Neurology key facts Flashcards
1
Q
What are the options for management of acute migraine? What are the contraindications for each?
A
- NSAIDs
- Aspirin
- Triptans e.g. sumatriptan (contraindicated in CV disease/CV accident)
2
Q
What are the options for prophylactic management of migraine? What are the contraindications for each?
A
- Propanolol (contraindicated in asthma)
- Topiramate (contraindicated in women of childbearing age/pregnancy)
- Amitriptyline
3
Q
How does idiopathic intracranial hypertension present?
A
Headache
Pressure like sensation behind the eyes
Visual disturbance
4
Q
What are the key investigations for Idiopathic intracranial hypertension (3)?
A
MRI/CT to exclude secondary causes
Lumbar puncture to assess CSF opening pressure - look for raised opening pressure with normal CSF.
Fundoscopy - shows bilateral papilloedema.
5
Q
What is the management for idiopathic intracranial hypertension?
A
Weight loss.
Acetazolamide is the first line medication.
Can use a CSF shunt if resistant to acetazolamide.
6
Q
Define the GCS scoring system.
A
6,5,4 - MoVE
Motor:
6 - Normal
5 - localises to pain
4 - withdraws from pain
3- flexes to pain
2 - extends from pain
1 - nothing.
Voice:
5 - Speaking normally
4 - confused
3 - random words
2 - random sounds
1 - no response
Eyes:
4 - open
3 - opens to voice
2 - opens to pain
1 - no response.
7
Q
What is the classic triad of symptoms for parkinsons disease?
A
Pill rolling tremor
Cogwheel Rigidity
Bradykinesia
8
Q
How is parkinsons tremor differentiated from essential tremor?
A
P - worse on rest
E - worse on movement
P - Worse with alcohol
E - Better with alcohol
P - asymmetrical
E - symmetrical
9
Q
What is the key difference between parkinsons disease dementia and lewybody dementia?
A
PDD - parkinsonian symptoms must be present 12 months before congnitive decline.
Lewy body - Parkinsonian symptoms come within 12 months/after the cognitive decline.
10
Q
What is the key management for parkinsons disease?
What is the main side effect of this?
A
Co-careldopa
(levodopa + carbidopa)
Main side effects are dystonia and chorea.
11
Q
What can be given to manage the side effects of co-careldopa?
A
Amantidine.
12
Q
What is taken with co-careldopa to slow the breakdown of levodopa in the brain?
A
COMT inhibitor (e.g. entacapone)
13
Q
What can be used to help with symptoms of essential tremor?
A
Propanolol
14
Q
What is the pathophysiology of MS?
What type of lesions are present?
A
Autoimmune condition involving demyelination of the CNS.
Lesions are disseminated in time and space.
15
Q
What is the most common initial presentation of MS?
A
Optic neuritis.
16
Q
What is relapsing-remitting MS?
A
Periods of disease and neurological symptoms followed by recovery.
17
Q
What is secondary progressive MS?
A
Relapsing remitting disease, but with progressive worsening of symptoms and incomplete remissions.
18
Q
What is primary progressive MS?
A
Worsening of neurological symptoms WITHOUT relapses and remissions.
19
Q
What are the key investigations for MS?
What are the characteristic findings for each?
A
MRI brain and spinal cord (high signal T2 lesions, periventricular plaques)
LP (oligoclonal bands)
20
Q
What is given to treat an acute MS relpase?
A
High dose steroids
IV methylprednisolone for 5 days.
21
Q
What is given to manage MS long term?
A
DMARDs:
e.g. natalizumab
22
Q
What is the most common cause of bacterial meningitis in a child under 3 months old?
A
Strep B
23
Q
What is the most common cause of bacterial meningitis in a person aged 3 months to 60 years old?
A
Neisseria meningitidis.
24
Q
What is the most common cause of bacterial meningitis in over 60 YO patients?
A
Strep pneumoniae.
25
What is the most common cause of bacterial meningitis in immunocompromised patients?
Listeria monocytogenes.
26
Overall, what are the two main causes of bacterial meningitis across all ages?
Neisseria meningitidis
Strep pneumoniae.
27
How does meningococal septicaemia present?
Non-blanching petechial rash.
28
What is the management pathway FOR THE PATIENT for suspected bacterial meningitis?
Primary care:
- IM benzylpenicillin but DO NOT DELAY TRANSFER.
Secondary care (if there is no indication to delay the lumbar puncture):
- IV access and take blood and blood cultures.
- LP
IV antibiotics:
Under 3 months: cefotaxime + amoxicillin
3 months - 50 years: cefotaxime
Over 50:
Cefotaxime + amoxicillin
Consider dexamethasone if there is no meningococcal septicaemia/ likely to be strep pneumoniae.
29
What is the management for household contacts of a patient with bacterial meningitis?
After bacterial meningitis has been confirmed, offer all close contacts for the past 7 days:
Single dose of oral ciprofloxacin.
30
What are the most common viral causes of meningitis?
Enterovirus
HSV
VZV
31
If the cause of meningitis is unknown, what are the two key tests that need doing?
CSF (LP) with viral PCR
Blood cultures
Meningococcal PCR blood test.
32
What is the treatment for viral meningitis?
Aciclovir.
33
How does the CSF vary for bacterial/viral meningitis?
Bacterial:
CSF cloudy
Protein raised
Glucose low
WCC primary neutrophils
Culture grows bacteria
Viral:
CSF clear
Protein normal/slightly raised
Glucose normal
WCC raised lymphocytes
Culture grows nothing.
34
What is guillian-barre syndrome?
Acute paralytic neuropathy triggered by an infection.
35
How does Gullian-barre clasically present?
Symmetrical ascending weakness that STARTS IN THE FEET.
Decreased reflexes.
After an infection.
36
What is the classical trigger for guillian barre?
Campylobacter jejuni
37
What investigations are carried out for suspected guillian-barre?
LP (raised PROTEIN)
Nerve conduction studies (reduced signal through the nerves)
38
What is the management for guillain-barre syndrome?
IV immunoglobulins first line.
39
What is the pathophysiology of lambert-eaton myasthenic syndrome?
Antibodies against voltage gated calcium channels.
40
how does lambert eaton myasthenic syndrome present?
Proximal muscle weakness (difficulty standing from seating, climbing stairs)
Reduced tendon reflexes.
41
What is the key difference in presentation between Lambert Eaton and Guillain Barre?
Lambert eaton - weakness improves with use of the muscle.
Guillain barre - gets worse with use.
42
What is the most common aetiology for lambert eaton?
Small cell lung cancer.
43
What is the management for lambert eaton syndrome?
Exclude underlying lung malignancy.
Amifampridine.
44
What are the two key special tests used in diagnosis of meningitis?
Kernig's test - lie patient on back, flex hips and knees and then extend the leg. Look for pain/discomfort.
Brudzinski's test - lie patient on back, and slowly flex neck to push chin into chest. Look for involuntary flexing at the hip and knee.
45
What is the pathophysiology of myasthenia gravis?
Autoimmune condition that produces aCh receptor antibodies. These block the NMJs and result in weakness.
46
How does myasthenia gravis present?
What is the key symptom?
Proximal muscle weakness of the limbs.
Small muscle weakness of the head and neck.
Gets BETTER with rest (worse throughout the day).
47
What is the first line treatment for myasthenia gravis?
Pyridostigmine - cholinesterase inhibitor.
48
What is myasthenia crisis? What is the management?
Acute worsening of MG symptoms, often as a result of a resp infection.
Resp muscles weaken, and can lead to resp failure.
Treat with IV immunoglobulins and plasmapheresis.
49
What is the difference between encephalitis and meningitis pathophysiologically?
Meningitis - inflammation of the meninges that surround the brain and spinal cord.
Encephalitis - Inflammation of the brain itself.
50
What is the most common pathogen responsible for encephalitis?
HSV-1
51
What is the treatment for encephalitis?
Aciclovir
52
What are the key investigations for encephalitis?
Brain imaging (MRI preferred)
LP with PCR.
53
What is a tonic-clonic seizure?
What can happen before and after?
What is the awareness?
Involve tonic (muscle-tensing) and clonic (muscle jerking).
Patients might experience aura before the seizure.
Prolonged post-ictal period after seizure.
LOSE CONSCIOUSNESS.
54
What are the symptoms for focal seizures in different areas of the brain?
What is the awareness?
Temporal lobe - Aura, deja vu, gastric symptoms and automatisms (lip smacking, picking at clothes etc.)
Frontal lobe - Head movements, eye movements, posturing.
Parietal lobe - Parasthesia (pins and needles)
Occipital lobe - visual disturbance (floaters/flashes)
Can be aware or impaired awareness.
55
What are the symptoms for myoclonic seizures?
Sudden, brief muscle contractions.
REMAIN AWARE.
56
What are the symptoms for a tonic seizure?
Awareness?
Body stiffens, usually resulting in a fall.
Can be aware or impaired awareness.
57
What are the symptoms for an atonic seizure?
Awareness?
Sudden loss in muscle tone causing a fall.
Usually aware.
58
What is an absence seizure?
Awareness?
Blank stare into space, then abrupt return to normal.
Impaired awareness.
Associated with children.
59
What is the alternative name for infantile spasms?
West syndrome.
60
What is the characteristic EEG finding for infantile spasms?
Hypsarrhythmia. Poor prognosis.
61
What are febrile convulsions?
Generalised tonic-clonic seizures that occur in children with a high fever.
62
What are the key differentials for epilepsy?
Vasovagal syncope
Cardiac syncope
Hypoglycaemia
TIA
Pseudoseizures
63
What are the key investigations for suspected epilepsy?
EEG
MRI head (exclude underlying pathology)
Blood glucose (exclude hypoglycaemia)
ECG (exclude cardiac cause).
Blood cultures/LP (infectious causes)
64
What is the treatment for generalised tonic clonic seizures?
Valproate first line
Lamotrigine/levetiracetam second line
65
What is the treatment for a focal seizure?
First line is lamotrigine or levetiracetam.
66
What is the treatment for a myoclonic seizure?
Valproate first line
Levetiracetam is second line.
67
What is the treatment for tonic/atonic seizures?
Valproate is first line
Lamotrigine is second line
68
What is the treatment for absence seizures?
Ethosuximide.
69
What is the management ladder for status epilepticus?
ABCDE
Secure airway
High dose O2
Check blood glucose
IV access.
IV lorazepam first.
Again after 5-10 mins if seizure continues.
Then IV phenytoin.
70
What are the alternatives to IV lorazepam used in the community for status epilepticus?
Rectal diazepam
Buccal midazolam.
71
What is the DVLA guidance for epilepsy?
DVLA must be notified of any seizures (first or recurrent)
First seizure - no driving for 6 months OR 12 IF THERE IS UNDERLYING PATHOLOGY.
Recurrent seizures - no driving for 12 months after most recent seizure.
72
What are the most important initial investigations for a suspected stroke? What is the purpose of each?
CT head (rule out ischaemic stroke).
Blood glucose (rule out hypoglycaemia).
73
What is the management for an ischaemic stroke?
What are the contraindications for thrombolysis? What is the alternative treatment?
Thrombolysis (within 4.5 or 9 hours)
Thrombectomy (within 24 hours)
Aspirin ASAP (within 24 hours) and continue for 2 weeks.
No thrombolysis, just aspirin if the patient has:
INR over 1.7
Unknown time of stroke
Takes warfarin.
74
What is the time window for thrombolysis? What factors influence this?
Alteplase should be given for an acute ischaemic stroke within 4.5 hours.
If there is also evidence of salvageable brain tissue on the MRI/CT, can be done up to 9 hours after.
75
What is the blood pressure threshold for commencing thrombolysis?
185/110.
76
What is the long term management following an ischaemic stroke?
Continue 300mg of aspirin for 2 weeks, then switch to clopidogrel long term.
IF THEY HAVE AF, SWAP TO DOAC RATHER THAN CLOPIDOGREL. e.g. APIXABAN, RIVAROXABAN.
77
What is the management for a haemorrhagic stroke?
Anticoagulation (if they take warfarin reversal with vitamin K).
Blood pressure control.
Neurosurgical intervention to remove a haematoma.
78
Which blood test can be used to differentiate between pseudoseizures and normal seizures?
Prolactin - raised in true seizures.
79
What tool is used in the community to identify a stroke?
FAST
80
What tool is used in ED to identify a potential stroke?
ROSIER
81
What is a TIA?
What is the time window for a TIA?
Temporary disruption of bloodflow to the brain.
Produces symptoms similar to a stroke, but must resolve within 24 hours.
82
What is the investigation of choice for a suspected TIA?
Diffusion weighted MRI scan.
83
What is the management for a TIA?
What are the relevant timeframes?
Start 300mg of aspirin immediately
Refer for a specialist neurology assessment
- Within 24 hours
- Within a week if more than 7 days since the episode.
Urgent carotid doppler to check for stenosis (potential for carotid endarterectomy)
84
What makes someone eligible for a endarterectomy following a TIA?
Over 70% occlusion of the artery.
85
How does an extradural haemorrhage present?
Lucid interval - period of improvement followed by decline of neurological symptoms.
86
What is the most common blood vessel involved in an extradural haemorrhage?
The middle meningeal artery.
87
What is the CT finding for an extradural haemorrhage?
Biconvex lesion that does not cross suture lines.
88
Who is most likely to have a subdural haemorrhage?
Elderly people
Alcoholics
89
What is the most common vessel involved in a subdural haemorrhage?
Bridging veins.
90
How does a subdural haemorrhage look on a CT scan?
Crescent shape
Not limited by suture lines
91
How does a subarachnoid haemorrhage present?
Thunderclap headache.
Usually during strenuous activity.
92
What is the most common vessel involved in a subarachnoid haemorrhage?
Rupture of a cerebral aneurysm.
93
What are the surgical options for a subdural or extradural haemorrhage?
Craniotomy
Burr holes
94
How does Giant Cell Arteritis present?
Scalp tenderness
Jaw caludication
Blurred/double vision
Thickened/tender temporal artery.
95
What is the definitive investigation for giant cell arteritis?
What is the key finding?
Temporal artery biopsy with multinucleated cells
96
What is the treatment for giant cell arteritis?
Prednisolone.
97
What is the main complication of giant cell arteritis?
Vision loss.
98
How does a tension headache present?
Mild ache or pressure in a band-like pattern around the head.
NO VISUAL CHANGES
99
What is the management for tension headaches?
Simple analgesia (paracetamol or ibuprofen)
Second line is amitriptyline.
100
How does a medication-overuse headache present?
How is it managed?
Similar to a tension headache (mild ache or band like pressure around the head).
Withdrawal of analgesia is treatment.
101
How does trigeminal neuralgia present?
Pain in the branches of the trigeminal nerve. Can be one or multiple branches affected.
Intense pain exacerbated by touch, eating, shaving or the cold.
102
What is the first line treatment for trigeminal neuralgia?
carbamazepine.
103
What are the three branches of the trigeminal nerve?
V1 - opthalmic
V2 - maxillary
V3 - mandibular
104
How does migraine present?
What are the timeframes for each attack?
What management strategy may a patient have developed to help with their migraine?
Usually unilateral.
Pounding/throbbing.
Photo and phonophobia
Aura
Nausea and vomiting.
Headaches typically last between 4 and 72 hours.
they come in episodes.
Patients may retreat to a dark quiet room and sleep when they have a migraine.
105
How does a cluster headache present?
What are the timeframes for the headache.
Extremely painful unilateral headache localised around the eye.
Red swollen watering eye.
Miosis.
Ptosis.
Nasal discharge.
Facial sweating.
Attacks come in clusters (e.g. 3-4 attacks a day for weeks or months, followed by being pain free for years).
106
What is the treatment for acute attacks of cluster headache?
High flow 100% oxygen.
Sumatriptan.
107
What is the prophylaxis for cluster headaches?
verapamil.
108
What are the key features of normal pressure hydrocephalus?
"Weird whacky and wet"
Worsening memory (dementia).
Personality and mood disturbance.
Urinary incontinence.
109
What age is normal pressure hydrocephalus most common in?
The elderly.
110
What is the treatment for normal pressure hydrocephalus?
Ventriculoperitoneal shunt.
111
What is the difference between idiopathic intracranial hypertension and normal pressure hydrocephalus?
IIH - younger patients and causes increased intracranial pressure. Ventricles are normal size or sometimes smaller.
NPH - older patients and no change to overall intracranial pressure, just ventricular enlargement.
112
How does Bell's palsy present?
Unilateral facial paralysis with FOREHEAD INVOLVEMENT.
113
What is the management for Bell's palsy?
Artificial tears/ocular lubricants.
Tape eye overnight.
Prednisolone.
114
When should a patient with Bells palsy be referred to secondary care (ENT/neuro)?
If there is no improvement after 3 weeks since symptoms started.
115
How does Horner's syndrome present?
Miosis.
Ptosis.
Facial anhidrosis.
116
How does diabetic neuropathy present?
Stocking and glove symptom distribution.
Bilateral numbness, tingling and burning sensation in the hands and feet.
117
What is the gold standard investigation for diabetic neuropathy?
Nerve conduction studies.
118
What is the management for diabetic neuropathy?
Intensive blood glucose control.
Gabapentin for the pain.
Lifestyle changes (increase exercise, lose weight, stop smoking)
119
What is the key symptom of syringomyelia?
What is the pathophysiology of this?
Cape-like (neck and arms) loss of temperature sensation.
Preservation of light touch, proprioception and vibration sense.
Because spinothalamic tract is affected first.
120
What is the investigation for suspected syringomyelia?
MRI spine with contrast.
121
Treatment for syringomyelia?
Drainage of the fluid. Shunt?
122
What are the red flags suggestive of cauda equina syndrome?
Loss of perianal sensation.
Bladder dysfunction.
Bowel dysfunction.
123
What is the investigation for cauda equina syndrome?
MRI lumbar spine.
124
What is the management of cauda equina?
Referral to neurosurgery for decompression.
125
What is the pathophysiology of brown-sequard syndrome?
How does brown sequard present?
Damage to half of the spinal cord (hemisection).
Causes loss of pain and temperature sensation on the opposite side to the lesion, and loss of motor function, proprioception and vibration on the side of the lesion.
(due to decussation of the spinothalamic at the level of innervation).
126
What is the general management for brown-sequard?
Surgical decompression.
127
When is carotid endarterectomy indicated?
When there is at least 70% stenosis of the artery.
128
What is Wernicke's Encephalopathy?
What is the triad of symptoms?
Acute thiamine (B1) deficiency.
- opthalmoplegia (paralysis/weakness of the eye muscles)
- confusion
- ataxia
Associated with chronic alcoholics.
129
What is the management of Wernicke's encephalopathy?
Thiamine Iv for 5 days.
130
What is the potential complication of Wernicke's encephalopathy if left untreated?
Korsakoff's syndrome.
Memory disorder with:
- Anterograde amnesia.
- Retrograde amnesia
- confabulation (unintentional fabrication of memories).
131
What is the first line treatment to slow progression of motor neurone disease?
Riluzole
