Neurology Week 3

Hydrocephalus & Headaches

100

List 4 red flags for a serious headache

Any 4 of:

Sudden onset, thunderclap character

RICP headache - morning with nausea, worse lying down/sneezing/coughing

Hx of malignancy, immunosuppression

A/w systemic symptoms - fever, rash, meningism, B symptoms

Focal neurological signs

200

List 6 drugs that can be used to treat an acute attack of migraine

PANTOP

Paracetamol

Antinauseants

NSAIDs

Triptans

Opioids

Paracetamol + antinauseant (e.g. metochlorpramide)

300

Give examples of primary and secondary headaches.

Can you describe the characteristics?

Primary: migraines (throbbing, pulsatile, aura), tension (band-like tightness usually worse at end of day), cluster, trigeminal neuralgia

Secondary: haemorrhage, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome, toxins, infection (meningitis/abscess), extracranial

400

What are the 2 main types of hydrocephalus?

Obstructive (non-communicating) most common type due to blockage of CSF pathway from ventricles to subarachnoid space

Communicating (non-obstructive) due to impaired reabsorption of CSF at arachnoid villi along dural venous sinus, usually due to SAH or infection

500

In prolonged hydrocephalus, how can patients present? What is the treatment?

Gait apraxia/magnetic gait

Dementia

Urinary incontinence

Place a ventriculoperitoneal shunt to drain excess CSF from ventricles into systemic circulation through peritoneum

Trauma

200

What are cerebral contusions and the subtypes?

A primary, focal injury to the CNS causing the brain to move and be crushed by violent contact with the skull or dura membranes

COUP LESIONS = contusions occurring at the site of impact (same side of impact)

CONTRECOUP LESIONS = contusions occurring opposite to the site of impact (other side of head)

300

What is an epidural haemorrhage? How do they present? How does it occur?

Rupture of middle meningeal artery in epidural space

Initial loss of consciousness immediately after head injury

Regain consciousness and return to baseline

Then rapidly decline

Commonly due to skull fracture

400

Clinical features of a patient with trauma to the corticospinal tract? What would they report below the level of the lesion?

Ipsilateral weakness below the level of the lesion

Corticospinal tract runs from cortex, decussates in medulla, then descends down spinal cord to LMN innervating the limbs. Since it decussates in the brainstem, the symptoms will be on the ipsilateral side to the lesion.

500

What are 4 types of brain herniation?

Cingulate (subfalcine) under falx cerebri

Transtentorial (central)

Uncal

Cerebellar tonsillar herniation into foramen magnum

Miscellaneous

200

Where are the bridging veins located? If ruptured, where would the haematoma be?

Subdural haemorrhage

300

What does the middle cerebral artery supply and how might someone with an MCA stroke present?

Lateral cortex - frontal (motor, Broca), parietal (sensory), temporal (Wernicke)

Weakness upper limbs > lower, contralateral

Contralateral hemisensory loss

Broca or Wernicke in DOMINANT only

400

Which of the following CANNOT cross suture lines? Why?

A: Epidural haemorrhage

B: Subdural haemorrhage

C: Subarachnoid haemorrhage

Epidural haemorrhages CANNOT cross suture lines (skull sutures are the areas where the dura is most tightly adhered to)

Subdural haemorrhages are below the dura and CAN cross suture lines

500

Describe the pathway up the spinothalamic tract. If there was a spinal cord lesion, what would expect to see clinically BELOW the lesion?

Axons enter spinal cord via dorsal root ganglion

Synapse at substantia gelatinosa of spinal cord with 2nd order neurons at that level (therefore, a lesion here will produce contralateral hemisensory loss below this point as it decussates at the level)

2nd order neurons decussate and ascend as anterior (crude touch, pressure) and lateral (pain, temperature)

Synapse with 3rd neurons in ventral posterolateral nucleus

Travels through posterior limb of internal capsule and corona radiata

To primary somatosensory cortex

Tumours/stroke

100

What vessel is ruptured in a subdural haemorrhage? In whom does this usually occur?

Subdural - bridging veins (usually elderly or infants)

200

What is a LMN lesion? How do they present compared to an UMN lesion?

LMN signs - hyporeflexia, hypotonia, paralysis/paresis, muscle atrophy

UMN signs - hyperreflexia, hypertonia, clonus, paralysis/paresis, Babinski

300

Which tumour is histologically described as a 'fried egg with chickenwire capillaries'

Oligodendroglioma

400

What are embryonal tumours? Histological feature?

Medulloblastoma (primitive neuroectodermal tumours)

Primitive small cells that resemble the multipotential cells of the developing foetal brain

Homer Wright Pseudorosettes - no true lumen, eosinophilic centre

500

What is a lacunar infarction? How does it occur?

Hyaline arteriolosclerosis of lenticulostriate arteries supplying the basal ganglia, internal capsule, thalamus 

A/w hypertension and diabetes

Pure sensory (thalamus)

Pure motor (internal capsule)

Sensorimotor (mixed)