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Year 4 Additional Notes > ACH > Flashcards

ACH Flashcards

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1
Q

Management of an ischaemic stroke

A

Transfer to stroke centre
Non contrast CT head then diffusion weighted MRI
Aspirin 300mg for 2 weeks
Alteplase if within 4.5 hours (and no contraindications/no wake-up stroke)-0.9mg/Kg/hour
Thrombectomy if within 6 or up to 24 hours (limited core volume) (and required)
Carotid endarterectomy if required
Resolution of AF if required
Support care eg. SALT/ VTE prophylaxis, oxygen if sats low etc.

NB:
-Secondary prevention (clopidogrel 75mg and atorvastatin 80mg, treat modifiable risk factors)
-Anticoagulation after 2 weeks if an embolic stroke (caused by AF)

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2
Q

Lateral medullary syndrome

A

Wallenberg syndrome
Posterior inferior cerebellar artery

Cerebellar features;
ataxia
nystagmus

Brainstem features;
ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss

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3
Q

Lateral pontine syndrome

A

Anterior inferior cerebellar artery

Horner’s syndrome
Facial paralysis and droop
Decreased taste (anterior 2/3 tongue)
Audiovestibular disturbance
Decreased facial sensation
Ataxia

NB- difference with posterior inferior cerebellar artery (wallenberg) is there would be no facial paralysis there and upper/lower limb involvement

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4
Q

Secondary prevention after ischaemic stroke

A

Clopidogrel 75mg (or dipyridamole 200mg BD + aspirin 75mg if contraindicated)
Atorvastatin 80mg

NB- not the same as secondary prevention following ACS

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5
Q

Contraindications to clopidogrel

A

Active bleeding
Allergy

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6
Q

Absolute contraindications to thrombolysis

A

Previous ICH
Seizure at stroke onset
Intracranial neoplasm
Suspected SAH
Stroke or traumatic brain injury in preceding 3 months
Lumbar puncture in preceding 7 days
GI haemorrhage in preceding 3 weeks
Active bleeding
Pregnancy
Oesophageal varices
Uncontrolled HTN (200/120)

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7
Q

Relative contraindications to thrombolysis

A

Concurrent anticoagulation (INR >1.7- higher the INR, the more likely they are to bleed)
Haemorrhagic tendency (ie. haemophilia)
Suspected intra cardiac thrombus
Major surgery or trauma in the preceding 2 weeks

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8
Q

Management of a haemorrhagic stroke

A

Transfer to stroke centre
Correction of coagulopathy
Reduce ICP eg. Mannitol and raised head
Surgery- craniotomy and clotting evacuation
Supportive- SALT/ VTE prophylaxis etc.

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9
Q

NIHSS Score

A

0- no Sx
1-4- minor stroke
5-15- moderate stroke
16-20- moderate to severe stroke
21-42- severe stroke

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10
Q

Management of a TIA

A

Immediate aspirin 300mg (even in community) for 2 weeks, unless patient has a bleeding disorder or is taking an AC (like aspirin)- needs to be referred for MRI head to exclude haemorrhage
Same day referral to the stroke service to be seen within 24 hours (carotid doppler/ ECG)
Lifestyle modification eg. Reduce BP (130/80), smoking cessation, diabetes review, AF management etc.

Then clopidogrel for life (+statin)- may require carotid endarterectomy

NB- no CT head if neuroimaging required (use MRI)

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11
Q

Contraindications to 300mg aspirin

A

Patient has a bleeding disorder or is taking an anticoagulant (haemorrhagic event needs to be excluded)

Patient already takes low dose aspirin regularly

Aspirin is always contraindicated in this patient eg. Allergy

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12
Q

Guidelines for a carotid endarterectomy

A

Suffered a stroke/ TIA

Stenosis is above 70% (European guidelines)

Not severely disabled

NB- significant stenosis should be operated on within 2 weeks

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13
Q

Embolic TIA (or stroke)- extra medications required

A

Anticoagulation eg. DOAC first line (edoxaban), started 2 weeks after the event, or warfarin

NB- Antiplatelet therapy if anticoagulation contraindicated eg. Aspirin 75mg, clopidogrel 75mg

NB- these patients will still be given aspirin and clopidogrel, then anticoagulants but timing depends on whether TIA or stroke

TIA- start when imaging excludes haemorrhage
Stroke- start after 2 weeks (when no haemorrhage)

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14
Q

Recognised complications of thrombolysis in acute stroke

A

7% angioedema (increased if using an ACE-I)
6% haemorrhage

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15
Q

Territory affected and upper/lower limb Sx

A

ACA- upper < lowers (ants are on the ground)

MCA- upper > lower

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16
Q

Barthes index

A

Measure a persons daily functioning post-stroke (AODL & mobility)

Level 1- mild dependent

Level 2- moderate dependent

Level 3- severe dependent

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17
Q

Ischaemic vs haemorrhagic stroke

A

Very difficult to differentiate, but if symptoms progress (get worse), could be haemorrhagic

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18
Q

Stroke mimic

A

Seizure- post ictal paresis (can be a dense hemiparesis)

Hypoglycaemia (BM is most important initial test)

Functional

TIA

Migraine

NB- difference is that the patient loses consciousness beforehand (unlikely with stroke/TIA)

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19
Q

Drugs that can induce Parkinsonism

A

Chlorpromazine, haloperidol (anti psychotics), risperidone, olanzapine, metoclopramide (anti emetic/GORD), prochloperazine (schizophrenia, anxiety, BPPV), cyclizine (depression)

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20
Q

Vascular Parkinson’s

A

Predominant lower body signs

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21
Q

Dementia with Lewy bodies

A

Dementia, Parkinson’s, and visual hallucinations (hallucinations first)
Cognition may fluctuate (like delirium), in contrast to other forms of dementia

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22
Q

Multi system atrophy

A

Prominent early autonomic features eg. Hypotension, bladder instability, erectile dysfunction
Cerebellar signs

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23
Q

PSP

A

Early falls, truncal rigidity, vertical gaze palsy

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24
Q

Normal pressure hydrocephalus

A

Dementia, gait disorder, bladder instability

Wet wobbly wacky

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25
Corticobasal degeneration
Asymmetrical Parkinsonism and dyspraxia, dementia, and aphasia
26
Parkinson’s disease with dementia
Dementia comes after initial Parkinsonism
27
Drug induced Parkinsonism
Rapid onset and bilateral Rigidity and rest tremor are uncommon
28
Differentiate IPD and Parkinson’s plus syndromes
Poor response to levodopa
29
PD and neuroleptic malignant syndrome
If medication isn’t taken or absorbed regularly (eg. Due to vomiting illness/ forgetfulness etc.) Patients need to be advised on the importance of regularly taking medication and how to spot symptoms of NMS NB- don’t give Drug holidays for this reason/ mess with patients drugs whilst they are in hospital
30
Neuroleptic malignant syndrome
Hyper pyrexia, mental status changes, muscular rigidity, autonomic dysfunction NB- raised creatinine, leukocytosis seen. AKI may develop secondary to rhabdomyolysis
31
Management of a tremor patient
Parkinson features- refer to movement disorder clinic Non Parkinson features; Review meds and check TFT’s Propranolol Safety net (come back if PD features develop)
32
Symptoms to ask in stroke or TIA history
Face Arms Speech
33
Features of narcolepsy
Hypersomnolence Cataplexy (sudden loss of muscle tone triggered by emotion) Sleep paralysis Vivid hallucinations
34
Investigations and management of narcolepsy
Multiple sleep latency EEG Give daytime stimulants (modafinil), and nighttime sodium oxybate
35
Neurofibromatosis 1
Cafe au lait spots Axillary/groin freckles Peripheral neurofibromas Iris hamatomas Scoliosis Phaeochromayctoma Mnemonic CRABBING; C – Café-au-lait spots (6 or more) measuring ≥ 5mm in children or ≥ 15mm in adults R – Relative with NF1 A – Axillary or inguinal freckles BB – Bony dysplasia such as Bowing of a long bone or sphenoid wing dysplasia I – Iris hamartomas (Lisch nodules) (2 or more) are yellow brown spots on the iris N – Neurofibromas (2 or more) or 1 plexiform neurofibroma G – Glioma of the optic nerve
36
Neurofibromatosis 2
Bilateral vestibular schwannomas Multiple intracranial schwannomas, meningiomas, ependyomas
37
Treatment of neuropathic pain
Either amitriptyline, duloxetine, gabapentin, or pregabalin (if it doesn’t work, stop and try another one- all used as mono therapy) Tramadol as a rescue therapy
38
Causes of delirium
PINCH ME Stroke Pain Infection (UTI, pneumonia, cellulitis, meningo-encephalitis) Nutrition (hypercalcaemia, hyperglycaemia, hyponatraemia, (any electrolyte disturbance) alcohol withdrawal, B12 & folate deficiencies) Constipation Hydration Medication Environment Stroke (acute infarct/bleed)
39
Features of delirium
Memory disturbance Agitated or withdrawn (hyper or hypoactive delirium) Disorientated Mood change Visual hallucinations Disturbed sleep cycle Poor attention
40
Factors favouring delirium over dementia
Impaired consciousness Fluctuating symptoms (worse at night, periods of normality) Abnormal perceptions (illusions and hallucinations) Agitation Fear Delusions
41
Risk factors for falls
Lower limb muscle weakness Vision problems Previous falls Balance or gait disturbance (diabetes, PD, RA) Poly pharmacy Incontinence 65+ Postural hypotension Arthritis Psychoactive drugs Cognitive impairment
42
Medications that cause postural hypotension
Nitrates Diuretics Anticholinergic medications Antidepressants Beta blockers Levodopa ACE-inhibitors
43
Medications that can cause falls for other reasons
Benzodiazapenes Antipsychotics Opiates Anticonvulsant Codeine Digoxin Sedative agents
44
What tools are used to assess frailty
Evaluation of gait speed Self reported health status PRISMA7 questionnaire (age, sex, health problems, assistance required, walking aid use)
45
STOPP START
STOPP- identifies medications where their risk outweighs therapeutic benefits START- identifies medications that may provide additional benefits eg. PPI for gastroprotection
46
Investigations for a confused/delirious patient
History (collateral (family, staff), notes), cognitive assessment (AMT10), thorough clinical examination (A-E with observations) Confusion screen -urinalysis with culture -bloods: FBC, UE, LFT, coagulation INR, TFT,Ca, B12, folate, haemanitics, glucose, blood cultures, bone profile -imaging: CT head if concerned about intracranial pathology, CXR (pneumonia, PE, pulmonary oedema)
47
Management of delirium
Supportive- same staff, gentle re orientation, clear and regular introductions, access to hearing aids and glasses, encourage independence, clocks, familiar objects and photographs, ensure lighting and noise are adequate, ask family and friends to visit Medication- avoid where necessary, haloperidol 0.5mg IM is first line, then benzos (0.5mg lorazepam). Avoid haloperidol in PD patients (always check)- use lorazepam Tell family and carers on discharge that delirium may never diss appear (some will be left with a degree of cognitive impairment)
48
How long after stroke will you see signs on CT
12 hours
49
Assess stroke symptoms in an acute setting (eg. AE)
ROSIER
50
Parkinson’s disease and inhibition
Dopamine receptor agonists are associated with inhibition eg. Ropinirole
51
Thrombectomy guidelines
Acute ischaemic stroke 6-24 hours, if limited infarct core volume demonstrated on scans
52
Levodopa side effects
Dyskinesia On off effect LESS EFFECTIVE OVER TIME Postural hypotension Cardiac arrhythmias Nausea and vomiting Psychosis Reddish discolouration of urine upon standing
53
What to check for in a man with osteoporosis
Testosterone
54
Management of osteoporosis
Offer bone protection if T score less than -2.5 Offer prophylactic bisphosphonates to those with a T-score < -1.5 if they are on steroids / going to be on steroids for 3 or more months (even if <65 years-old) NB- if they cannot tolerate alendronate, try risedronate NB- no bisphoshpanates below eGFR 35, try denosumab instead
55
Cabergoline (dopamine agonist)
Associated with pulmonary fibrosis
56
3 H’s when classifying a stroke
High function (speech, apraxia, neglect) Hemianopia Hemi loss (sensory or motor)
57
TACS
3/3 H’s
58
PACS
2/3 H’s
59
Lacunar stroke (Lacunar)
1/3 H’s
60
Posterior circulation stroke (POCS)
Occipital- isolated CONTRALATERAL homonymous field defect Cerebellar- IPSILATERAL cerebellar signs Brain stem- IPSILATERAL cranial nerve palsy
61
ACA occlusion
Contralateral arm and leg hemiplegia and sensory loss Apraxia
62
MCA occlusion
Contralateral lower facial, arm, leg hemiplegia and sensory loss Contralateral homonymous hemianopia Dysphasia (dominant hemisphere) Contralateral neglect (non dominant hemisphere)
63
Initial management for a patient who becomes unresponsive several hours after a fall/head injury
Insert an oropharyngeal airway and call anaesthetics for definitive airway management
64
What investigation can aid IPD diagnosis
single photon emission computed tomography (SPECT), especially if trying to distinguish ET and IPD
65
Management of PD
Refer to movement disorder clinic/ neurologist (don’t start treatment before they have seen the movement disorder specialist- will remove any signs and Sx) Conservative- physiotherapy, support groups, SALT assessment, occupational therapy Medical; -If the motor symptoms are affecting the patient's quality of life: levodopa (usually combined with a decarboxylase inhibitor eg. carbidopa (co-carbeldopa) or benserazide (co-benyldopa)) and a MAO-B inhibitor (sometimes a dopamine agonist too) -If the motor symptoms are not affecting the patient's quality of life: dopamine agonist (non-ergot derived eg. bromocryptine), levodopa or monoamine oxidase B (MAO‑B) inhibitor (selegiline) Surgical- DBS NB- drooling: glycopyrronium, orthostatic hypotension (midodrine), nausea- domperidone
66
COMT inhibitor
entacapone
67
Dopamine receptor agonists
bromocriptine, ropinirole, cabergoline, apomorphine Pulmonary fibrosis, hallucinations, impulse control, daytime somnolence
68
MAO-B inhibitor
selegilline
69
Antimuscarinics
procyclidine, benzotropine, trihexyphenidyl (benzhexol) block cholinergic receptors now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson's disease help tremor and rigidity
70
Amantadine
SE- ataxia, slurred speech, confusion, dizziness and livedo reticularis
71
Discontinuing benzodiazepines
Switch to diazepam slowly Reduce dose by 1/8 every 2 weeks When 1mg reached, stop completely
72
Features of a benign essential tremor
Fine tremor Symmetrical More prominent on voluntary movement Worse when tired, stressed or after caffeine Improved by alcohol Absent during sleep
73
Differentials for a tremor
Benign essential tremor Parkinson’s disease Multiple sclerosis Huntington’s Chorea Hyperthyroidism Fever Medications (e.g. antipsychotics, lithium, salbutamol) DT's
74
Areas a benign essential tremor affects
Voluntary muscles Hand tremor Head tremor Jaw tremor Vocal tremor
75
Investigations for a tremor
Bedside- thyroid, neuro, and PD exams Bloods- FBC UE TFT's folate B12 Imaging- not needed, SPECT if I wanted to differentiate BET and PD
76
Vertebral wedge fracture investigation
X ray
77
Ondansetron
5-HT3 antagonists used mainly in the management of chemotherapy-related nausea. It mainly acts in the chemoreceptor trigger zone area of the medulla oblongata. Adverse effects- constipation, prolonged QT interval
78
Bisphosphonate treatment holiday
Repeat DEXA scan and FRAX score now and stop the bisphosphonate if low risk, T score is now >-2.5, and review in two years The duration of bisphosphonate treatment varies according to the level of risk. Some authorities recommend stopping bisphosphonates at 5 years if the following apply: patient is < 75-years-old femoral neck T-score of > -2.5 low risk according to FRAX/NOGG
79
Weber's stroke syndrome
affects medial portion of midbrain ipsilateral III palsy contralateral limb weakness (not sensory loss)
80
DVT and subsequent stroke
Do an echocardiogram to rule out ASD/VSD (that's the only way you can have an embolic stroke following a DVT, if the thrombus can get into the opposite side of the circulation)
81
Anti-emetics in PD
domperidone
82
AF post stroke
following a stroke or TIA, warfarin or a direct thrombin or factor Xa inhibitor should be given eg. apixaban Antiplatelets should only be given if needed for the treatment of other comorbidities (eg. clopidogrel)
83
3 stroke syndromes
Weber's Wallenberg's (lateral medullary) Lateral pontine
84
Respiratory secretions and bowel colic
Hyoscine bromide and glycoporronium
85
Agitation and confusion at the end of life
Underlying causes of confusion need to be looked for and treated as appropriate, for example hypercalcaemia, infection, urinary retention and medication. If specific treatments fail then the following may be tried: first choice: haloperidol other options: chlorpromazine, levomepromazine In the terminal phase of the illness then agitation or restlessness is best treated with midazolam
86
Anticholinergics and dementia meds
work in opposite ways to one another so will reduce each others efficacy

Year 4 Additional Notes (17 decks)

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