Neuro

Question 1

Lacunar Strokes?

Answer 1

Lacunar infarcts account for around 20-25% of ischaemic strokes. They involve occlusion of a single penetrating branch of a large cerebral artery and affect the internal capsule, thalamus and basal ganglia.

Features
purely motor - most common lacunar syndrome
purely sensory
sensorimotor stroke
ataxic hemiparesis - ipsilateral weakness and limb ataxia that is out of proportion to the motor deficit
dysarthria-clumsy hand syndrome

Question 2

Aphasia? - Fluent speech that makes little sense, word substitution and neologisms
But comprehension is relatively intact.

Answer 2

Conduction aphasia

Question 3

Aphasia? - Fluent speech that makes little sense, word substitution and neologisms
And comprehension is impaired

Answer 3

Wernicke’s aphasia

Question 4

Aphasia? - Speech is non fluent (laboured, haliting). Content words may be preserved
And comprehension is impaired

Answer 4

Global aphasia

Question 5

Contraindications to thrombolysis

Answer 5

Absolute:
Previous intracranial haemorrhage
Seizure at onset of stroke
Uncontrolled HTN
Active bleeding
Intracranial neoplasm
GI bleeding in last 3 weeks
Oesophageal varices
Suspected SA haemorrhage
Stroke or traumatic brain injury in preceding 3 months
Lumbar puncture in preceding 7 days

Relative:
Pregnancy
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks

Question 6

Migraine - antiemetic of choice?

Answer 6

A prokinetic such as metoclopramide is the recommended antiemetic in these patients, as it helps to relieve the gastric stasis that can slow the transit and absorption of drugs during an acute migraine attack. In fact, NICE guidance on migraine suggests that it should be considered even in the absence of nausea and vomiting, solely due to its prokinetic effects.

While metoclopramide carries risks of extrapyramidal side-effects with long-term use, it is fairly low-risk given the short duration and relatively low frequency of attacks in this patient. Generally, patients should be advised that metoclopramide is taken for no longer than 5 days in a treatment course.