Flashcards in Neurology Deck (203)
A stroke is also referred to as cerebrovascular accident (CVA). CVA's are either ?
-Ischaemia or infarction of brain tissue secondary to inadequate blood supply
In regards to a CVA, disruption of blood supply can be caused by ? (4 points)
-Thrombus formation or embolus, for example in patients with atrial fibrillation
Transient ischaemic attack (TIA) was originally defined as symptoms of a stroke that resolve within 24 hours. It has been updated based on advanced imaging to now be defined as transient neurological dysfunction secondary to ischaemia without infarction.
TIA's often precede a full a stroke. What is a crescendo TIA ?
Where there are two or more TIAs within a week.
Note: This carries a high risk of developing in to a stroke.
In neurology, suspect a vascular cause where there is a sudden onset of neurological symptoms. What are the symptoms of a stroke ?
Stoke symptoms are typically asymmetrical:
-Sudden weakness of limbs
-Sudden facial weakness
-Sudden onset dysphasia (speech disturbance)
-Sudden onset visual or sensory loss
RF's for a stroke ? (10 points)
-Cardiovascular disease such as angina, myocardial infarction and peripheral vascular disease
-Previous stroke or TIA
-Carotid artery disease
-Combined contraceptive pill
FAST tool for identifying a stroke in the community ?
F – Face
A – Arm
S – Speech
T – Time (act fast and call 999)
What is the ROSIER tool + what does it indicate ?
Tool for Recognition Of Stroke In Emergency Room.
Stroke is likely if the pt scores anything above a 0.
Tool used for assessing pts with a suspected TIA to estimate their risk of subsequently having a stroke + what are its components ?
A - Age (>60 = 1)
B - Blood pressure (>140/90 = 1)
C - Clinical features (unilateral weakness = 2, dysphasia without weakness = 1)
D - Duration (more than 60 minutes = 2, 10 to 60 minutes = 1, less than 10 minutes = 0)
D - Diabeters = 1
Management of a stroke ?
-Admit pts to a specialist stroke centre
-Immediate CT brain to exclude primary intracerebral haemorrhage
-Aspirin 300mg stat (after the CT) and continued for 2 weeks
-Thrombolysis with alteplase can be used after the CT brain scan has excluded an intracranial haemorrhage. Alteplase is a tissue plasminogen activator that rapidly breaks down clots and can reverse the effects of a stroke if given in time. It is given based on local protocols by an experienced physician. It needs to be given within a defined window of opportunity, for example 4.5 hours. Patients need monitoring for post thrombolysis complications such as intracranial or systemic haemorrhage. This includes using repeated CT scans of the brain.
-Thrombectomy (mechanical removal of the clot) may be offered if an occlusion is confirmed on imaging, depending on the location and the time since the symptoms started. It is not used after 24 hours since the onset of symptoms.
Note: Generally, blood pressure should not be lowered during a stroke because this risks reducing the perfusion to the brain.
Management of TIA ?
-Start aspirin 300mg daily. Start secondary prevention measures for cardiovascular disease. They should be referred and seen within 24 hours by a stroke specialist.
Specialist imaging used to investigate strokes / TIAs + what is the aim of this imaging ?
-The aim of imaging is to establish the vascular territory that is affected. It is guided by specialist assessment.
-Diffusion-weighted MRI is the gold standard imaging technique. CT is an alternative.
-Carotid ultrasound can be used to assess for carotid stenosis. Endarterectomy to remove plaques or carotid stenting to widen the lumen should be considered if there is carotid stenosis.
Secondary prevention of stroke ? (4 points)
-Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily)
-Atorvastatin 80mg should be started but not immediately
-Carotid endarterectomy or stenting in patients with carotid artery disease
-Treat modifiable risk factors such as hypertension and diabetes
Stroke rehabilitation ?
Once patients have had a stroke they require a period of adjustment and rehabilitation. This is an essential and central to stroke care. It involves a multidisciplinary team including:
-Speech and language (SALT)
-Nutrition and dietetics
-Optometry and ophthalmology
Around 10-20% of strokes are caused by intracranial bleeds. Name 6 RF's ?
-Ischaemic stroke can progress to haemorrhage
-Anticoagulants such as warfarin
Presentation of intracranial bleeds ? (include key feature)
Sudden onset headache is a key feature. They can also present with:
-Other sudden onset neurological symptoms
In terms of a pts GCS, when do you need to consider securing their airway ?
When someone has a score of 8 or below.
What causes a subdural haemorrhage + where do they occur, what would a CT scan show and in which pts do they occur more frequently + why ?
-Subdural haemorrhage is caused by rupture of the bridging veins in the outermost meningeal layer. They occur between the dura mater and arachnoid mater.
-On a CT scan they have a crescent shape and are not limited by the cranial sutures (they can cross over the sutures).
-Subdural haemorrhages occur more frequently in elderly or alcoholic patients. These patients have more atrophy in their brains making vessels more likely to rupture.
What causes an extradural haemorrhage, what is it associated with, where does it occur, what would a CT scan show ?
-Extradural haemorrhage is usually caused by rupture of the middle meningeal artery in the temporo-parietal region.
-It can be associated with a fracture of the temporal bone.
-It occurs between the skull and dura mater.
-On a CT scan they have a bi-convex shape and are limited by the cranial sutures (they can’t cross over the sutures).
The typical history for someone presenting with an extradural haemorrhage is a young patient with a traumatic head injury that has an ongoing headache. They have a period of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.
Intracerebral haemorrhage involves bleeding into the brain tissue. How does it present ?
It presents similarly to an ischaemic stroke.
Note: These can be anywhere in the brain tissue:
-Lobar intracerebral haemorrhage
-Deep intracerebral haemorrhage
-Basal ganglia haemorrhage
They can occur spontaneously or as the result of bleeding into an ischaemic infarct or tumour or rupture of an aneurysm.
Principles of managing an intracranial bleed ?
-Immediate CT head to establish the diagnosis
-Check FBC and clotting
-Admit to a specialist stroke unit
-Discuss with a specialist neurosurgical centre to consider surgical treatment
-Consider intubation, ventilation and ICU care if they have reduced consciousness
-Correct any clotting abnormality
-Correct severe hypertension but avoid hypotension
Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane. This is usually the result of what ?
A ruptured cerebral aneurysm.
Subarachnoid haemorrhage has a very high mortality and morbidity. It is very important not to miss the diagnosis and you need to have a low suspicion to trigger full investigations. It needs to be discussed with the neurosurgical unit with a view to surgical intervention.
The typical history of a subarachnoid haemorrhage is a sudden onset occipital headache that occurs during strenuous activity such as weight lifting or sex. This occurs so suddenly that it is known as a what + name 3 other features ?
A thunderclap headache. It is is described like being hit really hard on the back of the head.
Other features are:
-Neurological symptoms such as visual changes, speech changes, weakness, seizures and loss of consciousness
Name 5 RF's for a SAH ?
-Excessive alcohol consumption
SAH is more common in ? (3 points)
SAH is particularly associated with ? (5 points)
-Sickle cell anaemia
-Connective tissue disorders (such as Marfan syndrome or Ehlers-Danlos)
-Autosomal dominant polycystic kidney disease
Investigations for SAH + what will they show ?
CT head is the first line investigation. Immediate CT head is required. Blood will cause hyperattenuation in the subarachnoid space.
Lumbar puncture is used to collect a sample of the cerebrospinal fluid if the CT head is negative. CSF can be tested for signs of subarachnoid haemorrhage:
-Red cell count will be raised. If the cell count is decreasing in number over the samples, this could be due to a traumatic lumbar puncture.
-Xanthochromia (the yellow colour of CSF caused by bilirubin)
Angiography (CT or MRI) can be used once a subarachnoid haemorrhage is confirmed to locate the source of the bleeding.