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Year 3 > neurosciences > Flashcards

neurosciences Flashcards

1
Q

define multiple sclerosis

A

autoimmune disease (T cell attack) causing demyelination of neurones

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2
Q

causes of multiple sclerosis

A
  • genetic susceptibility + environmental trigger
  • idiopathic

risk factors:

  • genetics
  • smokin
  • EBV
  • female
  • vit D deficiency
  • obesity
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3
Q

presenting symptoms of multiple sclerosis

LOVDIP

A
  • optic neuritis MOST COMMON (unilateral loss of visual acuity, eye pain on movement, rapid central vision loss)
  • sensory (pins and needles, burning, numbness)
  • motor (stiffness, difficulty walking, spasms, heaviness)
  • psychological (depression, amnesia, psychosis )
  • autonomic (incontinence, urgency, impotence, hesitancy)
  • sexual (erectile dysfunction)
  • GI (swallowing difficulty)
  • Cerebellum (scanning speech fails, intention tremor)
  • Limb weakness, lethargy, Lhermitte’s sign (electroc shock when neck flexed)
  • Optic neuritis
  • Vertigo
  • Diplopia
  • Incontinence
  • Parathesia (numbness/tingling)
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4
Q

examination findings of MS

A
  • visual acuity test (loss of vision)
  • loss of coloured vision
  • visual field test (central scotoma - blind spot in normal vision if optic nerve affected)
  • relative afferent pupillary defect
  • Internuclear Ophthalmoplegia (lateral gaze causes failure of eye adduction)
  • sensory (loss)
  • motor (UMN lesion signs)
  • cerebellum (dysdiadokinesia, ataxic wide gait, scanning speech, limb ataxia)
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5
Q

investigations for MS

A
  • To diagnose Mcdonalds criteria
  1. no other alternative diagnosis
  2. dissemination in space lesions in different places
  3. dissemination in time - symptoms at different times
  • Lumbar puncture
  1. Microscopy (exclude infection/inflammation)
  2. CSF electrophoresis (find mismatched oligoclonal bands)
  • MRI brain, cervical/thoracic spines- hyperintense lesions perpendicular to corpus callosum. find brain lesions/ plaques
  • Evoked potentials (visual, auditory somatosensory potentials - show reduced conduction velocity)
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6
Q

Management of MS

A
  • MS relapses => high dose corticosteroids (oral methylprednisolone)
    1. MS symptoms
  • visual problems- resolve on own
  • fatigue- lifestyle changes +/- amantidine
  • mobility - physiotherapy
  • muscle spasms - baclofen/ physio
  • emotional - antidepressants/ CBT
  • sexual - viagra
  • bladder- see urologist
  • bowel - laxatives
  • speech/language - therapist + changing diet
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7
Q

Define myasthenia gravis

A

autoimmune disease affecting the neuromuscular junction causing skeletal muscle weakness

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8
Q

causes of myasthenia gravis

A
  • AUTOIMMUNE antibodies against nicotinic acetylchonine receptors => depleting post-synaptic receptors (most common type)
  • paraneoplastic (SCLC)
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9
Q

Presenting symptoms of myasthenia gravis

A

muscle weakness - gets worse with more use

  • ocular- diplopia, ptosis
  • bulbar- facial weakness, hypernasal speech, difficulty smiling/chewing/swallowing
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10
Q

Define bulbar associated symptoms

A
  • relating to medulla oblongata (affects bulbar muscles associated with cranial nerves with nuclei in medulla) CN X- XII
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11
Q

Examination signs of myasthenia gravis

A
  • eye (ptosis, eye muscle paralysis/weakness = opthalmoplegia, check for ocular fatigue)
  • put ice on eyes =>reduces ptosis
  • reading aloud => dysarthria-slurred speech/ nasal speech
  • Weakened power of limbs
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12
Q

What is the subtype of myasthenia gravis which has autoantibodies against pre-synaptic Ca2+ channel => less ACh release?

A

Lambert-Eaton

symptoms:

  • muscle weakness gets better after repeated use/ exercise
  • gait difficulty before eye signs
  • autonomic problems (constipation, dry eyes)
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13
Q

Investigations of myasthenia gravis

A
  • Bloods
    • autoantibodies -ACH receptor/MUSK antibody
    • Creatine kinase-exclude myopathies
  • Electromyography (measures muscle response/ electrical activity to nerve stimulation of muscle)
  • CT- exclude thymoma
  • CXR - lung malignancies
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14
Q

Management for myasthenia gravis

A
  1. avoid triggers (tiredness, stress, infection, medicines, surgery)
  2. Pyridostigmine (anti cholinesterase) - helps electrical signals travel between nerves and muscles v short acting + diarrhoea/bradycardia risk
  3. Steroids (prednisolone) or higher dose immunosuppressants
  4. Surgery - remove abnormally large thymus gland
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15
Q

Treatment for a myasthenia crisis (sudden severe breathing/ swallowing problems)

A
  • oxygen
  • ventilator
  • intravenous immunoglobulin therapy - to temporarily improve muscle strength
  • plasmapheresis -filters harmful antibodies from blood
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16
Q

Define Parkinson’s disease

A

degeneration of dopaminergic neurons between substantia nigra => striatum due to mitochondrial DNA dysfunction

*>80% neuron loss = symptomatic

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17
Q

Causes of Parkinson’s disease

A
  1. sporadic parkinson’s => unknown cause
  2. secondary causes
  • neuroleptic therapy for schizophrenia
  • repeated head trauma
  • post-encephalitis
  • Wilson’s
  • HIV
  • MPTP toxin from illegal drug contamination
  • familial genes
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18
Q

Presenting symptoms of Parkinson’s (TRAP BS)

A
  • INSIDIOUS ONSET
  • Tremor
  • Rigidity
  • Akinesia (difficulty initiating movement)
  • Postural instability (frequent falls)
  • BRADYKINESIA (slow + STIFF movements)
  • smaller handwriting (micrographia)
  • mental slowness (bradyphenia)
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19
Q

Non-motor symptoms of Parkinson’s

A
  • depression + dementia
  • dribbling saliva
  • frequency/ urgency
  • reduced smell
  • visual hallucinations
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20
Q

Examination signs of Parkinson’s

A
  • pill rolling tremor (4-5Hz) asymmetrical
  • lead pipe rigidity + increased tone
  • cogwheel rigidity (tremor worse on distraction)
  • gait - shuffling, stooped, less arm swing, freezing
  • FACE: frontalis overactivation-furrowed brows, hypomimic face, soft monotonous voice, drooling, synkineses (involuntary movement one side)
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21
Q

Investigations for Parkinson’s

A
  • symptoms improve after levodopa

Exclude other conditions

  • bloods- Wilson’s
  • CT/brain MRI- hydrocephalus (can cause gait decline)
  • SPECT scan
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22
Q

Management of Parkinson’s

A
  1. L-DOPA (levodopa) + peripheral DOPA decarboxylase inhibitor

*efficacy reduces over time so need higher doses or OTHER DRUGS

  • DA receptor agonists
  • Anti-cholinergics for tremor
  • COMT inhibitor
  • MAO-B inhibitor
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23
Q

Mechanism + side effects of L-DOPA

A
  • levodopa crosses blood brain barrier gets converted to dopamine by dopamine decarboxylase => dopamine => stimulates dopamine receptors.
  • SIDE EFFECTS: dyskinesia (involuntary movements), dystonia (involuntary muscle tightness) psychosis, visual hallucinations*
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24
Q

define encephalitis

A

inflammation of brain parenchyma

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25
Q

causes of encephalitis

A

VIRAL (common)

  • Herpes simplex virus
  • VZV
  • Mumps
  • adenovirus
  • Coxsackie
  • RBV
  • HIV

non-viral

  • syphillis
  • Staph. aureus
  • autoimmune
  • paraneoplastic
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26
Q

causes of enceophalitis in immunocompromised patients

A
  • toxoplasmosis
  • listeria
  • CMV
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27
Q

presenting symptoms of encephalitis

A
  1. infectious (headache, fever, vomiting, rash, cold sores, conjunctivitis)
  2. neurological symptoms (dysphagia, hemiplegia), behavioral changes (confusion)
  • seizure history
  • CHECK TRAVEL Hx
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28
Q

Signs of encephalitis on examination

A
  • reduce consciousness
  • deteriorating GCS
  • Seizures
  • pyrexia
  • raised ICP (cushing’s response =>hypertension/bradycardia/irreglar breathing
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29
Q

Investigations for encephalitis

A

Bloods

  • FBC (high WCC= viral cause)
  • U&E (encephalitis => SIADH)
  • glucose
  • viral serology
  • ABG
  • Toxoplasma IgM titre
  • Malaria film

CT/MRI

  • exclude lesion/ mass
  • HSV => oedema in temporal lobe

Lumbar puncture

  • high lymphocytes
  • high monocytes
  • high protein
  • glucose (normal/low)
  • viral PCR

Electroenceophalogram (assess seizures)

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30
Q

Management of encephalitis

A
  • resuscitate - ITU
  • IV antibiotics
  • mechanical ventilation
  • anticonvulsants/ antipyuretics/ anti-emetics
  • analgesia
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31
Q

Differences between meningitis and encephalitis

A
  • meningism symptoms: photophobia/ neck stiffness
  • seizures + cranial nerve palsy rare in meningitis
  • minimal altered mental state in meningitis
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32
Q

Define Wernicke’s encephalopathy

A

thiamine deficiency causing neurological symptoms due to biochemical lesions of the CNS (hypothalamus, brain stem, cerebellum)

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33
Q

Causes of wenicke’s encephalopathy

A
  • chronic alcohol consumption
  • malnutrition (low B1)
  • eating disorders
  • prolonged vomiting (in chemo)
  • GI malignancy
  • thyrotoxicosis
  • subdural haematoma
  • AIDS
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34
Q

Presenting symptoms of wernicke’s enceophalopathy

A
  • confusion
  • vision changes - diplopia, eye movement abnormalities, ptosis
  • loss of muscle coordination- unsteady gait
  • amnesia + inability to form new memories
  • hallucinations
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35
Q

Examination findings of wernicke’s encephalopathy

A
  • confusion
  • opthalmoplegia (nystagmus, lateral rectus palsies)
  • ataxia- wide abnormal gait
  • reduced reflexes
  • low temp, rapid pulse
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36
Q

Investigations for Wernicke’s encephalopathy

A

Bloods:

  • FBC (high MCV sign of alcoholics, WCC- infection => confusion)
  • finger prick glucose => confusion
  • U&Es (metabolic imbalances => confusion)
  • serum thiamine
  • LFTs
  • ABG - hypercapnia/hypoxia => confusion

Rarer:

  • CT/MRI of brain
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37
Q

Management of wernicke’s encephalopathy

A

High suspicion => resus with fluids, thiamine + magnesium + multivitamins

Low suspicion => thiamine + magnesium + folic acid

Long term: Continue with dietary thiamine

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38
Q

Define motor neuron disease

A
  • build up of ubiquitinated protein which cause progressive motor neuron degeneration => death to lateral corticospinal tract
  • also known as amyotrophic lateral sclerosis/ Lou gehrig’s

*associated with frontotemporal dementia

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39
Q

Subtypes of motor neuron disease

A
  • ALS (amytropic lateral sclerosis/ Lou-gehrigs)- LMN/UMN lesion signs
  • progressive muscle atrophy variant - LMN lesion signs
  • progressive Bulbar Palsy variant (affects CN IX-XI)=> dysarthria, dysphagia, wasted fasiculated tongue, brisk jaw jerk reflex
  • Primary lateral sclerosis- UMN lesion signs
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40
Q

Presenting symptoms of motor neuron disease

A
  • muscle weakness
  • swallowing difficulty
  • behavioural changes (disinhibition)
  • speech problems (slurred, reduced volume)
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41
Q

examination findings of motor neuron disease

A

UMN lesion signs

  • Babinki’s (toes curling up)
  • hypertonia
  • hyperreflexia
  • spastic weakness

LMN lesion signs

  • fasiculations
  • muscle wasting
  • hypotonia
  • hyporeflexia
  • flaccid weakness

*NO SENSORY LOSS

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42
Q

Investigations for motor neuron disease

A

Bloods

  • FBC
  • raised ESR
  • raised CK
  • anti-GMI ganglioside antibodies

Other

  • EMG - electrical activity produced by muscles
  • Nerve conduction study- usually normal
  • CT/MRI- spinal chord compression/ brainstem lesions
  • Lumbar puncture - exclude infection/ meningitis
  • spirometry - assess resp muscle depression
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43
Q

Management of motor neuron disease

A

Riluzole (blocks glutamate release as XS injures nerve cells) + monitor FBC/LFTs (hepatotoxic drug)

Treat other symptoms:

  • muscle weakness- physiotherapy
  • resp depression- non-invasive positive pressure ventilation
  • depression- anti-depressants
  • dysphagia - diet change / percutaneous endoscopic gastrostomy
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44
Q

Define Bell’s palsy

A

gradual unilateral peripheral facial nerve palsy (weakness, paralysis) affecting all facial zones equally

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45
Q

Causes of bell’s palsy

A

UNKNOWN

swelling/inflammation of facial nerve on one side due to viral infection

  • HSV-1
  • herpes zoster virus
  • Epstein-barr
  • coxsacchie virus (foot-mouth disease)
  • adenovirus
  • flu
  • rubella
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46
Q

Presenting symptoms of bell’s palsy

A
  • rapid onset of unilateral mild facial weakness to total paralysis
  • facial droop + can’t make facial expressions (no smile)
  • dry eye- due to loss of blink function
  • pain behind jaw + ear on affected side
  • change in hearing sensitivity on one side
  • drooling
  • loss of taste
  • headaches
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47
Q

Differentials for bell’s palsy

A

bilateral weakness => lyme disease, Guillan-Barre, sarcoidosis, leukaemia

chronic recurrence =>

fever, rashes => lyme disease, autoimmune

Benign facial nerve schwannoma

trauma to temporal bone

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48
Q

Investigations for bell’s palsy

A

mainly CLINICAL don’t need investigation/tests

  • Bloods (WCC - exclude infection)
  • evoked electromyography + needle electromyography (no motor unit potentials)
  • serum borrelia burgdorferi (check for Lyme-disease parasite)
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49
Q

Management for bell’s palsy

A
  1. reassure patient
  2. eye-protection (glasses/ artificial tears to stop development of keratopathy)
  3. corticosteroids (prednisilone) if more than >72hrs => reduce inflammation
  4. soft foods if difficulty chewing

For severe:

  1. anti-virals (valociclovir/ aciclovir)
  2. surgical decompression
  3. refer to secondary care (>3 weeks symptoms, atypical findings, changes in vision)
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50
Q

What is meningitis?

A

inflammation of meninges (pia/arachnoid mater) usually due to infection.

=> causes cerebral oedema which increases intracranial pressure => herniation/ reduces cerbral perfusion

Types of meningitis

  • bacterial meningitis
  • meningicoccal disease (specifically nisseiria meningitis bacteria)
  • meningococcal septicemia
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51
Q

causes of meningitis (bacterial/ viral/ fungal)

A

bacterial:

  • neonates (E.coli, listeria monocytognes, group B streptococci),
  • childen/ adult (nisseiria meningitis, streptococcus pneumoniae, haemophilius influenza)
  • elderly (streptococcus pneumonia, listeria monocytognes)
    viral: enterovirus, Herpes Simplex Virus, mumps, Varicella roster virus, HIV
    fungal: cryptococcus (common in HIV patients)
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52
Q

risk factors for meningitis

A
  • >5 years or >60
  • immunocompromised (HIV)
  • immunosupressed
  • sinuitis
  • basal skull fratures
  • splenectomy
  • alcoholoism
  • sickle cell
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53
Q

presenting symptoms of meningitis

A

non-specific signs:

  • sudden fever
  • sudden headache
  • leg pain
  • cold hands/feet
  • abnormal skin

later:

  • MENINGISM (stiff neck, photophobia)
  • vomiting
  • reduced consiousness
  • altered mental state
  • petechial - NON-BLANCHING RASH

specific:

  • bacterial meningitis - photophobia, Kernig’s sign (flex knee to right angle and striaghten leg=> flex meninges => PAIN), Brudinski’s sign
  • meningococcal disease - non-blanching rash
  • septiciemia - mottled skin, cold hands/feet, hypotension, shock, reduced capillary refill
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54
Q

examination findings for meningitis

A
  • photophobia
  • neck stiffness
  • kernigs sign (knee can’t extend when hip is flexed) -bacterial meningitis
  • brudzinski’s sign (flexion of hip when knee is flexed)- bacterial meningitis
  • infection signs (hypotension/ pyrexia/ tachycardia/ altered mental state/ non-blanching rash)
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55
Q

what symptoms do babies/children present with for meningitis

A
  • commonly non-specific symptoms of infection (fever/ vomiting/ upper respiratory tract)
  • high pitched crying
  • hypotension
  • irritability
  • poor feeding
  • seizures (sign of bacterial meningitis)
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56
Q

management for meningitis

A
  1. Immediate:
  • if in GP / paramedic setting => IM/IV benzylpenicillin ASAP (UNLESS PENICILLIN ALLERGY) *infant =300mg, child=600mg adult =1,200mg
  • non-blanching rash/sepsis => antibiotics first then transfer
  • TRANSFER TO SECONDARY CARE (999/112)

IV fluids + ABs (cefotaxime). if >55- add ampicillin for listeria

  1. if no raised ICP => do Lumbar puncture
  2. IV dexamethosone (if lumbar puncture shows bacterial meningitis)
  3. Continue monitoring in ITU + adjust ABs for organism( cefotaxime)
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57
Q

investigations for meningitis in hospital setting

A
  1. Bloods:
  • FBC (if low WCC = immunocompromised NEED HELP)
  • LFT
  • U&E
  • coagulation screen (PT)- can develop clotting disorders (DIC)
  • glucose
  • blood PCR (EDTA sample - check for N. meningitidis)
  1. imaging - CT to exclude mass lesion + raised intracranial pressure
  2. Lumbar puncture - check CSF for MC&S (microscopy, culture& sensitivity), gram stain, glucose, protein, virology, lactate
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58
Q

When can a lumbar puncture be done before CT for suspected meningitis?

A
  • if GCS 15 + no focal symptoms + no symptoms of raised intracranial pressure
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59
Q

lumbar puncture results for

  1. bacterial meningitis
  2. viral meningitis
  3. TB meningitis
A
  1. Bacterial=> cloudy/turbid CSF, high neutrophils, v. high protein, low glucose, high pressure
  2. Viral=> clear CSF, high lymphocytes, high protein, normal glucose
  3. TB/ fungal => fibrinous CSF, high lymphocytes, high protein, low gluocse
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60
Q

prognosis for meningitis

A
  • bacterial meningitis + septicemia => 10-40% mortality
  • viral meningitis => self-limiting
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61
Q

define stroke

A

rapidly developing focal disturbance of vascular origin lasting >24hrs

*sudden brain cell death due to artery rupture or blockage

  1. ischaemic
  2. haemorrgaic -increased blood displaces brain tissue => oedema/swelling/irritation of brain
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62
Q

types + causes of stroke

A
  • ischaemic - vessel stenosis/occlusion
  1. thrombus (dehydration, thrombophillia)- lacunar infarcts, middle cerebral infarcts
  2. embolism (from carotid artery dissection/ AF)
  3. hypoptension
  4. vasculitis
  5. cocaine (arterial spasm)
  • haemorraigic (20%)- vessel rupture => subarachnoid haemorrhage
  1. hypertension
  2. microaneurysm in brain vessels rupture (Berry, atriovenous malformations)
  3. haemorragic necrosis (tumour/infection)
  4. venous outflow obstruction (central venous thrombosis- oedema=> bleed in brain)
  5. trauma
  6. altered homeostasis (on anticoags - worsen ruptured vessels)
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63
Q

risk factors for stroke

A
  • age >55
  • FHx of stroke
  • hypertension
  • smoking
  • diabetes
  • previous TIA/ stroke
  • Atrial fibrillation
  • Carotid artery stenosis
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64
Q

presenting symptoms of stroke (Hx)

A
  • SUDDEN ONSET
  • unilateral weakness (facial/arm)
  • dysphasia (difficulty speaking) , dysarthia (slurred speech)
  • ataxia/ impaired coordination (more in problems with posterior circulation)
  • visual distubrance -loss of sight in one eye (carotid artery stenosis)
  • impaired consciousness + not confused
  • sensory loss
  • headache (differentials migraines/subarachnoid haemorrhage)

PMHx - AF/MI/ valvular problems/ carotid artery stenosis/ head/neck trauma

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5
Perfectly
65
Q

Examination findings of stroke

A

Anterior cerebral

  • weakness
  • confusion/ change in behaviour

Middle cerebral (classic stroke)- FAST

  • contralateral facial/ limb weakness
  • contralateral sensory loss
  • apraxia
  • neglect (parietal lobe)
  • dysphasia (left side affected)

Posterior circulation

  • homonymous hemianopia, visual agnosia
  • Horner’s
  • head/neck pain
  • vertigo
66
Q

Investigations for stroke

A

Bedside:

  • Bp/HR- check for AF
  • ECG- check for arrhytmias
  • blood glucose

Bloods

  • FBC (exclude anaemia/ thrombocytopenia)
  • U&Es (exclude renal failure - contraindicate treatment)
  • clotting screen (check for thrombophillia)
  • troponin (exclude MI)

Imaging:

  • CT head (haemorrhage)
  • Echocardiogram
  • Carotid Duplex US scan - internal carotid artery stenosis (TIA)
  • MRI head
  • CT cerebral angiogram (angiography)
67
Q

Management of stroke

A

Suspected stroke

  • ABC (oxygen only if hypoxic + refer to stroke unit)

Confirmed stroke (<4.5hrs)

  • Supportive care + monitoring (GCS/oxygen/ swallowing assessment/seizures=> paracetomol/ hydration)
  • Altepase (tissue plasminogen activator) THROMBOLYSIS
  • CONSIDER SURGERY: endovascular thrombectomy (scoop out clot)/ >50% stenosis => carotid artery endarterectomy- remove plaque from carotid artery)
  • anti-platelet therapy (ASPIRIN 300mg)
  • VTE prophylaxis
  • high intensity statin

Lifestyle - optimise CVD risk factors

68
Q

Complications of stroke

A
  • Aspiration pneumonia
  • Cerebral oedema (Rasied ICP)
  • Immobility
  • Infection
  • DVT
  • CVD problems
  • DEATH
69
Q

define transient ischemic attack (TIA)

A

focal neurological disturbances that affect brain function with vascualr origin that resolve within 24hrs

70
Q

risk factors for TIA

A
  • smoking
  • hypertension
  • diabetes
  • Heart disease (AF/ valvular problems)
  • hyperlipidemia
71
Q

presenting symptoms of TIA

A

SUDDEN ONSET + brief lasting (<24hrs)

carotid

  • unilateral weakness
  • dysphasia
  • sudden visual disturbance (loss of vision in one eye)-carotid artery stenosis

vertebrobasilar region

  • ataxia, vertigo, impaired coordination
  • homonymous heminaopia
  • diplopia
72
Q

Examination findings of TIA

A
  • neurological exam may be normal if TIA resolved
  • auscultate carotids (bruits)- cartodi artery stenosis
  • pulse- irregularly ireegular = AF
73
Q

investigations for TIA

A

Bedside:

  • ECG (AF)
  • blood glucose (exclude hypoglycaemia)

Bloods

  • FBC (exclude infection)
  • U&Es
  • clotting screen - PT/INR/thromboplastin time (exclude coagulopathy for anti-platelet treatment)
  • Troponins (exclude MI)
  • lipid profile (hyperlipidemia)

Imaging

  • CT head (+/- haemorrhage)
  • Doppler ultrasound of carotid (check for stenosis/ embolism)
    *
74
Q

Management of TIA

A

Suspected => 300mg ASPIRIN + then reassess

Confirmed TIA

  • 300mg loading dose of Clopidogrel (anti-platelet)
  • 50mg Atorvastatin -High intensity Statin

=> followed by

  • anti-hypertensives
  • anti-platelets
  • statins
  • warfarin (if cardiac emboli)
  • >50%stenosis => SURGERY - carotid endarterectomy (remove plaque from carotid artery)
  • Assess for future stroke risk (ABCDE2 score)
75
Q

Complications + prognosis of TIA

A
  • recurrence
  • stroke (very high risk within first month after TIA)
76
Q

define trigeminal neuralgia

A

RARE severe unilateral facial pain caused by >1 trigeminal nerve branch irritaiton/damage

  • trigeminal nerve branches = opthalmic (S), maxillary (S), mandibular (M+S)
77
Q

epidemiology of trigeminal neuralgia

A
  • females (2:1)
  • 50-60
78
Q

causes of trigeminal neuralgia

A

primary

  • compression of trigeminal nerve branches due to vascular aberrant loop artery/vein

secondary

  • compression due to intracranial vessel aneurysm
  • compression due to tumour
  • MS
  • Shingles (Varicella-Zoster virus)
  • skull base malformation
79
Q

presenting symptoms of trigeminal neuralgia

A
  • S: unilateral facial pain
  • O: sudden
  • C: burning, shock-like
  • R: distribution of trigeminal branches
  • A: numbness, tingling, depression, weight loss
  • T: lasts seconds to minutes, episodic
  • E: light skin touch-shaving,vibration dental work, exposure to wind, talking, eating
  • S: severe
80
Q

investigations for trigeminal neuralgia

A
  • MRI brain (exclude secondary causes- MS/ tumours)
81
Q

management for trigeminal neuralgia

A
  • carbamazepine (anti-epileptic- reduces electrical activity of brain)
  • assess depression - PHQ-9 depression questionnaire
  • red flag signs refer to neurologist
82
Q

complications of trigeminal neuralgia

A
  • depression
  • weight loss
83
Q

define subarachnoid haemorrhage

A

haemorrhage in subarachnoid space (between arachnoid mater and pia mater)

84
Q

causes of subarachnoid haemorrhage

A
  • Berry aneurysm rupture (at base of skull)- 85%
  • vertebral artery dissection
  • arteriovenous malformations
  • UNKNOWN
85
Q

risk factors for subarachnoid haemorrhage

A
  • older age
  • hypertension
  • smoking
  • alcohol
  • bleeding disorders
  • geentic connective tissue disorders associated with aneurysm formation:Marfan’s/Erhlers Danos/SLE, coarctation of aorta, Polycystic kidney disease
  • acute cocaine use
86
Q

presenting symptoms of subarachnoid haemorrhage

A
  • SUDDEN onset thunderclap headache (usually occipital)
  • nausea/vomiting
  • collapse
  • neck stiffness
  • photophobia
  • reduced consciousness
  • seizures
87
Q

examination findings of subarachnoid haemorrhage

A
  • signs of meningism (photophobia, neck stiffness, kernig’s sign, pyrexia)
  • signs of raised ICP (papilloedema, headache, crainial nerve III/IV palsy)
  • calculate Glasgow Coma Scale
88
Q

investigations for subarachnoid haemorrhage

A
  • CT scan (light grey hyperdense areas) DIAGNOSTIC
  • Bloods: FBC, U&Es, CRP/ESR, clotting screen
  • angiography to detect location of bleeding
  • Lumbar puncture (if CT scan -ve and no contraindications)- check CSF for increased RBC (blood)
89
Q

Management of subarachnoid haemorrhage

A

GCS <8

  • Cariopulmonary support - protect airway, oxygen, saline
  • give nimodipine (CCB)- prevent delayed cerebral ischaemia
  • give anti-convulsants
  • stop anticoagulants

GCS >9

  • Refer to neurosurgeon ASAP
90
Q

define subdural haemorrhage

A

haemorrhage (collection of blood) in subdural space (between dura mater and arachnoid mater)

VENOUS BLEED- usually affects cerebral bridging veins

  • acute: 3 days- younger ppl after trauma
  • sub-acute: <3weeks
  • chronic: >3 weeks - most common elderly
91
Q

causes + risk factors of subdural haemorrhage

A
  • TRAUMA

risk factors:

  • falls (epileptics/alcoholics)
  • low ICP
  • elderly- brain atrophy so weak cerebral bridging veins
  • anticoagulation- increased bleeding risk
92
Q

presenting symptoms of subdural haemorrhage

A

Acute

  • Hx of major trauma
  • reduced consciousness

Sub-acute

  • worsening headache 7-14 days later
  • altered mental state

Chronic

  • headaches
  • seizures
  • sleepiness
  • confusion
  • gait deterioration
  • cognitive impairment
93
Q

examination findings of subdural haemorrhage

A

Acute

  • ipsilateral fixed dilated pupils
  • reduced consciousness
  • pressure on brainstem => bradycardia

Chronic

  • could have normal neuro exam
  • focal neurological signs (cranial nerve palsy)
94
Q

investigations for subdural haemorrhage

A
  • CT head - cresecent shaped blood collection in one hemisphere +/- midline shift
  • MRI brain- more sensitive
95
Q

management for subdural haemorrhage

A

mild

  • monitoring+ imaging
  • anti-epileptics (levetiracetam)
  • stop anticoagulation
  • lower ICP- raised head to 30

severe/neurological dysfunction/ expanding

  • craniotomy (temporary flap, remove haemotoma, suction)
96
Q

complications of subdural haemorrhage

A
  • raised ICP
  • cerebral odema
  • herniation
  • post op- seizures, reoccurance, meningism
97
Q

prognosis of subdural haemorrhage

A
  • acute- higher risk of brain injury => affect brain function
  • chronic - lower risk of brain injury/ better outcome than acute
98
Q

define epilepsy

A
  • >2 unprovoked seizures >24hrs apart
  • 1 unprovoked seizure and risk of recurrence
  • epilepsy syndrome
99
Q

risk factors for epilepsy

A
  • premature birth
  • cormorbidities - stroke/ cerebrovascular disease
  • dementia
  • FHx
  • trauma
  • infection - TB/Zika virus
100
Q

types of seizures

A
  • tonic=> abrupt,short lived general muscle stiffness + quick recovery
  • tonic-clonic => stiffness followed by rhythmic jerking movements, tongue biting, urinary incontinence (leaking)
  • absence => no movements
  • atonic => loss of muscle tone
  • myoclonic => brief involuntary SHOCK LIKE single/multiple jerks
101
Q

Hx of epilepsy in adults

A

HPC: what happened before, during and after seizure (patient/eye-witness)

  • before - aura (focal seizure)
  • during - seizure + other features (tongue biting, jerking, stiffness), how long did it last, onset
  • after - drowsiness, confusion, headache

Social history: (triggers)

  • stress
  • alcohol
  • sleep deprivation
  • light sensitivity

FHx - epilepsy

PMHx- stroke, dementia, genetic conditions

102
Q

investigations for epilepsy

A

EEG: if clinical Hx suggests seizure is likely to be epileptic

  • supportive investigation, do not use to exclude
  • perform after 2nd seizure, 1st if evaluated by specialist
  • DO NOT perform in case of probably syncope (false positive result possible)

neuroimaging: identify structural abnormalities

  • MRI
  • CT if MRI unavailable or contraindicated, if general anaesthetic/sedation required for MRI

if diagnosis cannot be clearly established => refer to tertiary epilepsy specialist

103
Q

management of epilepsy

A
  • during seizure:move objects around person, remove glasses, cushion
  • after seizure: protect airway, recovery position

if prolonged > 5mins/ reoccurance=> buccal midazolam

  • refer to specialist
  • caution: for jobs, driving, swimming, medication, birth control

Long term:

  • anti-epileptic drugs (carbamazepine, sodium valproate, phenytoin, phenobarbitan)- risks of osteoporosis/ risky pregnancy
104
Q

Define Sepsis

A

life-threatening condition caused by dysregulated immune response to an infection. Hypotension, reduced perfusion and tissue toxicity => END-ORGAN failure

105
Q

define essential tremor

106
Q

causes of essential tremors

A
  • age
  • genetics
107
Q

features of an essential tremor

A
  • gradual onset starting in one hand => both
  • worsened by movement (usually when using hands -drinking tea)
  • worsened by stress, caffeine, extreme temperature
108
Q

differences in tremors between essential tremors and Parkinson’s

A
  • timing of tremors: gradual, moving hands / hands at rest
  • associated symptoms: ataxia (gait disturbance)/ TRAP
  • parts of body affected: mainly hands/ hands, legs, chin
109
Q

investigations for essential tremor

A

Bloods:

  • U&Es
  • TFTs
  • drug screen
110
Q

Management for essential tremors

A
  1. mild = no treatment
  2. severe/affects daily activities
  • beta-blockers (propanolol)- treat tremors not for asthma/heart problems=> fatigue, lightheadedness
  • anti-epileptics (sodium valproate)
  • tranquilisers - if anxiety worsens tremors
  1. Severe/ disabling - deep brain stimulation
111
Q

define radicuolopathy

A

limited/blocked conduction along a spinal nerve and it’s roots due to a pinced nerve

112
Q

causes of radiculopathy

A
  • trauma => herniated disc
  • wear and tear - OSTEOARTHRITIS
  • compression fractures
  • spinal stenosis
  • sciatica
  • degenerative disc disease
  • CAUDA EQUINA (rare EMERGENCY)
113
Q

risk factors for radiculopathy

A
  • ageing
  • obesity
  • poor posture
  • poor lifting techniques
  • FHx of degenerative bone diseases
114
Q

types of radiculopathy

A
  • cervical radiculopathy- neck
  • thoracic radiculopathy- upper back
  • lumbar radiculopathy (MOST COMMON) - lower back
115
Q

presenting symptoms of cervical radiculopathy

A
  • neck/ shoulder/arm pain (in a dermatomal pattern)
  • pain can wake them up at night
  • sensory loss- numbness, tingling
  • motor loss - weakness in upper extremeties
116
Q

presenting symptoms for thoracic radiculopathy

A
  • shooting pains in ribs/side/abdomen
  • numbness + weakness
117
Q

presenting symptoms of lumbar radiculopathy (sciatica)

A
  • sharp lower back pain => foot
  • pain worse on sitting/ coughing
  • leg numbness
  • leg weakness
  • +/- bowel incontinence (if nerves compressed)
118
Q

RED flags for radiculopathy

A
  • fever, lymphadenopathy (infection)
  • neck stiffness/ photophobia/ nausea (meningitis)
  • major trauma/ recent neck surgery
  • unexplained weight loss, changes to appetitie (malignancy)
  • incontinence / saddle anaesthesia (cauda equina)
  • visual loss

Examination

  • L’hermittes sign - shock pain on neck flexion (MS)
  • Hoffman’s sign
  • Babinski’s (UMN lesion)
119
Q

examination findings of cervical radiculopathy

  • UL neuro exam (depends on nerve root affected)
A
  1. Restricted neck movement
  2. Postural assymetry - neck leaned on one side
  3. UL neuro exam
  • T-
  • P- reduced muscle power
  • R- reduced reflexes (tricep/bicep/suprinator)
  • S-reduced sensation

Special tests:

  • spurling test (checks dural involvment)

*C7 most common - reduced power: elbow +finger extension, wrist flexion, reduced tricep reflex, reduced sensation in middle finger

120
Q

investigations for radiculopathy

A
  • X-ray
  • MRI/CT- disc herniation/ disc degeneration
  • Electromyography - check nerve function
121
Q

management of radiculopathy

A

cervical- usually conservative and won’t need surgery

  • NSAIDs (naproxen, aspirin)
  • corticosteroids
  • analgesia
  • soft cervical collar
  • physio
122
Q

define Migraine

A

classic - episodic unilateral throbbing headache with aura

common - episodic unilateral throbbing headache without aura

variant - familalplegic, opthalmoplegic

123
Q

presenting symptoms of migraine

A
  • throbbing unilateral headache- lasting 4-72hrs (episodic)
  • accompanied by visual/ other aura’s (flashing lights, spots, blurring, blindspot, zig-zag lines, tingling limbs)
  • nausea, vomiting, photophobia
124
Q

causes of migraines

A
  • stress
  • lack of sleep
  • exercise
  • OCP
  • food (caffeine, alcohol, chocolate)
125
Q

investigations for migraines

A
  • Bloods (exclude infection)
  • CT/MRI of brain- exclude tumours
  • Lumbar puncture- exclude meningitis
126
Q

Management for migraines

A

acute:

  • sumatriptan
  • NSAIDs (diclofenac) + metaclopramide (anti-emetic)
  • analgesia (but overuse => migraines)
  • go to a dark room
127
Q

Prophylaxis of migraines

A
  • 1st line= Beta blocker (propanalol)
  • 2nd line= amitriptyline
  • topiramate
  • avoid triggers
  • for menstrual headaches => take OCP (careful)
128
Q

define tension headache

A
  • most common “everyday” headache
  • most common in females/young adults
  • episodic - <15 days/month
  • chronic- >15days/month
129
Q

presenting symptoms of tension headaches

A
  • S: bilateral pain
  • O:gradual onset
  • C: pressure/tightness around forehead, non-pulsatile
  • A:+/- scalp tenderness/ photophobia
  • T:
  • E: stress, better with analgesia
  • S: mild/moderate severity
130
Q

Common triggers for tension headaches

A
  • stress/anxiety
  • dehydration
  • bringht sunlight
  • loud noise
  • missing meals
  • medication (opioids)
  • squinting
  • poor posture
131
Q

management for tension headaches

A
  • reassure patient
  • identify + avoid triggers
  • avoid headache inducing medication (opioids)
  • take painkillers (aspirin, paracetomol, ibuprofen)
  • physio for neck stiffness

Reccurrent headaches - consider tricyclic antidepressants

prophylaxis: Amitriptyline

132
Q

define raised ICP

A

raised intercranial pressure due to mass/oedema/obstruction to fluid outflow

normal ICP = <15mmHg

133
Q

causes of raised ICP

A

Space-occupying lesion (SOL)

  • tumour
  • brain abscess/ cyst
  • haemtoma/ haemorrhage

Cerebral oedema

  • infection- meningitis, encephalitis
  • head injury
  • SAH
  • Reye’s (RARE brain swelling)

Increased blood pressure in CNS

  • vasodilator drugs
  • malignant hypertension
  • SVC obstruction

Hydrocephelous- Increased CSF production

Obstructed venous sinus/central venous thrombosis- poor drainage

134
Q

presenting symptoms of raised ICP

A
  • headache - worse with coughing/ leaning forwards/ in morning
  • vomiting/ nausea (first thing in mornig/ laying down at night)
  • blurred vision/ double vision (papiloedema)
  • changes to mental state- lethargy, irritability
  • visual changes - unilateral ptosis, III/IV cranial nerve palsies later => opthalmoplegia
  • motor changes (later) - hemiparesis, raised bp
135
Q

Emergency presentations of raised ICP

A
  • Head injury => bleeding =expanding haemtoma = rapid raised ICP
  • Syncope/meningism +abrupt headache = ruptured cerebral aneurysm
  • focal symptoms + seizure
  • talk and deteriorate = intracranial haemtoma
136
Q

examination findings of raised ICP

A
  • altered GCS
  • Cushing’s reflex, a paradoxical bradycardia and raised blood pressure, often with irregular breathing
  • reduced visual acuity
  • peripheral visual field loss

fundoscopy - PAPILLOEDEMA

  • blurred optic disc margin,
  • hyperemia
  • haemorrhages
  • vascular congestion
137
Q

investigations of raised ICP

A

Bloods:

  • FBC- infection
  • U&E,
  • LFTs
  • glucose
  • serum osmolality
  • clotting
  • blood culture

Imaging:

  • CT head /MRI of brain
  • CXR- chest infection => asbcess
138
Q

management of raised ICP

A
  • avoid fevers
  • manage seizures with anticonvulsants (sodium calproate, carbamazapine)
  1. analgesia (morphine) + sedation (propofol)
  2. NMJ blockers
  • CSF drainage
  • raise head of bed - lowers jugulr venous outflow + lowers ICP

other:

  • hyperventilation- lower ICP due to hypocapnoeic vasconsrtiction
  • Mannitol (diuretic)- reduce brain/eye swelling
139
Q

complications of untreated raised ICP

A
  • brain damage
  • stroke
  • coma
  • epilepsy
  • death
140
Q

define brain abscess

A

pus-swelling in the brain usuqally after infection/head injury

141
Q

causes of brain abscess

A
  • infection of skull- otitis media, sinusitis, mastoiditis, dental abscess
  • infection of body=> travelled to brain (common in weakened immune system- chemo/HIV): pneumonia, peritonitis, cystitis, endocarditis
  • infection after head injury
142
Q

symptoms of brain abscess

A
  • severe headache (one part of the head) not relieved by painkillers
  • fever
  • changes to mental state (irritation, confusion)
  • nerve damage - unilateral muscle weakness, slurred speech, paralysis
  • seizures
  • nausea, stiff neck (meningism symptoms)
  • abscess can compress optic nerve => blurry vision, double vision
143
Q

Investigations for brain abscess

A
  • Bloods- FBC (check for infection)
  • Imaging- CT/ MRI head

Other:

  • CT guided aspiration to analyse pus
144
Q

Management for brain abscess

A
  • medication: antibiotics/ antifungals
  • surgery (>2mm abscess)
  1. simple drainage
  2. craniotomy (open skull and remove abscess)
145
Q

complications of brain abscess

A
  • raised ICP => brain injury, seizure, coma, stroke, or death.
  • reoccurance- common in weakned immune system/ cyanotic heart disease
  • epilepsy
  • meningitis
  • brain damage
146
Q

define spinal chord compression

A

injury to the spinal chord => causing neurological symptoms depending on site of lesion

147
Q

causes of spinal chord compression

A
  • trauma (16-30)
  • vertebral disc disease (30-50)
  • tumours (metastasis from breast/lung/kdney) - (45-75 elderly)
  • spinal abscess
  • TB
  • haematoma (wafarin)
  • multiple myeloma
148
Q

symptoms of spinal chord compression

A
  • Hx of trauma/ malignancy
  • back pain
  • weakness
  • numbness
  • distubed bowel/bladder function
149
Q

Signs of spinal chord compression

A
  • diaphragamtic breathing
  • reduced anal tne
  • priapism (painful erections)
  • spinal shock (low bp without tachycardia)
  • sensory loss at level of lesion
  • weakness/ paralysis
  1. LMN signs at level of lesion (hypotonia, hyporeflexia)
  2. UMN signs below lesion (hypertonia, hypereflexia)
150
Q

Red flag symptoms that indicate cauda equina syndrome

A
  • back pain + sciatica type pain down legs
  • weakness + numbness in legs
  • saddle anaesthesia
  • urinary/bowel incontinence
  • reduced anal sphincter tone
151
Q

Red flag symptoms for conus medullaris syndrome

A
  • Mixed UMN/LMN leg weakness
  • early urinary retention and incontenence
152
Q

Investigations for spinal chord compression

A

Imaging:

  • MRI of spine
  • X-ray of spine (TRAUMA, fractures, alignment)
  • CXR for primary lung malignancy, TB

Bloods:

  • FBC (infection)
  • U&Es
  • Ca2+
  • ESR
  • immunoglobulin
  • electrophoresis (for multiple meloma)

Other:

  • urine analysis (Bence Jones proteins- multiple myeloma)
153
Q

Risk factors for spinal chord compression

A
  • trauma
  • malignancy
  • osteoporosis
  • high risk occupation- construction/agricultural workers => trauma/disc herniation
  • high risk recreational activities - racing, diving, gymnastics
  • metabolic bone disease
  • vertebral disc disease
154
Q

management for spinal chord compression

A
  • immobilise + stabilise
  • corticosteroids
  • supportive treatment for surgery: VTE prophylaxis, maintain bp + volume

treat cause:

  • malignancy => corticosteroids + surgery/radiotherapy
  • infection/abscess => antibiotics
155
Q

define peripheral nerve disease

A

damage to peripheral nerves which affects communication between the brain and other body parts. Can impair movement, sensation and can cause pain.

156
Q

types of peripheral nerve disease

A

mononeuropathy

  • carpal tunnel syndrome- overuse injury => numbness, tingling pain in 1/2/3rd digits
  • ulnar nerve palsy- numbness in 4/5th digits
  • radial nerve palsy- fractures of humerus
  • peroneal nerve palsy - compressed nerve at top of calf => foot drop

polyneuropathy

  • diabetic neuropathy
  • guillan-barre syndrome (rare)- autoimmune disease attacks nerves as they leave spinal chord
158
Q

causes of peripheral neuropathy

A

acquired:

  • injury
  • medical conditions: diabetes, Guillan- Barre
  • rare inherited diseases
  • alcoholism
  • poor nutrition/ vitamin deficiency
  • cancers
  • autoimmune- lupus, RA, Sjoren’s syndrome
  • medications
  • kidney/thyroid disease
  • infections

hereditary

idiopathic

159
Q

Symptoms of polyneuropathy

A
  • tingling
  • numbness
  • loss of sensation in arms and legs- burn themselves, open sores
  • burning sensation in hands and feet
  • +/- bladder/bowel incontinence
  • +/-sexual dysfunction
160
Q

Symptoms of Guillan-Barre

A
  • weakness and tingling that eventually may spread upward into the arms
  • Blood pressure problems
  • heart rhythm problems
  • breathing difficulty may occur in the more severe cases
161
Q

investigations for peripheral neuropathy

A
  • Electromyography- reduced muscle activity can indicate nerve injury
  • Nerve conduction studies
  • MRI
162
Q

management of peripheral nerve injuries

A
  • mostly self-resolving
  • if it doesn’t heal => surgery, restore function with electrical stimulator

Year 3 (27 decks)

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