Acute Neurological Issues Flashcards
Treatment & Surgical tx for TIA
Medical-Statin, AntiHtn tx, Antiplatelet, AC
Surgical-carotid endarterectomy-in cases of TIA caused by cervical internal carotid artery stenosis
Imaging
-Head CT first: Not sensitive acute phase 0-6h
Screens for hemorrhagic stroke
Screens for tumors to r/o imitators of stroke
Allows for TPA to be started (bleed ruled out)
MRI: Volume of blood in head-guide management
CTA-vessel occlusion
Hemorrhagic Stroke
-HTN; generally BG or cerebellar
-Amyloid; generally lobar
-Aneurysmal
-Arteriovenous Malformation; AVM
-Dural sinus thrombosis
-SBP control, Identify cause; treat if possible.
-External ventricle, clot removal, hemi-craniectomy
Differentiating Stroke-diagnosis
-Hemorrhagic: Hyperdense lesion in a non-contrast head CT
-TIA: Normal MRI head
-PRES: hypertension that can lead to confusion, visual changes, and seizures
MRI demonstrating cerebral edema in the posterior hemispheres
Posterior Reversible Encephalopathy Syndrome
-HA, Confusion, seizures, visual loss
-Risk; severe pre-eclampsia, eclampsia, malignant hypertension.
-MRI) of the brain, areas of edema (swelling) are seen. The symptoms tend to resolve after a period of time, although visual changes sometimes remain.
Contraindications to TPA
-hx of stroke/head trauma in the past 3 months
-hx of intracranial hemorrhage
major surgery in the past 14 days
-GI or urinary tract bleeding in the past 21 days
-MI in the previous 3 months
-arterial puncture at a non-compressible site in past 7 days
resolving stroke symptoms
-very minor and isolated neurological symptoms
seizure at the onset of stroke
-persistent hypertension SBP > 185 mmHg or DBP > 110 mmHg
-use of direct thrombin inhibitors, use of factor Xa inhibitors
Hydrocephalus
Abnormal accumulation of CSF within the ventricular system either from inability to resorb, or obstruction of flow
-Non-communicating
-Communicating
-NPH
Hydrocephalus s/s
–HA (esp postural), nausea, emesis, gait disorder, urinary difficulty, difficulty with memory, cognition, apathy.
Hydrocephalus management
-Lumbar puncture w/opening pressure
-High volume tap with video (Shows what CSF diversion will accomplish.)
-CSF diversion (VP shunt, VA shunt, VPI shunt)
Acute hydrocephalus
-Quick build up of CSF in ventricles:
-Pinching off of aqueducts, shunt failure, herniation.
-Coma, obtunded and death.
100% mortality in 24-48 hours if untreated.
Diffuse axonal injury
-Most common type of TBI, found in mild to severe injury. Most destructive injury.
-Result of accel/decel with rotational component
-Damage; shearing of axons and destruction of functional (myelinated) tracts.
-Common in MVC, shaken baby.
—MRI Flair sequence can demonstrate findings suggestive of DAI; dx only by autopsy
—-TX; supportive
Closed head injury are at risk for what?
-Swelling
Acute Subdural Hematoma
-common in the elderly and alcoholics due to cerebral atrophy.
–There is more strain on the bridging veins, which tear easily with minor trauma, and cause a venous bleed.
–SUB-dural = under the dura mater, andove the arachnoid mater.
Appearance:Crescent-shaped
Acute SDH Conservative & operative management
-monitored carefully if no significant mass effect and there is little or no cerebral edema.
-Acceptable in elderly patients: brain atrophy.
-Reimage at 6 h and again 24 h
-hematoma>1 cm in thickness
-hematoma causing>5 mm of midline shift, regardless of initial examination
-or a unilateral fixed and dilated pupil.
-Generally, mortality is lower if surgery is performed within 4 h of injury
Epidural hematomas
-Injury to the middle meningeal artery (MMA)
-Associated with skull fractures that lead to bone bleeding or injury to the middle meningeal artery (MMA)
-Risk of herniation
-Lucid moment
-»_space;30 cm need evacuation
- surgical emergency
-Conservative management: Less than 30cm3, <5mm shift, >8 GCS
-Low threshold to reimage—go to OR
