Stroke aka Cerebral Vascular Accident
Sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain causing cerebral dysfunctions lasting for more than 24 hours or death
Types of Stroke
Ischaemic (85%)
Haemorrhage (15%)
How common are Strokes
> 50yo
M>F
Higher rates amongst Asians, Africans and Hispanics
Pathophysiology of Ischaemic Strokes
Arterial thrombus present in carotid, vertebral or cerebral arteries. Vessel obstruction leads to brain ischaemia causing infarct. Infarcted area will become swollen and lack normal function.
Pathophysiology of Haemorrhagic Strokes
Arterial aneurysm becomes ruptured causing catastrophic bleeding. The area swells as pressure increases leading to further damage of neighbouring structures.
Risk factors for Strokes
HTN, Smoking, Male, AF
Diabetes, Heart Disease, Peripheral Vascular Disease, Alcohol, Syphillis, Clotting Disorder, Hyperlipidaemia, Hormone Replacement Therapy
Symptoms and Signs of Strokes
Neck stiffness, visual changes - hemianopia, photophobia, headache, weakness, sensory loss, aphasia, dysarthria, ataxia
Symptoms of Cerebral Hemisphere Infarct
- Contralateral hemiplegia
- Contralateral sensory loss
- Homonymous hemianoia
- Dysphasia
Symptoms of Brainstem Infarct
- Quadriplegia
- Vision disturbances
- Locked-in Syndrome
Symptoms of Lacunar Infarct (small infarcts in basal ganglia, internal capsule, thalamus and pons)
- Pure motor or sensory symptoms
- Ataxia
- Intact cognition and consciousness
Differentials for Stroke
CNS tumour Subdural Haemorrhage Drug Overdose Hemiplegic migraine Hepatic encephalopathy Hypoglycaemia
Investigations for Stroke
CT scan of head: Bright MRI angiography ECG Carotid doppler- scans for occlusions Intracerebral Haemorrhage Score (ICH) FBC, Clotting, ECG, LFTs
Management of Stroke Patients
EMERGENCY
1. Admit to stroke unit
2. Airway, O2 by mask, BP, assess emboli sources
3. Thrombolysis
4. Brain imaging
Assess whether stroke is ischaemic or haemorrhagic
Treatment for Stroke Patients
- Anti-hypertensives: ACEi, Beta blockers, CCB,
- Diuretics
- Anti-coagulants: heparin and warfarin
- Surgery
Complications of Stroke
DVT/PE Infection Seizures Delirium Aspiration pneumonia Hydrocephalus (accumulation of CSF)
Transient Ischaemic Attack (TIA)
Neurological Deficit due to cerebral or retinal ischaemia lasting <24 hours
ABCD2 Score
Used to predict the risk of stroke following a TIA
Age > 60 years
BP > 140/90
Unilateral weakness (2) or speech impairment (1)
Duration <10mis, 10-59mins, > 60mins
Diabetes
How common are TIAs
M>F
Increases with age >50
Less common with Asians
Causes of a TIA
- Micro-emboli from heart or atheromatous plaques
- Fal in cerebral perfusion due to cardiac dysrhythmia, postural hypotension, decreased flow due to atheroma
- Stenosis of blood vessels in the brain
Pathophysiology of TIAs
Cerebral blood flow is regulate to maintain flow of >50ml/100g/minute
If decreased to 20-50ml, the brain compensates.
<20ml neurological deficits occur
<15ml neuronal death occurs causing oedema
Risk factors for TIAs
HTN, smoking, DM, Heart Disease esp AF, valvular disease, carotid stenosis, congestive heart failure, alcohol , syphillis, clotting disorder, hyperlipidaemia
Symptoms and signs of TIAs
Unilateral weakness or sensory loss, aphasia, ataxia, cranial nerve defects, incoordination
Anterior circulation: Aphasia, Amarausis Fugax
Posterior circulation: Ataxia, Diplopia, Vertigo, Bilateral symptoms
Either: Hemianopia, hemiparesis, hemisensory loss
Amarausis Fugax
Painless temporary loss of vision in one or both eyes
Investigations for TIA
FBC, U&Es, ESR, glucose Prothrombin time, INR and APTT ECG MRI or CT Fasting lipid profileT Telemetry Carotid doppler
TIA mimics
Migraine, Seizure, Syncope
Differentials for TIA
Hypoglycaemia Seizure Todd's Paralysis: seizure followed by paralysis Migraine Haemorrhage, abscess or mass Conversion Disorder Benign Paroxysmal Positional Vertigo (BPPV) MS Bells Palsy: Facial Paralysis
Treatment for TIAs
Antiplatelet therapy: Aspirin, clopidogrel
Cardioembolic TIA: Warfarin, dabigatran, apixaban
Lipid-Loweing agent
Antihypertensives: ACEi, ARBs, CCB
Carotid Endarterectomy
Complications of TIAs
Stroke
Myocardial Infarction
Peripheral Neuropathy
Damage to peripheral nerves. Types:
Mononeuropathy
Mononeuritis Multiplex
Polyneuropathy
Myelopathy
Disease affecting the spinal cord
Radiculopathy
Disease affecting nerve roots and plexuses
Causes of Peripheral Neuropathy
- Demyelination by
- Axonal damage caused by HIV, MS
- Wallerian Degeneration
- Compression eg Carpal Tunnel Syndrome
- Infiltration of inflammatory cells e.g. Leprosy, Sarcoidosis, Neoplastic Granulomas
Symptoms and signs of Peripheral Neuropathy
Sensory: Numbness, tremor, gait abnormality, pain, itching and crawling, pins and needles
Motor: Weakness and tiredness, heaviness hyporeflexia, cramps, myalgia, tremor, fasciculations
Differentials for Peripheral neuropathy
Diabetes Post-Herpes Neuralgia Malnutrition- B12 and alcohol Hypothyroidism Guillain-Barre Syndrome Myasthenia Gravis
Investigations for Peripheral Neuropathy
Peripheral neuro examination Electromyography Nerve conduction studies Blood tests Fasting blood glucose, HBA1C, B12, lipid profile
Treatment for Peripheral Neuropathy
Amitriptyline, Pregabalin or Gabapentin
Glycaemic control if Diabetic Neuropathy
Complications of Peripheral Neuropathy
Wounds and ulcers, infections, gangrene, amputation, silent MI, death, depression
Epilepsy and Seizures
Recurrent and intermittent abnormal electrical activity in the brain manifesting as seizures.
Types of Seizures
Generalised seizure is onset of electrical discharge throughout the cortex involving 1 hemisphere.
Partial seizures are focal onset features relating to a specific part of one hemisphere
Causes of Seizures
Trauma, Head injury, tumour, stroke, hippocampal sclerosis, sarcoidosis and SLE, Polyarteritis Nodosa, Alcohol or benzodiazepine withdrawal, Metabolic: hypoxia, hypo/hyper natraemia/glycaemia, hepatic encephalopathy, infection, drugs
Symptoms and signs of Seizures
Prodrome: symptoms preceding by hours/ days e.g. change in mood or behaviour
Aura: symptoms experienced during seizures e.g. flashing lights, strange smells, gut feeling
Post-ictally: symptoms experienced after seizures e.g. headache, confusion, aching limbs and headache
Define Myoclonic, Atonic, Absence and Tonic-Clonic of Generalise Seizures
Myoclonic: Short muscle twitch without conscious impairment
Atonic: loss of tone and relaxed with conscious impairment
Absence: Quick onset and offset of jerking
Tonic: Stiff and flex
Clonic: violent muscle contractions/ convulsions
Signs of Toni-Clonic Seizures
Sudden fall Stiff limbs Jerking Loss of consciousness Tongue biting Incontinence
Differentials for Epilepsy and Seizures
Syncope Cardiac Arrhythmias TIA Migraine Benign Paroxysmal Vertigo Acute Encephalopathy Narcolepsy Panic Attacks
Treatment for Seizures
Sodium Valporate or Lamotrigine, Carbamazepine
If seizing, record time, protect them from injury, recovery position when sizure has stopped
Inform DVLA
Complications of Epilepsy
Sudden Unexpected Death in Epilepsy (SUDEP)
Status Epilepticus: Seizure lasting for more than 5 mins
Depression and Anxiety
Injuries
Meningitis
Inflammation of meninges and the under lying subarachnoid CSF
Causes of Meningitis: Bacterial
Neisseria Meningitidis
Streptococcus Pneumoniae
Haemophilus Influenzae
Causes of Meningitis: Viral
Enterovirus Herpes Simplex Varicella Zoster Mumps HIV
How common is Meningitis
Common for < 2 months and >60yo
Decreasing incidence due to vaccinations
Risk factors for Meningitis
<5 or >65yo Non-immunised infants Immunodeficiency Cancer No spleen
Symptoms and signs of Meningitis
Stiff neck and photophobia, fever, headache, altered mental status, confusion, vomiting, seizures, rash
Infants: hypothermia, irritability, lethargy, poor feeding, apnoea, bulging fontanelle
Kernig’s Sign
Patient supine, thigh flexed, hip and knee at 90degrees, attempts to straighten the leg are resisted and painful. Can indicate subarachnoid haemorrhage or meningitis
Brudzinski’s Sign
Flexion of the neck causes involuntary flexion of the knees and hips. Indicative of meningitis
Differentials for Meningitis
Subarachnoid Haemorrhage Encephalitis Pyrexia and severe infection Intracranial abscess Septicaemia
Investigations for Meningitis
- Lumbar Puncture: CONTRAINDICATED in patients with raised ICP. CSF will have low glucose, high WCC< elevated protein.
- Bloods: FBS, U&Es, glucose and coagulation
- Blood culture, Throat Swabs, Stool Culture
- CT Scan
Treatment for Meningitis
- Vancomycin AND Ceftriaxone
2. Dexamethasone
Treatment for Herpes Simplex Meningitis
Acyclovir
Prophylaxis for Meningitis
Rifampicin or Ciprofloxacin
How many days will it take for Viral Meningitis to resolve
4-10 days
Complications of Meningitis
Sepsis Septic Arthritis Raised ICP Pericardial Effusion Haemolytic Anaemia Subdural Effusions Seizures
Migraine
Neurological disorder characterised by recurrent moderate-severe headaches. Features with nausea, photophobia and headache.
Types of Migraines
Migraine without aura (common migraine 75%)
Migraine with aura (classic migraine 25%)
Childhood periodic syndromes
Retinal Migraine
Probable Migraine
How common are Migraines
F >M
Common around puberty and menopause
Causes of Migraines
- Changes to cerebral blood vessels
2. Primary brain disorder: Altered modulation of normal stimuli and trigeminal nerve dysfunction
Risk Factors for Migraines
CHOCOLATE Chocolate Orgasms Cheese Oral Contraceptives Lie-ins Alcohol Tumult (loud noise and crowds) Exercise
Symptoms and signs of Migraine
Unilateral throbbing headache Nausea and vomiting Photophobia Phonophobia (fear of loud sounds) Allodynia: stimuli producing pain which normally didn't
Differentials for Migraines
SAH or meningitis TIA Sensory epilepsy Cluster Headaches (severe pain around 1 eye, attacks last less than 3 hours) Tension Headaches (generalised throughout head, bilateral pressure, non-throbbing) Cervical Spondylosis HTN Raised ICP Ischaemic Stroke
Treatment for Migraines
- NSAIDS
- Triptans - to treat migraines
- Ergot Alkaloids - to treat migraines
- Prophylaxis
1st line: Propranolol, Amitriptyline
2nd line: Sodium Valporate, Pizotifen, Gabapentin and Pregabalin
Complications for Migraines
Depression Status migrainosus: lasting >24 hours Migrainous infarction: aura lasting >1 hour Migraine-triggered seizures Chronic Migraine
Symptoms of Migraine with aura (aka Classic Migraine)
Migraine with flashing lights, visual loss, scotoma, numbness, tingling, aphasia, dysphagia, paralysis, slurred speech and opthalmoplegia
Prognosis of Migraines
Children’s migraines normally seize when entering adulthood
Tension Headache
Diffused generalised pain throughout the head described as a ‘tight band.’ Can be either episodic or chronic.
How common are Tension Headaches
F>M
Most common type of headache
Onset 20-39yo
Prevalence decreases with age
Causes of Tension Headaches
Release and activation of inflammatory agents lead to sensitisation of trigeminal afferents and in hypersensitivity. Musculature is affected here, unlike migraine where it’s blood vessels and meningeal nociceptors.
Risk factors for Tension Headaches
Sleep deprivation Stress Eye Strain Depression Tumult
Symptoms and Signs of Tension Headaches
Bilateral Headache (mild-moderate) 'Tight band around head' Pain radiating to neck Pressure behind eyes Non-pulsatile Often frontal or occipital regions Neck tenderness
Differentials for Tension Headaches
Migraine Raised ICP Cluster headache Sinusitis Giant Cell Disorder TMJ Disorder
Treatment for Tension Headaches
- Ibuprofen
- Diclofenac
- Naproxen
- Paracetamol
- Relaxation therapies, physiotherapy, acupuncture and osteopathy
- Antidepressants: Amitriptyline
Parkinson’s Disease and Parkinson’s Triad
A movement disorder caused by degeneration of the CNS
Triad: asymmetric resting tremor, cogwheel rigidity and bradykinesia
How common is Parkinson’s Disease
Most common neurological disorder
0.3% in general population and 1% in people older than 60
Pathophysiology of Parkinsons Disease
Dopamine producing neurons in the Substance nigra pars compacta (SNc) degenerate. Lack of dopamine causing hypokinesia, rigidity and tremor
Causes of Parkinsons Disease
Mutation in PINK1, PARKIN, ALPHA SYNUCLEIN genes
DRugs that block dopamine receptors
Wilson’s Disease (Manganese and copper toxicity)
Encephalopahty
Trauma/ Boxing
HIV
Risk factors to Parkinsons
Increasing age FHx of Parkinsons Mutation in GBA genee MPTP exposure Chronic exposure to metals Head trauma
Symptoms and signs of Parkinsons
Bradykniesia Resting tremor Rigidity Postural instability Dysdiadokinesis Hypomimesis (expressionless face) Hypophonia (soft speech) Shuffling gait Depression Demenetia
Differentials for Parkinsons
Progressive supranuclear palsy Lewy body dementia Alzheimer's disease with parkinsonism Drug-induced Parkinsonism Normal pressure hydrocephalus Huntington's Wilson's Disease
Treatment for Parkinsons
- Levodopa- dopamine pre-cursor (tyrosine is the amino acid precursor of levodopa) with Carbidopa (prevents metabolism of Levodopa into dopamine)
- Benzotropine - controls tremor
- Dopamine - used in early stage of Parkinsons
- Apomorphine - potent dopamine agonist
- Anti-cholinergic - help tremor
- MOI-alternative to dopamine agonists in early PD
- Dopamine agonists: Bromocriptime, Pramipexole, Ropinirole
- Catechol-O-methyl transferase (COMT) Inhibitors - palliative drug
Management of Parkinsons
Assess disability and cognition regularly
Postural exercises
Drugs
Respite Care
Deep-brain stimulation - to stimulate dopamine responsive tissue
Surgical ablation of overactive basal ganglia circuits
Prognosis of Parkinsons
Progressive with duration of 15 years
Earlier onset = shorter lifespan
Unilateral symptoms become bilateral
Complications of Parkinsons
Levodopa-induced dyskinesia (excess dopmine causing excessive movements) Dementia Depression Aspiration Pneumonia Bed Sores Falls
Proximal Myopathy
Symmetrical weakness of proximal upper and/lower limbs
Causes of Myopathy
Drugs: statins and steroids Alcohol Thyroid Disease, Osteomalacia Malignancy Infections: HIV, Hepatitis, CMV, EBV Connective Tissue Disease: SLE, Sarcoidosis, Vasculitis
Symptoms and signs of Myopathy
Tone, reflexes and sensation will be normal
Symmetrical muscle weakness so power will be reduced
Malaise and fatigue
Muscle atrophy and tenderness (rare)
Waddling Gait
Fever (inflammatory cause)
Differentials for Myopathy
Motor Neuron Disease Gullian-Barre Syndrome Myasthenia Gravis Polymyalgia Rheumatica Fibromyalgia
Investigations for Myopathy
- Urinalysis -> myoglobinuria
- Blood - raised CK
- MRI- muscle inflammation
Treatment for Myopathy
Depends on severity of disease
Drug therapy e.g immunosuppressives, physical therapy, bracing to support weakened muscles, and surgery
Complications of Myopathy
Respiratory failure
Aspiration pneumonia
Rhabdomyolysis
Chest, spine or joint deformities
Multiple Sclerosis
Autoimmune condition resulting in demyelination of axons at multiple CNS sites
How common is Multiple Sclerosis
Common in young adults
F>M
Causes of Multiple Sclerosis
HLA genes
Toxins, viral exposures- EBV , sunlight exposure
Postnatal hormonal changes
Risk factors for Multiple Sclerosis
Female Aged 20-40 Genetics Smoking Vitamin D Deficiency Autoimmune disease
Symptoms and signs of Multiple Sclerosis
Visual disturbance in 1 eye Unilateral optic neuritis Numbness or tingling in the limbs Leg weakness/ Foot dragging Brain stem or cerebellar symptoms Bell's Palsy Relapses and Remission Imbalance/ Incoordination Spasticity/ increased muscle tone
Differentials for Multiple Sclerosis
Spinal Cord Neoplasms Acute Encephalomyelitis Sarcoidosis Transverse Myelitis Vasculitis Fibromyalgia Guillain-Barre Syndrome Amyotrophic Lateral Sclerosis (ALS) SLE
Treatment for Multiple Sclerosis
- Interferon Beta
- Non-immunosuppressive
- Monoclonal antibodies
- Methylprednisolone for acute relapses
Complications for Multiple Sclerosis
UTIs Osteopenia and osteoporosis Depression Visual Impairment Erectile Dysfunction Cognitive impairment Impaired mobility