legs)
2) hypertonia (spasticity) (inc. unsteady gait) (esp. legs)
3) hyperreflexia
4) clonus (series of involuntary rhythmic muscular contractions and relaxations)
5) pseudobulbar palsy (inc. dysarthria, dysphagia, hypomimesis)
146
Motor Neurone Disease - Signs (Amyotrophic Lateral Sclerosis) (2)
1) split hand sign (thumb sided hand muscle wasting)
| 2) Babinski sign (dorsiflexion (upward) of big toe when sole of foot is stimulated by blunt instrument)
147
Motor Neurone Disease - Complications (4)
1) frontotemporal dementia
2) aspiration pneumonia
3) respiratory failure
4) hepatoxicity (riluzole)
148
Motor Neurone Disease - Investigations (0/5)
consider
1) electromyogram
2) nerve conduction studies
3) brain MRI (exclude structural cause)
4) spinal MRI (exclude structural cause)
5) lumbar puncture (exclude inflammatory cause)
149
Motor Neurone Disease - Management (4/3/0)
```
conservative
1) physiotherapy
2) occupational therapy
3) SALT (speech and language therapy)
4) PEG tube feeding (dysphagia)
medical
1) riluzole (extends life by 3 months)
2) analgesia
3) symptom management
```
150
Meningitis - Description
inflammation of brain meninges due to infection
151
Meningitis - Causes (11)
1) Neisseria meningitides*
2) Streptococcus pneumoniae
3) Haemophilus influenzae
pregnant
4) Listeria monocytogenes
neonate
5) Escherichia coli
6) Streptococcus agalactiae
immunocompromised
7) Cytomegalovirus
8) Cryptococcus neoformans
9) Herpes simplex
10) HIV
11) tuberculosis
152
Meningitis - Risk Factors (7)
1) <5 years old
2) >65 years old
3) immunocompromised
4) crowding (e.g. university)
5) cancer
6) intrathecal drug administration
7) cochlear implant
153
Meningitis - Symptoms (Early) (4)
1) headache (worst ever)
2) fever
3) leg pain
4) cold peripheries
154
Meningitis - Symptoms (Late) (5)
1) meningism
2) altered mental state (cerebral oedema)
3) focal neurological deficit (20%)
4) seizures
5) non-blanching petechia (meningococcal septicaemia)
155
Meningitis - Symptoms (Meningism) (3)
1) headache (worst ever)
2) photophobia
3) neck stiffness
156
Meningitis - Signs (5)
1) Kernig’s sign (inability to extend knee when hip is flexed)
2) Brudizinski’s sign (when neck is flexed, hip and knee also flex)
3) papilloedema
4) hypotension (shock)
5) slow capillary refill (shock)
157
Meningitis - Complications (5)
1) meningococcal septicaemia (inc. DIC) (shock)
2) cerebral oedema
3) hydrocephalus
4) seizures
5) hearing loss
158
Meningitis - Investigations (10/0)
initial
1) blood culture (before LP) (exclude meningococcal septicaemia)
2) lumbar puncture + CSF studies* (analysis, MS+C, PCR, serology)
3) FBC (anaemia, leucocytosis, thrombocytopenia)
4) U+E (acidosis)
5) LFT
6) high CRP + ESR
7) serum Ca2+ (low)
8) serum Mg2+ (low)
9) serum glucose (low)
10) head CT (exclude stroke, space-occupying lesions)
159
Meningitis - Diagnosis (Lumbar Puncture) (3/3/3)
```
bacterial
1) neutrophils
2) very high protein
3) low glucose
viral
1) lymphocytes
2) normal protein
3) normal glucose
tuberculosis
1) lymphocytes
2) high protein
3) low glucose
```
160
Meningitis - Management (1/6/0)
conservative
1) notify Public Health England
medical
1) empirical IV ceftriaxone
2) + empirical IV amoxicillin (>60 years old or immunocompromised)
3) IV dexamethasone (cerebral oedema)
4) IM benzylpenicillin (meningococcal septicaemia) (community)
5) IV cefotaxime (meningococcal septicaemia) (hospital)
6) prophylactic ciprofloxacin (contacts)
161
Encephalitis - Description
inflammation of brain parenchyma due to infection
162
Encephalitis - Causes (9)
```
viral*
1) Herpes simplex (1+2)*
2) Varicella zoster
3) Measles
4) Mumps
5) Rubella
non-viral
6) bacterial meningitis
7) tuberculosis
8) malaria
9) aspergillosis
```
163
Encephalitis - Risk Factors (3)
1) <1 years old
2) >65 years old
3) immunocompromised (e.g. HIV, chemo)
164
Encephalitis - Symptoms (Early)
systemic viral symptoms
1) headache
2) fever
3) fatigue
4) myalgia
5) nausea
165
Encephalitis - Symptoms (Late) (5)
brain symptoms
1) confusion
2) behavioural change (odd encephalopathic behaviour)
3) drowsiness —> coma
4) focal neurological deficit (e.g. hemiparesis)
5) seizures
166
Encephalitis - Complications (5)
1) death
2) ischaemic stroke
3) seizures
4) meningoencephalitis
5) neurological sequelae (e.g. aphasia, amnesia, motor problems)
167
Encephalitis - Investigations (9/0)
initial
1) lumbar puncture + CSF studies (analysis, MS&C, PCR, serology)*
2) blood culture
3) other cultures (e.g. throat swab, stool culture)
4) FBC (leucocytosis)
5) U+E (hyponatraemia)
6) LFT (high)
7) high CRP + ESR
8) brain high contrast CT (exclude stroke, space-occupying lesions) (inflammation, swelling)
9) electroencephalogram (background slowing)
168
Encephalitis - Management (0/4/0)
medical
1) supportive care (e.g. endotracheal intubation)
2) empirical IV aciclovir (ASAP <30 mins, before test results) (herpes simplex, varicella zoster)
3) symptomatic treatment (e.g. antiseizure – phenytoin)
4) IM benzylpenicillin (suspected meningoencephalitis)
169
Shingles - Description
infection of dermatome due to reactivation of latent varicella zoster (chickenpox)
170
Shingles - Causes (1)
varicella zoster --> herpes zoster
171
Shingles - Risk Factors (5)
1) >50 years old
2) HIV
3) corticosteroids
4) malignancy
5) chemotherapy
172
Shingles - Pathophysiology (3)
1) varicella zoster remains latent in sensory dorsal root ganglia
2) varicella zoster reactivates due to
decline in cell-mediated immunity
3) varicella zoster travels down sensory afferent neurones to infect dermatomes
173
Shingles - Symptoms (4)
1) localised dermatome pain (days-weeks prior to rash)
2) localised dermatome paraesthesia (days-weeks prior to rash)
3) localised dermatome erythematous maculopapular rash --> clear vesicles --> crust (resolution in 2-3 weeks)
4) systemic symptoms (20%) (e.g. headache, malaise, fatigue)
174
Shingles - Complications (3)
1) herpes zoster ophthalmicus (inc. blindness)
2) skin lesion superinfection (esp. Staph. or Strep.)
3) post herpetic neuralgia (10%)
175
Shingles - Investigations (0/1)
consider
| 1) blood/rash PCR (immunocompromised)
176
Shingles - Management (1/5/0)
conservative
1) varicella zoster vaccine (>70 years old)
medical
1) aciclovir (<72 hours of rash onset)
2) analgesia (e.g. ibuprofen --> opioid)
3) topical antibiotics (skin lesion superinfection)
4) TCA (amitriptyline) (post herpetic neuralgia)
5) antiepileptic (gabapentin) (post herpetic neuralgia)
