Neurology- core conditions Flashcards
Parkinsons disease
Caused by the loss of dopaminergic neurones in the substantia nigra of the basal ganglia. The basal ganglia is essential for coordinating movement
Symptoms of parkinsons disease
• Bradykinesia- slow movement
• Tremor- rest, postural
• Rigiditity- cog wheeling, lead pipe
• Postural instability- late feature
• Early features- loss of sense of smell, REM sleep behaviour disorder, constipation, depression and anxiety
• Late complications- bladder and blood pressure problems, pyschosis and dementia
Differentials for Parkinsons disease
• Essential tremor
• Drug induced parkinsonism
• Dementia with Lewy bodies, multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration
• Alzheimer’s and multiple cerebral infarctions
Clinical examination- Parkinsonian gait
• Stooped posture
• Forward flexion of the trunk and the knees
• Arms flexed at the elbows and wrists
• Known as shuffling gait due to small and fast steps
• Difficulty initiating turning around
Clinical examination- Parkinsonian tremor
• Resting tremor
• Pill rolling, looks like the patient is trying to roll a pill between their thumb and index finger
• 4-6Hz
• Asymmetrical, worse at rest
• Improves with movement
• No change with alcohol
Clinical diagnostic criteria
Step 1- diagnosis of Parkinsonian syndrome
• Bradykinesia
• At least one of muscle rigidity, resting tremor, postural instability
Clinical diagnostic criteria
Step 2- exclusion criteria for Parkinsons disease
• History of strokes/ head injury/ encephalitis
• Oculogyric crisis
• Neuroleptic treatment at onset of symptoms
• Sustained remission
• Cerebrallar signs
• Cerebral tumour
Clinical diagnostic criteria
Step 3- supportive positive criteria for Parkinsons disease
• Three or more are required alongside step one
• Unilateral onset
• Resting tremor present
• Disease is progressive
• Good response to levodopa
Parkinsons- investigations
DAT scan- less dye is taken up. Reduced uptake in the substantia nigra, particularly in the posterior part of the putamen. Motor symptoms begin in stage 4
MRI/CT- to rule out other things
Bedside- physical examination, anosmia testing
Bloods
Management plan- Parkinsons
First line treatment- levodopa. Addition of a dopamine agonist/ MAO-B inhibitor as an adjunct if motor symptoms are not controlled
Supportive therapies- include physiotherapy/ occupational therapy/ speech and language therapy/ diet advice
Can give deep brain stimulation
Levodopa
Usually combined with carbidopa to prolong action (peripheral inhibitor of dopamine metabolism). Side effects include dyskinesia when doses are high, impulsive behaviour, NV, loss of appetite, hypotension. Becomes less effective over time
Dyskinesia with levodopa (defenitions)
• Excessive motor activity when the dose is too high
• Dystonia - excessive muscle contraction leading to abnormal postures and movements
• Chorea - abnormal involuntary movements that are jerky and random
• Athetoid - involuntary twisting or writhing movements typically of the fingers / feet / hands
Dopamine agonists
• Stimulate dopamine receptors in the basal ganglia
• Side effects include pulmonary fibrosis / dizziness / drowsiness / tachycardia / dry mouth / NV / memory, concentration and confusion problems
• Usually used to delay the use of levodopa and then used in combination with levodopa to reduce the dose needed
• They increase impulsivity, shows as disinhibited behaviours i.e. gambling and hypersexuality
• E.g. pramipexole, ropinirole, bromocriptine
Monoamine oxidase B inhibitors
• These block the affects of monoamine oxidase B (an enzyme which breaks down dopamine)
• Used to delay the use of levodopa and used to reduce the required dose
• For example, Selegiline, Rasagiline
COMT inhibitors
• COMT metabolises levodopa, the inhibitors slow this down and extends the effect of levodopa
• For example, Tolcapone, entacapone
Multiple system atrophy
• Progressive degeneration of the neurones in multiple brain areas e.g. basal ganglia, cerebellum, autonomic and peripheral nervous system
• Basal ganglia degeneration leads to parkinsonian presentation but there are also other symptoms e.g. a lot of autonomic dysfunction causing hypotension/incontinence/impotence/sexual dysfunction etc
• Also profound cerebellar dysfunction
• Parkinsons with autonomic disturbance e.g. atomic bladder/postural hypotension points towards MSA
Progressive supranuclear palsy
• Rapidly progressive neurological disease characterised by accumulation of tau protein in basal ganglia, brainstem, prefrontal cortex, and cerebellum
• Symptoms include difficulty moving eyes, mood changes, dysphagia, backwards falls, slurred speech, memory loss, apraxia, resting tremor
• Involves psudeobulbar palsy (dysarthria and dysphagia)
• Bradykinesia, Backwards falls, Slow vertical saccades, Loss of a vertical gaze
Dementia with Lewy bodies
• Dementia associated with features of Parkinson’s disease - the parkinsonian features develop after the memory loss
• Other features = visual hallucinations / delusions / disorders of REM sleep / fluctuating consciousness
Neuroleptic malgnant syndrome
Life threatening muscle rigidity, fever and rhabdomyolysis in response to antipsychotics
Stroke
A clinical syndrome of presumed vascular origin characterised by rapidly developing signs of focal or global disturbance of cerebral functions which lasts longer than 24 hours or leads to death.
Types of stroke- Haemorrhagic (15%), Ischaemic (85%)
Types of stroke
Ischaemic- due to occlusion of arteries of cerebral circulation, normally due to an embolism as a result of atrial fibrillation
Haemorrhagic- a collection of blood from a blood vessel rupture.
Stroke risk factors (conditions)
• Ischaemic heart disease
• Peripheral arterial disease
• Carotid atherosclerosis -> carotid stenosis
• TIA
• Vascular heart disease and heart failure
• Clotting disorders
• Atrial fibrillation
Stroke symptoms
• Sudden onset
• F- face may have drooped to one side
• A- weakness or numbness in one arm
• S- speech may be slurred or cant speak
• T- call 999 immediately
Diagnosing a stroke
Diagnose with ROSIER score
Exclude hypoglycaemia in people with sudden onset neurological symptoms as the cause
Stroke- investigation findings
• CT head within an hour, possibly a CT angiogram
• Check blood pressure to look for hypertension
• ECG to look for atrial fibrillation (AF)
• Blood tests in order to check lipids, blood sugar, FBC and clotting
• Carotid duplex ultrasound to look for atherosclerotic plaque if its an anterior circulation stroke
• Echocardiogram to check for a clot in ventricles caused by AF
Stroke- thrombolysis treatment
• Recombinant Tissue Plasminogen Activator- rTPA (alteplase)
• 0.9mg/kg (max 90mg)- 10% bolus and 90% infusion over 1 hour
• Medically: tPA (intravenous tissue plasminogen activator)
• NIHSS >4
• Administer within 4.5 hrs
• The earlier tPA is administered, the higher the likelihood of a positive neurologic outcome
• Activates blood clot removal system, restores blood supply, reducing the number of dead neurons
• Adverse outcome- intracerebral haemorrhage
Absolute contraindications for tPA
• Major surgery in last 14 days
• GI or urinary tract bleeding in last 21 days
• Stroke < 3 months ago
• Platelets <100
• Symptoms suggestive of subarachnoid bleed (even if CT Head clear)
• BP greater than >185 systolic or >110 diastolic unresponsive to medical treatment
• INR >1.7 or NOAC (novel oral anticoagulant) within 24-48 hours
tPa relative exclusion criteria
• Minor stroke symptoms or rapidly resolving symptoms
• Major surgery or trauma in the last 14 days
• GI or GU bleeding in last 14 days
• MI in last 3 months
• Seizure at onset of stroke symptoms
• Pregnancy
Endovascular treatment for stroke
The clot is caught in a stent and removed, used for moderate to severe stroke when there is large vessel occlusion. Must be administered within 6 hours, can follow tPa or be done when its contraindicated.
Relative exclusion criteria for EVT
• Minor stroke symptoms or rapidly resolving symptoms
• Major surgery or trauma in the last 14 days
• GI or GU bleeding in the last 21 days
• MI in last 3 months
• Seizure at onset of stroke symptoms
• Pregnancy
Stroke medication
• Aspirin (300mg daily) for two weeks, offer a PPI as well if they have dyspepsia
• Clopidogrel (75mg)
DVLA states no driving for a month after a stroke
Stop anticoagulation treatment in people with haemorrhagic stroke. Reverse the effects of warfarin through prothrombin complex concentrate and intravenous vitamin K.
TIA
Transient (less than 24 hours) neurological dysfunction caused by focal brain ischaemia without evidence of acute infarction. Tends to last less than an hour.
Give aspirin (300mg daily)
MRI can show extent of ischaemia
Meningitis
Inflammation of the meninges
Causes- most commonly Neisseria meningitidis or streptococcus pneumonia. In children/neonates its normally group B strep/ E.coli. Can also be viral/fungal. Neisseria meningitidis is a gram negative diplococci.
Symptoms of meningitis
• Neck stiffness
• Photophobia
• Non-blanching rash
• Severe headache
• Fever
• Neurological deficits e.g. seizures / difficulty concentrating
Vomiting
Meningitis- Kernigs test
• Patient is supine
• Their leg is passively flexed 90 degrees with the hip and knee flexed
• The knee is then extended
• This will stretch the meninges and lead to pain = positive test
Meningitis- Brudzinskis test
• Patient is supine
• Head of the patient is passively flexed
• This stretches the meninges and spinal cord
• If positive this causes the patient to flex their hip and knees due to the neck stiffness
Meningitis diagnosis
Bedside- Kernigs and Brudzinski. Lumbar puncture (definitive diagnosis)
Bloods- Blood cultures, FBC, UE, clotting, glucose, ABG
Imaging- CT for unclear diagnosis
Meningitis diagnosis
Bedside- Kernigs and Brudzinski. Lumbar puncture (definitive diagnosis)
Bloods- Blood cultures, FBC, UE, clotting, glucose, ABG
Imaging- CT for unclear diagnosis
Lumbar puncture results
• Cloudy/ pink/ yellow- bleeding
• Green- bilirubin
• Elevated protein- inflammatory condition/infection
• Elevated white blood cells- infection
• Low glucose- infection with bacteria
Treatment for bacterial meningitis
• Urgent IV antibiotics e.g. ceftriaxone for 7 days
• Monitor and correct any hypoglycaemia / acidosis / anaemia / electrolyte disturbances
• Dexamethasone for 4 days to help reduce the inflammatory response and prevent long lasting neurological damage
Give IM benzylpenicillin prior to urgent hospital transfer
Treatment for viral meningitis
• Usually self-limiting so requires just supportive treatment
• Can use acyclovir
Meningitis prophylaxis
Ciprofloxacine single dos, given as soon as possible after exposure. Risk of devloping meningitis after exposure is 7 days
Lumbar puncture contraindications
• Local skin infection
• Raised ICP - can cause brain herniation
• Suspicion of a mass
• Acute spinal trauma
• Anticoagulants
• Always do a CT head before lumbar puncture
Fungal meningitis
Cryptococcus neoformans - typically found in immunosuppressed patients e.g. HIV / AIDS
CSF: clear/cloudy, elevated opening pressure, WBC elevated, low glucose and elevated protein
Migraine symptoms
• Severe throbbing headache
• Usualy unilateral
• Sensitivity to light
• Nausea and vomiting
• Aura
Lasts from 4 hours to 3 days
Phases of a migraine
• Prodrome- symptoms before the migraine i.e. stiff neck/ irritability/ tiredness/ food cravings
• Aura- Perceptual disturbances. 90% are visual i.e. fortification spectra/ scotoma. Lasts up to an hour. Can also be sensory i.e. paraesthesia
• Headache
• Postdrome
Migraine diagnosis
At least 5 attacks lasting 4-72 hours with
• Nausea/vomiting
• Photo/phonophobia
And 2 of
• Unilateral headache
• Pulsating character
• Worsening by daily activities
Acute management of migraine
• Analgesia e.g. paracetamol, NSAIDs and aspirin
• Antiemetics
• Triptans e.g. sumatriptan - take when the headache starts not during aura
Migraines- prophylactic management
• Propranolol - CI asthma
• Topiramate i.e. anti-epileptic drug
• Antidepressants e.g. amitriptyline
Tension headache
• Headaches caused by muscle contractions in the head and neck - associated with stress
• Mild/moderate pain
• Feels like a tight band around the head
• Tend to last 30 mins to 7 days
Cluster headache
• Severe pain
• Unilateral pain around the eye / behind the eye
• Associated with ipsilateral autonomic symptoms e.g. rhinorrhoea / ptosis / eye watering
• ‘Suicide headache’
• Rapid onset
• Common in males and smokers
• Tends to last 15 mins to 3 hours
Thunderclap headache
• Indicative of a subarachnoid haemorrhage
• Reaches peak intensity within 3 seconds
• Get nausea and vomiting, alongside meningitis like symptoms
Giant cell arteritis
• Vasculitis of the extra cranial branches of the carotid artery, normally the temporal artery
• Symptoms- headache, scalp tenderness, jaw claudication, amorosis fugax and potential blindness, polymyalgia rheumatica i.e. shoulder/pelvic girdle pain
• Investigate with ESR, FBC, LFT
• Definitive investigation- temporal artery biopsy of 3-5cm
• Treat with high dose steroids i.e. 60mg OD prednisolone
Headache red flags
• New severe/unexpected headache
• Progressive headache
• Associated features e.g. fever / seizure / neck stiffness / papilloedema / neurological deficits
• Contacts with similar symptoms
• Head trauma within the past 3 months
• Co-morbidity
• Pregnancy
What blood tests correlates with seizure
Lactate
also dysregulated in sepsis
Symptoms of space occupying lesion
- Present on waking
- Worse I’m bending and straining
Meningitits- arterial blood gas reading
Shows metabolic acidosis
Features of upper motor neurone lesions
Extensor plantar responses, increased muscle tone, spasticity
Neurological symptoms- random
Echopraxia- the patient is imitating or copying what another person is doing
Inattention- a feature of non-dominant hemisphere lesions and patients will be noted to ignore their affected side
Perseveration- the patient keeps doing the same thing over and over again
Dyspraxia- inability to carry out a learned pattern of movement i.e. dressing
Visual field defects
Optic nerve- Monocular vision loss
Optic chiasm- Bitemporal hemianopia. Most likely due to pituitary adenoma
Optic tract- homonymous hemianopia
Optic radiation- quandrantopia
