other neuro conditions Flashcards
Shingles: causes, presentation
Viral infection of an individual nerve and the skin surface that is served by the nerve (dermatome). Vaccine offered to 70y, 78y
Causes: VZV
Presentation (Dx made clinically)
(1.) Prodromal: burning pain, can impact sleep + QoL, headache, photophobia, malaise, fever
(2.) Rash (maculopapular -> vesicles) - painful, itchy, and/or tingly, does not cross the midline of the body.
(3. ) Healing: vesicles burst, releasing VSV, and crust over within 7–10 days
- healing occurs over 2-4w, and often results in scarring and permanent pigmentation in the affected area
(4.) Post-herpetic neuralgia - persisting pain after rash onset
Mx of Shingles
Admission if
- serious complication: meningitis, encephalitis, or myelitis
- severely IMC or IMC child
- ophthalmic involvement
- systemically unwell
- severe/widespread rash or multiple dermatomes involved
(1. ) Acyclovir <72hrs onset
(2. ) Paracetamol +/- NSAID or codeine
(3. ) 2w PO steroid in IMC, severe pain, no response to rx
(4. ) Avoid contact with preg women, IMC, babies. Isolate + cover rash if weeping.
What is NEAD? Syx?
- NEAD can look similar to epileptic seizures or fainting spells, but it is not caused by abnormal electrical discharges or blood pressure.
- Attacks happen when brain can’t handle particular thoughts, memories, emotions, sensations.
Hx/Ex/Ix
(1.) Hx: psychiatric, somatoform disorders
(2. ) Triggers e.g. emotions - stress, fear, memories, trauma, PTSD, smells, colours
(3. ) Prolonged atonic, rhythmic pelvic movements, post ictal crying, eyes closed
(4. ) 1-20minutes
(5. ) Rapid or slow postictal recovery
Vasovagal/ Neurocardiogenic - aetiology, causes, dx, mx
- Problem with ANS regulating blood flow to brain
- Vagus nerve receives a strong stimulus (emotion/pain/temp change) can stimulate parasymp NS.
- Peripheral vasodilation, bradycardia, drop in BP -> cerebral circulation drops -> hypoperfusion -> TLOC
Causes
- Primary syncope: Dehydration, missed meals, extended standing in warm/heat, vasovagal stimuli e.g. surprise, pain, blood
- Secondary syncope: Hypoglycaemia, dehydration, anaemia, infection, arrythmia, hypertrophic obstructive CM
Dx = exclusion of other causes. Posture, Provoking factors, Prodromal syx suggests uncomplicated faint.
- Posture: blackout occurred after prolonged standing.
- Provoking factors: such as pain or a medical procedure.
- Prodromal syx: such as sweating or feeling warm/hot before the blackout.
Mx = avoid triggers, reassure prognosis is good
Cardiac Syncope: causes, presentation, mx
Causes
- Arrhythmias: bradycardias (sinus node dysfunction, AV conduction disorders) or tachycardias (supraventricular, ventricular)
- Structural: valvular, MI, hypertrophic obstructive cardiomyopathy
- Others: PE
Presentation
- Sudden
- associated with palpitations, chest discomfort, light headedness
- blackout occur on exertion
- rapid recovery
Mx
- refer to cardiac assessment
Carotid Sinus Syncope/hypersensitivity : what is it? RF? Presentation? Mx?
- Exaggerated response to carotid sinus baroreceptor stimulation.
- Gentle carotid sinus massage applied near carotid bifurcation 5-10s
- RF: HTN, CAD, Ley-body dementia.
Hx:
- Recurrent dizziness, syncope, falls
- Prodromal syx
- Fast recovery
- Triggers: shaving, head turning, neck extension or tight collars
- o/e: auscultation for carotid bruits
Mx
- Avoid triggers, maintain adequate fluid intake
- If >60y – cardio refer for carotid sinus massage
SAH: causes, presentation, ix + mx
Causes: Berry aneurysm in CoW, trauma, spontaneous, AV malformation etc
Presentation
(1. ) Thunderclap headach, sudden onset, pain is maximal. SAH until proven otherwise
(2. ) Neck stiffness
(3. ) Photophobia, vision changes
(4. ) Neuro syx: speech changes, weakness, seizures,
(5. ) LOC
(6. ) Vomiting
Ix
(1. ) CT (1st line)
(2. ) LP if CT -ve, look for xanthochromia
(3. ) CT/MRI angiography (GOLD for localisation of aneurysm once SAH confirmed)
Mx: ABCDE
(1. ) Managed by specialist neurosurgical unit
(2. ) Intubation if reduced consciousness
(3. ) Surgical intervention: coiling or clipping
(4. ) Nimodipine (CCB), prevent vasospasm (common SAH complication)
(5. ) AED for seizures
Multiple Sclerosis: RF, presentation
- Chronic demyelinating conditions
- RF = Female, 20-50y, Northern European, EBV, low vit D, smoking, obesity
Presentation
(1. ) Visual syx: optic neuritis, diplopia, nystagmus
(2. ) Sensory syx: trigeminal neuralgia, paraesthesia
(3. ) SC myelitis
- Lhermitte’s phenomena: neck flexion causes shock-like sensation down spine
- Urinary syx: urgency, frequency, retention
- Erectile dysfunction
(4. ) Cerebellar syx: ataxia, vertigo, clumsiness
(5. ) Dysarthria or dysphagia
(6. ) Uhtoff’s phenomena: syx worsen with heat e.g. hot shows causing numbness
Multiple Sclerosis Dx + Ix
Dx made by neurologist using McDonald Criteria
(1. ) Confirm episodes are consistent with inflammatory process.
(2. ) Exclude alternative dx.
(3. ) Establish lesions have developed at different times and are in different anatomical locations for dx of relapsing-remitting MS.
(4. ) Establish progressive deterioration over at least 1y for dx of primary progressive MS.
Ix
(1. ) Blood test: FBC, CRP, LFT, UE, Ca, HbA1c, TFT, B12, HIV serology
(2. ) MRI + contrast - demonstrate typical lesions
(3. ) LP - oligoclonal bands in CSF. NOT present in serum.
MS - acute mx and mx of syx
(1. ) MDT management: neurologists, nurses, physio, occupational therapy etc
(2. ) Acute: high dose Methylprednisolone (PO 5d or IV 3-5d)
(3. ) Disease-modifying drugs - beta-interferons
(4. ) Managing syx
- exercise
- CBT
- amitriptyline/ gabapentin for neuropathic pain
- baclofen/ gabapentin/ physio for spasticity
- catheterisation or anticholinergic for urgency or incontinence
Intracranial venous thrombosis: types, rf, presentation, ix, mx
- Intracranial venous thrombosis refers to occlusion of venous vessels in cranial cavity
- types include sagittal sinus thrombosis (50%) + cavernous sinus thrombosis
RF: female 20-35y, pregnancy, COCP, sepsis
Presentation
- Headache, confusion, N+V
- Sagittal = seizures, hemiplegia
- Cavernous = proptosis, painful ophthalmoplegia, periorbital oedema, CN6 palsy, central retina vein thrombosis
Ix
- Non-contrast CT
- MRI/CT venogram is highly dx for sagittal sinus thrombosis ‘the empty delta sign’
- BLoods
- LP if infection suspect but CI if RICP
Mx
(1. ) LMWH
(2. ) Anticonvulsants for seizures
(3. ) Endovascular procedures if severe presentation and deterioration despite anticoag
What is Wernicke’s Encephalopathy? syx? Ix? Mx?
Caused by thiamine/vit B1 deficiency.
RF: chronic alcohol abuse, malnutrition, bariatric surgery, hyperemesis gravidarum, stomach ca.
If left untreated can progress to Korsakoff’s syndrome (antero- and retrograde amnesia + confabulation/ fabricate memories)
Syx: triad of ophthalmoplegia, ataxia, confusion
- Ocular abnormalities (gaze-evoked nystagmus, spontaneous upbeat nystagmus, ophthalmoplegia)
Dx – made clinically
- FBC, UE, glucose, VBG, red cell transketolase activity
Mx
- Hi dose IV thiamine (Pabrinex IV) - do not delay Rx
What nerve is damaged to cause wrist + foot drop? causes? mx?
Wrist drop - Radial nerve
- Causes: trauma, repetitive injury, saturday night palsy
- mx: splint, physio
Foot drop - common peroneal nerve
- causes: prolonged leg crossing, squatting or kneeling, trauma to fibular, bakers cyst
- mx: avoid leg crossing/kneeling, physio, splints
Carpal Tunnel Syndrome: presentation, mx
- Paraethesia in thumb, index, middle finger
- Pt shakes hand to obtain relief, classically at night
- May be sensory loss and weakness of abductor pollicis brevis +/- thenar wasting
O/e - weakness of thumb abduction/APB
- wasting of thenar eminence
- Tinel’s sign +ve
- Phalen’s sign +ve
IX
Not necessary, but if in dx doubt and before surgery, nerve conduction studies (e.g. ENG) can be considered.
Management
- 6w trial of conservative Rx if mild-moderate syx
- steroid injections
- wrist splint at night
- Surgical decompression (flexor retinaculum division) if severe syx or syx persist
Myasthenia gravis: patho, presentation, ix, mx?
AI disorder where ab against nicotinic ach-R at NMJ of muscle fibres - thus reduces muscle contraction.
Presentation: muscle weakness in -
(1. ) limb muscles
(2. ) extra-ocular (drooping eyelids, diplopia)
(3. ) facial (difficulty smiling or chewing)
(4. ) bulbar (speech, swallow difficulty).
(5. ) Syx worse after prolonged movement or at end of day E.g. hanging clothes after pegging 3-4 shirt and need to relax arms before pegging more clothes
(6. ) THYMOMA
Ix
(1. ) Serum ach-R antibody
(2. ) Muscle specific tyrosine kinase (MUSK) antibodies if above is negative
(3. ) Chest CT - if thymectomy is required
(4. ) Nerve stimulation test (EMG)
(5. ) Spirometry test if myasthenic crisis
Mx
(1. ) Pyridostigmine (Ach inhibitor) 1st line
(2. ) Steroid
(3. ) Thymectomy
Myasthenic Crisis:
- Plasma exchange, IV Ig (to remove and lower production of ab)
- Monitor FVC +/- ventilate
- Identify trigger
