Neurology - Level 2 Flashcards
Investigations to perform in first fit?
o Consider alcohol/drugs, withdrawal states, hypoglycaemia, arrhythmias, head injury, SAH, TIA/stroke, infection, metabolic
o Investigations
BMG
Bloods – glucose, FBC, U&Es, cultures if pyrexial
ECG
CXR if signs
Urine pregnancy test
CT scan if:
• Focal signs, head injury, known HIV, suspected intracranial infection, bleeding disorder or conscious level does not improve
Discharge advice to patient with first fit?
Accompanied by adult if normal neurological and CV examination, ECG and electrolytes are normal
Make appointment with epilepsy specialist in coming week
Do not drive or use heavy machinery
Supervision when performing swimming/bathing
Admit patient with first fit if?
More than one seizure in day
Definition of status epilepticus?
- Continuous generalised seizure for 5 minutes or longer, or recurrent seizures one after the other without recovery in between
- Mortality and risk of permanent brain damage increase with length of attack
Risk factors of status epilepticus?
o Under 5 or elderly age
Precipitants of status epilepticus?
Cerebral infarction, trauma, CVA, metabolic disturbances, febrile seizures
Symptoms of status epilepticus?
- Tonic-clonic easy to distinguish, non-convulsive states harder to spot
Community management of status epilepticus? Drugs if over 5 minutes long
o Buccal midazolam 10mg 1st line
o Alternative: rectal diazepam 10-20mg, IV lorazepam (if IV access)
o Call ambulance if still fitting 5 minutes after medications, concerns about ABC
Initial management of status epilepticus?
o Time the seizure
o Position patient to avoid injury
o Open and maintain airway, lay in recovery position - Remove false teeth, insert Guedel/Nasopharyngeal airway
o High flow oxygen 15L/min via NRB mask + suction
o IV access and take blood (FBC, U&Es, LFTs, glucose, Ca, Mg, VBG, toxicology screen)
o Blood cultures if septic
o Check BM glucose
o Assess cardiac and respiratory function
Drug management (after 5 minutes) in status epilepticus?
o IV lorazepam 4mg slowly
o Repeat IV lorazepam after 10 minutes if seizures fail to respond or recur
Alternative: IV diazepam
If no IV access, buccal midazolam or rectal diazepam
Drug management in status epilepticus if alcohol abuse suspected?
o If alcohol abuse – IV thiamine 250mg over 30 mins
Drug management in status epilepticus if hypoglycaemic?
o Treat hypoglycaemia with 50ml of 20% dextrose (10g)
Further drug management (if fails to respond after 25 minutes)?
o Phenytoin 15-20mg/kg IVI at rate of 50mg/minute – if fails to respond after 25 minutes
Alternative diazepam infusion until seizures respond
Monitoring of status epilepticus?
- Monitor ECG and BP
- Anaesthetic help
o May need ICU and ventilation
o RSI – propofol, thiopental, miadazolam and tracheal intubation
Olfactory nerve lesion - anatomy?
olfactory cells are bipolar neurones passing through cribiform plate to olfactory bulb
Olfactory nerve lesion - symptoms?
reduced taste and smell but not to ammonia which stimulates the pain fibres carried in trigeminal nerve
Olfactory nerve lesion - causes?
Trauma, frontal lobe tumour, meningitis
Optic nerve lesion - symptoms - visual field defects?
Scotomas
Monocular blindness – MS, GCA
Bilateral blindness – methyl alcohol, tobacco, neurosyphilis
Bitemporal hemianopia – optic chiasm compression (internal carotid artery aneurysm, pituitary adenoma, craniopharyngioma)
Homonymous hemianopia (loss of same half of visual field in both eyes on opposite side of lesions e.g. right sided lesion causes loss of left side of visual field) - lesions behind optic chiasm in optic tract/lateral geniculate nucleus/optic radiations including tumour, stroke, abscess
Optic nerve lesion - symptoms - optic neuronitis?
Pain on moving eye, loss of central vision, afferent pupillary defect, papilloedema
MS, syphilis, sinusitis
Optic nerve lesion - symptoms - optic atrophy?
Pale optic discs and reduced acuity
MS, frontal tumours, Friedreich’s ataxia, syphilia, glaucoma, optic nerve compression
Optic nerve lesion - symptoms - papilloedema?
Raised ICP (tumour, abscess, encephalitis, hydrocephalus, benign intracranial hypertension)
Inflammation (optic neuritis)
Ischaemia (accelerated hypertension)
Symptoms of oculomotor nerve lesion?
- Fixed dilated pupil
- Ptosis
- Down and outward deviation of eye
Causes of oculomotor nerve lesion?
- DM
- GCA
- Syphilis
- PCA aneurysm
- Raised ICP
Symptoms of trochlear nerve lesion?
- Diplopia due to weak down and in eye movements
- Eye up and outwards
- Patient tilts head away from affected side
Causes of trochlear nerve lesion?
- Trauma to orbit
- DM
- Infarction
Symptoms of trigeminal nerve lesion?
- Reduced sensation over affected area
* Weakness of jaw clenching and side-to-side movement
Causes of trigeminal nerve lesion?
Sensory- trigeminal neuralgia, herpes, nasopharyngeal carcinoma
Motor – bulbar palsy, acoustic neuroma
Symptoms of abducens nerve lesion?
• Eye deviated medially due to unopposed action of medial rectus (LR paralysed)
Causes of abducens nerve lesion?
- MS
* Pontine CVA
Symptoms of facial nerve lesion?
- Facial weakness
• If LMN – forehead paralysed too
• If UMN – forehead spared due to crossing over of pathways
Cause of facial nerve lesion?
- LMN – Bell’s palsy, polio, otitis media, skull fracture, cerebellopontine angle tumur, parotid tumour, herpes (Ramsay hunt syndrome), Lyme disease
- UMN – stroke, tumour
Symptoms of vestibulocochlear nerve lesion?
• Unilateral sensorineural hearing loss, tinnitus
Symptoms of vestibulocochlear nerve lesion?
• Loud noise, Paget’s disease of bone, Menieres’ disease, herpes, acoustic neuroma, brainstem CVA, furosemide, aspirin
Symptoms of vagus nerve lesion?
• Palatal weakness, nasal speech, uvula moves asymmetrically (away lesion) when say ahh
Cause of vagus nerve lesion?
• Trauma, brainstem lesion, cerebellopontine angle tumour, polio, GBS
Symptoms of accessory nerve lesion?
• Weakness to sternocleidomastoid and trapezius
Causes of accessory nerve lesion?
• Trauma, brainstem lesion, cerebellopontine angle tumour, polio, GBS
Symptoms of hypoglossal nerve lesion?
- LMN lesion – wasting of ipsilateral side of tongue, fasciculations and protrusion of tongue deviates to side of lesion
- If UMN lesions – deviates away from lesion but tongue wont be wasted
Causes of hypoglossal nerve lesion?
• Polio, syringomelia TB
Lesions of cerebellopontine angle tumour?
CN 7, 8 then 10 and 9
Innervation of ulnar nerve?
- C7-T1
Pathology of ulnar nerve palsy?
- Vulnerable to elbow trauma – humeral fracture
- Most often damaged at epicondylar groove or in cubital tunnel
- Compression at wrist in Guyon’s canal
Symptoms and sign of ulnar nerve palsy?
- Weakness/Wasting of medial (ulnar side) wrist flexors
- Interossei (cannot cross fingers)
- Medial two lumbricals (claw hand) – cannot extend 4/5th fingers
- Hypothenar eminence wasting
- Sensory loss over medial 1 ½ fingers and ulnar side of hand
Management of ulnar nerve palsy?
• Rest • NSAIDs • Night-time soft elbow splinting for 6 months • Surgery Decompression Epicondylectomies
Innervation of median nerve?
• C6-T1
Definition of median nerve palsy?
- Compression of median nerve in carpal tunnel
- Carpal tunnel= bounded by carpal bones and transverse carpal ligament
- Reduction in dimensions cause pressure, ischaemia of median nerve and impairs conduction
- If continued, leads to segmental demyelination with more constant symptoms
Causes of median nerve palsy?
• Entrapment Hypothyroidism, DM, acromegaly, neoplasms, lipoma, OA, RA, amyloidosis, pregnancy, sarcoidosis • Excessive use of wrist • Tenosynovitis • Obesity
Symptoms and signs of median nerve palsy?
• Intermittent tingling, numbness or altered sensation
• Burning or pain in median nerve distribution (radial 3 ½ fingers and palm)
Worse at night and can disrupt sleep
Relieved by shaking it
• Loss of grip strength
• Atrophy of thenar eminence
Tests of median nerve palsy?
• Phalen’s Test
Flex wrist for 60s and brings on symptoms
• Tinnel’s Test
Tapping lightly over median nerve produces paraesthesia or pain in median nerve distribution
• If alternative cause:
Bloods (hypothyroidism)
US (ganglion)
Management of median nerve palsy - when to refer to specialist?
Symptoms severe or ADLs reduced
Symptoms recur following carpal tunnel surgery
Patient requests
Conservative management in primary care has failed
Management of median nerve palsy - primary care management?
Wrist splinting in neutral position – purchase at pharmacy
Corticosteroid injection
Specialist – Decompression surgery
DO NOT PRESCRIBE NSAIDs or DIURETICS
Innervation of radial nerve?
- C5-T1
Causes of radial nerve palsy?
• Compression against humerus
• Saturday night palsy – sleeping with arm over back of chair
Compression of lower brachial plexus
• Fracture or dislocation of head of humerus
• Shoulder crutches
Symptoms of radial nerve palsy?
- Wrist and finger drop
* Sensory loss variable – dorsal aspect of root of thumb (snuff box)
Investigations of radial nerve palsy?
- Nerve conduction studies
- US
- MRI
Management of radial nerve palsy?
- Usually recover spontaneously
- NSAIDs
- Entrapments requires surgical decompression
Innervation of phrenic nerve?
C3-C5
Causes of phrenic nerve palsy?
Malignancy Trauma Central lines Inflammation (pneumonia, empyema, pleurisy) AAA
Symptoms of phrenic nerve palsy?
If unilateral – asymptomatic
SOB and orthopnoea
Respiratory function tests – restrictive pattern
Management of phrenic nerve palsy?
Phrenic nerve stimulation
Direct muscular stimulation
Innervation of laternal cutaneous nerve of thigh?
- L2-L3
Symptoms of laternal cutaneous nerve of thigh palsy?
- Meralgia paraesthesia – anterolateral burning thigh pain from entrapment under inguinal ligament
- Pain reproduced by palpation under ASIS
- No motor weakness
Innervation of common peroneal nerve?
- L4-S1
Causes of common peroneal palsy?
- Trauma
- Sitting cross-legged
- Pressure to lateral leg as winds around fibular head
Symptoms and signs of common peroneal palsy?
- Foot drop
- Weak ankle dorsiflexion and eversion
- Inability to extend toes
- Sensory loss over dorsum of foot
Management of common peroneal palsy?
- Rest
- NSAIDs
- Aluminium night-shoe at night
- Ankle-foot orthoses in the day
Innervation of tibial nerve?
L4-S3
Causes of tibial nerve palsy?
- Ankle sprains and fractures
- Ill-fitting footwear
- Cysts
- Ganglia
- Arthritis
Symptoms of tibial nerve palsy?
- Inability to stand on tiptoe (plantarflexion), invert foot or flex toes
- Sensory loss of sole
Management of tibial nerve palsy?
- Rest
* NSAIDs
Definition of Guillain-Barre Syndrome?
- Acute inflammatory demyelination causing ascending and progressive polyneuropathy
- Trigger causes antibodies which attack nerves
- Peak ages 15-35 and 50-75
Triggers of Guillain-Barre Syndrome?
- Campylobacter jejuni
- CMV
- Mycoplasma
- Zoster
- HIV
- EBV
- Vaccinations
Pattern of Guillain-Barre Syndrome?
- 1-3 weeks after infection a symmetrical ascending muscle weakness starts
- Progressive phase up to 4 weeks, followed by recovery
Symptoms of Guillain-Barre Syndrome?
• Weakness
Ascending progressive symmetrical weakness starting in lower extremities
Facial weakness, dysphasia and dysarthria may develop
Severe cases leads to weakness in respiratory muscles
• Pain in legs common
• Paraesthesia and sensory loss starting in lower extremities
• Autonomic dysfunction – sweating, tachycardia, BP changes
Investigations of Guillain-Barre Syndrome?
- Bloods – U&E, LFTs
- LP - Protein high, normal WCC
- Spirometry – FVC determines needs to ITU admission and intubation
- Nerve conduction studies – slowed, repeat after 2 weeks if normal
Management of Guillain-Barre Syndrome?
• Respiratory involvement – need ITU transfer
FVC every 4 hours
Ventilate when FVC<1.5L, PaO2 <10kPa, PaCO2 >6kPa
• IV immunoglobulin 0.4g/kg/24h for 5d
• Plasma Exchange
• Neuropathic analgesia – gabapentin, carbamazepine
• VTE prophylaxis essential
Complications of Guillain-Barre Syndrome?
- Persistent paralysis
- Respiratory failure
- Hypo/Hypertension
- Pneumonia
- Urinary retention
- Depression/Anxiety
Prognosis of Guillain-Barre Syndrome?
- Good, 85% make complete or near-complete recovery
* Mortality 10%
Causes of head injury?
o RTAs o Falls o Assaults o Sporting/Leisure injuries o Workplace injuries
Symptoms of raised ICP?
o Changes or LOC o Headache o Vomiting o Eyes – papilloedema, dilated pupils, impaired eye movements o Aphasia o Seizures o Cushing’s triad – hypertension, bradycardia, bradypnoea (Cheyne-Stokes breathing) o Coning
When to refer head injury to hospital?
o Impaired conscious level o Amnesia o Neurological symptoms o Skull fracture o Worrying mechanism of injury
Examination of patient with head injury?
o Vital Signs
o BMG
o GCS
o Neurological assessment
o Evaluate lacerations and note skull/facial fractures
Basal skull # - haemotympanum, Panda eyes, CSF leakage, Battle’s sign
o Check for CSF leak
Investigations in head injury?
o U&Es, glucose, FBC, blood alcohol, toxicology screen, ABG, clotting
o CT scan
Skull fractures
Intracranial haematomas – midline shift
Extradural haematoma – high density lens shaped lesions
Subdural conform more to surface of brain
Contusions are low density
Cerebral swelling may shrink ventricles
Management of head injury - initial management?
o Oxygen if hypoxic, intubate if GCS<9
o Immobilise C-spine until excluded
o IV access, stop blood loss and treat shock
o Bloods – FBC, U&Es, clotting, cross-match, glucose
o Seizures – IV lorazepam +/- phenytoin
o Assess need for tetanus toxoid
Management of head injury - pain management?
o Splintage of limb fractures
o Catheterisation of full bladder
o IV opioids titrated against clinical response
Management of head injury - when to CT adult within 1 hour?
GCS <13 on initial assessment GCS<15 at 2 hours after injury >1 vomit Suspected open or depression skull fracture Sign of basal skull fracture Post-trauma seizure Focal neurological deficit
Management of head injury - when to CT adult within 8 hours?
If LoC or amnesia since head injury + 1 of:
Age>65
History of bleeding disorder
Dangerous mechanism of injury (>1 metre/5 stair fall, pedestrian struck by vehicle, occupant ejected from car)
>30 mins retrograde amnesia of events before head injury
Management of head injury - when to CT child within 1 hour?
GCS<14 or <15 for <1-year olds GCS<15 at 2 hours post-injury >5cm bruise on head of <1 year old LOC >5 mins, drowsiness, >2 vomits, dangerous mechanism of injury, amnesia >5 mins Non-accidental Post-traumatic seizure Suspected open or depression skull fracture Sign of basal skull fracture Focal neurological deficit
Management of head injury - when to CT on warfarin?
CT within 8 hours if no indication for earlier
Management of head injury - when to perform 3-view XR of C-spine within 1 hour?
o If cannot assess or patient cannot rotate neck to 45o to left and right
Management of head injury - referral to neurosurgery?
o GCS 8 or less after initial resus o Confusion >4 hours o Deteriorating GCS o Progressive focal neurological signs o Seizure without full recovery o Penetrating injury o CSF leak
Management of head injury - when to admit into hospital?
o Abnormal imaging, GCS<15, persistent vomiting, severe headaches, intoxicated or other concerns
Monitoring in head injury - what and how often?
GCS, pupil size, reactivity, limb movements, RR, HR, BP, temperature, O2 sats
Half-hourly until GCS 15
When GCS 15: half hourly for 2 hours, 1-hourly for 4 hours and 2-hourly thereafter
When to discharge person with head injury?
o When GCS 15 with somebody suitable at home to supervise for 24h
Advice given in head injury on discharge?
Rest for 24h Analgesia when required DO NOT drink alcohol for 24 hours, take sleeping tablets or tranquilisers DO take your normal medications If any of the following occur, return to hospital: • Headache not relived by painkillers • Vomiting • Vision disturbances • Balance problems • Fits • Unarousable
Pathology of subdural haematoma?
o Bleeding is from bridging veins between cortex and venous sinuses (vulnerable to deceleration injuries), haematoma between dura and arachnoid
o Leads to raised ICP, midline shift and eventually tentorial herniation and coning
Risk factors of subdural haematoma?
elderly, falls (epileptics, alcoholics), anticoagulation
Symptoms of subdural haematoma?
fluctuating consciousness, insidious physical or intellectual slowing, sleepiness, headache, personality change
Signs of subdural haematoma?
Raised ICP, seizures, localising symptoms occur late (unequal pupils, hemiparesis)
Investigations of subdural haematoma?
CT (crescent shaped collection of blood over 1 hemisphere, sickle-shaped)
Management of subdural haematoma?
Irrigation (Via burr twist drill and craniostomy), craniotomy
Pathology of extradural haematoma?
o Due to fractures temporal or parietal bone causing laceration to middle meningeal artery and vein, typically after trauma to temple
o Also tears in dural venous sinus
o Blood accumulates between bone and dura mater
Symptoms of extradural haematoma?
o Deteriorating consciousness after head injury, lucid period (LOC and then recovery before LOC when haematoma expands enough), increasing severity of headaches, vomiting, confusion and fits
o May have upgoing plantars, brisk reflexes, hemiparesis, ipsilateral pupil dilates, irregular breathing
Investigations of extradural haematoma?
CT (lens-shaped haematoma, tough dura mater keeps it localised), Skull XR (fractures)
Management of extradural haematoma?
Stabilise and transfer to neurosurgical unit urgently, clot evacuation and ligation of bleeding vessel, may need mannitol, ventilation and intubation
Definition of multiple sclerosis?
- Acquired, chronic, immune-mediated inflammatory condition of CNS affecting brain, brain stem and spinal cord
- Inflammation causes demyelination, gliosis and neuronal damage (cell loss) throughout CNS
- T-cell mediated attack of oligodendrocytes
Nerves affected in multiple sclerosis?
- Optic nerve, periventricular white matter, brainstem and cerebellum
- Peripheral nerves never affected
Definition of relapse of multiple sclerosis?
• Relapse is onset of new symptoms, or worsening, lasting >24 hours in absence of cause
Epidemiology of multiple sclerosis?
- Prevalence directly related to distance from equator
- About 1 in 2000, mean age 30 years, Women 3>1 Men
Types of multiple sclerosis?
Relapsing-Remitting
• Episodes or exacerbations of symptoms followed by recovery and periods of stability
Secondary progressive
• Onset of MS is of RRMS but at some point, disease course changes and neurological function worsens with or without relapses
• 25% of RRMS progress to SPMS within 6 years
Primary Progressive
• Steady progression and worsening from disease onset without remissions
Risk factors of multiple sclerosis?
- Genetics
- Smoking
- Obesity
- EBV exposure
- Vitamin D is PREVENTATIVE
Symptoms of multiple sclerosis?
Two or more distinct episodes of CNS dysfunction followed by remission
• Optic neuropathy
Unilateral optic neuritis
Partial or total unilateral visual loss developing over few days
Eye pain behind eye, particularly on eye movement
Reduced acuity with scotoma, disc swelling and atrophy
• Transverse Myelitis
Numbness/weakness/tingling in legs, trigeminal neuralgia, erectile dysfunction, urinary symptoms
• Brainstem demyelination
Diplopia, vertigo, dysphagia, nystagmus, ataxia
Relapse triggers in multiple sclerosis?
• Triggered by stress, heat, exercise
Investigations before referral in multiple sclerosis?
• FBC, CRP, ESR, LFT, U&E, calcium, glucose, TFT, VitB12, HIV
Investigations by neurologist in multiple sclerosis?
MRI – plaques in area of MS
CSF – IgG in CSF and not blood suggest inflammation
When to refer to neurologist in multiple sclerosis?
- If suspected MS or isolate optic neuritis confirmed by ophthalmologist
- Diagnosis made by consultant neurologist using McDonald Criteria
- Follow up within 6 weeks after diagnosis
Criteria used in diagnosis of multiple sclerosis?
McDonald Criteria
Management of multiple sclerosis - general management?
- Encourage stress free life
- Regular exercise and stop smoking
- Give vitamin D if low levels
Management of multiple sclerosis - symptom management?
Fatigue Emotionally labile Oscillopsia Spasticity Tremor Urgency
Fatigue
- Offer amantadine or CBT
Emotionally labile – amitriptyline
Oscillopsia – gabapentin (memantine)
Spasticity - Baclofen/gabapentin/tinzanidine
Tremor - Physiotherapist or OT, Botulinum toxin type A
Urgency – Intermittent self-catheterisation, tolterodine
Management of multiple sclerosis - rehab?
- Physio and OT management
- Walking Aids
- Alter home, garden, carers
- Benefits
Management of multiple sclerosis - acute relapse - what to rule out?
Rule out infection and make sure it is not disease progression
Management of multiple sclerosis - acute relapse - diagnose relapse when?
Worse or new symptoms lasting >24 hours in absence of infection after 1 month stable period
Management of multiple sclerosis - acute relapse - drug management?
Methylprednisolone 0.5g daily PO for 5 days
- Consider IV 1g if oral steroids failed or need admitting for severe relapse
Management of multiple sclerosis - Disease modifying agents in relapsing remitting MS?
Interferon 1A&1B
Alemtuzumab/Natalizumab
Glatiramer
Azathioprine (instead of interferon)
Management of multiple sclerosis - Disease modifying agents in secondary progressive?
Interferon Beta 1B
Management of multiple sclerosis - Disease modifying agents in primary progressive?
No effective treatment
Complications of MS?
- Fatigue
- Spasticity
- Ataxia and tremor
- Optic Neuritis
- Diplopia
- Reduce mobility
- Pain
- Bladder dysfunction
- Sexual dysfunction
