Neurosurgery/Neurology Flashcards
ICP cushings triad
Widened pulse pressure
Bradycardia
Irregular breathing
Raised ICP treatment
IV mannitol
Controlled hyperventilation
Head elevation
Unilateral dilated pupil and no light response in raised ICP
CN III compression may secondary herniation
Unilateral dilated pupil and exagerated light response in raised ICP
Optic nerve injury
CT scan immedietely when
GCS <13 initially or <15 after 2 hours
2 or more episodes vomiting
Skull fracture
Neurological deficit
CT scan within 8h
Age >65
Clotting disorders
Dangerous mechanism
Linked to SAH
Intracranial aneurysm - APKD
Diagnose SAH
1) CT head
2) LP after 12 hours - xanthochromia
SAH treatment
Coil by interventional radiologist
Nimodepine - prevent vasospasm
Subdural haemorrhage identify
High impact trauma
Fluctuating consciousness
Acute v chronic bleed CT
Acute - hyperdense
Chronic - hypodense, often subdural
Vessels in subdural bleed
Bridging veins
Vessels in extradural bleed
Middle meningeal artery
Identify extradural bleed
Low impact trauma, often young
Loses, regains then loses consciousness again (lucid interval)
Diagnose hydrocephalus
CT head
Treatment hydrocephalus
Acute - external ventricle drain
Long term - ventriculoperitoneal shunt
Triad of normal pressure hydrocephalus
Elderly:
- urinary incontinence
- dementia
- gait abnormality
Most common metastasis to brain
Lung cancer
Brain tumour worst prognosis
Astrocytoma (glioblastoma multiforme
Types of focal seizure
Focal aware
Focal impaired
Always starts specific region brain
Types of generalised seizure
Tonic clonic (grand mal) Tonic Clonic Typical absence (petit mal) Atonic
Starts both sides brain, always unconscious
Diagnose epilepsy
After first seizure:
- EEG
- MRI
Treat seizure
1) Give 5 mins
2) Benzo rectal/under tongue
3) Hospital - status epilapticus
Treatment epilepsy
Start epileptic after second seizure, or after first if:
- neurological deficit
- abnormal brain imaging
- abnormal EEG
Treatment generalised tonic clonic seizure
Sodium valproate
Treatment absence seizure
Sodium valproate or ethosuximide
Treatment myoclonic seizure
Sodium valproate
Treatment focal seizure
Carbamazepine or lamotrigine
Temporal seizure
Automatism (lip smacking, grabbing)
Frontal seizure
Jacksonian march
Post-ictal weakness
Parietal seizure
Paraesthesia
Occipital seizure
Visual
Identify infantile spasm
First few weeks of life
Saalam attack (flexion of head and extension of arms)
Poor prognosis
Identify absense seizure in kids
Onset 4-8y
Lasts few seconds to 30 with quick recovery, many per day
Identify Lennox-Gastraut syndrome
Onset 1-5y
Infantile spasm in past
Atypical absence, fall, jerk
Identify benign rolandic epilepsy
Paraesthesia on waking up
Identify juvenile myoclonic epilepsy
Onset teens
Infrequent generalised seizures
Migraine treatment
1) Triptin and NSAID
2) Non-oral metochlopramide
Migraine prevention
1) Topiramate or propranolol
PD plus syndromes
Multiple system atrophy - autonomic dysfunction
Dementia with lewy body
Progressive supranuclear palsy - problem moving eyes
PD treatment
1) Levodopa
2) Dopamine agonist, MAO-B inhibitor or COMT inhibitor to adjunct
PD treatment most common cause impulse control problems
Dopamine agonist therapy
PD treatment biggest effect on motor function and ADL
Levodopa
PD treatment most adverse effects
COMT inhibitor
PD treatment most hallucination risk
Dopamine agonist
Example dopamine receptor agonist
Bromocriptine
Cabergoline
Example MAOB inhibitor
Selegiline
Example COMT inhibitor
Etacapine
Diagnose temporal arteritis
Temoral artery biopsy - multinucleated giant cells
Treatment temporal arteritis
Urgent high dose glucocorticoid:
- prednisolone if no visual lose
- IV methylprednisolone if visual loss
Treatment bells palsy
Prednisolone
Eye drops
Identify essential tremor
Postural tremor worst when arms outstretched
Improved by alcohol and rest
Treatment essential tremor
Propranolol
Identify guillian barre syndrome
Following infection - compylobacter jejuni
Progressive symetrical weakness of all limbs - ascending (legs first)
Decreased reflexes
Diagnose guillian barre syndrome
LP - increase protein and normal WCC
Nerve conduction studies - decreased velocity
Criteria to diagnose guillian barre
Brighton criteria
Treatment guillian barre
IV immunoglobulin and supportive
Subtypes MS
Relapsing remitting (most common)
Secondary progressive
Primary progressive
Diagnose MS
Contrast MRI
CSF - oligoclonal bands
Treatment MS acute
High dose steroids 5d (methylprednisolone)
Treatment neuropathic pain MS
Amitriptyline or gabapentin
Treatment spasticity MS
1) Baclofen and gabapentin
2) Diazapam
Treatment bladder dysfunction MS
Anticholinergic
Identify subacute degeneration cord
B12 deficiency
Dorsal column first - vibration and properioception
Treatment acute tension headache
1) Aspirin, NSAID or paracetomol
Prophylaxis tension headache
Acupuncture
Wernickes encephalopathy triad
Opthalmoplegy/nystagmus
Ataxia
Confusion
Karsakoffs syndrome triad
Antero and retrograde amnesia
Confubulation
Cluster headache acute treatment
Oxygen and SC triptin
Cluster headache prophylaxis
Verapamil
Identify horners syndrome
Miosis (small pupil)
Ptosis
Anhidrosis (loss of sweating)
Location of lesion horners syndrome
Anhidrosis face arms and trunk:
- stroke
- syringomyelia
- MS
- tumour
Anhidrosis face:
- pancoast tumour
- cervical rib
No anhydrosis:
- carotid artery dissection
- carotid aneurysm
Identify Duchenne muscular dystrophy
Progressive proximal weakness from 5y
Calf pseudohypertrophy
Gowers sign - uses hands to stand from squated
Identify Becker muscular dystrophy
Develops after 10y
Intellectual impairment less common than Duchenne
Myasthenia gravis antibody
Acetylcholine receptors
Myasthenia gravis treatment long term
Long term acetylcholinesterase inhibitors - pyridostigmine
Myasthenia gravis crises treatment
IV immunoglobulins
Plasma electrophoresis
Treatment trigeminal neuralgia
Carbamazepine
TIA investigation
MRI including diffusion weighting
CT consider differentials
Urgent carotid doppler
TIA treatment
Initially aspirin 300mg and admission
Lifelong clopidogrel
Carotid artery endarectomy if >70% occlusion
Oxford stroke classification
3 criteria:
- unilateral hemiparesis or hemisensory loss
- homonymous hemianopia
- higher cognitive dysfunction (eg dysphagia)
Identify anterior cerebral infarct stroke
Contralateral hemiparesis and sensory loss
- lower limbs > upper
Identify middle cerebral infarct stroke
Contralateral hemiparesis and sensory loss
- upper > lower
Identify lucunar infarct
Pure sensory or motor
Identify posterior circulation infarct
1 of:
- cerebrallar or brainstem syndrome
- isolated homonymous hemianiopia
Identify posterior cerebral infarct
Contralateral homonymous hemianopia with macula sparing
Visual agnosia
Identify webers syndrome (posterior cerebral that supplies midbrain)
Ipsilateral CN III palsy
Contralateral limb weakness
Identify lateral medullary syndrome (posterior inferior cerebellar artery) - also called Wallenberg syndrome
Ipsilateral facial pain and temp loss
Contralateral limb pain and temp loss
Ataxia and nystagmus
Identify lateral pontine syndrome (anterior inferior cerebellar artery)
Similar to laterally medullary syndrome but ipsilateral paralysis and deafness
Identify basilar stroke
Locked in syndrome
Stroke screening tools
FAST - public
ROSIER - healthcare
Stroke diagnosis
Non contrast CT head
Stroke acute treatment
Aspirin 300mg once haemorrhage excluded
Statin if cholesterol >3.5
Stroke definitive treatment
Thombolysis if <4.5h
Thrombectomy if <6h if proximal anterior or posterior circulation, up to 24h if imaging shows salvagable tissue
Stroke secondary prevention
1) Clopridogrel
Wernicke aphasia
Fluent speech, comprehension impaired
Lesion superior temporal gyrus
Conductive aphasia
Fluent speech, comprehension intact
Global aphasia
Non-fluent speech
Comprehension impaired
Brocas aphasia
Non-fluent speech
Comprehension in tact
Lesion in frontal gyrus
Differentiate cerebellar hemisphere and vermis lesions
Hemisphere - peripheral ataxia (finger nose)
Vermis - gait ataxia
Frontal brain lesion
Brocas aphasia
Disinhibition
Parietal brain lesion
Inferior homonymous quadrotonopia
Sensory inattention
Temporal brain lesion
Wernickes aphasia
Superior homonymous quadrontanopia
Auditory agnosia
Occipital brain lesion
Homonymous hemianopia with macula sparing
Visual agnosia
Identify Brown sequard syndrome
Lateral hemisection of cord:
- ipsilateral weakness, proprioception and vibration loss
- contralateral loss of pain and temp
Identify cataplexy
Sudden and transient loss of muscle tone due to emotion
CN III palsy
Ptosis
Eye down and out
Dilated pupil
CN IV palsy
Defective downward gaze (vertical diplopia)
CN VI palsy
Defective abduction (hozizontal diplopia)
Vagus lesion
Uvula deviates away
Hypoglossal lesion
Tongue deviates towards
Driving after seizure
First - no driving 6m if normal investigation
Epilepsy - seizure free 12m
Driving after stroke
1m
Differentiate peroneal nerve lesion and L5 radiculopathy
Peroneal - foot drop and eversion effected
L5 - hip adduction affected to, foot eversion not
Identify degenerative cervical myopathy
Decreased motor function, sensory function, autonomic function
Hoffman sign - flicking one finger causes rest to flicker
Identify intranuclear opthalmoplegia
Impaired adduction same side lesion
Horizontal nystagmus abducting eye contralateral
Identify intracranial venous thrombosis
Sudden onset headache
Decreased consciusness
CN VI palsy
Diagnose intracranial venous thrombosis
MRI venography
Treatment neuropathic pain
1) Amitriptyline, duloxetine, gabapentin or pregabulin
2) Tramadol
Identify pituitary apoplexy
Sudden onset headache
Bitemporal superior quadrantia
Occular nerve palsies
Pituitary insuffienciency
Identify syringomyelia
Collection CSF in spinal cord:
- cape like loss of temp, preserved for touch proprioception and vibration
- spastic weakness
Identify tuberous sclerosis
Epilepsy
Shagren patches - rough over lumbar spin
Upper quadrant bitemporal hemianopia
Pituitary tumour
Lower quadrant bitemporal hemianopia
Craniopharyngioma
Barthel index
Disability after stroke
Incubate for what GCS
<8
