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Phase 3a > Neurology Investigations and Treatment > Flashcards

Neurology Investigations and Treatment Flashcards

1
Q

Alzheimer’s

Investigations
Treatment

A

First line - Mini Mental state examination

(Blood test to rule out other causes: FBC, serum B12)

GS - MRI of the brain (may show cortical atrophy)

Tx
Non pharmacological
- offer a range of activities tailored to patient’s preference
- group cognitive stimulation therapy (activities to help enhance memory)

Pharmacological
- Donepezil (acetylcholinesterase inhibitor. - rivastigmine) –> increases amount of acetylcholine to improve communication between neurons. slows down disease progression)

2nd line - memantine (NMDA receptor antagonist)

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2
Q

Parkinson’s disease

Investigations
Treatment

SIDE EFFECTS of medication

A

Clinical diagnosis
Bradykinesia + 1 of:
- Postural instability
- Muscle rigidity
- Resting tremor

Tx
First line
- Levodopa (side effect of dyskinesia e.g. writhing motions, chorea if used for long time)

second line
- Levodopa + COMT inhibitor (Entacapone)/dopamine agonist (Ropinirole/bromocriptine)

(Side effects of medications: hallucination, excessive sleepiness, impulse control disorders)

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3
Q

Vascular dementia

Investigations
Treatment

A

Investigations
- Mini mental state examination

GS - MRI of the brain (showing cerebrovascular lesion)

Treatment
Non pharmacological
- animal assisted therapy
- cognitive stimulation programmes

Pharmacological (if caused by embolism/atherosclerosis_
- Antiplatelet therapy with aspirin/clopidogrel

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4
Q

Motor neurone disease

Investigations
Treatment

A

Clinical diagnosis
(MRI can be performed to exclude spinal cord compression)

Tx
- Riluzole (Anti-glutaminergic) - too much glutamate damages nerve cells
+ Supportive care e.g. respiratory care (MDT approach)

(Percutaneous gastronomy tube for feeding if they are struggling with soft foods) - definitive long term option.

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5
Q

Multiple sclerosis

Investigations
Treatment

A

Investigations
GS - MRI scan –> 2 or more relapses disseminated in space and time

Lumbar puncture –> IgG oligoclonal bands

Tx
- IV Methylprednisolone

Relapsing remitting MS (ongoing prophylaxis) - Natalizumab (monoclonal antibody)
Interferon beta (disease modifying therapy)

Baclofen for spasticity and “muscle tightness” (baclofen and gabapentin relaxes muscles)

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6
Q

Huntington’s disease

Investigations
Treatment

A

Usually clinical diagnosis

GS - Genetic testing, CAG repeats >35 is positive for huntington’s

Treatment
1st line - Counselling for the patient and family
(Physiotherapy, occupational therapy)

Tetrabenazine for chorea (Promotoes depletion and decreases uptake of dopamine)

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7
Q

Meningitis

Investigations
Treatments

A

1st line –> Lumbar puncture and CSF analysis (contraindicated in increased ICP - tentorial herniation)

Tx
Primary care –> IV benzylpenicillin STAT (broad spectrum)

(NOTIFY PUBLIC HEALTH ENGLAND)

FL –> Ceftriaxone

(L.monocytogenes - Amoxicillin 21 days) - everything else ceftriaxone

Viral - Acyclovir

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8
Q

Describe CSF analysis for bacterial and viral meningitis (3)

A

Bacterial - Cloudy
Viral - Clear

Bacteria - > 1g/l of protein
Viral - Normal/mildly elevated (<1g/l)

Bacteria - Low glucose (<50% of plasma glucose)
Viral - normal (60-80% of plasma glucose)

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9
Q

Encephalitis

Investigations
Treatment

A

First line
- Lumbar puncture and CSF analysis (shows lymphocytosis, elevated protein)
- CT head - shows temporal lobe changes (in herpes simplex encephalitis)
- PCR for HSV-1

Treatment
IV Acyclovir for - HSV

Gancyclovir for - CMV

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10
Q

Guillain Barre syndrome

Investigations
Treatment

A

Investigations

GS - Nerve conduction studies - decreased conduction velocity of motor nerves

GS - Lumbar puncture - Elevated protein and normal WBC

Tx
IVIGs (CI in IgA deficiency)

(Plasma exchange if CI)

Supportive - intubation for respiratory difficulty

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11
Q

Cerebellar disorders

Investigations
Treatments

A

Investigations
- MRI scan
(Can detect tumours, evidence of stroke)
- (CT scan)

(Can assess for pathogenic genetic mutations/GAA repeats in inherited disorders)

Treatment
Paraneoplastic cause –> Chemotherapy, radiotherapy, immunosuppresants

Alcohol related –> Stop alcohol

Physical/occupational therapy, speech therapy

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12
Q

Bell’s palsy

Investigations
Treatment

A

Mostly clinical diagnosis

Treatment
- Prednisolone within 72 hours.
- Eyecare with lubricating eyedrops
(If unable to close eyes at bed time, tape it shut) - Night time eyelid covering

(If no improvement in 3 weeks refer urgently to ENT)

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13
Q

Epilepsy

Investigations
Treatment

A

Investigations
- Electroencephalogram and MRI scan
- Bloods (FBC, UnE)

Treatment
For generalised seizures in males - Sodium Valproate (teratogenic) - associated with weight gain

Everything else (women and focal seizures) - Lamotrigine - can lead to steven johnson/Levetiracetam

(others - carbamazepine 2nd line focal seizure)

(Fit free for 12 months before driving in established patients. If one off - fit free for 6 months)

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14
Q

Ischemic strokes

Investigation
Treatment

A

Investigation
- Urgent NCCT to classify as ischemic or haemorrhagic stroke.
(Cannot give aspirin if its haemorrhagic)

Treatment
- Thrombolysis with alteplase within 4.5 hours of symptom onset
+ CLOPIDOGREL rest of life

  • Thrombectomy if within 6 hours
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15
Q

Transient ischemic attack

Investigations
Treatment

A

300mg aspirin immediately and arrange urgent assessment by specialist stroke physician within 24 hours.

(Imaging preferred - MRI with diffusion-weighted imaging followed by carotid doppler)

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16
Q

Subarachnoid haemorrhage

Investigations
Treatment

A

First line
- NCCT - star shaped sign

  • If CT inconclusive –> Lumbar puncture 12 hours following onset of symptoms – xanthochromia (yellow CSF due to RBC haemolysis - bilirubin)

Treatment
- Neurosurgical clipping

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17
Q

Subdural haemorrhage

Investigations
Treatment

A

First line - NCCT - crescent shaped haematoma

Treatment - Craniotomy and burr hole (relieves the high pressure in the brain)

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18
Q

Epidural haemorrhage/Extradural haemorrhage

Investigations
Treatment

A

First line - NCCT - Lens shaped haematoma (restricted by suture lines)

Treatment
Urgent surgery
IV mannitol for increased ICP

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19
Q

Giant cell arteritis

Investigations
Treatment

A

First line - ESR, CRP
GS - Temporal artery biopsy - (granulomatous inflammation

Treatment
- Prednisolone (high dose)

If vision loss - IV methylprednisolone

(Bisphosphonates for bone protection as long term steroids is required)

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20
Q

Migraine

Investigations
Treatment

A

Clinical diagnosis (all 4 symptoms for 5 episodes)

Treatment
Acute - Sumatriptan (CI in ischaemic heart disease)

Prophylaxis - Propanolol
(Topiramate also, but CI in pregnancy)

Antiemetics - metoclopramide

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21
Q

Tension headache

Investigations
Treatment

A

Clinical diagnosis

Tx
First line - Simple analgesia e.g. paracetamol, ibuprofen (nsaid)

Prophylaxis - amitryptyline

22
Q

Cluster headache

Investigations
Treatment

A

Mostly clinical diagnosis

(can do MRI with gandolinium contrast)

Tx
Sumatriptan (CI in ischaemic heart disease)
or
100% high flow oxygen

Prophylaxis - Verapamil

23
Q

Delirium

Investigations
Treatment

and specific treatment for hyperactive delirium

A

Clinical diagnosis
- Can do an MMSE and compare to previous MMSE score
(Rule out dementia - are the symptoms acute or have been chronically present)
- Can use tools like CAM criteria, DSM-5 criteria (A) Disturbance in attention and awareness. B) Disturbance developed over short period of time = Acute. C) Additional disturbance in cognition e.g. memory, language, visuospatial. D) Disturbance is not explained by long term brain conditions. E) There is evidence the disturbance is due to a medical condition, withdrawal, substance intoxication

Essentially
4As
- Alertness
- Awareness/Cognition - testing orientation (Time, place, person, Age and date of birth)
- Attention (recitation of months in backwards order)
- Acute course

(Can do bloods e.g. FBC, UnE, LFTs, urinalysis, sputum culture, glucose)

Tx
- Correct precipitating factors and underlying cause (e.g. infection, pain, urinary retention)
- Reorientation - Keeping the area well lit, bringing items from their home to increase familiarity.

Advise family and carers
- Use REORIENTATION strategies (regular cues - explaining to the person 3 times a day time place and person, Encourage walking 3 times a day, Use easily visible clocks and calendars)
- Consistent care
- Encouraging visits by family or friends

1st line pharmacological
- Haloperidol - CI in parkinson’s

2nd line - Lorazepam (benzodiazepine)

24
Q

2 tools used to diagnose dementia

A

Addenbrooke’s cognitive examination (ACE test)
ACE III - < 82/100 means likely dementia

Montreal cognitive assessment test (MoCA test) <26/30 indicates mild cognitive impairment
(Used for early detection of dementia)

MMSE is better used in people with known dementia

25
Q

Lewy body dementia

Investigations
Treatment

A

Clinical diagnosis

MMSE
MRI brain - cortical atrophy

Treatment
Supportive care - occupational therapy

Donepezil - acetylcholinesterase inhibitor

26
Q

Frontotemporal dementia

Investigations
Treatment - for specific aggression

A

MMSE

Brain MRI - Focal atrophy in the frontal and/or temporal lobes

Treatment
Supportive care

(Lorazepam - if irritable and aggressive and de escalation strategies don’t work)

27
Q

Idiopathic intracranial hypertension

Investigations
Treatment

A

Investigations
- Fundoscopy - papilloedema
- Lumbar puncture - elevated opening pressure (>250mm H2O) – Absolute CI - midline shift, known masses e.g. tumour

Tx
Lifestyle changes - Weight loss (diet + exercise)

Acetazolamide/Topiramate

28
Q

Essential tremor

Investigations
Treatment

A

Clinical diagnosis

Tx
First line - Propanolol
(or primidone)

29
Q

Muscular dystrophies

Investigations
Treatment

A

Investigations
First line - Creatine kinase
GS - Genetic testing

(Muscle biopsy)

Tx
- Prednisolone (improves muscle strength and function)
- Physiotherapy
- Low impact exercise like swimming

30
Q

Brain abscess

Investigations
Treatment

A

First line - CT head (frontal ring enhancing lesion)

(or MRI with contrast)

Tx

If abscess <2.5cm
- IV antibiotics - Ceftriaxone + metronidazole

If abscess >2.5 cm
- Craniotomy and the abscess cavity debrided

Dexamethasone/IV mannitol given to treat increased ICP. (Dexamethasone usually given first especially if inflammation is present - mannitol only in emergencies)

31
Q

Herpes zoster

Investigations
Treatment

A

Clinical diagnosis

GS - PCR for varicella zoster

Tx
- Oral antiviral for 7 days - famiciclovir/acyclovir

32
Q

Malaria

Investigations
Treatment

A

GS - Giemsa stained thick and thin blood smears - detection of parasites

Tx
For uncomplicated malaria
First line - Artemether + lumefantrine

For severe
IV artesunate

33
Q

Glioblastoma

Investigations
Treatment

A

Investigation
First line - MRI (solid tumour with central necrosis)

Tx
Surgical resection with postoperative radiotherapy/chemotherapy

Use dexamaethasone/mannitol for oedema. (ICP)

34
Q

Meningioma

Investigations
Treatment

A

Investigations
First line - MRI (NICE guidelines)
Can CT after.

Tx
Depending on patient
- Observation
- Radiotherapy
- Surgical resection

35
Q

Vestibular schwannoma

Investigations
Treatment

A

Investigations
- Hearing test
- MRI (gadolinium enhanced)
- Contrast CT scan

Tx
Depending on patient
- Observation
- Radiotherapy
- Surgery

36
Q

Cerebral palsy

Investigations
Treatment

A

Investigations
- MRI brain
(clinical diagnosis?)

Treatment
- Multidisciplinary approach

For spasticity
- Diazepam
- Orthopaedic surgery

Anticonvulsants
Analgesia if needed

37
Q

Hypoxic ischemic encephalopathy

Investigations
Treatment

A

Investigations
- Head ultrasound
- MRI
- Cerebral function monitoring (CFM) –> records brain activity

Tx
Mild - observation

Moderate-severe –> Cooling therapy for 3 days

38
Q

Trigeminal neuralgia

Investigations
Treatment

A

Clinical diagnosis
(3 or more attacks with the typical symptoms)

Tx
Carbamazepine (anticonvulsant) - can cause steven johnson syndrome - rashes and skin changes

39
Q

Diabetic neuropathy

Investigations
Treatment

A

Clinical diagnosis

(HbA1C. Other blood tests to exclude other causes e.g. LFTs, UnEs)

Tx
For neuropathic pain
First line - Amitriptyline/duloxetine/gabapentin/pregabalin
(All monotherapy - by itself. If one doesn’t work switch to another one)

40
Q

Spinal cord compression (myelopathy)

Investigations
Treatment

A

Investigations

First line and GS - Whole MRI spine (within 24 hours of presenting)

Tx
- High dose oral dexamethasone
(Oncological assessment for radiotherapy)

  • Surgery is definitive
41
Q

Cauda equina

Investigations
Treatment

A

Investigations
First line - MRI (without contrast)

Tx
- Immediate surgical decompression

42
Q

Meniere’s disease

Investigations
Treatment

A

Investigations
(ENT assessment required to confirm diagnosis)
Audiometry - low to medium frequency sensorinueral hearing loss in one year.
+
Clinical diagnosis - of 2 episodes of vertigo and fluctuating aural symptoms

Tx
Acute attacks: buccal or IM prochlorperazine

Prevention: Betahistine
(Vestibular rehabilitation exercises)

43
Q

Chronic fatigue syndrome
(myalgic encephalomyelitis)

Investigations
Treatment

A

Screening blood tests to exclude other pathology e.g. FBC, UnE, LFT, glucose, TFT, ESR, CRP

DePaul symptom questionnaire (54 item checklist)

CLINICAL DIAGNOSIS OF - disabling fatigue that doesn’t improve with sleep/rest, post-exertional malaise, cognitive difficulties

Tx
- Multidisciplinary team management in collaboration with CFS specialist team.

Self management strategy - ensuring their activities stay within energy limit

Supportive plan in relation to physical functioning and mobility – bodily movements resulting in energy expenditure — NOT EXERCISE
- using mobility aids
- walking
- Stretching
(spread through the day )

44
Q

Wernicke’s encephalopathy

Investigations
Treatment

A

Serum thiamine
MRI of the brain
(blood alcohol levels?)

Tx
- Urgent replacement of thiamine

(IV Pabrinex - vitamin B and C)

45
Q

Mononeuropathy

Investigations
Treatment

A

Can use electromyograph and nerve conduction studies - assessing the nerve’s ability to conduct impulses

Tx
- Removal of pressure on the nerve
- Splints to immobilise the affected area
- Surgery - definitive
(corticosteroid injections)

46
Q

Mononeuritis multiplex

Investigations
Treatment

A

Electromyogram
(ESR, CRP elevated in vasculitis)
Range of antibodies test
e.g. Anti double stranded DNA for - SLE,

Nerve biopsy

Tx
- Prednisolone
- Analgesia
- Splints
- Physical/occupational therapy

47
Q

Myasthenia gravis

Investigations
Treatment

A

First line -
Acetylcholine receptor antibody analysis (serology)
Anti MuSK antibodies

CT thorax can be done to exclude thymoma

Electromyograph

(Edrophonium test - although not really used anymore)

Tx
First line - pyridostigmine (acetylcholinesterase inhibitor)

Immunosuppresants - Prednisolone
(thymectomy)

48
Q

Complication of myasthenia gravis - symptoms and treatment

A

Myasthenic crisis
An acute worsening of symptoms (muscle weakness) with severe respiratory weakness (that can be life threatening)

Tx
- Plasma exchange
- IV immunoglobulin

49
Q

Lambert-eaton syndrome

Investigations
Treatment

A

Investigations
- Anti voltage gated calcium channel antibodies
- Nerve conduction studies

Tx
- Amifampridine (prolongs depolarisation improving nerve conduction)

(Can consider prednisolone (immunosuppressant and IV immunoglobulins)

50
Q

Hydrocephalus

Investigations
Treatment

A

First line - NCCT head

(LP but contraindicated in obstructive hydrocephalus) - can be used for investigation and therapy to drain CSF to reduce pressure

Tx
- External ventricular drain
- Ventricular peritoneal shunting

(Plus treat the obstructive pathology in obstructive hydrocephalus)

51
Q

Normal pressure hydrocephalus

Investigations
Treatment

A

First line - NCCT head (ventriculomegaly with no sulcal enlargement)

Tx
- Ventricular peritoneal shunting

Phase 3a (7 decks)

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