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60 Cards in this Set
- Front
- Back
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What is trigeminal neuralgia
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sudden, unilateraly, severe, brief, stabinng recurrent eipsodes of pain the the distribution of one or more branches of the trigeminal nerve (usually V3)
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Aetiology of trigeminal neuralgia?
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Compression of the nerve root by:
- an aberrant loop of an artery or vein - most common - vestibular schwannoma, meningioma, epidermoid or other cyst, MS |
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how long does the pain last for with trigeminal neuralgia?
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pain lasts seconds/minutes over days/weeks
can remit for weeks/months |
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How do you manage trigerminal neuralgia?
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carbamazepine
if refractory to medical therapy - radiofrequency ablation, gamma knife or surgical decompression |
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What investigations should be done in someone with trigeminal neuralgia?
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MRI to rule out structural l esion, MS or vascular lesion
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What are the features suggesting a serious cause of a headache
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sudden onset of a severe headache
- "worst headache ever" accompanying impaired mental status, fever, seizures, or focal neurologic deficits or new headaches beginning after age 50 |
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What is an aura?
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fully reversible symptom of focal cerebral dysfunction lasting for < 60 minutes
Types: Basilar: bilateral visual symptoms, unsteadiness, dysarthria, limb paraesthesia Hemiplegic: aura of unilateral paralysis (may persist for some days) ophthalmoplegic - extraocular nerve palsies, homonynmous visual disturbance - zig zags, scintillating scotomata - spots) |
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What is a complicated migraine
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migraine with severe/persistent sensorimotor deficits
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What is the difference in location of headache between migraine, tension-type and cluster?
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Migraine - unilateral > bilateral (fronto-temporal)
Tension - bilateral frontal Cluster - retroorbital |
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What are the associated symptoms with cluster headaches?
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red watery eye
Nasal congestion or rhinrorrea unilateral horners |
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What pharmacological management is used for tension headaches?
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simple analgesics
TCAs |
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What pharmacological management is used as prophylaxis in migraines>
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If > 2 or 3 acute migraine attacks /month
Amitriptyline (TCA) or pizotifen or propranolol or sodium valproate or topiramate verapamil |
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What pharmacological management is used in acute migraine attacks?
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Analgesics: aspirin, diclofenac potassium, ibuprofen, paracteamol
Antiemetics 2nd line = triptans, ergotamine |
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When are triptans or ergotamines contraindicated?
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patients with vascular or CAD or uncontrolled hypertension
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What is a risk associated with repeated use of triptans?
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serotonin toxicity
particularly if used in association with MAO inhibitors, St John's wort |
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What are causes of SAH? Most common?
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Most common = trauma
Others: Spontaneous aneurysms (75-80%), idiopathic, AVMs Less common: coagulopathis, vasculitides, tumours |
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RF for SAH?
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Hypertension
pregnancy in patients with pre-existing AVMs, eclampsia OCP Substance acbuse Aneurysms |
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Clinical features of SAH?
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sudden onset of severe/thunderclap headache usually following exertion
N/V, photophobia miningismus (neck pain/stiffness, +ve kernigcs sign) Decreased LOC focal deficits occular haemorrhage reactive HTN |
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What are sentinel bleeds associated with SAH?
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SAH like symptoms lasting < 1 day
May have blood on CT or LP 50% of patients with SAH give history of sentinel bleeds within past 3 weeks |
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Investigations in SAH?
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Non-contrast CT
If CT -ve but +ve history for SAH do LP to loop for blood CTA/MRA/cerebral angiography used for locasiation of aneurysm and treatment planning |
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What are the complications associated with SAH?
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1. vasospasm - constriction of blood vessels in response to arterial blood clot outside vessels at base of brain
2. hydrocephalus - blood obstructing CSF drainiage or SA space 3. neurogenic pulmonary oedema |
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When does vasospasm associated with SAH present and how?
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4-14 days post SAH
confusion, decreased LOC, focal deficit (speech or motor) |
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Therapy for vasospasm associated with SAH?
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hypertension
hypervolaemia haemodilution using fluids and pressors (eg norepinenphrine, phenylephrine) |
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If you suspect vasospasm associated with SAH how do you detect it?
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clinically +/- angiogram or transcranial doppler (increased velocity or blood flow)
MUST do urgent CT to rule out other causes |
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What is an AVM?
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tangle of abnormal vessels/arteriovenous shunts, with no intervening capillary beds or brain parenchyma
congenital |
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Clinical features of AVMs
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haemorrhage - small more likely to bleed due to high pressure AV connections
seizures - more common with larger AVMs mass effect focal neurological signs secondary to ischaemia localised headache, increased ICP bruit may be asymptomatic |
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What's the best form of imaging to diagnose an AVM?
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MRI, MRA
angiography |
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How do you manage AVMs?
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surgical excision - treatment of choice
decreases risk of future haemorrhage and seizure Can treat conservatively (palliative embolisation, seizure control if necessary) |
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What is the most common type of intracranial aneurysm? Where are they located?
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saccular (berry)
located at branch points of major cerebral arteries (circle of willis) |
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What are the three types of intracranial aneurysms?
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berry
fusiform - atherosclerotic, rarely ruptures mycotic - secdonary to any infection of vessel wall |
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Symptoms of intracranial aneurysms>
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1. Rupture (90%)
2. Sentinel haemorrhage - requires urgent clipping/coiling to prevent catastrophic bleed 3. mass effect (giant aneurysms) may get hypopituitaryism, visual field defect, cranial nerve palsies 4. small infarcts 5. seizures 6. headaches |
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How do you manage an unruptured aneurysm?
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Surgical management if > 10mm
or 7-9mm if middle aged, younger or FHx follow small aneurysms with serial angiography |
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How do you manage rupture aneurysms?
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Early surgery or coiling (48-96 hours after SAH)
surgical: clip across aneurysm neck, trapping (clipping of proximal and distal vessels), rombosing using coils, wrapping |
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What are the signs of meningismus?
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Kernig's sign (resistance to knee extnesion when hip is flexed to 90)
Brudzinski's sign - passive neck flexion causes involuntary felxion of hips and knee Headachen worsens when head turned horizontally at 2-3 rotations/sec |
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Clinical features of meningitis
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headache
fever neck stiffnes, confusion, N/V, lethargy meningisums altered LOC seizures focal neurological signs |
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Treatment of meningitis
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empirocal antibiotis
neonates - amp + gent toehrs; vanc + cef + amp + dexamethasone |
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What are the most common organisms causeing meningitis in neonates?
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GBS
E Coli viral |
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What are the most common bacterial meningitis?
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HIB
Strep pneumoniae Neisseria meningitidis |
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What are the most common organisms causing viral meningitis?
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Enteroviruses
HSV-2 coxsackie mumps, measles |
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What is the most common cause of bacterial meningitis in adults?
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strep pneumoniae
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What is the most common cause of bacterial meningitis in children and young adults?
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n. meningitis
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What is the difference in CSF profiles for bacterial vs viral meningitis?
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Glucose - decreased in bacterial, N in viral
protein - extremely increased in bacterial, increased in viral WCC - very high in bacterial Neutrophils - bacterial Lymphocytes - viral |
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Clinical features of encephalitis?
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constitutional
meningeal involvement parenchymal involvement - seizures, mental status changes, focal neurological signs |
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Which lobe does herpes simplex enecphalitis usually occur in?
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temporal
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What is the difference in symptoms between viral and bacterial meningitis?
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focal neurological signs rarelyu occur in viral meningitis
You just get irriatability and meningism - neck stiffness, photophobia and headache |
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How do you treat encephalitis?
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supportive care + therapy against specific infecting agent
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Management of viral meningitis?
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supportrive
generally self-limiting illness |
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Clinical features of acute elevated ICP
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headache, worse in the morning
HTN N/V decreased LOC drop in GCS papilloedema +/- retinal haemorrhages (may take 24-48 hours to develop) Abonrla extra-ocular movements |
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What is cushing's traid of acute raised ICP
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irregular respirations
hypertension bradycardia (late finding) |
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What are the sx of chronic electated ICP
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headache - postural - worsened by coughing, straining, bending over
Worse in am/pm vasodilatation due to increased CO2 with recumbency visual changes |
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Treatment of elevated ICP
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elevate head of bed
prevent hypotension ventilate O2 mannitol sedation place drain |
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Describe the classic temporal arteritis headache?
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temporal regions
becoming progressively worse (can wax and wane) may be associated with visual changes |
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What is hypertensive encephalopathy
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cerebral hyperperfusion due to BP in excess of the capacity for cerebral autoregulation
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Sx of hypertensive encephalopathy
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headache
N/V mental status changes fundoscopic changes over hours can lead to coma/death |
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What is first line for hypertensive crisis?
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Parenerally
1. sodium nitroprusside OR diazoxide, hydralazine, clonidine, glyceryl trinitrate |
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What are the major sypmtoms of sinusitis?
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facial pain/pressure - worse when bending over
facial fullness/congestion nasal obstruction purulent/discoloured nasal discharge hyposmia/anosmia (ability to smell) fever |
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What are the minor symptoms of sinusitis?
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headache
halitosis (unpleasant odours exhaled in breathing) fatigue dental pain cough ear pressure |
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Most common viral causes of sinusitis?
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rhinovirus, influenza, para influenza
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What symptoms do you get with tempormandibular joint dysfunction?
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unilateral pain in mm of mastication
pain may radiate to ear or jaw dull ache, worse by chewing Can just present as a headache Clicking with TMJ movement |
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What is TMJ dysfunction usually due to?
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stress
jaw malocculsion jaw clenching - anxiety and stress |
