Stroke:
- Definition
- Causes
- Risk factors
- Symptoms
- Initial management
- Management + supportive
- Assessment tools
- Complications
- Stroke mimics
- Bamford classification
Stroke:
- Definition: a cerebrovascular accident where neurological deficit for >24 hours
- Causes: due to ischaemic (thrombus, embolus) or haemorrhagic (subarach due to avn malform or aneurysm, intracerebral due to htn)
- Risk factors: smoking, obesity, htn, dyslipid, previous, AF
- Symptoms: face drooping (forehead spared), arm contralat sensory loss or motor weaknesss, slurred speech, homonymous hemianopia, seizures
- Assessment tools: exclude hypoglycemia, ROSIER in a&e to work out if stroke or mimic (>0 = stroke likely), neuro ex
- Ix: ecg (af), fbc/clotting/lipids/glucose/u+es/lfts, carotid doppler uss, first line CT head non contrast where if black is isch and if white is blood
- Initial management: after ct admit to stroke centre, if <4.5 (or 9 if sleeping) hours iv thrombolysis altepase (not if prev haem/tumour/seiz/preg), then 24 hours after 300mg aspirin for 2 weeks OR straight away if no thrombolysis, thrombectomy in addition if large vessel/nihss >5 within 24 hours
- Management + supportive: SALT, physio, botulin if spasticity, no driving for 1 month, start 75 mg clopidogrel 2 weeks after aspirin + a statin if >3.5 48 hours after. Can also do carotid endartectomy if stenosis >50% within 7 days
NIHSS determines severity hence prognosis so if >22 bad and if <4 good. ASPECTs score is via CT findings
Monitor cbg, hydration, sats, temp, bp throughout, dvt - Complications: becomes haemorrhagic, cerebral oedema, seizures, bowel/bladder dysfunction, aspiration pneumonia, spasticity, immobility/ulcers, cognitive impairment
- Stroke mimics:
1. excluded via brain imaging: sol, ms, subdural haematoma
2. differences in symptoms: bppv, vestib neuronitis, syncope, transient global amnesia
3. further ix needed: migraine w aura, focal seizure, functional neurolog disorder
unlike these stroke should be stereotyped epsidoes, sudden, focal, and symptoms fit into a vascular territory
capsular warning syndrome are recurrent episodes of m/s signs without cortical signs (aphasia/apraxia/agnosia) which inc risk stroke - Bamford classification:
- TACs: 3 of homonymous hemianopea, contalat motor/sensory weakness, higher cerebral dysfunction (dysphasia, visuospatial dis, reduced conscious - proximal mca (upper limbs affected more)
- PACs: 2 of - mca branch
- LACs: 1 of pure sensory, pure motor or ataxic gait - lenticulostriate
- POCs: 1 of loss conciousness, homonymous hemian w macular sparing, cerebellar dysfunction, bstem dysfunction (m/s deficit with cranial nerve deficit) - vertebral/basilar/cerebellar artery
- Lateral medullary artery (wallenbergs syndrome): contralat limb sensory loss, ipsit (ataxia/facial numbness/dysphagia/cranial nerve palsy) - post inferior cerebellar art
- lateral pontine syndrome: same as wallenburgs but ipsat facial paralysis + deafness
- Webers: ipsilat cn3 palsy, contralat weakness
- amaurosis fugax - ophthalmic artery
- locked in syndrome - basilar artery
TIA:
- Definition
- Causes
- Risk factors
- Symptoms
- Management
- Investigations
TIA:
- Definition: focal neurolog deficit caused by focal brain/sc/retinal isch without acute infarction
- Causes: atherosclerosis
- Symptoms: m/s loss, aphasia, hemispatial neglect, dizzy, weak, amaurosis fugax
- Management: 300mg aspirin until seen, mri within 24 hours (or within 1 weeks if >7 days). then dual antip therapy: clopidogrel 300mg intial dose then 75mg indef , aspirin 75mg 21 days + ppi (if cont then ticagrelor + clopidogrel)
if recurrent no driving for 3 months - Investigations: rule out hypoglyc fbc/gluc/lipids/coag, carotid duplex uss within 24 hours, mri brain with diffusion weighted imaging
Delirium:
- Definition (5 ICD components)
- Subtypes + symptoms of each
- Clinical features
- Why is delirium bad - complications
- Risk factors
- Drug causes
- Causes
- Screening tools - and scores for each
- DD
- Investigations
- Management
Delirium:
- Definition: acute transient impairment of cognition
- Subtypes + symptoms of each:
Hyperactive, hypoactive - Clinical features: Disordered thinking, Emotional, Language impaired, Illusions/delusions/ carphologia, Reversal sleep wake cycle, Inattention, Unaware, Memory deficit
- Why is delirium bad - complications: inc risk falls
- Risk factors: age, renal impairment, hospitalisation, cognitive impairment, infection, previous
- Drug causes: opioids, steroids, antipark, antichol, antidep, benzos, antipysch
- Causes: infection, constip, urin retention, pain, hypoxia, metabolic abnormalities, alc withdrawal
- Screening tools - and scores for each: CAM, AMT4, 4AT
- DD: mood disorder, thyroid
- Investigations: GCS, hydration/neuro/abdo, urinalysis, fbc/crp/u+es/tfts/b12/f/glucose/bone profile, culture, cxr, ct head
- Management: optimise environment (well lit, home items, family, treat cause, haloperidol (lorazepam if parkinsons)
Dementia:
- Definition of cognitive impairment (4 components)
- Definition of dementia
- Risk factors
- Causes
- Symptoms
- Investigations
- Management
- Types
Dementia:
- Definition of cognitive impairment (4 components): decline in memory, thinking, judgement, language and perception
- Definition of dementia: cognitive impairment sufficient to impair ADLS >6 months
- Risk factors: TCAS, age, fx, dec IQ, vasc risk f
- Causes: head injury, infection, toxins, neurodegenerative, h/v impairment, metabolic abnormalities, normal pressure hydrocephalus
- DD: dementia, delirium, SOL, stroke, depression, hypothyroidism, substance misuse
- Investigations: 10CS, 6CIT, GPCOG, MMSE (<24/30) used in non specialist setting. Can also do bloods in primary care fbc/crp/u+es/lfts/tfts/glucose/b12/f/bone profile. If ok then to secondary care memory clinic for neuroimaging
Falls:
- Risk factors - intrinsic and extrinsic factors
- Complications
- Causes
- Investigations
- What is in a risk assessment
- Management
Falls:
- Risk factors - intrinsic and extrinsic factors
intrinsic: arthritis, cog impairment, visual/ h issues, incont
extrinsic: footwear, bad lighting, bad clothes, meds (diuretics, sedatives, hypoglyc, hypotensives) - Causes
general: mechanical, polypharm, sepsis, arthritis, hypoglycemia
cvs: arrhythmias, orthostatic hypotension, bradycardia, valve HD
neurolog: epilepsy, stroke
ENT: bppv, menieres, labrinthytis - Investigations:
bedside: lying + standing bp (>20 sys drop, >10 dias drop when 3 mins or sys<90), urine dip, ecg, cbg, med review, h/v test
bloods: fbc, crp, u+es, bone profile, lfts
image: cxr, ct head, ech - What is in a risk assessment: FRAT
- Management: mdt if >65 + >2 falls in 12 months or requires treatment or poor tined 180 test/timed up and go test
Frailty:
- Definition
- Physiological vs phenotypical definition
- Factors that identify it
- What’s in clinical frailty score
- Investigations
- Management
- Definition of comprehensive geriatric assessment CGA
- What is included in a CGA
Frailty:
- Definition: the clinically recognised state of increased vulnerability to resolution of homeostasis after an acute stressor. used for prognosis + prediction
- Physiological vs phenotypical definition: physio is when the body system looses inbuilt reserve and more vulnerable to adverse health outcomes. Phenotyp: reduced grip strength, reduced mobility, reduced weight, low energy
- Factors that identify it: CFS, no. admissions, reduced mobility, no. falls, incont, delirium
- What’s in clinical frailty score: 1 v fit -> 9 terminally ill
- Investigations: PRISMA-7 questionnaire, gait speed, timed up and go test
- Management: OT, physio, befriending
- Definition of comprehensive geriatric assessment CGA: a multidimensional interdisciplinary diagnostic process to determine physiological, medical and functional capabilities of frail person to come up with plan for treatment and follow up
- What is included in a CGA: problem, medicine, environment, social, mental health, nutrition, functional
Lewy body dementia:
- definittion
- symptoms
- ix
- mx
Lewy body dementia:
- definittion: 20%, lewy bodies which are alpha synuclein protein deposits within the bstem then substantia niagra
- symptoms: progressive impairment with day to day fluctuations, then parkinsonism features within 12 months, visual hallucinations of furry animals
- ix: clinical, SPECT
- mx: donepezil, rivastigmine, memantine. Avoid antipsychotics
Frontotemporal dementia (picks)
- Definition
- Types
- symptoms
Frontotemporal dementia (picks):
- definition: macroscopic atrophy of frontal/temporal lobes. Microscopic pick bodies (tau aggregations, gliosis, neurogib tangles and senile plaques)
- other types: progressive non fluent aphasia (sudden agrammatic utterances), semantic dementia (speech conveys little meaning)
- symptoms: sudden onset <65 years with preserved memory/visiospatial skills but personality change + impaired social conduct (disinhibition, inc appetite, inapp behaviours)
- ix: mri
Alzheimers:
- definition
- risk f
- symptoms
- ix
- mx
Alzheimers:
- definition: macroscopically cortical atrophy esp cortex/hippocampus, widened sulci and enlarged ventricles. Microscopically intracellular neurofib tangles and b amyloid plauqes extrac causing degeneration of cholinergic neurones. Can be sporadic or familial if early onset <65years
- risk f: age, fx, Caucasian, downs
- symptoms:
1. early: difficulty finding words/forgetting names or places
2. mid: lang problems, instrumental ADL problems, apraxia
3. later: disorient, incont, agnosia, agraphia, BPSD behaviour & psycholoigcal symptoms of dementia (affective: agitation, crying, apathetic: lack emotion/motivation, psychotic: delusions/hallucinations, hyperactive: wandering, disinhib)
- ix: SPECT differentiates from lewy body. CT shows atrophy
- mx
psych: animal assisted therapy, cognitive stimulation therapy
bio: inform DVLA + annual review, advanced care planning, OT for prompts, motion sensors for wandering, support groups, nursing
bio: acetycholinesterase inhibitors doneprazil (SE: insomnia, contra: bradyc), rivastigmine, galantamine (extrapyramidal SE), if severe NMDA antagonist memantine (gi, bradycard so check hr/ecg before starting, muscle spasms)
Factors to suggest delirium rather than dementia
- acute onset
- impairment of consciousness/attention
- fluctuation of symp (worse night, sometimes ok)
- disrupted sleep wake cycle
- normal autonomic feature
- illusions/hallucinations/delusions
- agitation/fear
Vascular dementia:
- definition
- risk f
- symptoms
- ix
- mx
Vascular dementia:
- definition: 2nd most common, due to stroke or multiple small infarcts
- risk f : hx stroke/tia, hyperchol, AF, diab, htn, obese, smoking
- symptoms: stepwise deterioration, visual dist, sensory/motor symp, attention/conc difficulties, seizures, memory, gait, speech/emotional disturbance
- ix: mri
- mx
pysch: cog stimuulation, music/art, animals
bio: only aceE inhib or mem if suspect alz/lewy comorb
