Ella Kulman Neurology

Give 3 examples of a primary headache

1. migraine
2. tension headache
3. cluster headache

Give 4 examples of a secondary headache

1. meningitis
2. subarachnoid haemorrhage
3. giant cell arteritis
4. medication overuse headache

give potential red flags for suspected brain tumour in a pt presenting with headache

1. new onset and hx of cancer
2. cluster headache
3. seizure
4. significantly altered consciousness, memory, confusion
5. papilloedema - swollen optic disc
6. other abnormal neuro exam

How long do migraine attacks tend to last?

4-72 hours

describe the pain of a migraine

1. unilateral
2. throbbing
3. moderate/severe pain
4. aggravated by physical activity

Would a pt with migraine experience any other symptoms?

photophobia and/or phonophobia are common complaints. may have nausea but not vomiting

what % of migraines are with/out aura?

20% with, 80% without

what would a pt experiencing migraine with aura complain of?

-visual disturbances e.g. flashing lights, zig-zag lines
-sensory disturbances e.g. tingling in hands/feet
-language aura and motor aura

describe treatment for migraine (non/pharmacological)

-lifestyle modification and trigger management
-PO triptan and NSAIDs
-anti emetics
-preventative treatments: propranolol, acupuncture, amitriptyline

how long do tension headaches usually last for?

30 mins - 7 days

describe the pain of a tension headache

1. bilateral
2. pressing/tight
3. mild/moderate pain
4. not aggravated by physical activity

would a pt with a tension headache experience any other symptoms?1

no!

what is the diagnostic criteria for medication overuse headache?

-headache present for >15 days/months
-regular use for 3mths+ of 1+ symptomatic treatment drugs
-headache has developed or markedly worsened during drug use

describe the pain of a cluster headache

-severe/very severe pain
-pain around the eye/temporal area
-unilateral
-headache accompanied by cranial autonomic features

how long do cluster headaches usually last?

15mins - 3hours

what features present in a history may indicate meningitis?

-pyrexia
-photophobia
-neck stiffness
-non-blanching purpura rash

investigations for suspected meningitis:

-bloods: FBC, U+E, CRP, serum glucose, lactate
-blood cultures
-throat swab
-lumbar puncture
-CT head

how would you describe the headache associated with sub-arachnoid haemorrhage?

thunderclap headache - maximum severity within seconds

describe the management for subarachnoid haemorrhage

1. resuscitation
2. nimodipine - CCB
3. early intervention and close monitoring will improve prognosis

what muscle needs to be working in order to test the action of superior and inferior rectus?

lateral rectus

superior and inferior oblique can never be isolated in action. how can they be tested?

position the eye so that superior and inferior recti are giving maximal rotation, and look for complete correction

name 3 organisms that can cause meningitis in adults

1. N.meningitidis (g-ve diplococci)
2. S.pneumoniae (g+ve cocci chain)
3. Listeria monocytogenes (g+ve bacilli)

name 3 organisms that can cause meningitis in children

1. E. coli (g-ve bacilli)
2. group B streptococci (e.g. s.agalactiae)
3. Listeria monocytogenes

give symptoms of meningitis

1. non-blanching petechial rash
2. neck stiffness
3. headache
4. photophobia
5. papilloedema
6. fever

what antibiotic is commonly given to treat meningitis?

cefotaxime

for which bacteria is meningitis prophylaxis effective against?

N.meningitidis

What can be given as prophylaxis against N.meningitidis infection?

Ciprofloxacin

at what vertebral level would you do a lumbar puncture?

L4/5

give 4 potential adverse effects of doing a lumbar puncture

1. headache
2. damage to spinal cord
3. paraesthesia
4. CSF leak

what investigations would you do on a CSF sample?

-protein and glucose levels
-MCS
-bacterial and viral PCR

what is the most common cause of viral meningitis?

enterovirus

what is the colour of CSF in someone with bacterial infection?

cloudy (it is normally clear)

give symptoms of encephalitis

-fever
-headache
-lethargy
-behavioural change

treatment for encephalitis

acyclovir

Give 5 symptoms of rabies

1. Fever
2. Anxiety
3. Confusion
4. Hydrophobia
5. Hyperactivity

Name the organism responsible for causing tetanus

Clostridium tetani (gram +ve anabrose) → infects via dirty wounds

3 symptoms of tetanus

1. Trismus (lockjaw)
2. Sustained muscle contraction
3. Facial muscle involvement

It a pt has aphasia, what region of the brain has been affected?

Broca's area

If a pt has receptive dysphagia what region of the brain has been affected?

Wernicke's area

Name 3 intracranial haemorrhages

1. Extra-dural
2. Sub-dural
3. Sub-arachnoid

What can cause sub-arachnoid haemorrhages?

rupture of a berry aneurysm around the circle of Willis

Give 5 symptoms of a sub-arachnoid haemorrhage

1. Sudden onset 'thunderclap' headache
2. Photophobia
3. Reduced consciousness
4. Neck stiffness
5. Nausea and vomiting

What is the treatment for a sub-arachnoid haemorrhage?

- Bed rest and BP control
- CCB to prevent cerebral artery spasm
- IV saline

what can cause a sub-dural haematoma?

head injury → vein rupture

Describe the natural history of a sub-dural haematoma

Latent period after the head injury. 8-10 weeks later the clot starts to breakdown, and there is a massive increase in oncotic pressure, water is sucked up into the haematoma → signs and symptoms develop. There is a gradual rise in ICP

3 symptoms of sub-dural haematoma

1. Headache
2. Drowsiness
3. Confusion

Treatment for a sub-dural haematoma?

surgical removal

What can cause an extra-dural haematoma?

Trauma to the temporal bone → bleeding from the middle meningeal artery

What do ventricles do to prolong survival in someone with an extra-dural haemorrhage?

The ventricles get rid of their CSF to prevent the rise in inter-cranial pressure

What is the treatment for an extra-dural haematoma?

Immediate surgical drainage

give 2 primary causes of intra-cerebral haemorrhage

1. hypertension → berry or Charcot-Bouchard aneurysms rupture
2. lobar (amyloid angiopathy)

give 5 secondary causes of an intra-cerebral haemorrhage

1. tumour
2. arterio-venous malformations (AVM)
3. cerebral aneurysm
4. anticoagulants e.g. warfarin
5. haemorrhagic transformation infarct

what is the most likely cause of bleeds in the basal ganglia, pons and/or cerebellum?

hypertension

describe the treatment for anti-coagulant related intra-cerebral haemorrhage

check warfarin INR (test for how long it takes for your blood to clot) and consider reversal with vitamin K

*if platelets low → platelet transfusion

define stroke

rapid onset of neurological deficit which is the result of a vascular lesion and is associated with infarction of CNS tissue

what can cause a stroke?

1. cerebral infarction due to embolus or thrombosis (85%)
2. intracerebral/sub-arachnoid haemorrhage (15%)

give risk factors for stroke

-hypertension
-diabetes mellitus
-cigarettes
-hyperlipidaemia
-obesity
-alcohol

signs of an ACA stroke

-lower limb weakness/loss of sensation
-gait apraxia (unable to initiate walking)
-incontinence
-drowsiness
-decrease in spontaneous speech

what does the ACA supply?

medial surface of frontal and parietal lobes

signs of a MCA stroke

-upper limb weakness/loss of sensation
-hemianopia
-aphasia (difficulty with speech/language)
-dysphasia (impairment in speech production)
-facial drop

What does the MCA supply?

Most of the lateral cortex,
speech/language/swallowing
& Broca/Wernicke

signs of a PCA stroke

-visual field defects
-cortical blindness (total/partial blindness in a normal-appearing eye)
-visual agnosia (impairment in recognition of visually presented objects)
-prosopagnosia (impairment in processing information about faces)
-dyslexia
-unilateral headache

What does the PCA supply?

occipital lobe

what is visual agnosia?

an inability to recognise/interpret visual info

what is prosopagnosia?

inability to recognise a familiar face

pt presents with weakness and loss of sensory sensation to the upper limb, aphasia and facial drop. which artery is likely to have been occluded?

middle cerebral artery

pt presents with weakness and loss of sensory sensation to the lower limb, incontinence, drowsiness and gait apraxia. which artery is likely to have been occluded?

anterior cerebral artery

pt presents with contralateral homonymous hemianopia, they are unable to recognise familiar faces and complain of a headache on one side of their head. which artery is likely to have been occluded?

posterior cerebral artery

what is the treatment for ischaemic stroke?

thrombolysis e.g. alteplase → IV infusion to break up the clot

what is MS?

a chronic auto-immune disorder of the CNS. it's an inflammatory and demyelinating disease characterised by progressive disability

where would MS plaques be seen histologically?

around blood vessels: perivenular

does myelin regenerate in someone with MS?

yes, but it is much thinner which causes inefficient nerve conductions

give 3 major features of an MS plaque?

1. inflammation
2. demyelination
3. axon loss

describe the relapsing/remitting course of MS

pt has a number of random attacks over a number of years, between attacks there is no disease progression

describe the chronic progressive course of MS

slow decline in neurological functions from the onset

what can exacerbate the symptoms of MS?

heat → typically a warm shower (relieved by cooler temps)

potential signs of MS

-spasticity
-nystagmus (involuntary eye movement)/double vision
-optic neuritis → impaired vision and pain
-paraesthesia
-bladder/sexual dysfunction

give 3 atypical MS symptoms (i.e. if they have these it is unlikely to be MS)

-aphasia
-hemianopia
-muscle wasting

potential differentials for MS

-SLE
-sjogren's
-AIDS

what investigations might you do in suspected MS?

-MRI of brain and spinal cord → lesions may be seen around ventricles
-lumbar puncture → CSF

what medication might you give to someone to reduce the relapse severity of MS?

short course steroids e.g. methylprednisolone

describe the pharmacological treatment for MS

-beta interferon (anti-inflammatory)
-natalizumab (mono-clonal antibody)
-stem cell transplant
-muscle relaxants for spasticity and other symptom relief

what is a UMN?

upper motor neuron → neurone located entirely in the CNS (cell body in the primary motor cortex)

signs of UMN weakness

-spasticity
-increased muscle tone
-hyper-reflexia
-minimal muscle atrophy

causes of UMN weakness

-MS
-brain tumour
-stroke

what is LMN?

neurone that carries signals to effectors → cell body located in the brain stem/spinal cord

signs of LMN weakness

-flaccid
-reduced muscle tone
-hypo-reflexia
-muscle atrophy
-fasciculations (muscle twitches)

what is epilepsy?

tendency to have seizures

define seizure

convulsion caused by paroxysmal discharge of cerebral neurones → abnormal and excessive excitability of neurones

give causes of transient loss of consciousness

-syncope
-epileptic seizures
-non-epileptic seizures
-intoxication e.g. alcohol
-ketoacidosis/hypoglycaemia
-trauma

give causes of epilepsy

-flashing lights
-CVD e.g. stroke
-genetic predisposition
-CNS infection (e.g.
-trauma

signs of an epileptic seizure

-30-120s in duration
-'positive' symptoms e.g. tingling and movement
-tongue biting
-head turning
-muscle pain

define syncope

insufficient blood/oxygen supply to the brain causing paroxysmal changes in behaviour, sensation and cognitive processes

give signs that a transient loss of consciousness is due to syncope

-situational
-5-30s duration
-sweating
-nausea
-pallor
-dehydration

what is likely to last for longer, an epileptic or non-epileptic seizure?

non-epileptic seizure can last from 1-20 minutes whereas an epileptic seizure lasts for 30-120s

what 2 categories can epileptic seizures be broadly divided into?

-focal epilepsy → only one portion of the brain is involved
-generalised → the whole brain is affected

give 3 examples of focal epileptic seizures

1. simple partial seizures with consciousness
2. complex partial seizures without consciousness
3. secondary generalised seizures

give 3 examples of generalised epileptic seizures

1. absence
2. myoclonic
3. generalised tonic clonic

describe a generalised tonic clonic seizure

sudden onset rigid tonic phase followed by a convulsion (clonic phase) in which the muscles jerk rhythmically

*episode lasts up to 120s and is associated with tongue biting and incontinence

describe a myoclonic seizure

isolated muscle jerking