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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
Acute—> Nimodipine (CCB) to prevent vasospasm (usually given for aneurysm)

  • 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
Lewy body dementia Investigations Treatment
Clinical diagnosis MMSE MRI brain - cortical atrophy Treatment Supportive care - occupational therapy Donepezil - acetylcholinesterase inhibitor
26
Frontotemporal dementia Investigations Treatment - for specific aggression
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
Idiopathic intracranial hypertension Investigations Treatment
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
Essential tremor Investigations Treatment
Clinical diagnosis Tx First line - Propanolol (or primidone)
29
Muscular dystrophies Investigations Treatment
Investigations First line - Creatine kinase GS - Genetic testing (Muscle biopsy) Tx - Prednisolone (improves muscle strength and function) - Physiotherapy - Low impact exercise like swimming
30
Brain abscess Investigations Treatment
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
Herpes zoster Investigations Treatment
Clinical diagnosis GS - PCR for varicella zoster Tx - Oral antiviral for 7 days - famiciclovir/acyclovir
32
Malaria Investigations Treatment
GS - Giemsa stained thick and thin blood smears - detection of parasites Tx For uncomplicated malaria First line - Artemether + lumefantrine For severe IV artesunate
33
Glioblastoma Investigations Treatment
Investigation First line - MRI (solid tumour with central necrosis) Tx Surgical resection with postoperative radiotherapy/chemotherapy Use dexamaethasone/mannitol for oedema. (ICP)
34
Meningioma Investigations Treatment
Investigations First line - MRI (NICE guidelines) Can CT after. Tx Depending on patient - Observation - Radiotherapy - Surgical resection
35
Vestibular schwannoma Investigations Treatment
Investigations - Hearing test - MRI (gadolinium enhanced) - Contrast CT scan Tx Depending on patient - Observation - Radiotherapy - Surgery
36
Cerebral palsy Investigations Treatment
Investigations - MRI brain (clinical diagnosis?) Treatment - Multidisciplinary approach For spasticity - Diazepam - Orthopaedic surgery Anticonvulsants Analgesia if needed
37
Hypoxic ischemic encephalopathy Investigations Treatment
Investigations - Head ultrasound - MRI - Cerebral function monitoring (CFM) --> records brain activity Tx Mild - observation Moderate-severe --> Cooling therapy for 3 days
38
Trigeminal neuralgia Investigations Treatment
Clinical diagnosis (3 or more attacks with the typical symptoms) Tx Carbamazepine (anticonvulsant) - can cause steven johnson syndrome - rashes and skin changes
39
Diabetic neuropathy Investigations Treatment
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
Spinal cord compression (myelopathy) Investigations Treatment
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
Cauda equina Investigations Treatment
Investigations First line - MRI (without contrast) Tx - Immediate surgical decompression
42
Meniere's disease Investigations Treatment
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
Chronic fatigue syndrome (myalgic encephalomyelitis) Investigations Treatment
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
Wernicke's encephalopathy Investigations Treatment
Serum thiamine MRI of the brain (blood alcohol levels?) Tx - Urgent replacement of thiamine (IV Pabrinex - vitamin B and C)
45
Mononeuropathy Investigations Treatment
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
Mononeuritis multiplex Investigations Treatment
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
Myasthenia gravis Investigations Treatment
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
Complication of myasthenia gravis - symptoms and treatment
Myasthenic crisis An acute worsening of symptoms (muscle weakness) with severe respiratory weakness (that can be life threatening) Tx - Plasma exchange - IV immunoglobulin
49
Lambert-eaton syndrome Investigations Treatment
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
Hydrocephalus Investigations Treatment
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
Normal pressure hydrocephalus Investigations Treatment
First line - NCCT head (ventriculomegaly with no sulcal enlargement) Tx - Ventricular peritoneal shunting

Phase 3a (9 decks)

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