MedEd acute neuro Flashcards
(164 cards)
1
Q
what is a stroke?
A
a sudden onset, focal neurological deficit of vascular origin lasting more then 24 hrs
2
Q
what are the 2 types of stroke and how do they differ?
A
ischaemic- due to vascular occlusion or stenosis
haemorrhagic- due to vascular rupture
3
Q
what type of stroke is more common?
A
ischaemic
4
Q
what are the 2 types of ischaemic stroke and how do they differ?
A
thrombotic= atherosclerotic plaque formation embolic= blood clot from elsewhere
5
Q
what is the difference between a thrombus and an embolus?
A
thrombus= blood clot that forms in a vein embolus= blood clot from elsewhere that travels until it reaches a smaller vessel and becomes lodged in it
6
Q
what are rf for stroke?
A
hypertension old age diabetes hyperlipidaemia/ hypercholesterolaemia smoking obesity
7
Q
what are signs and symptoms of a stroke?
A
acute onset facial and limb weakness slurring of speech loss of coordination and balance dizziness depends on what area of the brain is affected
8
Q
what is the difference between aphasia and apraxia?
A
aphasia= impaired ability to use or comprehend words apraxia= difficulty initiating and executing the voluntary movements needed to speak despite lack of paralysis to speech muscles
9
Q
define aphasia?
A
inability to use or comprehend words- language problem
10
Q
define apraxia?
A
difficulty initiating and executing the voluntary movements needed to produce speech- speech problem
11
Q
out of deficits in brocas and wernicke’s area what causes aphasia and what causes apraxia?
A
brocas region deficit causes apraxia
wernickes region deficit causes aphasia
12
Q
what parts of the brain does the anterior cerebral artery supply?
A
medial and superior frontal lobe
anterior parietal lobe
13
Q
what are associated signs of an anterior cerebral artery stroke?
A
contralateral hemiparesis- more the legs than the arms and face
behavioural changes
14
Q
if someone has contralateral hemiparesis (more so in the legs than the face/arms) and behavioural changes after a stroke what artery is it likely to have been in?
A
anterior cerebral artery
15
Q
what does the middle cerebral artery supply?
A
lateral parts of the frontal, temporal and parietal lobes
16
Q
what are associated symptoms for a stroke of the middle cerebral artery?
A
contralateral hemiparesis more so of the face and arms than the legs aphasia apraxia contralateral hemisensory loss quadrantopia
17
Q
if someone has contralateral hemiparesis (more face/arms than legs), contralateral hemisensory loss, aphasia, apraxia, and a quadrantopia after a stroke what is the most likely artery affected?
A
middle cerebral artery
18
Q
if contralateral hemiparesis is more significant in the face/arms than the legs and vice versa after a stroke what arteries were affected?
A
more in the face/arms than the legs= middle cerebral artery
more in the legs than in the arms/face= anterior cerebral artery
19
Q
a lesion where will cause a contralateral homonymous inferior quadrantopia?
A
parietal upper optic radiation
20
Q
a lesion where will cause a contralateral homonymous superior quadrantopia?
A
temporal lower optic radiation
21
Q
what does the posterior cerebral artery supply?
A
occipital lobe
inferior temporal lobe
22
Q
what are associated signs of a posterior cerebral artery stroke?
A
contralateral homonymous hemianopia
agnosia (inability to recognise familiar faces and objects)
23
Q
if someone has a contralateral homonymous hemianopia and agnosia post stroke what artery is likely affected?
A
posterior cerebral artery
24
Q
how can you distinguish cerebellar lesions from other strokes?
A
they give ipsilateral signs whereas other stroke signs are contralateral signs
25
what acronym is used to remember cerebellar signs and what does it stand for?
```
DANISH:
dysdiadochokinesia
ataxia
nystagmus
intention tremor
slurred speech
hypotonia
```
26
where is damage in a posterior circulation stroke?
in the brainstem
27
what is the difference between a posterior circulation and posterior cerebral artery stroke?
posterior circulation stroke= damage in brainstem= cerebellar DANISH signs
posterior artery stroke= lesion in posterior cerebellar artery supplying occipital lobe and inferior temporal lobe= contralateral homonymous hemianopia, agnosia
28
what ix are done for stroke, why and what is GS?
GS: urgent non contrast CT head within 1 hr to see if its ischaemic (dark area of old blood) or haemorrhagic (white area of fresh blood)
glucose- hypoglycaemia can mimic stroke
UEs- hyponatraemia
cardiac enzymes- troponin etc to rule out MI alongside stroke
FBC- check for thrombocytopenia prior to possible initiation of thrombolysis/anticoagulants
29
what ix must be done immediately in stroke and within how long?
non contrast head CT
| must be done within an hr
30
does normal CT rule out ischaemic stroke?
NO
31
what score can be used in stroke when someone is waiting and what does it calculate?
rosier score while the CT is being arranged= risk of stroke in the emergency room
32
how is ischaemic stroke managed? give names and doses of drugs
always rule out haemorrhagic stroke with non contrast head CT first
if they present within 4.5 hrs- thrombolysis with IV alteplase (or r-TPA second line) then 300mg aspirin
if they present after 4.5 hrs- 300mg aspirin
33
what are contraindications for thrombolysis in stroke patients?
presentation after 4.5 hrs
haemorrhagic stroke
other haemorrhage eg subarachnoid
prolonged PT, APTT, high INR
34
what is done in a stroke unit?
swallow assess
early mobilisation and rehabilitation
VTE prophylaxis
MDT approach with lots of staff involved
35
how is secondary antiplatelet prevention of a stroke done in patients with AF?
warfarin prophylaxis
36
how is secondary antiplatelet prevention of a stroke done in non AF patients?
75mg aspirin for 2 weeks
| lifelong clopidogrel 75mg daily
37
what is the difference between antiplatelet stroke prophylaxis in AF vs non AF patients?
AF= warfarin
| non AF= 75mg aspirin for 2 weeks then lifelong 75mg clopidogrel daily
38
how is haemorrhagic stroke managed?
refer to neurosurgery for evaluation
they will either do surgery or put them in ITU for monitoring and support
discontinue anticoagulant medications and do not give aspirin or other thrombolysis
39
what score must be used when someone has a TIA and what does it calculate
ABCD2 score, it used to estimate risk of stroke in someone with a TIA
40
how is ABCD2 score interpreted?
if the score is 4 or over refer them to a stroke specialist
| if the score is 6 or over there is an 8% risk of stroke in 2 days and 35.5% risk of stroke in a week
41
how is a TIA managed when it presents?
if suspected 300mg aspirin STAT
if presenting within 7 days of episode specialist review in 24 hrs
is presenting after 7 days of episode specialist review in 7 days
42
how is secondary prevention carried out after TIA?
75 mg clopi OD
high intensity statin eg atorvastatin OD
antihypertensive if BP needs to be controlled
43
what 3 medications and doses are given for secondary prevention after TIA?
75 mg clopi OD
atorvastatin OD
antihypertensive if needed
44
what are complications of stroke?
aspiration pneumonia
DVT
death
45
what ix are done in TIA?
only do a non contrast head CT if the patient is known to be taking an anticoagulant or bleeding disorder (to exclude haemorrhagic stroke)
ECG- may reveal AF or MI
bloods- FBC, UEs, clotting profile, cholesterol
46
what artery is most commonly ruptured in an extradural haemorrhage and why?
middle meningeal artery
this is because extradural haemorrhage is usually due to trauma and the pterion is the weakest point in the skull susceptible to fracture and the middle meningeal artery runs just under it
47
what artery runs right under the pterion?
middle meningeal artery
48
what is the sequelae of events in and extradural haemorrhage?
trauma
LOC
lucid interval (where the patient is ok)
rapid deterioration with headache, decreasing mental status and signs of raised ICP developing
49
what ix is done for extradural haemorrhage? what is seen and how do you remember this?
urgent non contrast head CT- you see a lemon/lenticular white shape on one side with midline shift
might do an MRI
50
how is extradural haemorrhage managed?
urgent referral to neurosurgery who will do burrholes or craniotomy
51
what is ruptured in a subdural haemorrhage?
bridging veins
52
what is the difference between blood in an extradural vs subdural haemorrhage?
```
extradural= arterial blood
subdural= venous blood
```
53
what is the difference between an acute, subacute and chronic subdural haemorrhage?
```
acute= presents after trauma within 72 hrs
subacute= presents within 3-20 days
chronic= presents after 3 weeks
```
54
how long might it take a subdural haemorrhage to present and what do you need to consider?
it can take up to 9 weeks and the patient may have forgotten about the trauma that caused it
55
in what haemorrhage are bridging veins ruptured?
subdural
56
in what haemorrhage is the middle meningeal artery ruptured?
extradural
57
what are rf for subdural haemorrhage?
```
elderly
head trauma
falls
alcoholics
anticoagulation
```
58
what are rf for extradural haemorrhage?
trauma
road traffic accidents
young people (under 20/30 yrs)
59
what will headache in subdural haemorrhage be like?
continuous and gradual
60
what are signs and symptoms of a subdural haemorrhage?
gradual and constant headache
fluctuating consciousness
confusion
symptoms of raised ICP
61
what ix is done for subdural haemorrhage and what will you see?
urgent non contrast head you see a banana shape on one side of the head- white if its acute and dark if its chronic
62
how is subdural haemorrhage managed?
```
if small (<10mm) and no neuro deficits admit and observe
if large (>10mm) or significant neuro deficits burrhole/ craniotomy
```
63
what size is a small v large subdural haemorrhage?
small: <10mm
large: >10mm
64
what ruptures in a subarachnoid haemorrhage?
saccular aneurysm
65
what are rf for subarachnoid haemorrhage?
```
polycystic kidney disease
alcohol
hypertension
smoking
hypertension
```
66
what haemorrhage is polycysctic kidney disease a rf for?
subarachnoid
67
what are signs and symptoms of subarachnoid haemorrhage?
sudden onset thunderclap headache- worst pain in their life in the occipital region
meningism (neck stiffness, photophobia, headache)
68
what ix do you do for subarachnoid haemorrhage- include what you might have to do if they present late? what will you see
urgent non contrast head CT- look for hyper attenuation around the circle of willis
if they present after 12 hs specificity is low so do a LP instead and you will see xanthochromic CSF
69
what is xanthochromic CSF seen in and when?
after 12 hrs in a subarachnoid haemorrhage
70
what is present in xanthochromic CSF? what does it look like compared to normal haemoglobin
xanthochromia and oxyhaemoglobin
| looks more yellow then normal clear CSF
71
how is subarachnoid haemorrhage mananged?
same as haemorrhagic stroke- refer to neurosurgery who will either ICU and observe or surgery (endovascular coiling or surgical clipping)
give nimodipine to prevent delayed cerebral ischaemia
72
why is nimodipine given in SAH?
to prevent delayed cerebral ischaemia
73
how are the different head heamorrhages managed?
```
extradural= immediate referal to neurosurgery (burrholes and craniotomy)
subdural= if small (<10mm) then ITU and observe, if large or significant neuro deficit (>10mm) then immediate neurosurgery referral (burrholes or craniotomy)
subarachnoid= medically manage w nimodipine or refer to neurosurgery for endovascular coiling or clipping
```
74
what surgery can be done for SAH?
endovasular coiling or clipping
75
what is epilepsy?
recurrent tendency to have unprovoked seizures
76
what triggers seizures in epilepsy?
they are unprovoked in nature
| triggers can be lack of sleep, flashing lights, stress, alcohol
77
what is a seizure?
an abnormal paroxysmal discharge of cerebral neurons
78
out of glutamate aspartate and GABA what is excitatory and what is inhibitory?
glutamate aspartate= excitatory
| GABA= inhibitory
79
in a seizure what happens to the balance between glutamate aspartate and GABA?
glutamate aspartate= upregulated= more excitation
| GABA= downregulated= less inhibition
80
what do you need to ask in an hx if someone has a seizure?
what happened before, during and after specifically
| was there a witness
81
what signs and symptoms might you get before a seizure?
aura- strange feeling in stomach, deja vu, strange smells or tastes, visual disturbance eg zigzag lines
82
what signs and symptoms might you get during a seizure?
duration under 3 mins
tongue biting
incontinence
jerking movements
83
what signs and symptoms might you get after a seizure?
slow recovery
post ictal headache
post ictal confusion
post ictal myalgia
84
in terms of what areas of the brain are involved what are different types of seizures?
localised
| generalised
85
what are the types of localised seizures?
focal seizure with impaired awareness
focal aware seizure
focal seizure with secondary generalisation
86
what are some characteristics of focal frontal lobe seizures?
motor symptoms eg jacksonian march, post ictal weakness, involuntary actions
87
what are some characteristics of focal temporal lobe seizures?
aura eg epigastric discomfort
automatisms eg lip smacking, playing with fingers
hallucinations
88
what are some characteristics of focal parietal lobe seizures?
sensory disturbance eg pain, numbness, tingling
89
what are some characteristics of focal occipital lobe seizures?
visual distrubance eg spots, lines, flashes
90
what type of seizures are more common in kids?
absence
91
what some types of generalised seizure?
```
myoclonic
tonicclonic
clonic
atonic
myoclonic
absence
```
92
how do you remember which types of seizure are generalised?
anything with 'tonic' in + absence seizures
93
what might be raised on bloods in a seizure?
prolactin
94
what ix are done for seizures? why
EEG
| bloods- check glucose to exlcude hypoglycaemia, UEs to exclude electrolyte abnormalities, prolactin may be raised
95
how many seizures are needed for a diagnosis of epilepsy and how far apart do they have to be?
at least 2 (or more) seizures 24 hrs
96
what is seen on EEG in focal vs generalised seizures?
```
focal= normal activity then craziness in just a few leads
generalised= normal activity then craziness in all leads
```
97
how are seizures managed?
```
generalised= lamotrigine or carbamazepine
focal= first line sodium valproate second line carbamazepine
```
NOTE= sodium valproate is teratogenic so avoid in women of child bearing age and give lamotrigine instead
98
what medications are given for generalised seizures?
carbamazepine
| lamotrigine
99
what medications are given for focal seizures?
first line sodium valproate
| second line carbamazepine
100
what antiepileptic do you give child bearing age women instead of sodium valproate?
lamotrigine
101
what are general side effects of anti epileptics?
weight gain
| psychiatric effects eg anxiety, depression
102
what are specific side effects of carbamazepine?
neutropenia and osteoporosis
103
what are specific side effects of lamotrigine?
steven johnsons syndrome- starts with flu then rash develops which is individual blemishes that look like targets (darker in the middle and lighter on the outside) and can be in oral, mucosal and genital membranes
104
what antiepilaptic causes neutropenia and osteoporosis as a side effect?
carbamazepine
105
what antiepileptic causes steven johnsons syndrome as a side effect?
lamotrigine
106
how does steven johnsons syndrome present?
flu like symptoms
followed by a rash appearing which is individual blemishes that look like targets (dark in the middle and light on the outside) on the skin, mucous membranes, genitals etc
107
what are dissociative seizures? how do you identify them and how are they managed?
seizures that are not epileptic
they usually are prolonged in duration and there may be hx of abuse, psychological or emotional precipitants
management involves psychotherapy
108
what is status epilepticus?
when a seizure lasts more then 5 mins or there are 2 seizures back to back without recovery or gain of consciousness in between
109
what are triggers of status epilepticus?
non adherence to medication
alcohol abuse
overdose and drug toxicity
110
how is status epilepticus managed?
A-E approach
secure the airway and give high flow oxygen
IV lorazepam or PR diazepam, repeat in 10 mins if it doesnt help
IV phenytoin
refer to ITU
111
how do benzodiazepines work?
they bind to GABA A receptors and increase channel opening frequency. This increases chloride conductance and neuronal hyperpolarisation leading to increased inhibitory neurotransmission
112
what is SUDEP and how can it be avoided?
sudden unexpected death in epilepsy
get enough sleep, adhere to medication, avoid alcohol, avoid known triggers, train family in first aid, consider night time monitoring if needed
113
what are epilepsy complications?
SUDEP- sudden unexpected death from epilepsy
fractures from seizures
medication side effects
behavioural problems
114
what is guillian barre syndrome?
an acute autoimmune demyelination of the peripheral nerves
115
what often precedes guillian barre syndrome?
gastroenteritis caused by campylobacter jejuni
116
what organism usually causes gastroenteritis before someone presents with guillian barre syndrome?
campylobacter jejuni
117
what are signs and symptoms of guillian barre syndrome?
```
ascending parasthesia and weakness of limbs
flaccid paralysis
hypotonia
symmetrical limb weakness
altered sensation/numbness
fasciculations
```
118
where might guillian barre progress to and cause death? what is it therefore important to do
the respiratory muscles- if they are paralysed
| it is important to do spirometry
119
what is miller fischer syndrome?
triad of opthalmoplegia, areflexia and atonia
NO muscle weakness
it occurs in 25% of people with guillian barre
120
what is absent in miller fischer syndrome?
muscle weakness
121
what is the diagnostic definitive ix for guilian barre? what is seen?
nerve conduction studies- reduced conduction (do on arms/hands)
122
what ix are done for guillian barre? what is seen
nerve conduction studies- reduced conduction is seen
spirometry
lumbar puncture- high protein, normal glucose and WCC
bloods- anti ganglioside antibody in miller fischer variant
123
what is seen on bloods in miller fischer syndrome?
anti ganglioside antibodies
124
in what condition are anti ganglioside antibodies seen?
miller fischer syndrome
125
how is guillian barre syndrome managed?
```
conservative= respiratory support, DVT prophylaxis
medical= IV immunoglobulins (IVIG) or plasma exchange (if theres IgA deficiency or renal failure)
```
126
what are causes of spinal cord compression in young vs elderly?
```
young= more commonly trauma
old= cancer, osteoporosis, corticosteroids, disc herniation
```
127
what are symptoms of spinal cord compression
```
UMN signs below level of lesions
LMN signs at level of lesion
limb weakness (hemiplegia or paraplegia)
sensory loss below the lesion
back pain
constipation
urinary retention
erectile dysfunction
```
128
in spinal cord compression where are UMN symptoms seen?
below the level of the lesion
129
in spinal cord compression where are LMN symptoms seen?
at the level of the lesion
130
what are the 3 categories of symptoms seen in spinal cord compression?
motor
autonomic
sensory
131
what ix are done in spinal cord compression and why? what is GS
GS= MRI spine
may so CT and lateral x rays
bloods= FBC, UEs, calcium, ESR, immunoglobulin electrophoresis to check for multiple myeloma
urine= bence jones proteins if due to multiple myeloma
132
what are the 2 main ix for multiple myeloma and what is seen?
urine- bence jones proteins
| immunoglobulin electrophoresis- one band is seen instead of multiple
133
what is cauda equina syndrome?
compression of the nerve roots forming the cauda equina
134
what are symptoms of cauda equina syndrome?
```
LMN symptoms (hypotonia, hyporeflexia)
bilateral sciatica
perianal parasthesia
leg weakness
reduced anal tone
bladder retention
```
135
what bladder symptom do you get in cauda equina syndrome?
urinary retention
136
what is radiculopathy?
symptoms that rise due to compression of a nerve at or near its root as it exites the spinal cord
137
what symptoms do you get in radiculopathy?
LMN symptoms for muscles innervated by this spinal root
| Dermatomal pattern of pain and numbness
138
what are signs and symptoms of sciatica?
pain radiating from buttock down the ipsilateral leg
| weakness of calf muscles
139
how is sciatica diagnosed?
by doing the straight leg test- there will be pain in the distribution of the sciatic nerve when the leg is passively flexed
140
what is the straight leg test done to diagnose?
sciatica
141
what is lasegue's sign?
positive straight leg test
142
how is spinal cord compression managed?
A-E approach
insert catheter if needed
high dose corticosteroids in malignancy (alongside PPI)
urgent referral to neurosurgery for surgical decompression
143
how is spinal cord compression managed if due to malignancy?
high dose corticosteroids (alongside PPI)
| urgent referral to surgery for surgical decompression
144
what ix is done for cauda equina syndrome?
MRI spine
145
how is cauda equina managed?
A-E approach
give analgesia when stable
insert a urinary catheter urgently
refer to neurosurgery for decompression by laminectomy (removal of lamina) or discectomy (removal of intervertebral disc)
146
what are complications of cauda equina syndrome?
chronic sexual dysfunction
chronic urinary retention or bowel incontinence
paraplegia
147
what ix are done for sciatica?
urgent MRI spine if neurological deficit present or mass is suspected
lumbosacral spine x ray to evaluate fractures
148
how is sciatica managed?
```
conservative= physiotherapy
medical= NSAIDs, opioid analgesia, local corticosteroid injections
surgical= if there is no improvement in pain after 6-8weeks refer to neurosurgery to assess disc herniation, epidural abscess and tumors etc
```
149
what is hydrocephalus?
excessive accumulation of CSF in the brain's ventricular system
150
what happens to ICP in hydrocephalus?
it is raised
151
how is more likely to get hydrocephalus?
young and elderly (bimodal age distribution)
152
what are the 2 types of hydrocephalus?
communicating
| non communicating
153
what is communicating hydrocephalus?
when CSF can freely flow through the ventricular system
| the issue is in that there may be decreased reabsorption or increased production of CSF
154
what is non communicating hydrocephalus?
when the flow of CSF through the ventricular system is disrupted eg due to narrowing (posterior fossa lesion eg tumor or blood compress the 4th ventricle)
155
what is the key difference between communicating and non communicating hydrocephalus?
in communicating CSF can flow freely through the ventricles
| in non communicating it can't
156
what is normal pressure hydrocephalus?
chronic dilation of the ventricles causing hydrocephalus WITHOUT raised ICP
157
in what type of hydrocephalus is ICP not raised? explain why
normal pressure hydrocephalus
it occurs due to dilation of the ventricles so although there is accumulation of excess CSF the compensatory increase in ventricular volume means the pressure does not rise
158
what is hydrocephalus ex vacuo?
hydrocephalus where ventricles enlarge due to chronic brain conditions that cause atrophy eg alzheimer's
159
what is the triad for normal pressure hydrocephalus and how do you remember it?
wet, wacky and wobbly:
urinary incontinence
cognitive impairment
gait apraxia
160
what are signs and symptoms of acute onset hydrocephalus?
signs of raised ICP:
papilloedema
headache
nausea and vomitting
161
what are signs and symptoms of chronic onset hydrocephalus?
wet wacky wobbly
double vision
CN palsy
162
what are some signs you might see in children with hydrocephalus?
```
sunset eyes (papilloedema and iris pushed to bottom and half visible like a sunset)
enlarged skull
```
163
what ix are done for hydrocephalus? what will you see
CT/MRI head- shows ventricular enlargement or cause eg tumor
CSF analysis- may show infection
LP- only do if there isnt raised ICP
Levodopa challenge- no response
164
how is hydrocephalus managed?
```
conservative= stop smoking, increase exercise, reduce salt intake
medical= BP medications and statins if needed
surgical= ventriculoperitoneal shunting to drain CSF (GS)
```
