Week 22 - Brain metastasis, epilepsy, meningitis, migraine Flashcards
what are the four main types of migraines
migraine without aura
migraine with aura
silent migraine
hemiplegic migraine
what are the five stages of a migraine
premonitory or prodromal
aura (lasts for up to 60mins)
headache (lasts 4-72hrs)
resolution
postdromal or recovery phase
what may the prodromal phase involve
subtle symptoms such as yawning, fatigue or mood change
what are the typical features of a migraine headache
usually unilateral
moderate-severe intensity
pounding or throbbing
photophobia
phonophobia
osmophobia
aura (visial changes)
nausea or vomiting
what can migraine aura affect
vision, sensation or language
what are the visual symptoms associated with aura
sparks in the vision
blurred vision
lines across the vision
loss of visual fields (scotoma)
what do sensation aura changes include
tingling or numbnessw
what language aura symptoms may be found in migraine
dysphasia - difficulty speaking
what is the main features of hemiplegic migraines
hemiplegia - unilateral limb weakness
what other symptoms may be seen in hemiplegic migraines
ataxia - loss of coordination
impaired consciousness
what is familial hemiplegic migraine
an autosomal genetic condition characterised by hemiplegic migraines that run in families. however, they may occur without any genetic link or family history
what can hemiplegic migraines mimic
can mimic a stroke or a TIA - it is essential to exclude a stroke with sudden-onset hemiplegia
what are the common triggers for the onset of migraines
Stress
Bright lights
Strong smells
Certain foods (e.g., chocolate, cheese and caffeine)
Dehydration
Menstruation
Disrupted sleep
Trauma
what is the acute medical management of migraines
NSAIDs (naproxen or ibuprofen)
paracetamol
triptans - sumatriptan
antiemetics if vomiting occurs
what is NOT used in the treatment of migraines and why
opiates are NOT used to treat migraines and may make the condition worse
when are triptans used
used to abort migraines when they start to develop.
what is the mechanism of action of triptans
They are 5-HT receptor agonists (they bind to and stimulate serotonin receptors), specifically 5-HT1B and 5-HT1D. They have various mechanisms of action, including:
- Cranial vasoconstriction
- Inhibiting the transmission
of pain signals
- Inhibiting the release of inflammatory neuropeptides
what are the main contraindications related to triptans
vasoconstriction for example, hypertension, coronary artery disease, or previous stroke, TIA, or MI
what are the usual prophylactic medications used to reduce the frequency and severity of migraine attacks
Propranolol (a non-selective beta blocker)
Amitriptyline (a tricyclic antidepressant)
Topiramate (teratogenic and very effective contraception is needed)
give two names of prophylactic triptans
frovatriptan or zolmitriptan
when are prophylactic triptans used
for menstrual migraines
symptoms tend to occur two days before until three days after the start of menstruation
regular triprans may be used at this time
what are the risks associated with migraines
migraines are assoiated with a slightly increased risk of stroke, particularly when associated with aura.
the risk of stroke is further increased with the combined pill, making them a contraindication to the combined pill
what is epilepsy characterised by
seizures
what are seizures
transient episodes of abnormal electrical activity in the brain
what are the common 5 types of seizures seen in adults
Generalised tonic-clonic seizures
Partial seizures (or focal seizures)
Myoclonic seizures
Tonic seizures
Atonic seizures
what are the types of seizures more commonly seen in children
absence seizures
infantile spasms
febrile convulsions
what do generalised tonic-clonic seizures involve
tonic (muscle tensing) and clonic (muscle jerking) movements associated with a complete loss of consciousness
what are generalised tonic-clonic seizures also called
grand mal seizures
what may patients experience before a generalised tonic-clonic seizure
aura, an abnormal sensation that gives a warning that a seizure will occur.
there may be tongue biting, incontinence, groaning or irregular breathing
what happens after the seizure
there is a prolonged post-ictal period, where the person is confused, tired and irritable or low
where do partial seizures/focal seizures occur
in an isolated brain area, often in the temporal lobes
what do partial seizures affect
hearing, speech, memory and emotions
what is the common state of the patient during a partial seizure
patients remain awake during partial seizures
they remain aware during simple partial seizures but lose awareness during complex partial seixures
what are the various symptoms associated with partial seizures, depending on the location of the abnormal electrical activity
Déjà vu
Strange smells, tastes, sight or sound sensations
Unusual emotions
Abnormal behaviours
how do myoclonic seizures present
with sudden, brief muscle contractions like an abrupt jump or jolt. they remain awake.
what do tonic seizures involve
a sudden onset of increased muscle tone, where the entire body stiffens.
what do tonic seizures usually result in and how long do they last
usually result in a fall if the patient is standing, usually backwards
they last only a few seconds, or at most a few minutes
what do atonic seizures involve
sudden loss of muscle tone, often resulting in a fallh
how long do atonic seizures last and are patients awake during them?
They last only briefly, and patients are usually aware during the episodes. They often begin in childhood.
what kind of syndrome may atonic seizures be indicative of
Lennox-Gastaut Syndrome
what are absence seizures and in who are they usually found
usually seen in children.
the patient becomes blank, stares into space and then abruptly returns to normal
what are infantile spasms also known as
West syndrome
when do infantile spasms start
rare, start at around six months of age
how does West syndrome present
with clusters of full-body spasms.
what is the characteristic ECG finding in West syndrome
Hypsarrhythmia
what is the treatment of West syndrome and what is the prognosis like
it is associated with developmental regression and has a very poor prognosis
treatment is with ACTH and vigabatrin
what are febrile convulsions
tonic-clonic seizures that occur in children due to a high fever
are febrile convulsions caused by epilepsy
no.
may occur in children between 6 months and 5 years
what are the differential diagnoses for epilepsy
Vasovagal syncope (fainting)
Pseudoseizures (non-epileptic attacks)
Cardiac syncope (e.g., arrhythmias or structural heart disease)
Hypoglycaemia
Hemiplegic migraine
Transient ischaemic attack
what will happen with the DVLA regarding epilepsy
the DVLA will remove their driving license until a specific criteria is met - e.g being seizure free for one year
what are the safety precautions taken with epilepsy
Taking showers rather than baths (drowning is a major risk in epilepsy)
Particular caution with swimming, heights, traffic and dangerous equipment
what does epilepsy treatment aim for
aim to be seizure free on the minimum anti-epilelptic medications
what is given to men and women who cannot have children with generalised tonic-clonic seizures
sodium valrpoate
what is given for generalised tonic-clonic seizures in women able to have children
lamotrigine or levetiracetam
what is given for partial/focal seizures in all men and women
lamotrigine or levetracetam
what is given for myoclonic and tonic/aclonic seizures in men and women who cannot have children
sodium valporate
what is given for myoclonic seizures in women who can have children
Levetiracetam
what is given for tonic and aclonic seizures in women who are able to have children
lamotrigine
what is given in all men and women with absence seizures
ethosuximide
how does sodium valporate work
increasing the activity of the GABA which has a calming effect on the brain
what are the notable side effects of sodium valporate
teratogenic
liver damage and hepatitis
hair loss
tremor
reduce fertitilty
what may sodium valporate cause in pregnancy
cause neural tube defects and developmental delay
what is in place to ensure effective contraception and an annual risk acknowledgement form
the Valproate pregnancy prevention programme
what is status epilepticus
a medical emergency defined as either:
- a seizure lasting more than 5 mins
- multiple seizures without regaining consciousness in the interim
what does management of status epilepticus involve
an ABCDE approach, including;
Securing the airway
Giving high-concentration oxygen
Checking blood glucose levels
Gaining intravenous access (inserting a cannula)
what is first line treatment for status epilepticus
a benzodiazepine first line, repeated after 5-10 mins if the seizure continues
what are second and third line treatments for status epilepticus
Second-line options (after two doses of benzodiazepine) are IV levetiracetam, phenytoin or sodium valproate
Third-line options are phenobarbital or general anaesthesia
what are the options for benzodiazepines
Buccal midazolam (10mg)
Rectal diazepam (10mg)
Intravenous lorazepam (4mg)
what is meningitis
inflammation of the meninges due to infection.
what are the meninges
are the lining of the brain and spinal cord.
CSF is contained within the meninges
what are the causes of bacterial meningitis
Neisseria meningitidis
Streptococcus pneumoniae (pneumococcus)
Haemophilus influenzae
Group B streptococcus (GBS) (particularly in neonates as GBS may colonise the vagina)
Listeria monocytogenes (particularly in neonates)
what is neisseria meningitidis
a gram-negative diplococcus bacteria.
they are circular bacteria that occur in pairs
commonly known as meningococcus
what is meningococcal meningitis
when the bacteria infects the meninges and the CSF.
what does meningococcal septicaemia mean
when the meningicoccal bacterial infection is in the blood stream
this is what causes the non-blanching rash
what are the most common causes of viral meningitis
Enteroviruses (e.g., coxsackievirus)
Herpes simplex virus (HSV)
Varicella zoster virus (VZV)
what is used to treat herpes and varicella
aciclovir
what are the typical symptoms of meningitis
Fever
Neck stiffness
Vomiting
Headache
Photophobia
Altered consciousness
Seizures
what are the non-specific symptoms that neonates and babies can present with in the case of meningitis
hypotonia, poor feeding, lethargy, hypothermia and a bulging fontanelle
what do the NICE guidelines on sepsis recommend as part of the investigation in children
The NICE guidelines on sepsis recommend lumbar puncture as part of the investigations for children with suspected sepsis who are:
- Under 1 month, presenting with fever
- 1 to 3 months and are unwell or have a low or high white blood cell count
what are the two special tests you can perform to look for meningeal irritation
Kernig’s test
Brudzinski’s test
what is involved in Kernig’s test
involves lying the patient on their back, flexing one hip and knee at 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees
this causes a slight stretch in the meninges. Where there is meningitis, it will produce spinal pain or resistance to movement
what does Brudzinski’s test involve
lying the patient flat on their back and gently using your hands to lift their head and neck off the bed, flexing their chin to their chest
a positive test, indicating meningitis is when this causes the patient to flex their hips and knees involuntarily
where is the needle usually inserted for lumbar puncture
L3-L4 or L4/L5 intervertebral space
what is the appearance of bacterial and viral CSF
bacterial - cloudy
viral - clear
what is the protein and glucose in bacterial and viral CSF
bacterial - protein is high and glucose is low
viral - protein is mildly raised or normal and the glucose is normal
what is the white cell count in bacterial and viral CSF
bacterial - high WCC (neutrophils)
viral - high WCC (lymphocytes)
what is the culture seen in bacterial and viral CSF
bacterial - bacteria
viral - negative
TOM TIP: Lumbar puncture interpretation is a common exam question. Think about what will happen with bacteria or viruses living in the CSF rather than rote learning the results. Bacteria swimming in the CSF will release proteins and use up glucose. Viruses may release a small amount of protein and do not use up glucose. The immune system releases more neutrophils with bacteria and lymphocytes with viruses.
which type of meningitis is the most serious
bacterial meningitis is the most serious and is a medical emergency
what are children seen in primary care given if they have suspected meningitis AND a non-blanching rash
urgent dose of benzylpenicillin (IM or IV) while awaiting transfer to hospital
what are the blood tests for bacterial meningitis
Blood tests should include a meningococcal PCR if meningococcus is suspected. This tests for meningococcal DNA. It can give a result faster than blood cultures (depending on local services) and will still be positive after the bacteria has been treated with antibiotics.
what is added to treatment of meningitis if viral meningitis is suspected
aciclovir - herpes simple virus
when should vancomycin be added to meningitis treatment
if there is a risk of penicillin-resistant pneumococcal infection (e.g., recent foreign travel or prolonged antibiotic exposure).
why are steroids used in bacterial meningitis treatment
to reduce the frequency and severity of hearing loss and neurological complications
which types of meningitis are notifiable disease to the UK health security agency
Bacterial meningitis and meningococcal infection
what is the usual choice for post exposure prophylaxis in the case of meningococcal infection
single dose of ciprofloxacin
what are the complications of meningitis
Seizures and epilepsy
Cognitive impairment and learning disability
Memory loss
hearing loss - A KEY COMPLICATION
Focal neurological deficits, such as limb weakness or spasticity
