What are the 5 causes of blackouts?
- No blood
- Blood no good
- Brainstem
- Cerebral
- Psychological
What are the causes of "no blood" black outs?
Vasovagal syncope
Postural Hypotension
Hyperventilation
Cardiac Dysrhythmia
What are the causes of "blood no good" blackouts?
Hypoxia
Hypoglycaemia
What is Vasovagal Syncope?
Fainting
What causes Vasovagal snycope?
Vagal activity increaces will symapthetic activity decreses
As a result the heart slows and blood pools in the peripheries.
Cardiac output decreases resulting in inadequate perfusion to the brain.
The patient then collapses, venous return improves and cardiac output goes back to normal
What is postural hypotension?
Patient feels dizzy upon standing, blacks out and collapses
Why does postural hypotension occour?
Decreased symapthetic activity affecting the heart and peripheral circulation
Normal cardio-acceleration and peripheral vasoconstriction in response to standing does not occour.
Cardiac output is no sufficiant resulting in loss of consciousness
What is usually the cause of postural hypotension?
Decreased sympathetic activity due to anti-hypertensive drugs
occasionally due to a physical lesion of the sympathetic pathways
What kind of person experiances postural hypotension
middle aged or elderly
Parkinson's disease
Peripheral neuropathy
What happens during hyperventilation?
Patients overbeath and wash out CO2 from their blood.
Arterial hypocapnia is a potent cerebral vasocontrictive stimulus.
Inadequate perfusion to the brain resulting in loss of consciousness
How can you prevent hyperventialtion?
Rebreathing into a paper bag.
Stops hypocapnia as you are rebreathing air which has more CO2 in it
What signs and symptoms are suggestive of cardiac dysrhytmia being the cause of blackouts?
- Older patient
- attacks unrelated to posture
- Hx of Ischaemic heart disease
- Palpatations
- Dizziness and colour change prior to collapse
- Dizziness and colour change prior to collapse
What are Vertebro-basilar transient iscaemic attacks?
Thrombo-embolic material from the heart of proximal large arteries occlude arteries supllying the brainstem.
Cause ischemia of the brainstem tissue untill they are dislodged
what are the symptoms of Vertebro-basilar transient ischaemic attack?
Lasting about 8 minutes
Vertigo
Visual field defects (diplopia, hemianopia)
Auditory phenomena (sudden sensorineural hearing loss)
Facial numbness or paresthesias
Dysphagia, dysarthria, hoarseness
Syncope (drop attacks)
Hemisensory extremity symptoms (eg, contralateral to facial component
What factors make Vertebro-basilar transient ischaemic attacks more likely in a patient?
Older patient
know arteriopathic history
Presence of a source of emboli - MI, atrial fibrilation, neck bruits etc
What is a "hysterical attack"
Some patients attract attention to themselves, at a conscious or unconscious level by having blackouts.
Attacks consist of apparent loss of conciousness with falling and sometimes simulated convulsive movements.
What is narcolepsy?
episodes of sleep of unatural duration and stength occouring at unsual times.
Sufferers may also experiance
- Cataplexy
- Sleep paralysis
- Hypnogogic Hallucintions
What is transient global amensia?
For a few hours the patient acts normally but afterwards they cant remember anything that happened
usually ony happens a couple times in a patients life
What are the layers of the meinges?
Dura mater
Arachnoid mater
Pia mater
What causes Viral Meningitis?
Enteroviruses like ECHO virus
How do you diagnose viral meningitis?
Viral stool culture
Throat swab
CSF PCR
How do you treat viral meningitis?
Supportive - Self limiting
What is the most common cause of community aquired bacterial meningitis in children?
H. influenza
What is the most common cause of community acquired bacterial meningitis in ages 10-21?
Neisseria meningitidis
What is the most common cause of community acquired bacterial meningitis in adults
streptococcus pneumoniae
What is a major risk factor for streptococcus pneumoniae meningitis?
Fracture of the cribiform plate
What type of meningitis does " decreased cell mediated immunity" increase the risk for?
Listeria monocytogenes
What type of meningitis does head trauma or neurosurgery put you at higher risk off?
S. aureus
S. epidermidis
What type of meningitis does a basilar skull fracture put you at higher risk of?
S.pneumoniae
H. influenzae
beta-hemolytic strep group A
What causes meningococcal meningitis?
Neisseria meningitis
How does Neisseria meningitis cause symptoms?
Endotoxins
Who gets memingococcal meningitis?
Young children
What is characterisitic of Tuberculous Meningitis?
Reactivaion:- Elderly
Previous TB on CXR
Non specific ill health
How do you treat Tuberculous Meningitis?
Isoniazid + rifampicin
What is cryptococcal meningitis?
Fungal meningitis presenting mainly in HIV disease
What is Chorea?
Fragments of movements flowing irregulary from one body segment to the next
What is ballismus?
Extreme chorea
What are the two broad subtypes of parkinson's disease?
Tremor dominant Parkinson's Disease
Non-tremor dominant Parkinson's Disease
What sub type of parkinsons disease is associated with a slower rate of progression and less functional disability
Tremor-dominant subtype
What are the non-motor features of parkinson's disease?
Olfactory dysfunction
cognitive impairment
psychiatric symptoms
sleep disorders
autonomic dysfunction
pain
fatigue
What is the classic disease progression of parkinson's disease?
Diagnosed made with motor symptoms but non motor symptoms have been around for a while
Initally motor features are well controlled
at 17 years 80% report gait freezing and falls while 50% report choking
At 20 years 83% have dementia
What does the disease progression graph look like for Parkinson's disease
What are the pathological hall marks of parkinsons disease?
Loss of dopaminergic neurons within the substania nigra and lewy body pathology
What are Lewy bodies?
Build ups of insoluble misfolded alpha-synuclien
Does having parents with parkinson disease increase your risk of parkinson's disease?
Yes
What mutations are the most common causes of parkinsons disesae?
LRRK2
Parkin
What is the most common cause of meningitis in children under the age of 4 ?
H. influenzae
How do you treat parkinson's disease ?
Increase dopamine in the brain
What are the adverse side affects of dopamine treatment in parkinsons?
Impulse control disorders made worse
Hallucinations - Carefull in the elderly
Nausea
Oedema
Daytime somnolence
What are the long term complications of dopaminergic therapy in parkinson's disease?
Motor flucations:- on time/off time
Dyskinesia and chorea (corrolates with levodopa conc)
Hallucinations
What are the motor symptoms of parkinsonisim?
Bradykinesia
Rest tremor
Rigidity
Postural and gait impariment
What is typical with Vascular Parkinsonism?
Predominantly affects lower limbs
Poor levodopa response
Resting tremor uncommon
What is Duchenne muscular dystrophy?
X linked genetic disease resulting in progressive muscle weakness
What is huntington disease?
Progressive neurodegenerative disorder
onsent between 30-50 yrs
How is huntington disease inherited ?
Autosomal Dominant
What is the most common cause of dementia?
Alzheimer's disease (50-70%)
What are the 5 things measured in the cerebral spinal fluid when ivestigating meningitis?
WBC count
Neutrophils
Protein
Glucose
What would you expect the WBC count to be in the CSF during bacterial meningitis?
WBC count >2000
What would you expect the neutophil count to be in the CSF of expected bacterial meningitis?
Neutrophils >1180
What would you expect of the protein content in the CSF of expected bacterial meningitis?
Protein >220 mg/dl
What would you expect the glucose level to be in the CSF of expected bacterial meningitis?
Glucose <34mg/dl
What CSF findings are 99% perdictive of bacerial meningitis?
WBC >2000
Neutrophils >1180
Protein >220mg/dl
Glucose <34 mg/dl
What should you do when a patient is addmitted to hospital with acute adult bacterial meningitis
- Take blood for culture and coagulation screen
- Take throat swab
- Swab any skin lesions
- Start "intial therapy before pathogens are identified" treatment
What types of patients which acute adult bacterial meningitis need a CT prior to lumbar puncture?
- Immunocompromised patients
- History of CNS disease
- New onset of seizure
- Papilloedema
- Abnormal levels of consciousness
- Focal neurological deficit
-
- Focal neurological deficit
What is the empiracal antibiotic for acute adult bacterial meningitis?
IV ceftriaxone 2g bd
if listeria is suspected add
Amoxicillin 2g qds
What is the empiric antibiotic for acute adult bacterial meningitis for someone with a penicillin allergy?
Chloramphenicol IV 25 mg/kg every 6hrs
plus
Vancomycin IV 500 mg every 6 hours
Whats the deal with steriods and bacterial meningitis?
Give to all patients suspected of bacterial meningitis before or with the first dose of antibiotics and then every 6 hours
When are the only times you wouldnt give steriods in adult acute baterial meningitis ?
- Post surgical meningitis
- Severe immunocompromise
- septic shock
What must you remeber to do when you have a paient with meningitis?
Call Public Health
Explain the concept of Cerebral Perfusion Pressre?
Cerebral perfusion pressure = mean arterial pressure --- intracranial pressure
What are the ideal CPP = MAP --- ICP pressures that you want to keep
Cerebral perfussion pressure = Mean arterial pressure --- Intracranial pressure
>60mmHg = >80mmHg --- < 20mmHg
What is normal adult Intercrainial Pressure?
9-11mmHg
How can you spot an anteior cranial fossa fracture?
Panda eyes
How can you spot a middle crania fossa fracture?
"battle sign"
What kills patients with head injuries?
Hypoxia
Hypotension
Raised Intracranial Pressure
When should you request a CT scan of the head in patients with head trauma?
Any patient with :
- Skull fracture
- GCS <15
- Focal neurological signs
- Taking anti-coagulants
What are the types of traumatic intracranial bleeding from outside to inside?
Extradural haematoma
Subural haematoma
Traumatic subarachnoid haemorrhage
Intracerebral contusion
Intracerebral haematoma
Intraventricular haemorrhage
Why is sedation useful in the management of head injuries?
Reduces cerebral metabolic rate
Reduces cerebral blood flow
Reduces ICP
What is the most common cause of spontaneous subarachnoid haemorrhage?
Ruptured aneursym
What is a saccular aneurysms?
True aneurysms with involvement of all layers of the vessle
What is classic in Lower motor neurone disorders?
- Weak
- Low tone
- Fasiculations
- Fasiculations
What causes botulism?
Clostridium botulinum - PWID
How does botulinum toxin work?
Cleaves presynaptic protiens involved in vesicle formation and block vesicle docking
What is Lambert Eaton Myasthenic Syndrome?
Antibodies to presynaptic calcium channels leading to less vesicle release.
What is strongly associated with Lambert Eaton Myasthenic Syndrome?
Small cell carcinoma
What is the most common disorder of the neuromuscular junction?
Myasthenia Gravis
What is Myasthenia Gravis?
Autoimmune antibodies to acetyl choline receptors
Reduced number of functioning receptors leads to muscle weakness and fatiguability
When do you first start to experiance symptoms in myasthenia gravis?
When ACh receptors are reduced to 30% of normal
When are the two peaks of indcidence in myasthenia gravis?
Females: 30 - 40
Males: 60 - 80
What are the common clincial features of myasthenia gravis?
Weakness typically fluctuating
Extraocular weakness, facial and bulbar weakness
proximal limb weakness
How do you treat myasthenia gravis?
Immunomodulating
Steriods/azathioprine
emergency treatment wih plasma exchange or immunoglobulin
How does myasthenia gravis cause death?
Respiratory failure (diaphram)
and
Aspiration pneumonia
What are fasiculations?
Visible, fast, fine and spontaneous muscle twitch
What is myotonia?
Failure of muscle channel relaxation after use
What does myalgia mean?
Muscle weakness
What cause myotonia?
Problem with the cholride channel
What is Rhabdomyolysis?
"Dissolution of muscle"
Damage to skeletal muscle causes leakage of large quantities of toxic intracellular contents into the plasma
What is multiple sclerosis?
An inflammatory demyelinating disorder of the central nervous system
When do people with multiple sclerosis usually present?
30s and 40s
What are the 6 clincial features of Multiple Sclerosis?
Pyramidal dysfunction
Optic neuritis
Sensory Symptoms
Lr Urinary tract dysfunction
Cerebellar and brain stem features
Cognitive impairment
What does pyramidal dysfunction in MS cause?
Increased tone
Spasticity
Weakness
Extensors of upper limbs
Flexors of lower limbs
What is Optic neuritis?
Painful visual loss lasting 1-2 weeks
common in Multiple Sclerosis
What causes Diplopia in MS?
Abducens nerve palsy
What causes facial weakness in multiple sclerosis?
Facial nerve
What is internuclear ophthalmoplegia?
Medial longitudinal fasciculus resulting in distortion of binocular vision due to failure of adduction
What urinary symptoms do people with multiple sclerosis get?
Frequency
nocturia
urgency
urge incontinence
retention
What is required to diagnose MS?
At least 2 episodes suggestive of demyelination
dissemination in time and place
What should be on your differential diagnosis list for multiple sclerosis?
Vasculitis
Granulomatous disorder
vascular disease
structural lesion
infection
metabolic disorder
What are the three principes to treating multiple sclerosis?
- Acute exacerbations
- Symptomatic treatment
- Disease modifying therapy
-
- Disease modifying therapy
How do you treat a mild , moderate and severe acute exacerbation of multiple sclerosis?
Mild - symptomatic treatment
Moderate - Oral steriods
Severe - IV steriods
What are the treatment options for spasticity in multiple sclerosis?
Physio
Oral medication - Baclofen and tizanidine
Botulinum toxin
Intrathecal baclofen
What does intrathecal mean?
Via the CSF
How can you manage the sensory symptoms of Multiple sclerosis?
Anti-convulsant
Anti-depressant
Tens machine
Acupunture
Lignocaine infusion
What anti-convulsant is appropriate in multiple sclerosis?
Gabapentin
What antidepressant drug is usefull in multiple sclerosis?
Amitriptyline
What three problems do people with multiple sclerosis get with regards to their bladder?
Increased tone at bladder neck
Detruser hypersensitivity
Detruser sphyncteric dyssenergia
What is detruser sphyncteric dyssenergia?
Dyscoordination of the detruser muscles and external sphincter muscles
How do you treat unrinary tract dysfunction in multiple sclerosis?
- Bladder drill / diary
- anti-cholinergics - oxybutynin
- Desmopressin
- Catherterisation
-
- Catherterisation
How do you treat fatigue in patients with Multiple sclerosis?
Amantadine
or if sleepy Modafinil
What is the first line disease modifying therapy in multiple sclerosis
Interferon beta
Glitiramer acetate
Tecfedira
What are there second line disease modifying drugs for multiple sclerosis
Monoclonal antibody
Fingolimod
What is the third line therapy for multiple sclerosis?
Mitoxantrone
What are interferon Beta and Copaxone?
Injectable disease modifying drugs for multiple sclerosis (first line)
What effect does interferon Beta and Copaxone on multiple sclerosis?
Decrease relapse rate by 1/3
Decrease severity of relapses by 50%
has an effect on disability
What is Tecfidera ?
Oral agent used in multiple sclerosis
What affect does Tecfidera have on Multiple Sclerosis?
44 % reduction in relapse rate
How does Fingolimod work in the treatment of multiple sclerosis?
Sphingosine-1-phosphate modulator
What affect does Fingolimond have on multiple sclerosis?
>50% reduction in relapse rate
What are the features of a large motor fibre nerve damage?
Symptoms
Power
Sensation
Reflexes
Symptoms - Weakness, unsteadiness, wasting
Power- reduced
Sensation - normal
Reflexes - Absent
What are the features of a large sensory fibre nerve damage?
Symptoms
Power
Sensation
Reflexes
Symptoms - Numbness, paraesthesia, unsteadiness
Power - Normal
Sensation - Vibration and joint posistion sense
Reflexes - Absent
What are the symptoms of small fibre nerve damage?
Symptoms
Power
Sensation
Reflexes
Symptoms - Pain, Dyesthesia
Power - Normal
Sensation - Pin prick and termperature reduced
Reflexes - Present
What are the features of autonomic nerve damage?
Symptoms
Power
Sensation
Reflexes
Symptoms - Dizziness, Impotence and nausea
Power - Normal
Sensation - Normal
Reflexes - Present
What does Radiculopathy mean?
Problem with the anterior or posterioir rami
How would you describe this pattern of loss?
Glove and stocking
What is an acute cause of Demyelinating neuropathy?
Guillaine Barre Syndrome
What is characterisitc of Guillain-Barre Syndrome?
Progressive paraplegia over days up to 4 weeks
What are the sequence of events during an exacerbation of Guillian-Barre Syndrome?
Sensory symptoms
Parapelgia, weakness and pain
What are the 6 broad families of axonal neuropathies?
Idiopathic
Vaculitic
Paraneoplastic
Infections
Drugs/toxins
Metabolic
What infections can cause axonal neuropathies?
HIV
Syphillis
Lyme
Hepatitis B/C
What drugs/toxins can cause Axonal Neuropathies?
Alcohol
Amiodarone
Phenytoin
Chemotherapy
What are the metabolic causes of Axonal Neuropathies?
Diabetes
B12 folate deficiencies
Hypothyroidism
Chronic Uremia
Porphyria
What are the (a) chronic and (b) acute causes of autonomic neuropathy?
Chronic - Diabetes, Amyloidosis, Hereditary
Acute - GBS, Porphyria
How can you treat Vasculitic axonal peropheral neuropathy?
Pulsed IV methylprednisolone + cyclophosphamide
Do cases on Peripheral lecture
DO IT
What is characterisitc of Non REM sleep?
Partial muscle relaxation
Reduced cardiac output
Snychronised rythmic EEG
Non-narrative dreams
What is characterisitc of REM sleep?
Mostly at the end of the night
EEG shows fast activity similar to being awake
Atonic muscles
Cerebral blood flow increased
Impaired thermal regulation
Narrative dreaming
How do you investigate narcolepsy?
Overnight polysomnography
What can you measure in the CSF to help with a diagnosis of Narcolepsy?
CSF hypocretin
What CSF hypocretin level is suggestive of narcolepsy?
less than 110pg/ml
What is nociceptive pain?
An appropriate physiological response to painful stimuli via an intact nervous system
What is neuropathic pain?
An inappropriate response caused by dysfunction in the nervous system
What does allodynia mean?
Pain from stimulus that is not normally painful
What does hyperalgesia mean?
More pain than expected from a painful stimulus
How do topical analgesics affect pain?
Reduce pain impusles transmitted by A-Delta-fibres and C-fibres
How do brain tumours commonly present?
Progerssive neurolgical deficit 70%
Motor weakness 50%
headache 50%
sexiures 25%
What is classical for a headache caused by a brain tumour ?
Worse in the morning
Wakes them up when they are asleep
Worse with coughing and leaning forward
Learn this
What are the four grades of Astrocytic tumors?
I Pilocytic
II Low grade astrocytoma
III Anaplastic astrocytoma
IV Glioblastoma
What is a Grade 1 astrocytoma?
Truly benign low growing legion
Who gets grade 1 astrocytomas?
Children and young adults
How do you treat grade 1 astrocytomas?
Surgery - Curative
What is this ?
Pilocytic Astrocytoma grade 1
Where do people normally get "low Grade" astrocytomas?
Temporal Lobe
Posterior Frontal lobe
Anterior Parietal lobe
How do low grade astrocytomas nomrally present ?
Seizures
What are the treatment options for grade II astrocytomas?
No treatment
Raidation
Chemotherapy
Combined Radiation and Chemotherapy
Plus or minus surgery
What factors suggest a poor prognosis in Grade II astrocyomas?
- Age >45
- Low performance score
- tumor >6cm
- Tumour crossing midline
- Incomplete resection
-
- Incomplete resection
What is Glioblastoma Multiform?
Stage 3 / 4 astrocytoma
Most common primary tumor
median survival < 1yr
What is an Anaplastic astrocytoma?
Grade III/IV malignant astrocytoma
Median survival 2 years
How do you treat grade 3 and 4 astrocytomas?
Surgery - not curative but can help symptoms
Post operative radiotherapy
Where do people get olidodendroglial tumors and at what age?
Frontal lobes
Adults 25-45 yrs old
How do people with Oligodendroglial tumors present ?
With seizures
How do you treat Oligodendroglial tumors ?
Chemothrapy + surgery
What is the median surivial for Oligodendroglial tumors?
10 years
What are the brain tumor red flags for adults and children?
Adults
Headaches that wake you +/- vomiting
New neurological deficit incl seizures
Children
Tiptoeing, ataxia and vomiting
What are the red flags for headaches?
- New onset headache over aged 55
- Known/previous malignancy
- Immuno-suppressed
- Early morning headache
- Exacerbated by valsalva
What exaerbating symptoms should you ask about in headaches
Posture
Valsalva
How do you diagnose a migraine?
Pain that is 2 Of:
- Moderate/severe
- Unilateral
- Throbing
- Worst on movement
And 1 of:
- Photophobia
- Phonophobia
What is the pathophysiology of Migraines?
Stress triggers changes in the brain releasing serotonin
Blood vessels constrict and dilate
Chemicals including substance P irritate the nerves and blood vessels
What is an Aura when refering to a migraine?
Fully reversible visual, sensory , motor or language symptom
What are common triggers for migraines ?
Sleep
Dietary
Stress
Hormonal
Physical exertion
Headache diary can help identify triggers
How do you treat a migraine?
Aspirin
Naproxen
Ibuporfen
ASAP ( sooner the better)
What are Triptans?
5HT agonist used to treat migraines
Take at the start of the headache
Sublingual
Whats the problem with triptans?
Not sure if they are really that great and they are pretty expensive
When would you consider prophylaxic treatment for migraines ?
More than 3 attacks per month
Very severe attacks
What can be used as prophylaxis for migraines?
Propanolol
Topiramate
What prophylatic affect does propanolol have on migraines?
Reduces frequency by 60-80%
What are the contraindications for propanolol?
Contraindicated in asthma and heart failure
What is the downside to using Topiramate as a prohylaxis for migraines
It takes a while to start working
Many side effects:- weight loss, paraesthesia, impaired concentration enzyme inducer
What are trigeminal autonomic cephalgias?
Group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs with prominent ipsilateral cranial autonomic features.
Give examples of Ipsilateral cranial autonomic features
Ptosis
Miosis
Nasal stuffiness
Nausea/vomiting
Tearing
Eye lid oedema
What are the 4 types of trigeminal autonomic cephalgias?
Cluster
Paroxsymal hemicrania
Hemicrania continua
SUNCT
Who gets cluster headaches?
People in their 30s and 40s
When do people usually get cluster headaches?
Around sleep time
What are the features of cluster headaches
How long do they last and how frequent are they
Severe unilateral headache
Lasting 45-90 mins
1-8 time a day for weeks to months
How do you treat cluster headaches?
High flow Oxygen for 20 mins
Sub cut sumatriptan 6mg
Steroids reducing course over 2 weeks
What can be used as a prophylaxis for Cluster headaches?
Verapamil
Who gets paroxysmal hemicrania?
Elderly 50s-60s
What are the features of paroxysmal hemicrania?
How long does it last?
How frequent ?
Severe unilateral headache with unilateral autonomic features
10-30 mins
1-40 times a day
How do you treat paroxysmal hemicrania?
Responds well Indomethicin
What are the main differences between Paroxysmal Hemicrania and cluster headaches?
Paroxysmal Hemmicranias have a shorter duration and are more frequent than cluster headaches
They also respond really well to Indomethicin
What does SNUCT stand for?
S - short lied (15-120 seconds)
U - unilateral
N - neuralgiaform headache
C - conjunctival injections
T - tearing
How do you treat SUNCT?
Lamotrigine
or
Gabapentin
What investigations would you do for someone with new onset unilateral cranial autonomic features?
MRI brain
MR angiogram
Who gets trigeminal neuralgia?
Older people >60
Woman
What triggers trigeminal neuralgia ?
Touch - usually V2/3
What are the features of trigeminal neuralgia?
Duration ?
Frequency?
Severe stabbing unilateral pain
1-90seconds
10 - 100 times a day
few weeks to months before remission
how do you treat trigeminal neuralgia?
Carbamazepine
Gabapentin
Phenytoin
Baclofen
Surgical - Abalation vs decompression
When is a CT scan appropriate in someone who presents with falls/seziures ?
- Suspected skull fracture
- Deterioratting GCS
- Focal signs
- Head injury with seizure
- Failure to be GCS 15/15 4hrs after arrival
- Failure to be GCS 15/15 4hrs after arrival
If it is your 1st seziure how long must you wait before you can drive again?
6 months
If you have epilepsy how long must you wait before driving again?
1 year
or
3 years during sleep
What conditions are commonly confused with eplilepsy ?
(i.e should be on your differential diagnosis list)
Syncope
Non-epilepti attack disorder
Panic attacks/Hyperventilation
Sleep phenomena
What is Epilepsy?
A tendency to recurrent, usually spontaneous eplieptic seizures
What is a an eplieptic seizure?
Abnormal synchronisation of neuronal activity
Usually excitaory with high frequency action potentials
What are the 7 types of eplileptic seizures?
Partial
Simple
Complex
Generalised
Absence
Myoclonic
Atonic
Tonic
Tonic Clonic
When does primary generalized epilepsy usually present ?
Childhood or early teens
How do you treat primary generalized epilepsy?
Sodium Valproate
or
Lamotrigine
What is important to remember about Sodium Valproate?
Its teratogenic
What is focal onsent epilepsy?
Epilepsy with an underlying stuctural cause
How do you treat Focal onset epilepsy?
Carbamazepine
Iamotrigine
What are the symptoms of Focal onset epilepsy?
Complex partial seizures with hippocampal sclerosis
How effective are Anti-epiletic drugs (AEDs)
55% seizure free on monotherapy
What can be used as an anticonvulsant during an acute seizure?
Phenytoin
What are the two best anti-convulsant?
Lamotrigine
Levetiracetam
What is important to remeber about anti-convulsants?
Interfere with the oral contraceptive pill
What are the the three types of spontaneous intracranial haemorrhage?
Subarachnoid haemorrhage
Intracerebral haemorrhage
Intraventricular haemorrhage
What is a subarachnoid haemorrhage?
Bleeding into the subarachnoid space
What is the mortality of subarachnoid haemorrhages?
45% at 1 month
How does a subarachnoid heamorrhage present?
Sudden onset:
- Severe headache
- Collapse
- Vomiting
- Neck pain
- Photophobia
What is a good investigation for looking for brian aneurisims?
Cerebral Angiography
What is the risk of a subarachnoid heamorrage re-bleeding at
(a) 2 weeks
(b) 6 months
2 weeks - 20%
6 months - 50%
After someone has a subarachnoid heamorrage what 3 things do you have to look out for ?
Delayed Ischaemia
Hydrocephalus
Hyponaturaemia
How do you treat delayed ischaemia ?
Nimodipine
How do you treat hydrocephalus?
CSF draingage
What is an intracerebral haemorrhage?
Bleeding into the brain parenchyma
What is the most common cause of Intracerebral haemorrhages?
Hypertension - 50%
How do intracerebral haemorrhages present?
Headache
Focal neurological deficit
Decreased conscious level
How do you treat intracerebral haemorrahge?
Surgical evacuation of haematoma
What is a Intraventricular haemorrhage and how does it happen?
Bleeding into a ventricle
Occurs with rupture of a subarachnoid or intracerebral bleed into a ventricle
What are the clincial features of a upper motor neurone lesion?
Increased tone
Hyper reflexia
Muscle wasting
No fasiculation
What are the clinical features of a lower motor neurone lesion?
Decreased tone
Muscle wasting
Fasciculation
Diminished reflexes
What do the spinothalamic tracts do?
Pain
temperature
crude touch
Do the spinothalamic trats govern the ipsilateral or contralateral side of the body?
Contralateral
What do the Dorsal columns of the spinal cord do?
Fine touch
Proprioception
Vibration
What is motor neuron disease?
untreatable and rapidly progressive neurodegenerative condition
How does motor neurone disease progress?
Starts focal and then spreads continously untill generalzed paresis
What is the average survival time of Motor Neuron disease?
3 years
Is motor neuron disease familial or sporadic?
10% familial , 90% sporadic
What is Amyotrophic lateral sclerosis?
It is the most common subtype of motor neuron disease
What is the most common age range for motor neuron disease?
50-75 year
Where does Motor Neuron Disease usually start?
Normally extremeties ( mostly upper)
What things must you warm someone with parkisnons about when they are first starting on Levodopa?
Impulse control disorders made worse
Sleepiness
Psychotic symptoms
What is the frist lime pharmacological treatment for alzehmiers ?
Acetlylholinesterase inhibitors
Donepezil
Galantamine
Rivastigmine
What is the second line pharmacological treatment for alzehimers?
Memantine
NMDA antagois