Content Headache Giddiness Loss of Consciousness WeaknessLethargy Headache Approach Primary vs Secondary Red Flags Patterns Raised ICP features thunderclap visual disturbances hypertension ID: 1032740
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1. PACES Approaches Ep1: Neurology Approaches (I)
2. ContentHeadacheGiddinessLoss of ConsciousnessWeakness/Lethargy
3. Headache
4. ApproachPrimary vs SecondaryRed FlagsPatterns: Raised ICP features, thunderclap, visual disturbances, hypertensionIntracranial vs Extracranial (don’t forget SYSTEMIC things like pheochromocytoma, OSA, hyperviscosity)
5. Primary HeadachesSecondary HeadachesMigrainePreceding light flashes, abnormal smellsPrefer dark roomRed Flags: Progressive, thunderclap (sudden onset, worst ever headache), raised ICP (cough, lying down), neurological symptoms, meningism (neck stiffness, photophobia, rash), constitutional symps (fever, LOW/LOA), extremities of ageClusterUnilateral tearing, rhinorrhea, droopy eyelidIntracranialVascular (sudden): SAH (APKD), venous sinus thrombosis, pituitary apoplexy, carotid/vertebral artery dissectionTensionBand likeStressorsInfection: Meningitis, encephalitis, abscessTumour: Primary, haematological malignancy, metastasis, pituitary (acromegaly)Others: Benign intracranial hypertensionExtracranialGCA, sinusitis, glaucoma, dentalSystemicHypertension (pheochromocytoma, OSA) medication induced (analgesia, CCB, nitrates), hyperviscosity (polycythemia, haem malig)
6. Important ConditionsNeuro: Cebebral venous sinus thrombosis (hypercoagulable states), BIH, SAH (b/g APKD)Endocrine: Pituitary apoplexy, pheochromocytoma, acromegalyRheum: GCAOthers: OSA
7. PatternsHypertension: Pheochromocytoma, Hypertension causing HA, CCB use, Raised ICP with Cushing’s reflex, Pituitary tumours with 2’ endocrinopathy (acromegaly, cushing’s)BOV: GCA, glaucoma, BIH, SOL with visual tract compromise (pituitary tumour, cerebral SOL)Thunderclap : SAH, cerebral venous sinus thrombosis, cervical artery dissection, reversible cerebral vasoconstriction syndromesRaised ICP features: SOL (rmb pituitary tumour), BIH, thrombosis/hemorrhage
8. Giddiness
9. ApproachBig Groups: Vertiginous (central vs peripheral)Pre-Syncope (similar causes to syncope)Light-headednessPre-syncope causes feature quite significantly – Especially postural hypotension group (DM, Drugs, Autonomic, Adrenal Insufficiency, Anemia)Other conditions: Conduction defects (Ank spond, DM/PM, MD), NF2 with acoustic neuroma, hypoglycemia (adrenal insufficiency, MEN1)
10. Vertiginous: Spinning sensationPeripheral-BPPV, Vestibular neuronitis, Labyrinthitis, Meniere’s, migrainous vertigo-Ear: Otitis media, ototoxic drugs (aminoglycosides) Central-Cerebellar: All causes, CPA, MS -Brainstem: VBI, posterior fossa infarctionAcute vs chronic? Episodic vs first episode? Ear symptoms: Ringing in ears? Deafness? Fullness of ear? Neurological symptoms: Especially cerebellar (coordination) Acoustic neuroma (ask hearing loss, consider NF2)Presyncope:Near black out?Improve with sitting/lying?Preceding cardio/neuro symptoms?Postural association?Cardiac-Aortic stenosis, AMI, HOCM, arrhythmias (brady, sick sinus, heart block, VT, QT prolong) – PACES conditions that cause CMP/arrhythmia problems include muscle pathology (MD, DMD), Ank spond Vascular: Subclavian steal syndrome Neuro: -Carotid sinus hypersensitivity-Vasovagal, situational (cough, micturition, defecation) Orthostatic / Postural Hypotension:DehydrationDrugsAutonomic: DM, PD/MSA, LEM, GBS/CIDPAdrenal insufficiencyAnemia Chest pain, SOB, diaphoresis, palpitations Sudden head movements, wearing tight collar? Oral intake. Polyuria/polydipsia? Tremors/slowing of movements? Hot environment, prolonged standing?TCM useBlood loss Light-headedness Hypoglycemia (adrenal insufficiency, insulinoma in MEN)Any form of acute illness (electrolytes, sepsis)Missed meals?Do you have any fever? LOW/LOA
11. Loss of Consciousness
12. ApproachBig GroupsSeizures – Consider neurocutaneous disordersSyncope – Cardiogenic, vasovagal, subclavian steal (vasculitis)Others: Drop attacks, fell asleep, drowsinessRemember to consider counselling regarding driving/high risk activity
13. Seizures: Aura, jerking/tensing, up-rolling of eyes, frothing around mouth, tongue biting loss of bowel/urinary continence, post-ictal confusion, Todd’s paralysisSyndromes: Sturge Weber, Tuberous sclerosis, Down’s syndromeAcute: Infection, inflammation (SLE), electrolyte disturbances, drug overdose, vascular, uremic/hepatic encephalopathy, alcohol withdrawalChronic: Any CNS insult Syncope: Quick resolution following recumbency Exertion association (general exertion, upper limb exertion)Postural association Cardiac: Valve (aortic stenosis), arrhythmia (HOCM), underlying myopathy (Myotonic dystrophy, DMD/BMD, ank spond), arrhythmics (heart failure, congenital pathology like WPW, Brugada)Postural Hypotension: Hypovolemia, drugs, neurological disorder (DM, Parkinson’s, GBS), adrenal insufficiencyVasosagal: Prolonged standing, emotion (fear), situational (micturition)Steal Syndrome: Triggered by upper limb activityCardiac: Chest pain, palpitations Postural Hypotension: Precipitated by postural changes, fluid losses, medicationOthers: Drop attacks, fell asleepDrop Attack: Meniere’s, CataplexyFell Asleep: OSA DrowsinessCNS pathology: Infection, mets, vascular eventHypoglycemiaElectrolytes: Hypercalcemia, Hypo/hypernatremiaDrugs – Opioids Uremia, hepatic encephalopathy, hypoxia/CO2 narcosis
14. Weakness/Lethargy
15. ApproachImportant to ascertain if it is true weakness vs generalized lethargy/malaiseIf true weakness:Onset, persistent vs episodicPattern: Distribution (which limbs? bulbar?), proximal vs distalOther neurological symptoms: Sensory, CN, extrapyramidal, cerebellar, autonomicFor lethargy/malaise/fatigue groupEndocrinopathies: Hypothyroid, adrenal insufficiency, panhypopitOSAAnemiaSystemic diseasesMuscle Pains: Myositis, PMR, fibromyalgia
16. Fatigue/ LethargySpecific: OSA, anemia, heart failure, panhypopit, hypothyroidism, adrenal insufficiency, drugs (beta blockers), depression, chronic fatigue syndrome, fibromyalgiaGeneral: Cancer, chronic infections (HIV, TB), systemic diseases (liver, kidney dysfunction), autoimmune disorders (polymyalgia rheumatica, fibromyalgia)Weakness-Onset-Which limbs?-Proximal vs distal vs global-Sensation-Neck/ brainstem symptoms By Distribution: -Hemiparesis Pattern: Usually brain pathology (unless traumatic brown sequard)-Paraparesis Pattern: Usually spinal cord pathology (ask for bowel/urinary incont)-Quadri/Tetraparesis Pattern: Tends to be more non specific – cord (neck pain/sensory level) vs LMN>Proximal WeaknessMyopathy: Metabolic, Congenital, Rheum (Dermatomyositis, polymyositis), Endocrine (Grave’s, Hypothyroidism, Cushing’s, Acromegaly, Adrenal insufficiency), Neoplastic, DrugsNMJ: Myasthemia, Lambert Eaton (small cell lung ca)Anterior horn cell: MNDGBS>Distal WeaknessPeripheral neuropathies Episodic Weakness: Hypokalemic periodic paralysis, hemiplegia migraine, TIA, hypoglycemia