Neurology - Level 3 Flashcards
Classes of brain tumours?
o High-grade – grows rapidly and is aggressive
o Low-grade – grows slowly but which may/may not be successfully treated
Epidemiology of brain tumours?
- 2% of all tumours
- Lifetime risk is 1 in 77
- Common 50-70
Risk factors of brain tumours?
o Ionising radiation o Vinyl chloride o Immunosuppression o Oil refining, embalming, textiles o Neurofibromatosis, VHL disease, TSC, Li-Fraumeni syndrome, Cowden’s disease
Types of brain tumours - malignant?
o Metastases most commonly from other sites 10x
Lung, breast, stomach, prostate, thyroid, colorectal, melanoma, kidney
Types of brain tumours - high grade?
Gliomas, glioblastoma multiforme
Primary cerebral lymphomas
Medulloblastoma
Types of brain tumours - low grade?
Meningioma Acoustic neuroma Neurofibromas Pituitary tumours Pineal tumours Craniopharyngioma
Symptoms of brain tumours?
o Headache Worst in mornings, coughing o Nausea and vomiting o Seizures o Progressive focal neurological deficits Diplopia, visual field defect, upper/lower limbs o Behavioural changes o Papilledema
Symptoms related to location of mass of brain tumours - temporal?
dysphasia, contralateral homonymous hemianopia, amnesia, odd phenomenon
Symptoms related to location of mass of brain tumours - frontal?
hemiparesis, personality change (indecent, indolent, facetious), Broca’s dysphasia, unilateral anosmia, concrete thinking, perseveration, executive dysfunction
Symptoms related to location of mass of brain tumours - parietal?
hemisensory loss, sensory inattention, dysphasia
Symptoms related to location of mass of brain tumours - occipital?
contralateral visual field defects, seeing multiple images
Symptoms related to location of mass of brain tumours - cerebellum?
DASHING (dysdiadochokinesia, ataxia, slurred speech, hypotonia, intention tremor, nystagmus, gait abnormalities)
Investigations in brain tumours?
• Urgent direct access MRI scan of brain (CT if MRI CI)
Progressive, sub-acute loss of central neurological function
• Urgent referral appointment for children within 48 hours
• Others: Technetium brain scan, Magnetic resonance angiography, PET
- Stereotactic biopsy via skull burr-hole
Investigations in gliomas?
MRI
MDT team
MR perfusion/spectroscopy
Molecular markers (IDH1&2, ATRX, 1p/19q, H3.3K27M, BRAF, MGMT, TERT)
Management of glioma - low grade?
- 5-ALA-guided resection (within 6 months)
• If not appropriate: Biopsy to attain histology and molecular diagnosis - If very low grade – active monitoring – then resection if progressing
- Post-surgical Radiotherapy followed by 6 cycles of PCV chemotherapy
• If 1p/19q, IDH-low grade glioma and >40 or residual tumour
Management of glioma - Grade 3?
5-ALA-guided resection (within 6 months)
- Post-surgical radiotherapy followed by PCV chemotherapy
• If newly diagnosed grade 3 glioma with 1p/19q codeletion
Management of glioma - Grade 4?
- Radiotherapy with temozolomide chemotherapy
• If newly diagnosed glioma
Management of glioma - Recurrent grade 3 or 4?
- PCV or lomustine chemotherapy
Investigations in meningioma?
MRI (CT if assessing bones)
Management of meningioma?
5-ALA-guided resection (within 6 months)
Radiotherapy
Investigations in brain metastases?
MRI (CT if assessing bones)
Management of brain metastases - single?
- Systemic anti-cancer therapy if likely to respond (germ cell, small-cell lung)
- Surgical excision
- Stereotactic radiosurgery or radiotherapy
Management of brain metastases - multiple?
- Adjuvant stereotactic radiosurgery/radiotherapy if 1-3 metastases
Follow up in brain tumours?
- MRI scans and clinical assessment
Other medications used in management of brain tumours?
- Analgesics – codeine
- Anticonvulsants – phenytoin
- Corticosteroids – dexamethasone, mannitol for raised ICP
Complications of brain tumours?
- Acute haemorrhage
- Hydrocephalus
- Increases in ICP
Definition of encephalitis?
- Inflammation of brain parenchyma, often caused by viral infections
Risk factors of encephalitis?
- <1 or >65
- Immunodeficiency
- Viral infection
- Animal/Insect bites
Viral types of encephalitis?
- Acute (caused by direct viral infection)
- Post-infectious (autoimmune process)
Viral causes of encephalitis?
- Herpes Simplex 1&2
- CMV
- EBV
- VZV
- Measles
- Mumps
- Adenovirus
- Influenza
- Polio
- Rubella
- Rabies
- HIV – toxoplasmic meningoencephalitis
Bacterial causes of encephalitis?
Any cause of bacterial meningitis
Fungal causes of encephalitis?
Cryptococcosis, histoplasmosis, candidiasis
Parasitic causes of encephalitis?
Trypanosomiasis, toxoplasmosis, schistosomiasis
Symptoms of encephalitis?
- Triad:
• Fever, headache, altered mental status - May have confusion, seizures, focal neurological signs
- Symptoms of raised ICP – headache, vertigo, nausea, convulsions
Investigations of encephalitis?
- Bloods • FBC and film • U&E • LFTs • CRP/ESR • Viral PCR • Malaria film
- Blood Cultures
- Throat swab
- CT Scan
• Focal bilateral temporal lobe involvement – HSV
• Before LP - Lumbar Puncture
• Send for cells, protein, glucose, lactate and PCR
• Viral – lymphocytosis, normal glucose ratio - EEG
• Diffuse slowing with periodic discharges
What to send for in LP of encephalitis?
- Send for cells, protein, glucose, lactate and PCR
* Viral – lymphocytosis, normal glucose ratio
Management of encephalitis - initial management?
- Assess using ABCDE and check glucose
- Immediate LP
• If contraindications for LP then urgent CT scan
• Send for opening pressure, CSF and serum glucose, CSF protein, 2x M, C &S, virology PCR, lactate
Management of encephalitis - if CSF findings do not suggest encephalitis?
• Repeat LP in 24 hours
Management of encephalitis - if CSF findings suggest encephalitis?
• IV Aciclovir (within 30 mins of arrival)
10mg/kg/8h
- Neonate 20mg/kg
- 3 months – 12 years – 500mg/m2
14 days if >12 years
21 days if immunosuppressed or <12 years old
Adjust dose according to eGFR every 12/24h
- MRI within 24-48 hours if not already performed
- ICU or HDU if severe
Management of encephalitis - symptomatic treatment?
- Intubation and ventilation
- Phenytoin for seizures
- Sedatives
Management of encephalitis - if elevated ICP?
- Elevate head of bed to 45 degrees
- Hyperventilation
- Corticosteroids
- Mannitol
Management of encephalitis - specific treatments to CMV, Syphilis, Rocky Mountain fever?
- CMV – ganciclovir + foscarnet
- Syphilis – Benzylpenicillin
- Rocky Mountain spotted Fever – Doxycycline
Clinical contraindications to LP?
- GCS <13 or fall or 3 or more
- Focal neurological signs (unequal, poorly dilating or responsive pupils)
- Abnormal posture
- Papilloedema
- After seizures until stabilised
- Relative bradycardia and hypertension
- Abnormal doll eyes movements
- Immunocompromise
- Systemic shock
- Coagulopathies – platelets <100, anticoagulation therapy
- Local infection at puncture site
- Respiratory insufficiency
- Suspected meningococcal septicaemia
Pathology of fibromyalgia?
- Chronic pain disorder
o Aberrant peripheral and central pain processing
o Allodynia and hyperaesthesia
Epidemiology of fibromyalgia?
- Women 10x
- Aged 20-50
Risk factors of fibromyalgia?
o Female o Middle Aged o Low income o Divorced o Low educational status o Psychosocial: Sickness behaviours, social withdrawal, emotional problems, problems at work
Associations of fibromyalgia?
o Chronic fatigue syndrome, IBS, chronic headaches, RA/SLE
Symptoms of fibromyalgia?
o Chronic widespread pain
Multiple sites, low back pain
Worse in cold and stress
o Morning stiffness
o Fatigue
o Poor concentration
o Low mood
o Sleep disturbances
o Numbness, tingling, cold/heat insensitivity, TMJ dysfunction
Investigations to perform in fibromyalgia?
o Normal – FBC, TFTs, CRP/ESR, RF, Anti-CCP, ANA
o Other tests all normal
Diagnosis made of fibromyalgia when?
o >3 months
o Widespread (left and right sides, above and below waist and axial skeleton) with no inflammation
o Pain on palpation (4kg/cm2)of at least 11/18 tender points (left and right):
Suboccipital muscle insertion
Anterior aspect of inter-transverse spaces at C5-7
Midpoint of upper border of trapezius
Origin of supraspinatus near medial border of scapular spine
Costochondral junction of 2nd rib
2cm distal from lateral humeral epicondyle
Upper outer quadrant of gluteal
Posterior to greater trochanter
Knee, at medial fat pad proximal to joint line