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Neurology 1 Flashcards

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1
Q

Definitions

Seizure
Epilepsy
Syncope

A

Seizure - Clinical manifestation of abnormal and excessive neuronal discharge

Epilepsy - A tendency to have seizures
(2 or more seizures > 24 hours apart)

Syncope - Transient global cerebral hypoperfusion

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2
Q

Epilepsy - Associated conditions

A 
Cerebral palsy
Tuberous sclerosis
Downs
Mitochondrial disease
SLE 
Cerebral vascular disease
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3
Q

Focal seizures

A

Focal aware

  • No LOC
  • No memory loss
  • No post-ictal symptoms

Focal impaired awareness

  • LOC
  • Memory loss
  • Post-ictal confusion

Jacksonian - Spreads distal to proximal
Todd’s - Paralysis after a seizure

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4
Q

Temporal seizures

A

Hallucinations
Deja vu
Post-ictal dysphasia

Automatisms

  • Lip smacking
  • Grabbing
  • Pulling
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5
Q

Frontal seizures
Parietal seizures
Occipital seizures

A

Frontal seizures

  • Movements
  • Post-ictal weakness
  • Jacksonian march

Parietal seizures - Paraesthesia

Occipital seizures

  • Floaters
  • Flashes
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6
Q

General seizures

A

Both hemispheres
Always LOC

Incontinence
Tongue biting

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7
Q

Pre-ictal symptoms

A

Prodrome - Change in mood or behaviour

Aura

  • Strange feeling in gut
  • Deja vu
  • Flashing lights
  • Olfactory changes
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8
Q

Post-ictal symptoms

A 
Headache
Confusion
Myalgia
Sore tongue
Temporary weakness - Frontal lobe
Dysphasia - Temporal lobe
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9
Q

Organic causes of seizures

A

VITAMIN D

Vascular - Stroke, SAH, haematoma
Infection - Meningitis, abscess
Trauma
Autoimmune - SLE 
Metabolic - See separate card!
Iatrogenic - See separate card! 
Neoplasm - Primary and secondary metastases 
Degenerative
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10
Q

Metabolic causes of seizures

Iatrogenic causes of seizures

A

Metabolic

  • Hypoglycaemia
  • Hypoxia
  • Alcohol withdrawal
  • Hyponatraemia
  • Hypocalcaemia
  • Hypokalaemia
  • Hypernatraemia
  • Hypercalcaemia
  • Uraemia

Iatrogenic

  • Tricyclics
  • Benzos
  • Tramadol
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11
Q

Epilepsy investigations and management

A

EEG / MRI

Start management after second epileptic seizure

Start after first seizure if…

  • FND
  • Brain imaging shows structural abnormality
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12
Q

Focal seizure management

A

Carbamazepine
Lamotrigine
Valproate
Levetiracetam

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13
Q

Generalised seizure management

A

Absence - Valproate + Ethosuximide

Tonic-clonic - Valproate + Lamotrigine + Carbamazepine

Myoclonic - Valproate + Lamotrigine + Clonazepam

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14
Q

Valproate side effects

A 
Vomiting
Anorexia / ataxia
Liver toxicity
Pancreatitis
Retention of weight
Oedema
Alopecia
Teratogenic - Neural tube defects
Enzyme inhibitor - CP450
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15
Q

Epilepsy driving rules

A

Cannot drive for 6 months after first unprovoked seizure
(If no structural defect on imaging + No epilepsy on EEG)

If epilepsy - Must be seizure free for 12 months

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16
Q

Status epilepticus

A

Seizure > 5 minutes

> 2 seizures in 5 minutes

Causes

  • Stopping anti-epileptic drugs
  • Alcohol withdrawal
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17
Q

Status epilepticus management

A 
ABCDE
Buccal midazolam
Rectal diazepam
IV lorazepam
Phenytoin / Phenobarbitol
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18
Q

Status epilepticus complications

A 
AKI from rhabdomyolysis
Lactic acidosis
Hypercapnia
Vomiting
Hypoxia
Pneumonia
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19
Q

Headache red flags

A

Raised ICP - SOL
Jaw claudication - GCA

Paraesthesia and FND - Stroke / migraine

Visual disturbance - TN / SAH / meningitis

Thunderclap headache - SAH

Neck stiffness - Meningitis / SAH

Personality changes - Stroke / tumour / frontal lobe pathology

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20
Q

Migraine criteria

A

ABCDE

At least 5 incidents, fulfilling the criteria…

B - Headache lasting 4-72 hours

Characteristics - 2 of…

  • Unilateral
  • Pulsating
  • Moderate/severe pain
  • Aggravated by / or avoidance of physical activity

During - 1 of…

  • N/V
  • Photophobia

Examination/history does not suggest secondary headache

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21
Q

Migraine investigations

A

Ophthalmoscopy
BP
Full neuro assessment

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22
Q

Migraine management

A

Acute

  1. Combination therapy - Sumatriptan + NSAIDs
  2. Metoclopramide
  3. Prochlorperazine

Prophylaxis > 2 attacks per month

  • Topiramate - CI in pregnancy
  • Propranolol - CI in asthma
  • Acupuncture
  • Riboflavin
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23
Q

Tension headache management

A

Avoid triggers (LADS)

  • Sleep hygiene
  • Meditation

Acute

  • Aspirin
  • Paracetamol
  • NSAIDs

Prophylaxis - Acupuncture

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24
Q

Cluster headache

A

More common in men

Severe unilateral orbital stabbing pain
“ Worst pain of all time”
Relieved by movement
Worse at night

Once a year
15-180 minutes
Clusters of 6-12 weeks

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25
Cluster headache triggers
``` Alcohol Smoking Exercise Heat Histamine ```
26
Cluster headache management
Avoid triggers Acute - Sumatriptan - O2 Prophylaxis - Verapamil - Topiramate - Prednisolone
27
Trigeminal neuralgia aetiology and triggers
Associated with MS Triggers - Light skin contact - Washing - Shaving - Talking - Brushing teeth + Smoking!
28
Trigeminal neuralgia presentation
Shock-like sensations in trigeminal nerve Most commonly the maxillary branch Severe unilateral pain Worse on touching face Up to 100 attacks per day 1-180 seconds
29
Trigeminal neuralgia investigations
CT/MRI - Rule out SOL Referral if red flags... - Sensory deficit - Optic neuritis - Family history MS - Onset < 40
30
Trigeminal neuralgia management
Carbamazepine Alternatives... - Lamotrigine - Phenytoin - Gabapentin - Surgery - Radiotherapy
31
GCA aetiology
Associated with PMR (Proximal muscle and joint pain) Cause - Vasculitis More common in females
32
GCA presentation
Women and older men Severe pain - Jaw claudication - Scalp pain - Worse with chewing, talking, brushing hair Amaurosis fugax Muscle and joint pain B symptoms
33
GCA investigations
Bloods - ESR ^ - Platelets ^ - ALP ^ - Hb - LOW Colour duplex USS + Temporal artery biopsy - Granulomatous inflammation - May be negative due to skip lesions!
34
GCA management
Prednisolone (+Bisphosphonate) Asprin (+Omeprazole) Urgent ophthalmology review if visual symptoms
35
GCA complications
Irreversible bilateral visual loss Aneurysms CVA Seizures
36
SAH causes
Aneurysm - HTN, PKD, AVM Common places... - ACA and anterior communicating - MCA bifurcation - Posterior communicating and internal carotid
37
SAH presentation
Sudden onset Severe "thunderclap" headache ``` Meningism Focal neurological deficit CN3 palsy - Posterior communicating Seizures Reduced GCS Vomiting ``` Similar to meningitis - Are they systemically unwell?
38
SAH investigations
CT - Star shaped lesion in basal cistern LP - Xanthochromia - RBD breakdown product - Protein ^ ECG - Long QT - ST elevation Ophthalmoscopy - Loss of light reflex - Intraocular haemorrhage
39
SAH management
Neurosurgery - Endovascular coiling Nimodipine - Reduces spasm Shunt if ICP ^
40
SAH complications
Rebleed Vasospasm - Stroke Hyponatraemia Hydrocephalus Loss of sympathetic reflex - HTN ^^^
41
SDH aetiology
Tear in bridging veins Alcoholics Elderly - Anticoagulants? Shaken babies
42
SDH presentation
Head trauma followed by... ``` LOC FND Headache Personality changes Reduced GCS ```
43
SDH investigations
CT - Concave lesion - Not limited by suture lines Dark lesion = Old bleed Bright lesion = New bleed Midline shift?
44
SDH management
Burr holes Craniotomy Old lesion = Conservative management
45
EDH aetiology
Low-impact head trauma Pterion - Joining of parietal, frontal, temporal, sphenoid bones Middle meningeal artery - 90% Dural venous sinus - 10%
46
EDH presentation
Trauma followed by lucid interval Sudden drop in GCS Headache ^ ICP symptoms Brisk reflexes Upward plantars Symptoms of skull fracture - Asymmetrical face - CSF rhinorrhoea
47
EDH investigations and management
CT - Convex lesion - Limited by suture lines XR - Skull fracture LP is contraindicated! Management - Mannitol to treat raised ICP - Burr holes
48
Parkinson's aetiology
Degenerative Loss of dopaminergic neurons in SN More common in men Mean age of diagnosis is 65 (Associated with ^ age) Repeated head trauma - Boxing? Iatrogenic - Metoclopramide - Neuroleptics
49
Alternative causes of tremor
Other causes of tremor... - SSRIs - Amphetamines - Salbutamol - Lithium - Alcohol - Thyroid disease ``` Wilson's disease Cerebellar trauma EPSE NPH LBD ```
50
Parkinson's presentation
1. Bradykinesia 2. Resting tremor - Pill rolling 3. Rigidity - Cog wheel Shuffling gait Reduced arm swing ``` REM sleep disorders Anosmia Monotone voice Micrographia Loss of facial expression Dementia Depression Urinary incontinence - NPH? Sexual dysfunction ```
51
Parkinson's investigations
Clinical diagnosis - Bradykinesia + 1 other Histology - Lewy bodies - Eosinophilic cytoplasmic inclusions consisting of alpha synuclein Exclude differentials - Medications? - Cerebellar disorder - Imaging? - Wilson's - Bloods? Screen for depression
52
Parkinson's pharmacological management
Increase dopamine - Levodopa Dopamine agonist - Ropinirole Decrease dopamine breakdown - Rasagiline - Entacapone Tremor - Amantidine - Anticholinergics Depression - SSRI?
53
Parkinson's non-pharmacological management
``` PT SALT OT DBS Surgery - Interruption of overactive BG circuits ```
54
Parkinson's meds S/E
Ropinirole - Drowsiness - Impulsivity - Inhibition disorder - N/V - Dizziness - Visual hallucinations Anti-ACh - Falls Levodopa - Reduced efficacy with time - On/off effect - Fluctuations - Freezing - N/V - Dry mouth - Hypotension - Dyskinesia - Arrhythmias
55
Parkinson's PLUS
VIVID Vertical gaze palsy - Supranuclear gaze palsy Impotence / incontinence - Multiple system atrophy Visual hallucinations - LBD Interfering limb - Cortico-basal degeneration Diabetes / HTN - Vascular Parkinson's
56
Tremor causes
Cerebellar disease - DANISH Parkinson's Essential tremor - Vocal cords - Worse with arms outstretched - Improved by alcohol and rest - BBs Orthostatic - Legs Multiple system atrophy - Autonomic symptoms Iatrogenic - See separate card
57
Drugs causing tremor
CALVSS ``` Caffeine Amphetamines Lithium Valproate Salbutamol SSRIs ```
58
NPH aetiology
Reduced CSF resorption at arachnoid villi ``` Idiopathic Meningitis Head injury CNS tumour SAH ```
59
NPH presentation / investigations / management
Wet Whacky Wobbly - Urinary incontinence - Dementia - Falls Investigations - CT - Enlarged 4th ventricle - LP - Normal opening CSF pressure Management - VP shunt - Acetazolamide
60
Hydrocephalus aetiology
Obstructive - Tumour - Haemorrhage Non-obstructive - NPH - Increased production - Choroid plexus tumour
61
Hydrocephalus presentation / investigations / management
Raised ICP symptoms - Headache - N/V - Papilloedema Investigations - CT - Dilatation of ventricles above lesion - LP - Diagnostic and therapeutic Management - Eternal ventricular drain - VP shunt
62
Huntington's aetiology
Mutation of Huntingtin gene 4p16.3 AD Trinucleotide repeat CAG Degeneration of cholinergic and GABA neurons in BG
63
Huntington's presentation
Early - Personality changes - Apathy - Chorea / tics / myoclonus Late - Seizures - Spasticity / clonus - Supranuclear gaze palsy Psych - Dementia - Depression
64
Huntington's investigations
Genetic testing MRI - Loss of corpus striatum volume - Large frontal horns of lateral ventricles
65
Huntington's management
Chorea - Benzodiazepines - Valproate Dopamine depleting agents - Tetrabenzene DBS SSRI Antipsychotics
66
Reflex syncope
Vasovagal - Emotion - Stress - Standing too long Situational - Coughing - Micturition - GI - Exercise Carotid sinus hypersensitivity
67
Cardiogenic syncope
All arrhythmias Structural defects - MI - Valve disease - Aortic stenosis - Tamponade - Dissection BBB Brugada syndrome Heart block WPW
68
Orthostatic hypotension
Dehydration - Infection - Haemorrhage Drugs - Diuretics - Alcohol - Vasodilators AI failure - Parkinson's - LBD - Uraemia - Diabetic neuropathy
69
Syncope investigations
Lying / standing BP Change > 20/10 = Abnormal Systolic BP < 90 24hr ECG Cardiology exam Neurology exam Tilt table test FBC - Anaemia? Inflammatory markers EEG
70
NEAD
Disorder of movement, sensation or experience Resembles an epileptic seizure without cerebral ictal discharge More common in females Attacks do not occur when patient is alone
71
NEAD aetiology
Family history - Epilepsy? Childhood abuse Neglect Psychiatric illness - Depression - Schizophrenia
72
NEAD presentation
Pelvic thrusting Post-ictal crying Gradual onset Long duration Violent thrashing Ability to control seizure location
73
NEAD investigations and management
Prolactin - Normal Video telemetry Management - Talking therapy / CBT
74
Stroke classification
Anterior - ACA/MCA - Weakness - Paraesthesia - Homonymous hemianopia - Higher cognitive disorder - Dysphasia? Posterior - Vertebrobasilar - LOC - Homonymous hemianopia - Cerebellar disorder - CN palsy - Contralateral motor/sensory deficit Lacunar - Perforating arteries - Pure motor - Pure sensory - Ataxic hemiparesis - Mixed sensory/motor
75
Additional strokes
Weber - PCA - CN3 - Contralateral hemiparesis Wallenberg - Posterior inferior cerebellar artery - Ipsilateral sensory loss of pain - Loss of gag reflex - Hoarse voice - Horner's syndrome Lateral pontine syndrome - Anterior inferior cerebellar artery - Same as Wallenberg + Ipsilateral face paralysis + Deafness Locked in syndrome - Basilar artery - Unable to move except eyes - Extraocular muscles
76
Aphasia
Wernicke's - Superior temporal gyrus - MCA - Fluent - Impaired comprehension Broca's - Inferior frontal gyrus - MCA - Not fluent - Normal comprehension Conduction aphasia - Arcuate fasciculus - Fluent - Normal comprehension - Poor repetition - Aware of errors Global aphasia - All 3 areas
77
Stroke investigations
``` Glucose U&E Cardiac enzymes Clotting - INR / PT FBC ECG ``` CT head - Non-contrast
78
Ischaemic stroke management
Acute - ABCDE - Aspirin 300mg - Presentation < 4.5 hours - Thrombolysis (IV alteplase) - Presentation > 4.5 hours - Endovascular thrombectomy ``` Secondary prevention - Aspirin 300mg - 2 weeks - Clopidogrel 75mg - For life - Statin if cholesterol > 3.5mmol/L after 48 hours Anticoags - AF patients ```
79
Haemorrhagic stroke management
Factor 7A Reverse warfarin - Vitamin K Reverse heparin - Protamine Symptom control - Seizures - Lamotrigine - ICP - Mannitol - BP - BB Surgical evacuation
80
TIA definition
Transient episode of neurological dysfunction Caused by focal brain, spinal cord, or retinal ischaemia WITHOUT acute infarction
81
TIA presentation and investigations
Presentation - Same as stroke - Amaurosis fugax Investigations - 24 hour ECG - MRI - Carotid doppler
82
TIA management
Aspirin 300mg Clopidogrel 75mg Statin Carotid endarterectomy Lifestyle changes
3B
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