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Neurology - Coggle Diagram

- - - - resting tremor
        
        cog wheel rigidity
        
        low frequency
        
        worst at rest
        
        worse with distraction
        
        better with conscious movement
        
        pill rolling
      - bradykinesia
        
        needed for diagnosis
        
        repeated movements slow down
        
        handwriting can get smaller and smaller
        
        hypophonia
        
        loss of facial expressions
      - rigidity
        
        stooped posture
        
        leadpipe rigidity
      - postural instability
    - - loss of normal sleep cycle
    - - fantosmia
    - - shuffling
      - involuntary hurrying (festination)
      - freezing
        
        difficulty initiating movement
        
        difficulty turning
      - reduced arm swing/arm swing asymmetry
      - small steps
  - - - early onset can affect younger people
  - - - co-careldopa (+ carbidopa)
      - co-beneldopa (+ benserazide)
    - - ropinirole
      - pramipexole
    - - selegiline
      - rasagiline
    - - entacapone
    - - PT
      - OT
      - SALT
      - psych
      - deep brain stimulation
- - - - pathology
        
        traumatic
        
        aneurysmal
        
        berry aneurysm in circle of Willis
        
        AV malformation
        
        typical patient
        
        hypertension
        
        polycystic kidney disease
        
        connective tissue disorders
        
        Marfan's
        
        Ehlers-Danlos
      - presentation
        
        Site: often occipital
        
        Onset: thunderclap (really fast, reaching maximum intensity within seconds)
        
        Character: hit on back of head
        
        Radiation: none
        
        Associated symptoms: meningism (neck stiffness, headache, photophobia, phonophobia), N&V
        
        Timing: until treated
        
        Exacerbating factors: bright lights
        
        Severity: worst pain ever
      - prognosis
        
        will continue until treated, eventually leading to death
      - investigations
        
        non-contrast CT head
        
        hyperdense blood in basal cisterns (starfish around circle of Willis)
        
        lumbar puncture after 12 hrs
        
        xanthochromia (blood breakdown products make CSF look yellow)
        
        CT angiogram
        
        ECG
        
        ST elevation
      - management
        
        refer to neurosurgery
        
        endovascular coiling/clipping
        
        nimodipine (CCB to prevent vasospasm)
        
        manage ICP
    - - meningitis
        
        presentation
        
        fever
        
        slight altered consciousness/confusion
        
        pathology
        
        inflammation of meninges
        
        Meningococcus (Neisseria meningitidis)
        
        Pneumococcus (Strep. pneumoniae)
        
        viral
        
        not as severe, tends to be self-limiting
        
        prognosis
        
        investigation
        
        Koenig's sign
        
        neck stiffness
        
        Brzezinski's sign
        
        bloods
        
        raised WCC (esp. neutrophils if bacterial, lymphocytes if viral) & CRP
        
        LP
        
        gram stain
        
        decreased glucose & cloudy if bacterial
        
        CT head
        
        exclude other pathology
        
        management
        
        IV antibiotics
        
        3rd generation cephalosporins (e.g. ceftriaxone)
        
        dexamethasone (if within time frame)
      - encephalitis
        
        presentation
        
        pronounced altered consciousness/confusion
        
        headache
        
        seizures
        
        fever
        
        N&V
        
        focal signs
        
        pathology
        
        usually viral
        
        Herpes simplex 1
        
        changes typically in temporal lobe
        
        inflammation of brain matter
        
        prognosis
        
        very high mortality
        
        investigations
        
        LP
        
        viral PCR
        
        CT/MRI head
        
        management
        
        IV aciclovir
      - management
        
        give IV ceftriaxone & aciclovir before LP results if unsure
    - - frontal lobe tumour
        
        presentation
        
        cognitive issues
        
        sleepiness
        
        personality change
        
        new/worsened headache
      - 3rd ventricular colloid cyst
        
        presentation
        
        headache
        
        loss of consciousness
    - - presentation
        
        non-specific headache
        
        scalp tenderness
        
        visual disturbance
        
        may be systemically unwell
      - investigations
        
        bloods
        
        ESR
        
        raised
        
        CRP
        
        raised
        
        FBC
        
        raised platelets
      - management
        
        high dose prednisolone stat
    - - pathology
        
        intracranial hypertension
        
        idiopathic intracranial hypertension
        
        hydrocephalus
      - presentation
        
        new daily persistent headache
        
        rapidly progressive
        
        progressive focal neurological features
        
        visual obscurations (blacking/fading of vision on movement
        
        pulsatile tinnitus
        
        seizures
        
        cognitive change
        
        drowsiness
        
        loss of consciousness
        
        bilateral papilloedema
        
        headache wakes patient
        
        worsened by Valsalva manoeuvres
        
        cough
        
        bending down
        
        elevated CSF opening pressure (10–25 cm is normal)
        
        progressive episodic/persistent headache (can progress from intermittent to constant over a few wks)
        
        often enlarged blind spot
      - management
    - - presentation
        
        worsens when standing upright, better when lying down (may completely resolve)
      - investigations
        
        MRI
        
        subdural hygroma (black area around white line)
        
        venous engorgement (white line around brain)
      - management
        
        bed rest
        
        fluids
        
        epidural blood patch
        
        analgesia
        
        IV caffeine (or 1 red bull can 4x daily)
      - prognosis
        
        most resolve on their own
    - - sinusitis
  - - - presentation
        
        tight band
      - management
        
        simple analgesia
    - - typical patient
        
        female
        
        FH
        
        obesity
        
        motion sick
      - presentation
        
        Site: unilateral
        
        Onset: gradual
        
        Character: pulsating/throbbing
        
        Radiation: none
        
        Associated symptoms: N&V
        
        Timing: 4–72 hrs
        
        Exacerbating factors: bright lights, loud noises
        
        Severity: disabling
        
        a few may have aura
      - treatment
        
        acute
        
        paracetamol
        
        NSAID
        
        aspirin 900mg
        
        ibuprofen
        
        triptans
        
        oral sumatriptan
        
        antiemetic (even if not nauseous, as it can help with paracetamol/aspirin absorption)
        
        metoclopramide
        
        avoid opiates
        
        prophylactic
        
        propranolol (beta-blocker)
        
        not in asthma
        
        amitriptyline (tricyclic antidepressant)
        
        caution in elderly
        
        topiramate (anticonvulsant)
        
        teratogenic
        
        trigger avoidance
      - pathology
        
        GI tract slowed down a bit
        
        may have triggers
        
        strong smells
        
        certain tastes
        
        dehydration
        
        stress
    - - cluster headache
        
        typical patient
        
        male
        
        FH
        
        smoker
        
        presentation
        
        Site: unilateral (usually temporal/periorbital)
        
        Onset: sudden (max 9 mins)
        
        Character: boring/sharp/throbbing
        
        Radiation: none
        
        Associated symptoms: migrainous symptoms, lacrimation, rhinorrhoea, ptosis, miosis & red sclera
        
        Timing: 15 mins–3 hrs (usually 45––90 mins, most commonly 90 mins), rapidly stops; may have constant background pain; attacks often occur at same time during day/year, often waking patients up; usually episodic, clustered into 1–3 mth bouts with remission of at least 1 mth, from every other day to 8 per day, average 1–2 per day; sometimes chronic, with bouts lasting >1 yr with remissions <1 mth
        
        Exacerbating factors: sitting still, alcohol (within 30–60 mins)
        
        Severity: severe
        
        management
        
        acute
        
        sumatriptan
        
        SC (6mg up to bd)
        
        intranasal (zolmatriptan)
        
        high flow non-rebreather oxygen (10–15l) (if >2x a day, or triptan contraindicated)
        
        avoid simple analgesia & opiates
        
        prophylactic (same time as prednisolone taper)
        
        verapamil (CCB) (high dose of 240–960 mg daily with ECG monitoring)
        
        topiramate (50–800mg per day)
        
        gabapentin (900–3600 mg/day)
        
        pregabalin (100–600mg/day)
        
        levetiracetam (2g–4g/day)
        
        melatonin (9–15mg/day, usually adjunct)
        
        sodium valproate (600mg–2g/day)
        
        lithium (400mg–2g dail, monitor 0.8–1mM)
        
        transitional
        
        oral prednisolone taper (1 mg/kg up to 60 mg daily for 1 wk, tapering by 10mg every 2 days)
        
        greater occipital nerve block (depomedrone 80mg + lidocaine 20mg)
      - paroxysmal hemicrania
        
        presentation
        
        almost the same as cluster headache except
        
        2–30 mins duration
        
        prominent ipsilateral autonomic symptoms
        
        attacks may be precipitated by bending/rotating head
        
        2–40 attacks per day
        
        no circadian rhythm
        
        management
        
        absolute response to indomethacin
      - Short-lasting Unilateral Neuralgiform headache with Conjunctival Injection & Tearing (SUNCT)
        
        presentation
        
        usually orbital/supraorbital/temporal pain
        
        stabbing/burning/pulsing pain (single stabs, groups of stabs or saw-tooth with stabs so frequent pain doesn't go down to normal)
        
        3–200 attacks/day
        
        10–240s
        
        pain accompanied by conjunctival injection & lacrimation
        
        management
        
        medical
        
        lamotrigine
        
        topiramate
        
        oxcarbazepine
        
        carbamazepine
        
        duloxetine
        
        pregabalin/gabapentin
        
        transitional
        
        greater occipital nerve block
        
        surgical
        
        occipital nerve stimulation
        
        deep brain stimulation
      - Short-lasting Unilateral Neuralgiform headache with Autonomic symptoms
        
        presentation
        
        stabbing/pulsing pain
      - Hemicrania continua
        
        presentation
        
        unilateral
        
        weeks–months
        
        episodic/chronic
        
        moderately severe background headache with superimposed exacerbations lasting 20 mins–several days
        
        comes on gradually
        
        eases off gradually
        
        mainly orbital & temporal
        
        often remember exact day of onset
        
        pain becomes continuous & unremitting within 24 hrs
        
        management
        
        limit medications
    - - trigeminal neuralgia
        
        pathology
        
        more often maxillary/mandibular division
        
        commonly caused by vascular compression
        
        MS
        
        intracranial AV malformation
        
        intracranial tumour
        
        brainstem lesions
        
        presentation
        
        triggered & spontaneous stabbing pain (each stab 5–10s)
        
        triggers
        
        wind/cold
        
        touch
        
        chewing
        
        brushing teeth
        
        refractory period if pushing through pain
        
        rare autonomic symptoms
        
        patient moving around with pain
        
        treatment
        
        medical
        
        carbamazepine/oxcarbazepine
        
        surgical by glycerol ganglion injection
        
        stereotactic radiosurgery
        
        microvascular decompression
        
        lamotrigine
        
        pregabalin
        
        gabapentin
        
        lacosamide
        
        severe exacerbation
        
        load phenytoin
- - - - ischaemic (~85%)
      - haemorrhagic (~15%)
    - - HYPERTENSION
      - increasing age
      - atrial fibrillation
      - carotid artery stenosis
      - DM
      - hypercholesterolaemia
      - smoking
      - alcohol excess
    - - Face drooping
      - Arm weakness
      - Speech slurring
      - contralateral deficit
      - leg weakness
      - sensory deficit
      - visual loss
    - - urgent non-contrast CT head
        
        haemorrhage?
      - ECG
        
        atrial fibrillation
      - carotid doppler
        
        carotid artery stenosis
    - - aspirin 300mg
      - thrombolysis
        
        within 4.5 hrs
        
        alteplase
        
        has to remain in bed after thrombolysis
      - thrombectomy (clot retrieval)
      - secondary prevention
        
        clopidogrel (anti-platelet) 75mg daily
        
        high-dose statin (atorvastatin 80mg)
        
        manage modifiable risk factors
    - - thrombolysis could make symptoms worse
      - 2nd most common cause of death globally
- - - - airway
      - oxygen
      - IV access
    - - IV lorazepam 4mg
      - buccal midazolam or rectal diazepam 10mg
    - - IV phenytoin
      - IV levetiracetam
      - IV sodium valproate
- - - - facial nerve palsy
    - - face drooping of all of one side