Neuro Flashcards
what differentiates between stroke and TIA?
Stroke, symptoms lasting for > 24 hours
TIA, symptoms lasting < 24 hours
what is crescendo TIA
> 2 TIA in 1 week
aetiology of ischaemic infarction
small vessel occlusion or thrombosis in situ
cardiac emboli –> AF, endocarditis
atherothoromboembolism eg carotids
vasculitis
aetiology of haemorrhagic infarction
CNS bleeding –> HTN, ruptured aneurysm, anticoagulation, thrombolysis
what are some rapid recognition screening tools which can be used to identify stroke
in primary care - FAST - face, arm, speech, test (any focal neuro loss)
in ER - ROSIER
what are the different types of stroke according to oxford/Bamford classification for ischaemic stroke
total anterior circulation syndrome
Partial anterior circualtion syndrome
Posterior circulation syndrome
Lacunar syndrome
what are the criteria for total anterior circulation syndrome
must have all 3
1) unilateral weakness +/- a sensory deficit of face, arm or leg
2) homonymous hemianopia
3) high cognitive unction - dysphagia, visuospatial disorder
what are the criteria for partial anterior circulation syndrome
must have 2
1) unilateral weakness +/- a sensory deficit of face, arm or leg
2) homonymous hemianopia
3) high cognitive unction - dysphagia, visuospatial disorder
what are the criteria for posterior circulation syndrome
1 of the following:
cerebellar or brainsteam syndrome - Webner’s syndrome etc
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
loss of consciousness
isolated homonymous hemianopia
Conjugate eye movement disorder – gaze palsy
Cerebellar dysfunction – ataxia, nystagmus, vertigo
clinical features of TIA
• Suspect TIA if sudden onset focal neurological deficit which has completely resolved within 24 hrs Unilateral weakness or sensory loss. Dysphasia. Ataxia, vertigo, or incoordination. Syncope. Sudden transient loss of vision in one eye (amaurosis fugax). Homonymous hemianopia. Cranial nerve defects.
clinical features of stroke
o Weakness − sudden loss of strength in the face or limbs.
o Sensory loss – paraesthesia or numbness.
o Speech problems such as dysarthria.
o Visual problems – normally homonymous hemianopsia
o Dizziness, vertigo or loss of balance — isolated dizziness is not usually a symptom of TIA.
o Specific cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis).
o Inattention/neglect
o Confusion, altered level of consciousness and coma.
o Difficulty with fine motor co-ordination and gait.
o Neck or facial pain (associated with arterial dissection).
o Initially flacid and no reflexes then Spasticity +/- clonus, ↑ tendon reflexes
o Weakness in extensors of arms and flexors of legs = hemiplegic gait – UMN lesion
o Posterior circulation strokes:
Acute, persistent continuous vertigo
Dizziness with nystagmus
N+V
Head motion intolerance
New gait unsteadiness
what are the criteria for Lacunar syndrome
1 of the following
- unilateral weakness +/- sensory deficit of face and arm and leg or all 3
- pure sensory stroke
- ataxic hemiparesis
what are some differentials for stroke
Bell’s palsy - don’t have forehead sparing
migraines - with aura, aura without headache etc
Metabolic causes - hypo/hypergycaemia, hypocalcemia
MS
epilepsy
blackouts/syncope
subdural haemorrhage (trauma-related)
what are the criteria for immediate CT head (next available slot or within 1 hour)?
- indications for thrombolysis or early anticoagulation treatment
- on anticoagulant treatment/known bleeding tendency
- GCS < 13
- unexplained progressive or fluctuating symptoms
- papilloedema, neck stiffness or fever
- severe headache at onset of stroke symptoms
what is the management of an ischaemic stroke
thrombolysis with altepase (IV) - within 4.5 hours of symptoms onset
CT head again at 24 hours after alteplase
aspirin 300mg from Day 2 for 2 weeks
SALT team involvement for swallowing assessment
early mobilisation
screen for malnutrition
what happens if alteplase cannot be given
300mg aspirin for 2 weeks
what specialist managements are there for stroke
maintenance or restoration of homeostasis
- O2 if stats < 95%
- BM between 4 -11
- IV insulin and glucose for DM pts
- antihypertensive therapy only in hypertensive emergency
- consider BP reduction to 185/110 to lower
Pharmacological management of ischaemic stroke
aspirin 300mg for 2 weeks from alteplase then switch to clopidogrel 75mg long-term
statin - start 48 hours after alteplase if not already on it
warfarin/dabigatran if potential causes of cardiac thromboembolism (AF, prosthetic valves)
defer antihypertensive for 1-2 weeks as inc BP can be physiological
what are some management for hemorrhagic stroke which can be carried by the neurosurgeons?
decompressive hemicraniectomy for MCA infarct
intracerebral haemorrhage - surgery for hydrocephalus, combination of prothrombin and Vit K in patients on anticoagulants
definition of meningitis
viral or bacterial infection to the meninges of the brain
what is the bacterial cause of meningitis in neonates
Listeria
Group B streptococcus
what is the bacterial cause of meningitis in infants/young children
H.influenza
strep. pneumoniae
what is the bacterial cause of meningitis in adult
strep. pneumoniae
Neisseria meningitis
what are some viral causes of meningitis
herpes
enterovirus
varicella zoster
clinical features of meningitis in children and adult
headache
fever
N+V
photophobia
neck stiffness
altered consciousness - confusion
seizure
• focal neurological signs non-reactive pupil, abnor of ocular motility, abnor visual fields, gaze palsy, arm or leg drift
• non-blanching rash meningococcal meningitis
• Kernig’s sign – pain in lower back or back of thigh on extension of knee when hip is flexed at 90 degree
• Brudzinski’s sign – forced flexi of the neck elicit a reflex flexion of the hips
clinical features of meningitis in neonates and babies
non-specific signs and symptoms - hypotonia, poor feeding, lethargy, hypothermia, bulging fontanelle
investigation for meningitis
LP + blood culture (prior to abx) blood glucose pneumococcal and meningococcal PCR FBC, U&E, CRP, LFT, Clotting, VBG viral PCR serum HIV
what does the lumbar puncture show if bacterial meningitis
cloudy appearance inc protein reduce glucose inc WCC and neutrophils dominant culture - usually +ve
what does the lumbar puncture show if viral meningitis
clear appearance normal protein level normal glucose level inc WCC lymphocytes usually can not be cultured
management of meningitis
if discovered in the community –> IV/IM benylpenicillin
< 1 year - 300mg
1-9 years - 600 mg
> 10 - 1200mg
if discover in the hospital
< 3 months - cefotaxime + amoxicillin (cover listeria contracted during pregnancy from mother)
> 3 months - ceftriaxone or cefotaxime
Dexamethasone for 4 days can help reduce inflammation and preserve hearing in children
• Single dose ciprofloxacin for close contact within 7 days prior to the onset of symptoms.
public health notifiable
what prophylaxis do you provide with those who had close contact with a patient who is confirmed to have bacterial meningitis
single-dose ciprofloxacin
what is another name for acute confusional state
delirium - alternating cognition with a fluctuating course
what is the ICD-10 definition for acute confusional state
Aetiology non-specific syndrome characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion and the sleep-wake cycle (that is) transient and of fluctuating intensity.
causes of acute confusional state?
PINCH ME
pain infection nutririon/electrolyte imbalance/meatbolic disturbances constipation hydration
medications
environmental
RF for acute confusional state
- Age > 65
- Hospitalisation
- Dementia
- Frailty/multiple co-morbidities
- Significant injuries such as hip fracture
- Functional impairment (for example immobility and the use of physical restraint’s)
- Hx of /current excess alcohol use
- Sensory impairment
- Poor nutrition
- Lack of stimulation
- Terminal phase of illness
clinical features of acute confusional state
acute onset fluctuating course (lucid interval during day and worse at night) 2 types - hypoactive/hyperactive
cognitive/consciousness - clouded, poor concentration, confusion, slow response, memory and language impairment
inattention - person is easily distractible and have difficulty focusing
disorganised thinking
perception - visual and auditory hallucination possible
physical
if hypoactive - more lethargic, reduced mobility, lack interest in daily activities, reduced appetite, become quiet and withdrawn
if hyperactive - increased sensitivity to their immediate surroundings with agitation, restlessness, sleep disturbance, and hyper-vigilance. Restlessness and wandering are common.
social - lack of co-operation with a reasonable request, withdrawal or alterations in communication, mood, and attitude
investigation for acute confusional state
initial screening - history (both patient and collateral hix to assess acute onset and fluctuating course)
assess cognition - AMTS
A-E assessment - full assessment looking for signs of infection and any other causes for deirium
confusion bloods- FBC, U&E, LFT, TFT, Ca2+, glucose, B12, folate, CRP/ESR, syphilis
urine dip +/- urine drug screen
review medication charts
management of acute confusional state
biological
- identify any underlying causes
- supportive management eg hydration, nutrition, address pain, restrict use of catheters
- antipsychotics or sedation in pt who are aggressive (haloperidol/olanzapine)
- Benzo for alcohol withdrawal (delirium tremens)
psychological
- Identify and treat reversible cause e.g. dementia.
- Supportive: safety, encourage engagement reminders of time, orientation, familiar objects/people, maintain a sleep-wake cycle, calm manner, avoid physical restraints, encourage them to walk.
social -
- Minimise change and moving of environment.
- Control environment e.g. single room, quiet.
- Control disruptive behaviours which may harm other patients
- No driving until delirium has resolved
definition of subarachnoid hemorrhage
bleeding into the subarachnoid space (between the pica and archnoid matter) –> usually result of ruptured cerebral aneurysm
aetiology of subarachnoid hemorrhage
rupture of berry aneurysm (circle of willis)
RF for subarchnoid haemorrhage
hypertesnion smoking excessive alcohol consumption cocaine use female 45-70 yrs old black FHx sickle cell anaemia Av malformation, coarctation of aorta PCKD, ehlers danlos, marfans neurofibromatosis
clinical features of subarchnoid haemorrhage
sudden onset thunderclap headache - occurs during strenuous activity eg exercise/sex
depressed/loss of consciousness
CN3 compression - eyelid dropping, diplopia with mydriasis, orbital pain
papilloedema, retinal bleed
meningism - stiff neck photophobia, N+V
+ve Kernig (extend leg pain) and Brudzinski (bow)
neuro signs - speech changes, weakness, seizures
investigation for subarachnoid hemorrhage
non-contrast CT head - if SAH - blood around the circle of willis ie starfish of death
FBC, U&E, LFT, Clotting, BM (hypoglycemia)
ECG - arrythmia, prolong QT, ST segement, tall T-wave
LP - if CT inconclusive & after 12 hours - red cell count high + xanthochromic, 3 samples needed
CT angiography - once confirmed SAH to look for bleeds location for fixation prep
management of SAH
A-E assessment, urgent referral to a specialist neurosurgical unit. monitor CNS, BP, pupils, GCS
anaesthetist if GCS < 8
fluid to inc cerebral perfusion (aim system > 160)
nimodipine (Ca antagonist) to dec vasospasm and cerebral ischaemia risk
dexamethason - dec cerebral oedema
analgesia and anetiemtics
antiepileptic - treat seizures
surgery to treat aneurysm - endovascular coiling, Stents, Ballon, clipping
what is the most common complications of SAH
hyponatremia - can lead to arrhythmia - cardiac arrest
definition of sub-dural haematoma
collection of blood between the dural and arachnoid covering of the brain
aetiology of sub-dural haematoma
- Most common cause = trauma (in both Acute and chronic)
- Rupture of a cerebral aneurysm (less common)
- Vascular malformation – AV malformation or dural fistula
- All of the above damage to the bridging vein leading to subdural bleeds
- Common in elderly and alcoholics
