Neurology Level 2.2 Flashcards
1
Q
Definition of Parkinson’s disease?
A
- Chronic, progressive neurodegenerative condition resulting from loss of dopamine-containing cells of substantia nigra pars compacta (associated with Lewy bodies then cell loss) by mitochondrial DNA dysfunction
- Dopamine deficiency within basal ganglia leads to movement disorder
2
Q
When does Parkinson’s disease become apparent?
A
Parkinson’s disease not clinically apparent until 50% cell loss
3
Q
Definition of Parkinsonism?
A
- Umbrella term for syndrome of bradykinesia, tremor, rigidity and/or postural instability
- Causes: Parkinson’s disease, drug-induced, cerebrovascular disease, Lewy-body dementia
4
Q
Epidemiology of Parkinson’s disease?
A
- Prevalence increasing sharply
- Mean age of onset 65 years old
5
Q
Risk factors of Parkinson’s disease?
A
- Family History
- Genetics
- Opioid use
6
Q
Symptoms of Parkinson’s disease?
A
Tremor
Rigidity
Bradykinesia
7
Q
Types of tremor of Parkinson’s disease?
A
- 4-7Hz pill-rolling tremor over thumb
* Most obvious in hands and improved by involuntary movements
8
Q
Type of rigidity of Parkinson’s disease?
A
- Increased tone, combined with tremor, makes cogwheel rigidity
- During rapid pronation/supination
9
Q
Type of bradykinesia of Parkinson’s disease?
A
- Slow to initiate movement
- Lose facial expression
- Decreased blinking
- Slow and monotonous speech
- Writing micrographic and small
- Gait – Decreased arm swinging, shuffling steps with stooped trunk, freeze on turning
10
Q
Other symptoms of Parkinson’s disease?
A
- Reduced smell
- Constipation
- Depression, hallucinations, dementia
- Drooling of saliva
- Weight loss
- Urinary difficulties
- Reflexes asymmetrical
11
Q
Drugs that cause Parkinsonism?
A
• Reserpine, phenothiazines, metoclopramide, 1st gen antipsychotics
12
Q
Diagnosis of Parkinson’s disease?
A
- Clinical Diagnosis based on UK Parkinson’s Disease Society Brain Bank Criteria
- Single photon emission CT (SPECT) if tremor cannot be clinically differentiated from parkinsonism
13
Q
Management of Parkinson’s disease - referral?
A
- Urgent referral to neurologist
- If drug-induced, stop drug in primary care if possible
14
Q
Management of Parkinson’s disease - general advice?
A
• Leaflet on Parkinson’s, support and drug treatment
• Inform DVLA and car insurer of disease
May drive if vehicle control is safe at all times, if condition disabling or significant variability in motor function then may not be able to drive
• Consider referral to SALT, physiotherapy, OT, dietetics
• Take vitamin D regularly
15
Q
Management of Parkinson’s disease - drug management - first line treatments?
A
Levodopa, usually given with dopa decarboxylase inhibitor as co-beneldopa (Madopar) or co-careldopa (Sinemet)
- Efficacy reduces with time – increasing doses/frequency
- Off freezing and end of dose reduced response
If develop dyskinesia, weaning off, add:
- Dopamine agonists – pramipexole, ropinirole
- Monoamine oxidase-B inhibitors – selegilline, rasagilline
- Oral catechol-O-methyl transferase (COMT) - entacapone
16
Q
Management of Parkinson’s disease - drug management - adjuvant treatments?
A
Apomorphine – used SC to even out end of dose effects
DBS for advanced Parkinson’s disease not controlled on best medical therapy
17
Q
Management of Parkinson’s disease - managing complications - constipation?
A
- Increase dietary fibre and fluid intake
- Increase exercise levels
- Consider laxatives
18
Q
Management of Parkinson’s disease - managing complications - N&V?
A
- If persistent – use low-dose domperidone or switch medications
19
Q
Management of Parkinson’s disease - managing complications - sleep disturbance?
A
- Rapid eye movement sleep disorder – clonazepam or melatonin
- Nocturnal akinesia – levodopa or oral dopamine agonist
20
Q
Management of Parkinson’s disease - managing complications - dementia?
A
- Reduce drugs causing cognitive impairment, seek specialist advice
21
Q
Management of Parkinson’s disease - managing complications - psychotic symptoms?
A
- Mild- no treatment
- Severe – withdrawal of anti-Parkinsonism or quetiapine under specialist supervision
22
Q
Management of Parkinson’s disease - managing complications - orthostatic hypotension?
A
- Increase salt and fluid intake, avoid caffeine at night and alcohol
- Elevate bedhead to 30-40o
- Reduce contributing medications
- Liase with specialist – midodrine or fludrocortisone
23
Q
Management of Parkinson’s disease - managing complications - excessive salivation?
A
- Referral to SALT
- Glycopyrronium bromide or botulinum toxin A
24
Q
Prognosis of Parkinson’s disease?
A
- Slowly progressive, rate depends on:
• Age of onset and disease duration
• Early-onset disease may have later onset of motor and cognitive impairments - Reduced life expectancy and increased risk of dementia
25
Complications of Parkinson's disease - motor?
* Deteriorating function
* Loss of drug effect
* Motor fluctuations
* Dyskinesia
* Freezing of gait
* Falls
26
Complications of Parkinson's disease - non-motor?
* Mental health complications
* Constipation
* Orthostatic hypotension
* Dysphagia and weight loss
* Bladder and sexual dysfunction
* Nausea and vomiting
* Pain
* Sleep Disturbance
27
Definition of epilepsy?
- Recurrent, tendency to spontaneous, intermittent, abnormal electrical activity in brain, manifesting as seizures
Epilepsy is defined as:
o >2 unprovoked seizures occurring >24 hours apart
28
Classification of epilepsy?
o Generalised – discharge arises from both hemispheres
o Partial – seizures arise from one or part of one hemisphere
o Complex – loss of consciousness
o Simple – maintained conscious level
29
Definition of status epilepticus?
- Status epilepticus is a continuous seizure for 30 minutes or longer, or recurrent seizures without regaining consciousness lasting 30 minutes or longer
30
Elements of epilepsy?
o Seizure – convulsion caused by paroxysmal discharge of cerebral neurones
o Epilepsy – tendency for seizures
o Partial Seizure – Epileptic activity confined to one area of cortex, can spread to secondary
o Generalised seizure – epileptic activity in both hemispheres
o Aura – Stereotyped perception caused by initial focal electrical events before partial seizure
o Prodrome – Lasting hours/days before seizure, change in mood or behaviour
o Post-ictal – may be headache, confusion, myalgia, sore tongue, weakness
31
Risk factors of epilepsy?
- Familial
- Genetic conditions (Neurocutaneous syndromes e.g. tuberous sclerosis)
- Febrile seizures – 2-7% increase in risk
- Intracranial infections
32
Aetiology of epilepsy?
- 2/3 idiopathic (often familial)
- Flashing lights/Flickering
- Structural defects
o Cortical scarring
o Lesion occupying space
o Stroke
o Vascular malformations
33
Epidemiology of epilepsy?
- Prevalence 5x greater in developed world
- Risk of seizure is 5%
- 1% said to have active epilepsy
34
Other causes of epilepsy?
- Trauma, stroke, haemorrhage
- Raised ICP, alcohol/benzo withdrawal
- Low glucose, oxygen, calcium, sodium
- High temperature
- Drugs (TCAs, cocaine, tramadol)
35
Types of generalised seizures?
* Absence Seizures (petit mal)
* Myoclonic seizures
* Tonic Seizure
* Tonic-clonic seizures (grand mal)
* Atonic Seizure
36
Description of absence seizure (petit mal)?
Brief (10s), transient loss of consciousness with abrupt onset/termination, may be some flickering of eyelids but no major muscle phenomenon
37
Description of myoclonic seizure?
Brief, often repetitive jerking movements of limbs, neck or truck
Child thrown suddenly to the ground
38
Description of tonic seizure?
Generalised increase in tone
39
Description of tonic clonic seizure (grand mal)?
Rhythmical contraction of muscle groups followed by tonic phase
Do not breath, cyanosed, saliva may accumulate in mouth
Tongue biting, incontinence of urine
There is unconsciousness or deep sleep for hours after
40
Description of atonic seizure?
Sudden loss of muscle tone, no LOC
41
Features present in generalised seizures?
Loss of consciousness
No warning
Symmetrical seizure
Bilaterally synchronous seizure discharge on EEG
42
Types of partial seizures?
• Simple
Awareness is unimpaired with focal deficits, no post-ictal phase
• Complex
Awareness impaired, may have aura
Common in temporal lobe and post-ictal phase
• Partial with 2o generalisation
2/3 of partial seizures
43
Characteristics of frontal seizures?
Involve motor cortex
Clonic movements, may travel proximally (Jacksonian march)
Paralysis of involved limb (Todd’s palsy)
44
Characteristics of temporal seizures?
```
Most common of all epilepsies
Strange aura, with smell and taste abnormalities and distortions of sound and shapes
Lip-smacking, rubbing face, running
Deja-vu feelings
Consciousness can be impaired
```
45
Characteristics of occipital seizures?
Cause distortion of vision, flashes, lines
46
Characteristics of parietal seizures?
Cause contralateral dysaesthesias (altered sensation) or distorted body image
47
Features of focal seizures?
* Begin with small group of neurones in one of the cerebral hemispheres
* May be heralded by an aura which reflects site of origin
* Usually no LOC
48
Features of post-ictal period?
* Drowsiness or amnesia.
* Injury, including bites to the sides of the tongue.
* Aching limbs or headache.
* Focal neurological deficit, that slowly recovers
49
Triggers of epilepsy?
• Alcohol, stress, fever, sounds, lights
50
Diagnostic investigations performed in epilepsy?
• Seen by specialist neurologist
• EEG to support diagnosis if likely epileptic seizure
Focal cortical spikes and waves
Repeat if EEG negative
Sleep EEG can be used if standard has not contributed to diagnosis
• ECG in all
• Bloods (FBC, U&E, glucose, Ca)
• MRI
• Refer to neuropsychological assessment if educational or occupational difficulties, MRI abnormality or cognitive decline/deficit
51
Management of epilepsy - general advice?
* Referral to neurology specialist if epileptic seizure
* Stop driving until seeing the specialist (only allowed after 1 year of seizure free)
* Avoid dangerous work or activities, swimming etc
* Do not operate heavy machinery
* Help of epilepsy nurse specialist
52
Management of epilepsy - when to give drug therapy in epilepsy?
• When >2 fits in a year (or 1 if neurological deficit, EEG shows epileptic activity or structural abnormality)
53
Management of epilepsy - drug treatment - generalised tonic clonic?
- 1st line - Sodium valproate (boys, women not of childbearing age)/Lamotrigine (1st line), then carbamazepine
- Adjunct if monotherapy not effective – clobazam, lamotrigine, levetiracetam, sodium valproate, topiramate
54
Management of epilepsy - drug treatment - absence?
- 1st line - ethosuximide
- Alternative – sodium valproate (male), lamotrigine or levetiracetam
- Adjunct if monotherapy not effective – clobazam, clonazepam, levetiracetam, topiramate
55
Management of epilepsy - drug treatment - tonic/atonic?
- 1st line – Sodium Valproate (males) , – lamotrigine (females)
- AVOID CARBEMAZEPINE, GABAPENTIN, PHENYTOIN, PREGABALIN
56
Management of epilepsy - drug treatment - myotonic?
- 1st line - Sodium valproate (males), levetiracetam (females)
| - AVOID CARBEMAZEPINE, GABAPENTIN, PHENYTOIN, PREGABALIN
57
Management of epilepsy - drug treatment - Partial?
- Carbamazepine or lamotrigine (1st line), then sodium valproate or levetiracetam
- Options for adjunctive treatment – clobazam, gabapentin, sodium valproate
58
Management of epilepsy - alternative treatments?
* Ketogenic Diet
| * Vagal Nerve Stimulation
59
When to refer epilepsy to tertiary centre?
* Seizure not controlled with medication within 2 years
* Management unsuccessful after two drugs
* Child <2 years
* Unilateral structural lesion
* Diagnostic uncertainty
* Treatment failure
60
Complications of epilepsy?
* Sudden Unexpected Death in Epilepsy
* Status Epilepticus
* Depression/Anxiety
* Behavioural Problems
* Injuries
61
Prognosis of epilepsy?
* Depends on epilepsy syndrome, frequency of seizures and response to drug treatment
* About 30% will have ongoing seizures
62
Classification of tension headache?
```
o Infrequent (<1 day per month)
o Frequent episodic (<15 days per month for >3 months)
o Chronic (>15 days per month for > 3months)
```
63
Epidemiology of tension headache?
- Most common primary headache disorder
| - Generally, between 20-30 years old
64
Aetiology of tension headache?
- Thought to be due to peripheral pain mechanisms and increase sensitivity
65
Symptoms of tension headache?
Headache
o Bilateral and occipito-nuchal or bi-frontal
o Pressing/Tightening/Band-Like
o Non-pulsating
o Mild-to-Moderate
o Lasts minutes to days
o Not aggravated by routine physical activity
Muscle stiffness in neck
Difficulty concentrating
Symptoms of stress and anxiety
Usually no N&V, autonomic symptoms
66
What to exclude in assessment of tension headache?
Primary
Migraine
Trigeminal autonomic cephalgias
Cough headache, cold headache
Secondary
Trauma
Cranial vascular events (GCA, venous thrombosis, haemorrhage)
Idiopathic intracranial hypertension or neoplasm
Substance abuse or withdrawal
Infection
67
When to investigate further by referral in tension headache?
o Worsening with fever
o Sudden-onset reaching maximum within 5 minutes
o New-onset neurological/cognitive/personality defects
o Impaired consciousness
o Triggered by cough, Valsalva or sneeze, exercise
o GCA, acute narrow angle glaucoma
68
Initial investigation of tension headache?
```
Headache diary
o 8 weeks
o Frequency, duration and severity of headaches
o Any associated symptoms
o Possible precipitants
```
69
Diagnosis of tension headache made when?
```
Diagnosed tension headaches if:
o Bilateral headache
o Pressing/tightening
o Mild or moderate
o Not aggravated by routine activities of daily living
o 30 minutes-continuous
```
70
Acute treatment of tension headache?
o Simple analgesia – paracetamol, NSAIDs or aspirin
DO NOT OFFER OPIOIDS
o Identify stressors – mood, sleep, pain and try to manage
71
Prophylactic treatment of tension headache?
o Consider up to 10 session of acupuncture over 5-8 weeks
o Low dose amitriptyline (10-75mg daily)
If don’t respond – discontinue and discuss with neurology
If do respond – withdrawal if improvement maintained for 4-6 months
72
Prognosis of tension headache?
o Occurs in large proportion of adults and usually self-limiting and simple analgesia effective
73
Complications of tension headache?
o Considerable disability and loss of QoL
| o May lead to medication overuse headache
74
Definition of migraine?
- Primary episodic headache disorder
- It is characterized by episodic severe headaches (commonly, but not always unilateral, and often described as throbbing or pulsating), with associated symptoms such as photophobia, phonophobia, and nausea and vomiting
75
Pathophysiology of migraine?
- Pathophysiological cause is not fully understood. May be due to the trigeminovascular system and its relationship with pain pathways
- Migraine with aura – headache preceded by aura (visual, sensory or motor)
76
Epidemiology of migraine?
- 15% incidence
- Females 3:1 Males
- Migraine without aura 90% of migraines
77
Trigger of migraine?
* Chocolate
* Hangovers
* Orgasms
* Cheese/Caffeine
* OCP
* Lie-ins
* Alcohol
* Travel
* Exercise
78
Risk factors of migraine?
* FHx
| * Obesity
79
Prodrome phase of migraine?
• Yawning, cravings, mood/sleep changes, poor concentration
80
Aura of migraine?
* Negative phenomenon (hemianopia, scotoma)
* Positive phenomena (zigzag lines)
* Paraesthesia
* Ataxia, dysphasia, hemiparesis
81
Symptoms of migraine?
* Unilateral, throbbing headache
* Nausea and vomiting
* Photophobia/Phonophobia
* Allodynia
82
Postdromal phase of migraine?
• Fatigue or elated/depressed mood may occur for up to 48 hours
83
Types of migraine?
* Episodic migraine refers to headache which occurs on less than 15 days per month.
* Chronic migraine refers to headache which occurs on 15 or more days per month.
* Menstrually-related migraine is diagnosed when migraine without aura regularly occurs between 2 days before and 3 days after the start of menstruation
84
When can clinical diagnosis of migraine without aura be made?
- >5 headaches lasting 4-72 hours + nausea/vomiting (or photo/phonohobia) + any 2 of:
• Unilateral
• Pulsating
• Impairs routine activity
85
When can clinical diagnosis of migraine with aura be made?
- At least 2 attacks with:
• One or more typical fully reversible aura symptoms including:
Visual symptoms – zigzag lines, scotoma
Unilateral pins, needles, numbness
Speech and language problems
```
• At least three of :
At least 1 aura spreads gradually over 5 minutes
Two or more aura in succession
Each aura lasts 5-60 minutes
At least 1 aura is unilateral
Aura is followed by headache
```
86
When to refer atypical migraines?
Refer if atypical neurological symptoms
| • Motor weakness, double vision, poor balance, decreased consciousness
87
Initial investigation in migraines?
- Headache diary for 8 weeks to assess triggers, severity and frequency of attacks
88
Management of migraines - avoiding triggers?
* Stress management
* Sleep hygiene
* Keep hydrated
* Regular meals
* Maintain healthy body weight
89
Management of migraines - acute attacks?
• Paracetamol 1g or ibuprofen 400mg/600mg or aspirin 900mg
• Oral sumatriptan 50-100mg (can give intra-nasal or SC)
Nasal if 12-17 years old
• Metoclopramide 10mg or prochlorperazine 10mg
• Follow up after 2-8 weeks
90
Management of migraines - non-pharmacological management?
* Warm or cold packs to head
| * Acupuncture if both topiramate and propranolol fail to prevent attacks
91
Management of migraines - prophylactic agents?
* Propanolol OR
* Sodium topiramate (not for childbearing age women, would need contraception)
* Amitriptyline
* If both topiramate and propranolol unsuitable or ineffective – offer 10 sessions of acupuncture over 5-8 weeks
* Review after 6 months
* Botulinum toxin type A – if chronic migraine not responding to 3 prior prophylactic drugs
92
Management of migraines - menstrual related migraines?
Frovatriptan 2.5mg BD or zolmitriptan 2.5mg BD on days migraine expected
93
Management of migraines - pregnant women migraines?
* Paracetamol
* Avoid ibuprofen in 3rd trimester due to risk of PDA closure
* Sumatriptan preferred if needed
94
Prognosis of migraines?
• Usually improve with age
95
Complications of migraines?
* Reduced QoL
* Chronic migraines
* Status migrainosus (debilitating migraine attack lasting more than 72 hour)
* Increased risk of stroke
96
Myotomes - hip flexion?
L2, L3
97
Myotomes - hip extension?
L4, L5
98
Myotomes - hip adduction?
L1-4
99
Myotomes - hip abduction?
L5, S1
100
Myotomes - knee extension?
L3, L4
101
Myotomes - knee flexion?
L5, S1
102
Myotomes - dorsiflexion of foot?
L4, L5
103
Myotomes - plantarflexion of foot?
S1, S2 (ankle reflex too)
104
Myotomes - eversion foot?
L5, S1
105
Myotomes - inversion foot?
L4, L5
106
Myotomes - shoulder flexion, abduction and external rotation?
C5
107
Myotomes - shoulder extension, adduction, internal rotation?
C6-C8
108
Myotomes - elbow flexion?
C5, C6
109
Myotomes - elbow extension?
C6, C7
110
Myotomes - wrist flexion?
C6, C7
111
Myotomes - wrist extension?
C6, C7
112
Myotomes - arm pronation?
C7, C8
113
Myotomes - arm supination?
C6
114
Myotomes - digital flexion/extension?
C7, C8
115
Myotomes - digital abduction/adduction?
T1
116
Dermatomes upper limb landmarks
```
C4 shoulder tip
C5 outer part of the upper arm
C6 lateral aspect of the forearm and the thumb
C7 middle finger
C8 little finger
T1 medial aspect of the upper arm
```
117
Dermatomes lower limb landmarks
L2 upper thigh
L3 around the knees
L4 medial aspect of the leg
L5 lateral aspect of the leg, medial side of the dorsum of the foot
S1 lateral aspect of the foot, the heel and most of the sole
S2 posterior aspect of the thigh
S3, S4, S5 concentric rings around the anus, the outermost of which is S3
