Headache and stroke Flashcards by Anna Hay

What score is used to determine the severity of stroke?

NIHSS

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Differentials for weakness - i.e. stroke mimics

Stroke/TIA
Seizure
Sepsis
Toxic/metabolic
Space occupying lesion
Syncope

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How to clinically differentiate between stoke and seizure?

Seizure will be postical and drowsy

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What is the most important investigation

CT Head
White - haemorrhage
Dark - ischaemia - unlikely to see new infarct

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Describe the Bamford Classification

TACS:
All three
1. Unilateral weakness (and/or sensory deficit) of face, arm, legs.
2. Homonymous hemianopia
3.. Higher cerebral cerebral dysfunction (dysphasia, visuospatial disorder)

PACS:
Two of:
1. Unilateral weakness (and/or sensory deficit) of face, arm, legs.
2. Homonymous hemianopia
3.. Higher cerebral cerebral dysfunction (dysphasia, visuospatial disorder)

POC:
One of 
1. Cerebellar or brainstem syndromes
2. LOC
3. Isolated homonymous hemianopia

LACS:
Subcortical stroke due to small vessel disorder. No evidence higher cerebral dysfunction
One of
Unilateral weakness (and/or sensory) of face and arm, arm and leg or all three.
Pure sensory stroke
Ataxic hemiparesis

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Describe blood supply to brian

Internal carotid → anterior circulation

* Veterbral artery → posterior circulation

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Mgmt of acute ischaemic stroke

ABCDE

Thrombolysis - 4.5 hrs and not CI

Aspirin 300mg 14 days

Bloods: FBC, U&Es, coagulation, HbA1c and cholesterol

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How to manage BP - how dif in iscahemic and haem strokes

BP < 180 for ischaemic
BP < 140 for haemorrhagic
Oral/BG amlodipine or labetolol infusions

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Causes of haemorrhagic stroke

HTN (majority!!)
Aneurysms/ AV malformation
Anticoagulation
Recreational drugs

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Causes ischaemic stroke

AF - emboli
Atherosclerosis
Dissection - young person for message

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What medications to give - embolic (AF) vs thrombotic

Embolic: NOAC/warfarin
Thrombotic: Clopidogrel 75mg

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Why do you NOT give LMWH in the acute mgmt of ischaemic or haemorrhagic stroke?

Risk of haemorrhagic tranformation

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Long term Ischaemic stroke mgmt

admit to stroke ward

Clop/NOAC/warfarin (unless ↑ hasbleed)
Atorvastatin 80mg
IPC stocking - as use LMWH
SALT
PHYSIO

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What next investigation of choice 24 hours?

Diffuse weighted MRI head

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Common complication

Aspiration pneumonia
Seizures (15%)
Depression, anxiety, pseudobulbar effect
DVTs

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After 24 hours in anterior stroke

ECHO
Carotid doppler if anterior circulation
Consider 24 hour tape if AF

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CT criteria

GCS < 13 on injury 
< 15 2 hours after admission
Open or depressed skull fracture 
Basal skull fracture 
post-tramutic seizure 
Focal neurological deficit 
> 1 episode vomiting

Describe Extradural haem
Where and how?
Presentation?
Mortality 
What type of person 
How does the CT criteria help you?

Head injury + LOC
‘Lucid internal’ → pt degeriates
30% mortality
Acute (60%), subacute (30%), Chronic (10%)
Temopral or parietal bone fracture → damages meningeal artery
Less common in small children and ppl > 60 years.
Blood between dura mata and skill

→ think about cervical spine
→ the associated symptoms can be any of the CT criteria

Mgmt extradural

Complications?

ABCDE + imaging
Reverse coagulopathy + cushing’s response
Small → asymptomatic - regular obs + scans
Surgery: focal signs, large, ↑ICP, midline shift

Surgery - emergency craniotomy or clot evacuation

Complications:
Death - cerebellar herniation
↑ ICP 
cerebral oedema 
Seizures
Permanent neurological or cognitive deficit due to pressure effects on brian
coma

Subdural haematoma
Aetiology and cause :
Time courses:

Tearing of bridging veins in subdural space
• Blunt trauma (most common)
• Spontaneously

Acute, subacute (3-7 days), chronic  (2-3 weeks)
Blunt trauma (most common)

Which high risk group

Infants - physical abuse
elderly - cerebral atrophy causes tension on veins. Consider anticoagulation
Alcoholics - RF for thrombocytopenia, ↑bleeding time, ↑head injury, cerebral atrophy

Mgmt and complications for subdural

Same as extradural

Subarachnoid 
Causes 
Mean age
Risk factors 
Associated disorder

Berry aneurysm otherwise traumatic brain injury

Mean 50 years

RF: HTN, cocaine, smoking, alcohol XS

associated: Ehlers-danlos, NFM1

Sudden onset headache
Pulses to occiput
Ass vomiting, seizure delirum
Neck stiffness → late sign

What do 10-15% experience before the SAH Common CF

Sentinel bleeds - small bleed or expansion of aneurysm Headache, dizzy, orbital pain, diplopia, vision loss, ↓consciousness

Inv

CT without contrast - positive in 95% - do ASAP | LP at 12 hours for xanthachromia

MGMT

* CT angiography - find bleeding site * start nimodipine (prevent vasospasm) * Surgical Tx - endovascular embolisation or surgical clipping Comps → the same as other bleeds

Red flags for headache What headaches do you always wanna rule out

``` Worsening of headache Sudden-onset reaching max intensity in 5 mine New neurological deficit New onset cognitive deficit change in personality ↑ consciousness Head trauma painful or red eye - acute angle glaucoma ↓ vision - temporal arteritis jaw claudication vomiting ``` • Bleeds, giant cell arteritis, acute angle glaucoma, meningitis/encephaltiis

Things in the pmhx to son cider

↓ immunity | cancer Hx

Giant cell arteritis - Typically patient - CF - Investigation

60 , europeans recent onset temporal headache, myalgia, malaise fever, jaw claudication +- systemic symptoms = fever, anorexia, wt loss, sweats, malaise, temporal artery maybe prominent, tender and pulseless Bloods: ESR + anaemia Biopsy → shows vasculitis

Tx for giant cell

40mg prednisaoline (60mg if claudication present) IV methylpred if vision loss 75mg aspirin + PPI

Complication

Loss of vision Aneurysm, dissection and stenosis of the aorta due to vasculitis Steroid related complications → osteoporosis + cushing's

Acute closure glaucoma What is it? RF? CF?

Obstruction of anterior chamber angle (lens catches on cornea) → ↑ pressure in anterior chamber RF: ↓ Age (lens grows with age), genetics, hyperopia (long-sightedness) ``` CF • Pain (severe and rapid progressive) • blurred vision, visual loss • Coloured haloes • Systemic malaise (N+V) ```

3 most common primary headaches

Migrane Tension Cluster

What is the most common recurring headache - describe it How many do you have to have a month for it to be considered chronic Tx

Tension headache, bilateral, feels tight, not aggravated by routine activities. * episodic <15 days a month, * chronic > 15 a month Tx: headache diary, ensure not medication induced or associated with depression analgesia

``` Migrane Features Tiggers Mgmt - when to give prophylaxis ```

• unilateral, pulsating, moderate-severe, aggravated by routine activities, sensitive to light/sound +- vomiting Trigger: choco, wine, alcohol, exercise, COCP Prophylaxis if 2/3 attacks producing disability for 3+ days 1) BB +-Amitryptalline - if associated with pain, depression or insomnia 2) Topiramate or sodium valoprate 3) Pitozifen Acute - NSAIDS + antiemetics → if these fail triptans

``` Cluster headache CF When do these typically occur? Triggers? How many must you have for a diagnosis? Tx? ```

Unilateral, sharp, burning, severe, restless, red/watery eye, nasal congestion, swollen eyelid Occur at night, 1-2 hour after falling asleep Lasts for 45-90 mins trigger alcohol, heat, exercise, sleep deprivation Must have 5 for diagnosis. Episodic (7D in 1 year) Chronic (1 year or more with remission < 1 month) Tx actually with triptans and oxygen

Most common presentation of metastasis

Seizure

What is a UBO

unidentified bright object associated with migrant

What is the cushing's triad