Year 3 - Neuro > General > Flashcards

General Flashcards

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1
Q

What are 5 red flags in headache presentation?

A 
New onset >55
Previous malignancy
Immunosuppression
Early morning headache
Exacerbation by Valsalva
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2
Q

In headache more common in men or women?

A

Women

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3
Q

What is the criteria for a diagnosis of migraine without aura?

A

5+ attacks lasting 4-72 hours
2 of: unilateral throbbing pain, worse on movement
1 of: photophobia, phonophobia, autonomic features

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4
Q

What is an “aura”?

A

Full reversible, visual, sensory , motor or language symptoms lasting 20-60 minutes

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5
Q

What can trigger a migraine?

A

Sleep, foods, stress, hormones, exercise

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6
Q

How is migraine managed?

A

Avoid triggers
Relaxation and stress management
Pharmacological

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7
Q

How can migraine triggers be identified?

A

Use of headache diary

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8
Q

How can headaches be treated pharmacologically?

A

NSAID, 5HT agonists

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9
Q

What NSAIDs can be used for headache?

A

Aspirin 900mg
Naproxen 250mg
Ibuprofen 400mg

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10
Q

How are 5HT agonists taken for migraine?

A

Orally, sublingual or s/c

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11
Q

What 5HT agonist (triptans) can be used for migraine?

A

Frovatriptan

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12
Q

When would migraine prophylaxis be considered?

A

3 attacks/month or very severe

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13
Q

What prophylaxis can be used for migraine?

A

Propanolol 80-240mg
Topiramate (carbonic anhydrase inhibitor) 25-100mg
Amitriptyline 10-75mg

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14
Q

What lifestyle factors affect migraine?

A

Hydration
Caffeine
Stress
Exercise

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15
Q

What are the 6 types of migraine

A 
Acephalgic
Basilar
Retinal
Ophthalmic
Hemiplegic
Abdominal
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16
Q

What is an acephalgic migraine?

A

No headache but aura present

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17
Q

What is a basilar migraine?

A

Migraine with vertigo/dizziness

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18
Q

Which type of migraine is common in kids?

A

Abdominal

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19
Q

How are tension type headaches treated?

A

Relaxation physiotherapy and anti-depressants

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20
Q

What does a tension type headache feel like?

A

Pressing, tingling, bilateral headache

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21
Q

What is a trigeminal autonomic cephalgia?

A

Primary headache disorder

Causing unilateral trigeminal distribution pain with cranial autonomic features

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22
Q

What cranial nerve features are present in trigeminal autonomic cephalgia?

A

Ptosis, miosis, n&v, nasal stiffness, tearing, eye lid oedema

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23
Q

What are the 4 types of trigeminal autonomic cephalgias?

A

Cluster
Paroxysmal
Hemicrania continua
SUNCT

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24
Q

Who gets a cluster type trigeminal autonomic cephalgia?

A

Men 30-40s

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25
What is a cluster type trigeminal autonomic cephalgia?
Unilateral, EXTREME, headache lasting 30mins to 2 hours
26
What is the pattern of cluster type trigeminal autonomic cephalgia?
1-8 per day for months
27
What is the treatment for a cluster type trigeminal autonomic cephalgia?
High flow oxygen for 20 mins S/c sumatriptan 6mg Steroids over 2 weeks Verapamil for prophylaxis
28
Who gets paroxysmal hemicrania type trigeminal autonomic cephalgia?
Women 50-60s
29
How does paroxysmal hemicrania type trigeminal autonomic cephalgia present?
Unilateral with autonomic features
30
What is the pattern of paroxysmal hemicrania type trigeminal autonomic cephalgia?
Comes and goes Lasts 10-30 mins Get 1-40 per day
31
How is paroxysmal hemicrania type trigeminal autonomic cephalgia treated?
Indomethicin 50mg TDS always works
32
How does SUNCT type trigeminal autonomic cephalgia present?
Short, unilateral headache with tearing
33
How are SUNCT type trigeminal autonomic cephalgias treated?
Lamotrigine, gabapentin
34
What investigations should be done for headaches?
MRI, MR angiogram, CT
35
Who gets idiopathic cranial hypertension?
Obese females
36
How does headache from idiopathic cranial hypertension present?
Headache with diurnal variation, worse on lying down
37
How is headache from idiopathic cranial hypertension investigated?
MRI with sequence
38
Describe pressure in CSF with idiopathic cranial hypertension?
Elevated >30
39
How does idiopathic cranial hypertension affect vision?
Visual acuity probably stays normal but there is loss of visual fields Eventually can go blind
40
Who gets trigeminal neuralgia?
Old women
41
How does trigeminal neuralgia present?
Severe stabbing unilateral pain lasting 1-90s
42
What is the pain in trigeminal neuralgia?
Lasts 1-90s, 10-100x daily | Weeks to months before remission
43
How is trigeminal neuralgia treated?
Carbamazepine, gabapentin, phenytoin, baclofen, surgical ablation and decompression
44
What investigation should be done in trigeminal neuralgia?
MRI
45
Which symptoms would a brain tumour present with?
Headache that wakes you up at night Progressive neuro symptoms Motor weakness Seizures (25%)
46
What is the most common extra-axial brain tumour?
Meningioma
47
How likely is it for a meningioma to become malignant?
Not
48
What is the second most common malignancy in children?
Meningioma
49
How does increased intercranial pressure present?
Headache, vomiting, mental changes, seizures
50
What are signs that increased intercranial pressure needs treated immediately?
Blown pupil | Rapidly reducing gcs
51
What can you give in increased intercranial pressure to reduce pressure in cavity?
Mannitol
52
Which cell type is mostly likely to be involved in brain tumour?
Oligodendrocytes
53
Who gets glial tumours?
25-45 year olds
54
Which tumour is solid, grayish with a "toothpaste" morphology?
Oligodendrocyte tumour
55
What are the 4 types of astrocytic tumours?
Type I - Pilocytic, pleomorphic xanthoastrocytoma Type II - Low grade, but becomes malignant Type III - Anaplastic Type IV - Glioblastoma multiforme
56
Who gets type I astrocytic tumours?
Children and young adults
57
Which type I astrocytic tumour is curable?
Cerebellar
58
How is a type I astrocytic tumour treated?
Surgery
59
How does a type II astrocytic tumour present?
Seizure
60
What are poor prognostic factors for type II astrocytic tumours?
``` >50 Focal deficit Short duration Raised ICP Altered consciousness Enhancement on contrast ```
61
How is a type II astrocytic tumour treated?
Surgery +/- radio or chemo
62
What is brachytherapy?
Placement of radioactive isotopes directly onto the tumour
63
What is the mean survival of a type III anaplastic astrocytic tumour?
2 years
64
What is the life expectancy with type IV astrocytic tumour?
15 months
65
How likely is a meningioma type III to become malignant?
90% are benign
66
How does a meningioma appear on a CT?
Homogenous Oedema Hyperostosis/skull blistering
67
How does a meningioma appear on an MRI?
Dural tail | Patent dural sinuses
68
What is the peak incidence of a germ cell tumour?
10-12 yrs
69
How does a germ cell tumour appear on CT?
Iso- or hyper-dense Enhancing Mixed histology
70
What is the most common CNS germ cell tumour?
Geminomas
71
What bloods should be done with any midline brain tumour in a child?
ALP HCG LDH
72
What are the features of POCS stroke?
``` Cranial nerve deficit Bilateral motor/sensory deficit Eye movement disorders Cortical blindness Cerebellar deficits ```
73
What are the features of TACS stroke?
Hemiplegia | Cortical signs incl dysphagia, diploplia, nystagmus and neglect
74
What are the features of PACS?
2/3 TACS features | Isolated cortical dysfunction
75
What are the features of LACS?
Occlusion of single deep penetrating artery affecting 2 of: face, leg, arm
76
Which stroke classification has the best prognosis?
LACS
77
What is small vessel disease classified into?
Types 1-6
78
What type of small vessel disease is most common?
Type 1
79
What is type 1 small vessel disease?
Arteriosclerotic
80
What is type 2 small vessel disease?
Sporadic and hereditary cerebral amyloid angiopathy | blood vessel in brain problem
81
What is type 3 small vessel disease?
Genetic
82
What is type 4 small vessel disease?
Inflammatory and immunologically mediated
83
What is type 5 small vessel disease?
Venous collagenosis
84
What is type 6 small vessel disease
Post radiation
85
What are the two main causes of primary intracerebral haemorrhage?
Hypertension | Amyloid angiopathy
86
What are causes of secondary intracerebral haemorrhage?
Arteriovenous malformation, aneurysm, tumour
87
What investigations are done in stroke?
``` Full lipid profile BP Carotid scan ECG Echo ```
88
What is the acute management of stroke?
``` Thrombolysis Imaging Swallow assessment Anti-platelets Stroke care unit DVT prophylaxis ```
89
What is the window of opportunity for TPA treatment in stroke?
4.5 hours
90
How much CSF is in the body?
150ml
91
What is the mean pressure of CSF?
14cmH20
92
Which drug reduces CSF production by 50%
Acetozolamide
93
When is the max volume of CSF?
Approx 2am
94
How heavy is the brain?
1.5kg
95
How does hydrocephalus present at birth?
Large head Thin/shiny scalp Bulging/tense fontalles
96
How can hydrocephalus be picked up prenatally?
USS
97
How does hydrocephalus present at infancy?
``` Moving up head centiles Poor feeding Vomiting Sleepiness Muscle stiffness Lack of up gaze Pupils unreactive to light ```
98
How is hydrocephalus treated?
Shunt placed posterior to the parietal eminence
99
What are complications of getting a shunt placed?
``` Over drainage Underdrainage Infection Haemhorrage Seizures Dissemination of tumour ```
100
How does a blocked CSF shunt present?
Headache Vomiting Sunsetting in eyes Blurred vision
101
How is a blocked shunt treated?
Tap shunt, CT, surgical intervention
102
What is ETV for hydrocephalus?
Opening created in the floor for the third ventricle to allow CSF to bypass the blockage prevent it from circulating
103
What major structure is at risk during ETV?
Basilar artery
104
Who gets normal pressure hydrocephalus?
Elderly
105
What is normal pressure hydrocephalus?
When the ventricles are enlarged but the pressure is normal
106
How does normal pressure hydrocephalus present?
Ataxia, memory decline, incontinence
107
How is normal pressure hydrocephalus investigated?
CT, MRI, LP tap test
108
What is an LP tap test for normal pressure hydrocephalus?
Measure pressure, drain 30mls CSF | If walking improves or general function is better after, this indicates hydrocephalus
109
How is normal pressure hydrocephalus managed?
70% success with shunt but only functional for 1 year
110
What is benign intracranial hypertension?
Normal ventricles but high intracranial pressure
111
Who gets benign intracranial hypertension?
Young, obese females with hypothyroidism Abs use Steroid withdrawal Sleep apnoea
112
How does benign intracranial hypertension present?
Headaches Visual loss Papilloedema Loss of VA
113
How is benign intracranial hypertension managed?
Acetazolamide Heparin for thrombosis Diuretics, shunt, decompression Weight loss
114
What is the common side effect of acetazolamide?
Tingling in hands and feet
115
What type of history must be taken in epilepsy?
Collateral
116
What is epilepsy?
The tendency to have spontaneous/unprovoked seizures
117
What are the two types of epileptic seizure?
Focal | General
118
Who is most likely to have epilepsy?
Infancy and >55
119
What are risk factors for epilepsy?
``` Pregnancy or delivery problems Developmental delay Seizures in past Head injury Substance misuse FHx Medications ```
120
Which medication are risk factors for epilepsy? (8)
``` Abs Tramadol Anti-emetics Diamorphine Theophylline Lithium Ketamine NSAIDs ```
121
What are the features of an epileptic fit?
``` Rigid muscle Head turned Tongue biting Potentially wet yourself Sweaty Drowsy No memory ```
122
Describe focal seizures
Specific jerking movement, somatosensory and memory symptoms Focal part of the brain had abnormal structure and electrical activity
123
What makes a focal/partil epileptic seizure complex?
Impaired consciousness level
124
What are the types of general epileptic seizure?
``` Absence Myoclonic Atonic Tonic Tonic clonic ```
125
Who mostly gets general absent epileptic seizures?
Young kids
126
What is an atonic general epileptic seizure?
No muscle tone at all
127
What is a tonic general epileptic seizure?
Stiff rigid muscles | Arms my bend as flexors typically stronger than extensors but this it not clonic
128
Describe a general tonic clonic seizure
Phase 1 - rigid muscles, tense and tight | Phase 2 - jerky movements, clonic
129
What examinations should be done with epileptic seizures?
Full neuro and cardio
130
What investigations should be done with epileptic seizures?
ECG Imaging EEG
131
What is a cardio exam and ECG done with seizures?
To check for arrhythmias
132
When would imaging be done urgently in seizure?
Suspected skull fracture, lesion, lowering gcs, focal neuropathy, haemorrhage, gcs <15 4 hours later
133
What is the only situation in which someone who is not a neurologist should do an EEG?
To confirm non-convulsive status
134
Is an EEG specific to epilepsy?
No - just helps to confirm clinically suspected epilepsy
135
When can you drive following a seizure?
Car - after 6 months | HGV - after 5 years
136
When can you drive after a nocturnal seizure?
Car - 6 months | After 1 year of having ONLY nocturnal seizures
137
When can you drive an HGV after confirmed epilepsy diagnosis?
10 years seizure free
138
What is SUDEP?
Sudden unexplained death in epilepsy
139
What are risks of SUDEP?
Drugs Alcohol Non-compliance Sleeping alone
140
How is partial-seizure epilepsy treated?
Carbamazepine or lamotrigine
141
What should the patient be made aware of if taking carbamazepine?
Makes other drugs less effective including chemotherapy and OCP
142
Why is sodium valproate avoided?
Weight gain, hair loss, fatigue and teratogenic
143
What should NEVER be given to treat generalised epilepsy?
Carbamazepine
144
How is general epilepsy treated?
Sodium valprotate | Lamotrigine
145
Why is lamotrigine dose started low?
If too high can cause Steven-Johnsons syndrome
146
What can lamotrigine make worse?
Myoclonus
147
How are myoclonic seizures treated?
Sodium valproate Levetiracetam Clonazepam
148
How are absent seizures treated?
Sodium valproate Ethosuximide Topiramate
149
How effective is treatment for epilepsy?
65% seizure free with treatment
150
Which anti-convulsants should be used with caution when used together?
Sodium valproate and lamotrigine
151
Why shouldn't you use sodium valproate and lamotrigine together?
Sodium valproate inhibits the metabolism of lamotrigine | Risk of Steven Johnson syndrome
152
What is phenytoin used for in epilepsy?
Acute management 6 months - 1 year
153
Which drug for epilepsy can be used which is well tolerated and causes some mood swings?
Levetiracetam
154
Which epileptic drug causes sedation, weight loss and isn't well tolerated?
Topiramate
155
Which form of contraception should females on anti-convulsants not use?
Progesterone only
156
What should females on anti-convulsants also be prescribed?
Vit K | Folic acid
157
What epileptic situation are classed as emergencies?
Continuous seizures >30 mins Recurrent fits without full recovery of consciousness Conscious in altered state Epilepsia partialis continua
158
What is a tic?
Involuntary stereotyped movement or vocalisation
159
What is chorea?
Brief irregular purposeless movement which flows from one body part to another
160
Why is epileptic status dangerous?
Excessive energy use leads to muscle damage, hyperthermia, rhabomyolsis, loss of BBB
161
What should be given in epileptic emergency?
Patient's normal medication Benzo - buccal midazolam, 10mg PR diazepam Phenytoin Valproate
162
When should someone in epileptic status be sent to intensive care?
If there is no improvement with medication after 30 mins
163
What is sleep?
Normal, recurring, reversible state in which you are not conscious or unconscious
164
In which type of sleep do you experience non-narrative images?
Non-REM
165
What are non-narrative images?
Dream without a story which has evoked an emotional response
166
Which type of sleep occurs at the start of the night?
Non-REM
167
Which type of sleep is associated with reduced cerebral flow, heart rate and BP?
Non-REM
168
During which type of sleep does protein synthesis occur?
Non-REM
169
During which type of sleep is there synchronised, rhythmic EEG activity?
Non-REM
170
Which type of sleep occurs at the end of the night?
REM
171
In which type of sleep is there fast EEG activity and increased brain activity?
REM
172
In which type of sleep is cerebral blow flow increased?
REM
173
In which type of sleep is there impaired thermal regulation?
REM
174
Which germ layer is microglia derived from?
Mesoderm
175
In which injury reaction is there shrinking and angulation of the neuron?
Acute
176
In which injury mechanism is there a "red neuron" ?
Acute
177
In which injury mechanism is the visibility of the nucleolus lost?
Acute
178
Describe axonal damage
Distal degeneration in the axon in response to injury Increased protein synthesis Chromatolysis causing loss of Nissl granules
179
Which response to injury involves reactive gliosis replacing neural tissue?
Simple neuron atrophy
180
What occurs during simple neuron atrophy?
Neurons shrink, angulate and are lost | Accumulation of lipofuscin pigment
181
Which type of damage are oligodendrocytes sensitive to?
Oxidative | De-myelination
182
Which cells line the ventricular system ?
Ependymal
183
How do ependymal granulations occur?
Disruption and local proliferation of sub-ependymal astrocytes produce small irregularities on ventricular surfaces
184
How do microglia respond in injury?
Proliferate and form aggregates
185
What do M1 microglia do?
Encourages inflammation in chronic disease
186
What do M2 microglia do?
Anti-inflammation, acute, phagocytic
187
Define cerebrovascular disease
Abnormality of the brain caused by pathological process of blood vessels
188
Give an example of a cause of focal hypoxia
Vascular obstruction
189
Give an example of a cause of global hypoxia
Cardiac arrest, hypotension
190
When does cytotoxic oedema occur?
Intoxication, Reye's and severe hypothermia
191
Why does cytotoxic oedema occur?
Dying cells accumulate water because osmotically active ions move into the cell
192
Why does ionic oedema occur?
BBB dysfunction | Sodium ions cross BBB and drive chloride ion transport creating an osmotic gradient for water accumulation
193
Why does vasogenic oedema occur?
Due to disruption of endothelial tight junctions and plasma proteins
194
When does haemorrhagic conversion occur?
When endothelial integrity is lost and blood enters extracellular space
195
What is a stroke?
A sudden disturbance of cerebral function of vascular origin which lasts >24 hours or causes death
196
What is macroscopically and microscopically visible 0-12 hours after a stroke?
Very little
197
What is macroscopically visible 12-24 hours after stroke?
Pale, soft, swollen ill defined margins between injured and non-injured brain
198
What is microscopically visible 12-24 hours after stroke?
Red neuron, oedema
199
What is microscopically visible 24-48 hours after stroke?
Neutrophils, extravasation of RBCs, haemorrhagic conversion and activation of astrocytes and microglia
200
What is macroscopically visible 2-14 days after stroke?
Reduction in oedema | Gelatinous tissue
201
What is microscopically visible 2-14 days after stroke?
Microglia become predominant cell type, myelin breakdown, reactive gliosis
202
What is macroscopically visible several months after stroke?
Formation of cavity lined by dark grey tissue
203
What is microscopically visible several months after stroke?
Phagocytosis brings increasing cavitation and surrounding gliotic scar formation
204
Who presents with MS?
Females in 30s who live far from the equator
205
How can vitamin D affect MS?
Lowers development risk but doesn't help prevent disease
206
What is the most common form of MS?
Relapsing and remitting
207
What is secondary progressive MS?
Cases which get worse after several years of relapsing and remitting
208
What is primary progressive MS?
Never relapse
209
How does pyramidal dysfunction in MS present?
Spasticity, hyperreflexia, weakness in upper limbs
210
What are common symptoms of MS?
Sensory impairment Urinary tract disturbance Cerebellar and brainstem features
211
How is MS investigated?
``` MRI FBC Renal, liver, bone profile Auto anti-body screen HIV and syphilis screen ```
212
How is pyramidal dysfunction in MS treated?
``` Anti-spasmodic agents Physio OT Botox Baclofen, tizanidine, phenol ```
213
How are sensory symptoms in MS treated?
``` Gabapentin Amitriptyline TENS Acupuncture Lignocaine infusion ```
214
How are urinary symptoms in MS treated?
Bladder drill Anti-cholinergic Desmopressin Catheterisation
215
What medication is given in moderate MS?
500mg weekly meta-prednisolone
216
What medication is given in severe MS?
IV steroids 1000mg over 3 days
217
What DMARDs can be given first line in severe MS?
Interferon beta Glatiramer acetate Tecidera
218
What DMARDs can be given second line in MS?
Monoclonal antibodies | Fingolimod
219
What can be done third line in severe MS?
Mitoxantrone | Stem cell transplant
220
Given an example of primary demyelination disorders
MS Acute disseminated encephalomyelitis Acute haemorrhagic leukoencephalitis
221
Give an example of secondary demyelination disorders
Progressive multifocal leukoencephalopathy Central pontine myelinolysis Toxins - CO, organic solvent, cyanide
222
Which gene is associated with MS?
HLA DRB1
223
What is the criteria for diagnosis of MS?
Two distinct neurological defects occurring at two different sites Multiple distinct lesions on MRI
224
What does MRI show in MS?
Irregular but well demarcated, glassy plaques
225
Are perivascular inflammatory cells a marker of an active or inactive plaque in MS?
Active
226
Are oligodendrocytes involved in active or inactive MS plaques?
Inactive
227
Are microglia involved in active or inactive MS plaques?
Active
228
Does gliosis occur with active or inactive MS plaques?
Inactive
229
What is dementia?
Acquired, persistent and generalised disturbance of mental function in an otherwise fully alert person
230
Which sex is more likely to get dementia?
Females
231
Which genes are implicated in Alzheimer's?
Amyloid precursor protein | Presenilin 1 & 2
232
What are the 3 main symptoms of Alzheimer's?
Progressive disorientation, memory loss and aphasia
233
What brain changes occur in Alzheimer's ?
``` Decreased size of brain Widening of sulci Narrowing of gyri Compensatory dilatation of ventricles Plaques Neuronal atrophy Neurofibrillary tangles Amyloid angiopathy ```
234
What part of the brain is spared in Alzheimer's?
Cerebellum
235
Where are neurofibrillary tangles found in the brain in Alzheimer's?
Hippocampus and temporal lobe
236
Which type of plaques are found in Alzheimer's and where?
A-beta amyloid plaques | Around astrocytes
237
How does Lewy body dementia present?
Progressive with hallucinations and fluctuating levels of attention and cognition
238
Which part of the brain degenerates in Lewy body dementia?
Substantia nigra
239
What is a classical Lewy body?
Intracytoplasmic eosinophilic body with a dense core and a pale halo Made of alpha-synuclein
240
Which set of symptoms are commonly found in Lewy body dementia?
Parkinsonian symptoms
241
What is Pick's disease otherwise known as?
Fronto-temporal dementia
242
What is the common age of onset of Pick's disease?
50-60 years
243
How does Pick's disease present?
Personality and behaviour changes Communication problems Change in eating habits Reduced attention span
244
How long does Pick's disease last?
2-10 years
245
What are the brain changes in Pick's disease?
Extreme atrophy of cerebral cortex in frontal them temporal lobe Brain weight <1kg Neuronal loss Pick's cells and bodes found
246
What is a Pick's body?
Intracytoplasmic filamentous inclusion
247
Which protein and Pick's bodies enriched in in Pick's disease?
Tau
248
What is the typical age of onset of Huntington's?
35-50
249
How does Huntington's present?
Chorea, myoclonus, clumsiness, slurred speech, depression, irritability, apathy
250
What chromosome is implicated in Huntington's?
4p | Additional CAG repeats
251
What brain changes are seen in Huntington's?
Atrophy of basal ganglia, caudate nucleus and putamen
252
What are the four main primary causes of dementia?
Lewy body Huntington's Alzheimer's Pick's disease
253
What are the main secondary causes of dementia?
Vascular, infection, trauma, substances
254
What is vascular dementia?
Deterioration in mental function due to cumulative damage to the brain through hypoxia or anoxia
255
Who is most likely to get vascular dementia?
Males, >60 | Or middle aged hypertensives
256
Why are those with vascular dementia more prone to depression and anxiety?
They are aware of the defects
257
How does vascular dementia progress?
Stepwise
258
What is parkinsonism?
Group of symptoms | Loss of facial expression, stooping, shuffling gait, slow initiation of movement, stiffness and rolling tremor
259
In what conditions is Parkinsonism seen?
``` Idiopathic Parkinson's disease Lewy body dementia Substance use Medications - phenothiazines Trauma Multisystem atrophy Progressive supranuclear palsy Cortico-basal dengeneration ```
260
What three things can cause hydrocephalus?
Obstruction to CSF flow Decreased resorption of CSF Overproduction of CSF
261
What can lead to obstruction of CSF flow?
Inflammation, pus, tumours
262
What can lead to decreased resorption of CSF?
SAH | Meningitis
263
What can lead to overproduction of CSF?
Tumour of choroid plexus (rare)
264
What are the two types of hydrocephalus?
Communicating and non-communicating
265
What is non=communicating hydrocephalus?
Obstruction to flow of CSF occurring within the ventricular system
266
What is communicating hydrocephalus?
Obstruction to CSF out with the ventricles
267
What is the outcome if hydrocephalus occurs before the closure of the cranial sutures?
Cranial enlargement
268
What is the outcome if hydrocephalus occurs after the closure of the sutures?
Raised ICP and expansion of ventricles
269
What are the 4 types of herniation?
Subfalcine Tentorial Cerebellar Transcalvarial
270
What are the signs and symptoms of raised ICP?
Papilloedema Headache N&V Neck stiffness
271
What can cause a single brain abscess?
Local extension of mass | Direct implantation of pathogen
272
What can cause multiple brain abscesses?
Haematogenous spread from pneumonia, endocarditis,etc
273
How is a brain abscess investigated?
CT
274
What is a linear skull fracture?
Straight sharp fracture line that may cross sutures
275
What does coup describe?
Injury with a response that occurs at the site of the injury
276
What does contrecoup describe?
Injury with a response which occurs on the opposite side
277
What is pain?
Unpleasant sensory and emotional experience associated with actual tissue damage or described in terms of such damage
278
Describe acute pain
Associated with (usually) obvious tissue damage Protective function Increased nervous system activity Pain resolves on healing
279
Describe chronic pain
Pain beyond an expected period of healing | Doesn't serve a useful purpose
280
Which fibres perceive painful stimuli?
A-delta and C fibres
281
Which substance is released on activation of A-delta and C fibres?
Substance P
282
Where is substance P released onto when a painful stimulus is perceived?
Laminae I and V
283
Where does Laminae I signal painful stimuli information to?
Amygdala and hypothalamus
284
Where does Laminae V signal to in the case of painful stimuli?
Thalamus then somatosensory cortex
285
What is nociceptive pain?
Appropriate physiological response to painful stimuli
286
What is neuropathic pain?
Inappropriate response caused by a dysfunction in the nervous system
287
What is allodynia?
Experiencing pain from a stimulus which is not expected to be pain
288
What is hyperalgesia?
More pain than expected from a painful stimulus
289
What are common causes of chronic pain?
``` Shingles Surgery Trauma Diabetic neuropathy Amputation ```
290
What can be given as adjuvants to pain medication in chronic pain?
Antidepressants | Anti-convulsants
291
How do NSAIDs act?
inhibit COX1 and prostaglandin synthesis
292
What are the side effects of NSAIDs?
GI irritation GI bleed CV side effects
293
How does paracetamol work?
Inhibits central prostaglandin synthesis
294
Give an example of a weak opioid
Tramadol | Codeine
295
Give an example of a strong opioid
Morphine | Oxycodone
296
What type of pain are opioids and NSAIDs used in?
Nociceptive
297
How do opioids work?
Stimulates receptors in the limbic system to eliminate feeling pain
298
What are common side effects of opioids?
``` N&V Constipation Dizziness Somnolence Pruritus ```
299
What type of pain are anti-depressants and anti-convulsants used for?
Neuropathic pain
300
What are side effects of tricyclic antidepressants?
``` Constipation Dry mouth Insomnia Increased appetite Abnormalities in heart rate and rhythm ```
301
What are the side effects of SSRIs and SNRIs?
``` N&V Constipation Somnolence Dry mouth Increased sweating Loss of appetite ```
302
Which anticonvulsants are used in neuropathic pain?
Gabapentin Carbamazepine Pregabalin
303
What are the side effects of anticonvulsants?
Sedation, dizziness, ataxia, peripheral oedema, nausea and weight gain
304
What channels does Gabapentin act on?
Voltage dependent calcium channels
305
Which channels does pregabalin act on?
N-type calcium channels
306
What does carbamazepine do?
Blocks Na+ and Ca2+ channels
307
What are side effects of topical analgesics?
Rash, pruritic, erythema
308
What physical treatments can be complementary to medication in chronic pain?
Massage Aromatherapy Reflexology Acupuncture
309
What psychological therapies can be used in chronic pain?
CBT | Solution focused brief therapy
310
How can you localise a lesion in the cervical region of spinal cord?
Lateral may only affect arms | Central can affect anywhere in spinal cord down from that point
311
How can you tell if there is a lesion in the spinal cord?
Some leg problems with little to no arm involvement
312
How can you localise a legion to the lumbar region of spinal cord?
Only legs involved, no UMN features
313
How is tone in UMN lesions?
Increased
314
How is tone in LMN lesions?
Decreased
315
Is there more atrophy in UMN or LMN lesions?
LMN UMN may have some but it comes later
316
Are fasciculations found in UMN or LMN lesions?
LMN
317
Describe the reflex change with an UMN lesions
Increased
318
Describe the reflex changes with LMN lesions
Decreased or absent
319
Is clonus present in UMN ro LMN lesions?
UMN
320
How does a cervical disc prolapse present?
Arm pain Pain in relevant dermatomes LMN problems
321
How does a thoracic disc prolapse present?
Thoracic back pain
322
How does a lumbar disc prolapse present?
Leg pain | LMN symptoms
323
How does spinal claudication present?
Intermittent burning, achey pain, worse on movement Better on bending forward and walking up hill Altered sensation Weakness Urinary dysfunction
324
How is spinal claudication investigated?
MRI urgently
325
How is spinal claudication treated?
Surgery - not curative, only to stop it getting worse
326
What is a cervical myelopathy?
Compression in the cervical spine
327
How does cervical myelopathy present
"Numb clumsy hands" Paraesthesia in fingertips Reduced mobility UMN signs
328
What is Hoffman sign positive in?
Cervical myelopathy
329
What is failed back syndrome?
Chronic pain in the back
330
What can cause failed back syndrome?
``` Recurrence of previous problem Srugery causing instability Infection Depression and anxiety Diabetes Smoking Higher BMI ```
331
What should be the treatment for pure neck/back pain only?
Physio | Risk of surgery not worth it
332
What is a subarachnoid haemorrhage?
Blood in the SA space
333
What abnormality is normally underlying in subarachnoid haemorrhage?
Berry aneurysm
334
What is the most common finding when identifying underlying cause in subarachnoid haemorrhage?
No cause identified
335
How does a subarachnoid haemorrhage present?
``` Sudden onset thunderclap headache Collapse Vomiting Neck pain Photophobia Decreased consciousness ```
336
What is benign coital cephalgia?
Sudden onset headache before orgasm
337
How is subarachnoid haemorrhage investigated?
CT immediately LP Cerebral angiography
338
When is LP done in subarachnoid haemorrhage?
No papilloedema and after normal CT
339
What does CSF look like in subarachnoid haemorrhage?
Bloodstained or xanthochromatic
340
How would a traumatic tap be indicated in LP results?
Decreased levels of RBCs in ;labelled samples
341
Why may an aneurysm be missed on cerebral angiography?
Vasospasm not allowing vessels to fill with contrast
342
What are the five main complications of subarachnoid haemorrhage?
``` Re-bleeding Delayed ischaemic deficit Hydrocephalus Hyponatraemia Seizures ```
343
How is re-bleeding of a subarachnoid haemorrhage treated?
Endovascular techniques
344
When does a delayed ischaemic deficit occur after a subarachnoid haemorrhage?
3-12 days
345
How is a delayed ischaemic deficit after subarachnoid haemorrhage treated?
Nimodipine
346
Should you fluid restrict in hyponatraemia following subarachnoid haemorrhage?
No
347
What is the risk of seizures following subarachnoid haemorrhage?
10% over 5 years
348
What in an intracerebral haemorrhage?
Bleed into the brain parenchyma
349
What abnormalities/conditions may precede intracerebral haemorrhage?
Hypertension (50%) | Aneurysms and AV malformations (30%)
350
How does an intracerebral haemorrhage present?
Headache that is less intense and sudden than SAH Focal neurological illness Decreased conscious levels
351
How is intracerebral haemorrhage investigated?
CT | Angiography if suspicion of underlying vascular abnormality
352
How is an intracerebral haemorrhage treated?
Surgical evacuation of haematoma with treatment of underlying abnormality Non-surgical more common
353
What is an intraventricular haemorrhage?
Blood in the ventricles | Occurs with rupture of SA or intracerebral bleed
354
What can AV malformations cause?
Seizure, haemorrhage, headache, steal syndrome
355
How is an AV malformation treated?
Surgery to remove Endovascular embolisation to block Stereotactic radiotherapy - takes about 2 years to work
356
Where does the corticospinal tract dessucate?
Medulla
357
What is the spinothalamic tract for?
Pain, temp, crude touch
358
Where does the spinothalamic tract dessucate?
Spinal level
359
What is the dorsal column for?
Fine touch, proprioception, vibration
360
Where does the dorsal column pathway dessucate?
Medulla
361
What are acute causes of spinal cord compression?
Trauma, tumour, bony mets, infection, haemorrhage
362
What are chronic causes of spinal cord compression?
Degenerative disease eg spondylosis, tumours, rh arthritis
363
What is the flaccid areflexic paralysis after cord transection termed?
Spinal shock
364
What does central cord syndrome follow?
Hyperflexion or hyperextension of a stenotic neck
365
How does central cord syndrome present?
Distal upper limb weakness Cape-like spinothalamic sensory loss is across a few dermatomes Lower limb power preserved
366
Where do extradural metastases normally come from?
Lung, breast, kidney, prostate
367
Give an example of an intradural extramedullary tumour
Meningioma | Schwannoma
368
Give an example of an intradural intramedullary tumour
Astroctyoma | Ependymoma
369
What is spinal stenosis?
When the spinal canal gets narrowed by "weak and tear" changes
370
What structural problems can cause spinal stenosis?
Osteophyte stenosis Intervertebral disc bulging Facet joint hypertrophy Sublaxation
371
Why is dexamethasone given in spinal mets?
To improve weakness | Not curative
372
Which nuclear treatment is used on plasmacytoma?
Chemo
373
Who is most likely to get motor neurone disease?
50-75 year old white male
374
What is the genetic link between ALS and frontotemporal dementia?
C9ORF repeat expansions
375
What genes are implicated in motor neuron disease?
TDP43 | C9ORF
376
What are the 4 main subtypes of motor neuron disease?
Amyotrophic lateral sclerosis (ALS) Progressive muscular atrophy (PML) Primary lateral sclerosis (PLS) Progressive bulbar palsy (PBP) **Note these are most common --> least common
377
Which subtype of motor neuron disease does not show LMN features?
Primary lateral sclerosis (PLS)
378
Which subtype of motor neurone disease have the best survival?
Primary lateral sclerosis (PLS) | 5 years
379
How does motor neuron disease present?
Muscle weakness and wasting Speech and swallow problems Breathing problems Cognitive impairment
380
How does motor neuron disease begin and progress?
Begins are focal symptoms and spread until general paresis
381
Give examples of UMN signs
``` Increased tone Hyper-reflexia Extensor planter responses Spastic gait Exaggerated jaw-jerk Slowed movements Babinski sign ```
382
Give examples of LMN signs
``` Muscle wasting Weakness Fasciculations Areflexia Muscle cramp ```
383
What are the criteria for definite ALS?
UMN and LMN signs in bulbar and at least two of: lumbosacral, thoracic and cervical regions
384
What are the bulbar UMN signs?
Exaggerated snout reflex, clonic jaw jerk, emotional lability, forced yawning
385
How is motor neuron disease managed?
SALT, communication aids Nutritional needs assessed via dietician based on swallow ability Rilozole
386
How do NSAIDs work, generally?
Act at site of injury to decrease nociceptor sensitisation in inflammation
387
How do local anaesthetics work?
Block nerve conduction
388
How do opioids and anti-depressants work as pain killers?
Supress transmission of nociceptive signals in the dorsal horn
389
Give an example of an NSAID
Diclofenac, ibruprofen, indomethacin, naproxen
390
Is codeine a weak or strong opioid?
Weak
391
Is tramadol a weak or strong opioid?
Weak
392
Is morphine a weak or strong opioid?
Strong
393
Is oxycodone a weak or strong opioid?
Strong
394
Is dextropropoxyphene a weak or strong opioid?
Weak
395
Is hydromorphone a weak or strong opioid?
Strong
396
Is fentanyl a strong or weak opioid?
Strong
397
What is supraspinal anti-nociception?
When regions of the brain involved in pain perception project to the brainstem and spinal cord to modify input
398
Which regions in the brain are involved in supraspinal anti-nociception?
Periaqueductal grey (PAG) Nucleus raphe magnus (NRM) Locus coeruleus
399
Which receptors mediate opioid action?
beta-gamma units on GPCRs which signal to Gi/Go
400
What does opioid action on GPCRs produce?
Inhibition of voltage activated Ca2+ channels | Opening of K channels
401
What does the inhibition of Ca channels in opioid use do?
Suppresses neurotransmitter release therefore reducing signals in the dorsal horn
402
What does the opening of K channels in opioid use do?
Hyperpolarises post-synaptic cell so that it can't produce an AP, therefore reducing signalling
403
What are the three classifications of opioid receptors?
Mu - mop Delta - DOP Kappa - KOP
404
What type of opioid receptor can be pro-convulsant?
Delta (DOP)
405
Which opioid receptor is associated with sedation, dysphoria and hallucination?
Kappa (KOP)
406
How does opioid use produce apnoea?
Blunting of medullary respiratory centre to CO2
407
How does opioid use produce orthostatic hypotension?
Reduce sympathetic tone and bradycardia (via medulla) | Histamine-evoked vasodilation due to mast cell degranluation
408
How does opioid use produce GI effects?
Action on CTZ, increased smooth muscle tone, decrease motility
409
What CNS effects can opioid use produce?
Confusion, euphoria, dyshphoria, hallucinations, dizziness, myoclonus, hyperalgesia
410
How is morphine metabolised?
By the liver by glucuronidation at 3 and 6 positions
411
What is morphine metabolised into?
M3G and M6G
412
How are morphine metabolites excreted?
By the kidney
413
By which route is diamorphine given?
IV
414
How is codeine metabolised?
By the liver by demethylation to morphine by CYP2D6 and CYP3A4
415
How is codeine given?
Orally
416
By which route is fentanyl given?
IV in maintenance | Transdermal and buccal in chronic pain
417
How is pethidine given?
IV, IM, SC
418
When is pethidine used?
Acute severe pain (like labour)
419
Which class of drugs should pethidine not be given in conjunction with?
monoamine oxidase inhibitors
420
Which metabolite of pethidine can cause seizures?
Norpethidine
421
When is buprenorphine given?
Chronic pain
422
How is buprenorphine given?
IV or sublingual
423
Which opioid receptor does tramadol act on?
Mu (MOP)
424
How does tramadol work?
Excites descending serotonergic (NRM) and adrenergic (LC) pathways
425
What condition should tramadol not be given in?
Epilepsy
426
Which opioid receptor does methadone work on?
Mu (MOP)
427
Other than opioid receptors, where does methadone act?
K channels, NMDA glutamate and 5HT receptors
428
When in methadone used?
Chronic pain | Withdrawal from strong opioids
429
When is naloxone used?
Reverse opioid toxicity
430
How does naloxone work?
Competitive antagonist of mu (MOP) receptors
431
What might cause the need for naloxone to be given to a newborn?
Respiratory depression caused by pethidine given to mother in labour
432
What are alvimopan and methylnatrexone used for?
Reducing GI effects of chronic opioid use
433
How do NSAIDs reduce inflammation?
Inhibit synthesis and accumulation of prostaglandins by COX
434
What is prostaglandin's affect on nociceptors?
Decreases the activation threshold
435
How do gabapentin and pregabalin work as pain killers?
Reduce cell surface expression of alpha-2-delta subunits which are upregulated in damaged sensory neurons
436
Give an example of when gabapentin is prescribed
In migraine prophylaxis
437
Given an example of when pregabalin is prescribed
Painful diabetic neuropathy
438
How does carbamazepine work as a pain killer?
Blocks subtypes of voltage activated Na channels that are upregulated in damaged cells
439
What is given first line in trigeminal neuralgia?
Carbamazepine
440
How to tricyclic anti-depressants work as painkillers?
Decrease uptake of noradrenaline
441
What are the three most common causes of bacterial community acquired meningitis in <60?
Pneumococcus Meningococcus H. Influenzae
442
What is the most common cause of bacterial community acquired meningitis in >60 or immunocompromisation?
Listeria
443
What is the treatment for bacterial community acquired meningitis?
Ceftriazone IV 2g bd + Dexamethasone IV 10mg qds listeria cover is amoxicillin 2g 4 hourly
444
Describe the CSF findings in viral meningitis
``` Lymphocytes Gram stain negative Bacterial antigen negative Protein normal/slightly high Glucose normal ```
445
Describe the CSF findings in bacterial meningitis
``` Polymorphs Gram stain positive Bacterial antigen detection positive Protein high Glucose <70% blood glucose ```
446
Describe the CSF findings in TB
Lymphocytes Bacterial antigen detection negative Protein very high Blood glucose less than 60% blood glucose
447
Where is S. pneumococcus found?
Nasopharynx
448
What procedure puts kids at risk for S. pneumococcus infection?
Cochlear implant insertion
449
Who gets Neisseria m. infections?
Young children and 10-21
450
Who gets listeria infections?
>60s, alcoholics, immunosuppressed people
451
What antibiotics are used to treat TB?
Rifampicin Isoniazid Pyrazinamide Ethambutol
452
Who gets H. influenza
Children
453
How does meningitis present?
Stiff neck, rash, irritability, seizures, fever, drowsy, headache, photophobia
Year 3 - Neuro
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