Neurology + Psychiatry Flashcards
Stroke management:
- 1st line (1)
- 2nd line (1)
- what to do with blood pressure?
- what else to give? (1)
- within 4.5 hr = THROMBOLYSIS
- within 6 hr = THROMBECTOMY
- BP should NOT be lowered in acute phase unless complications eg hypertensive encephalopathy or thombolysis
- give aspirin ASAP once haemorrhagic excluded
Stroke:
- what do do RE anticoagulation for AF? (1)
usually start 14 days post ischaemic stroke (and obviously stop in hemorrhagic)
what to do RE blood pressure and thrombolysis
lower to < 185/110
Absolute contraindications to thrombolysis?
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
Relative contraindications thrombolysis?
- Pregnancy
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
Stroke:
- who gets thrombolysis AND thrombectomy? (1)
within 6 hours of symptom onset
AND
occlusion of the proximal anterior circulation
Stroke:
- secondary prevention drug? (1)
- who gets carotid endarterectomy? (1)
clopidogrel (aspirin if contraindicated)
> 50% occasion
TIA mimics (2)
hypoglycaemia
intracranial haemorrhage (–> IMAGING)
TIA:
- medication for resolved TIA awaiting specialist review within 24hr (1) reviewed bt specialist within initial 21 days (1) and long term after the 21 days (1)
- what to give alongside? (1)
- aspirin first
- then DAPT first 21 days
- then clopidogrel after 21 days
clopidogrel (initial dose 300 mg followed by 75 mg od) + aspirin (initial dose 300 mg followed by 75 mg od for 21 days) followed by monotherapy with clopidogrel 75 mg od
if not appropriate for DAPT, just clopidogrel
give PPI
Stroke:
when to consider carotid artery endartectomy?
Carotid artery endarterectomy can be considered if there is a stroke or TIA in the carotid territory, and the patient is not severely disabled.
(if stenos >50%)
MS:
diagnosis?
MRI with contrast
MRI
high signal T2 lesions
periventricular plaques
Dawson fingers: often seen on FLAIR images - hyperintense lesions penpendicular to the corpus callosum
CSF
- oligoclonal bands (and not in serum)
increased intrathecal synthesis of IgG
Visual evoked potentials
- delayed, but well preserved waveform
Uhthoff’s phenomenon
Uhthoff’s phenomenon occurs when you get “Uhthoff” the bath.
(worsening of vision following rise in body temperature)
MS
- diagnosis?
2+ relapses (clinical objective or 2+ lesions)
Lhermitte’s syndrome
paraesthesiae in limbs on neck flexion
Epilepsy:
when yo start treatment after 1 seizure? (4)
the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable
Epilepsy treatment:
- generalised tonic clinic? men/women (2)
- focal seizure (2)
- absence (1)
- myoclonic (1)
- tonic/ atonic seizure (1)
- men: SV
- women: lamotrigine or levetiracetam (DUE TO PREGNANCY ISSUES of SV)
- lamotrigine or levetiracetam
- ethosuximide
- men: SV
- women: levetiracetam
- men: SV
- women: lamotrigine
antiplatelet regimens is recommended following an acute ischaemic stroke?
aspirin 300mg for 2 weeks then clopidogrel 75mg
Brocas dysphaisa:
- what is it? (1)
- what lobe? (1)
- how different to Wernickes? (1)
Broca’s dysphasia: speech non-fluent, comprehension normal, repetition impaired
FRONTAL lobe
Spoken word is heard at the ear. This passes to Wernicke’s area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca’s area. The Broca’s area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).
Conduction aphasia
Classically due to a stroke affecting the arcuate fasiculus - the connection between Wernicke’s and Broca’s area
Speech is fluent but repetition is poor. Aware of the errors they are making
Comprehension is normal
Herpes simplex encephalitis:
- which lobe? (1)
- features? (1)
- which organism? (1)
temporal lobe
fever, headache, psychiatric symptoms, seizures, vomiting
focal features e.g. aphasia
peripheral lesions (e.g. cold sores) have no relation to the presence of HSV encephalitis
HSV-1
Herpes simplex encephalitis:
- investigations? (4)
- management? (1)
CSF: lymphocytosis, elevated protein
PCR for HSV
CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients
MRI is better
EEG pattern: lateralised periodic discharges at 2 Hz
IV aciclovir
third nerve palsy signs
ptosis, down and out deviation of eye, mydriasis
Raised ICP causes herniation of which cranial nerve
3rd nerve
Horners syndrome
Miosis, ptosis, anhidrosis, and enophthalmos
neuropathic pain meds adjustment - how to do it
Drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added
first-line treatment*: amitriptyline, duloxetine, gabapentin or pregabalin
neuropathic pain- what is used as ‘rescue therapy’ for exacerbations?
tramadol
