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Year 4 Additional Notes > ACH > Flashcards

ACH Flashcards

1
Q

Management of an ischaemic stroke

A

Transfer to stroke centre
Non contrast CT head then diffusion weighted MRI
Aspirin 300mg for 2 weeks
Alteplase if within 4.5 hours (and no contraindications/no wake-up stroke)-0.9mg/Kg/hour
Thrombectomy if within 6 or up to 24 hours (limited core volume) (and required)
Carotid endarterectomy if required
Resolution of AF if required
Support care eg. SALT/ VTE prophylaxis, oxygen if sats low etc.

NB:
-Secondary prevention (clopidogrel 75mg and atorvastatin 80mg, treat modifiable risk factors)
-Anticoagulation after 2 weeks if an embolic stroke (caused by AF)

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2
Q

Lateral medullary syndrome

A

Wallenberg syndrome
Posterior inferior cerebellar artery

Cerebellar features;
ataxia
nystagmus

Brainstem features;
ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss

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3
Q

Lateral pontine syndrome

A

Anterior inferior cerebellar artery

Horner’s syndrome
Facial paralysis and droop
Decreased taste (anterior 2/3 tongue)
Audiovestibular disturbance
Decreased facial sensation
Ataxia

NB- difference with posterior inferior cerebellar artery (wallenberg) is there would be no facial paralysis there and upper/lower limb involvement

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4
Q

Secondary prevention after ischaemic stroke

A

Clopidogrel 75mg (or dipyridamole 200mg BD + aspirin 75mg if contraindicated)
Atorvastatin 80mg

NB- not the same as secondary prevention following ACS

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5
Q

Contraindications to clopidogrel

A

Active bleeding
Allergy

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6
Q

Absolute contraindications to thrombolysis

A

Previous ICH
Seizure at stroke onset
Intracranial neoplasm
Suspected SAH
Stroke or traumatic brain injury in preceding 3 months
Lumbar puncture in preceding 7 days
GI haemorrhage in preceding 3 weeks
Active bleeding
Pregnancy
Oesophageal varices
Uncontrolled HTN (200/120)

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7
Q

Relative contraindications to thrombolysis

A

Concurrent anticoagulation (INR >1.7- higher the INR, the more likely they are to bleed)
Haemorrhagic tendency (ie. haemophilia)
Suspected intra cardiac thrombus
Major surgery or trauma in the preceding 2 weeks

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8
Q

Management of a haemorrhagic stroke

A

Transfer to stroke centre
Correction of coagulopathy
Reduce ICP eg. Mannitol and raised head
Surgery- craniotomy and clotting evacuation
Supportive- SALT/ VTE prophylaxis etc.

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9
Q

NIHSS Score

A

0- no Sx
1-4- minor stroke
5-15- moderate stroke
16-20- moderate to severe stroke
21-42- severe stroke

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10
Q

Management of a TIA

A

Immediate aspirin 300mg (even in community) for 2 weeks, unless patient has a bleeding disorder or is taking an AC (like aspirin)- needs to be referred for MRI head to exclude haemorrhage
Same day referral to the stroke service to be seen within 24 hours (carotid doppler/ ECG)
Lifestyle modification eg. Reduce BP (130/80), smoking cessation, diabetes review, AF management etc.

Then clopidogrel for life (+statin)- may require carotid endarterectomy

NB- no CT head if neuroimaging required (use MRI)

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11
Q

Contraindications to 300mg aspirin

A

Patient has a bleeding disorder or is taking an anticoagulant (haemorrhagic event needs to be excluded)

Patient already takes low dose aspirin regularly

Aspirin is always contraindicated in this patient eg. Allergy

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12
Q

Guidelines for a carotid endarterectomy

A

Suffered a stroke/ TIA

Stenosis is above 70% (European guidelines)

Not severely disabled

NB- significant stenosis should be operated on within 2 weeks

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13
Q

Embolic TIA (or stroke)- extra medications required

A

Anticoagulation eg. DOAC first line (edoxaban), started 2 weeks after the event, or warfarin

NB- Antiplatelet therapy if anticoagulation contraindicated eg. Aspirin 75mg, clopidogrel 75mg

NB- these patients will still be given aspirin and clopidogrel, then anticoagulants but timing depends on whether TIA or stroke

TIA- start when imaging excludes haemorrhage
Stroke- start after 2 weeks (when no haemorrhage)

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14
Q

Recognised complications of thrombolysis in acute stroke

A

7% angioedema (increased if using an ACE-I)
6% haemorrhage

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15
Q

Territory affected and upper/lower limb Sx

A

ACA- upper < lowers (ants are on the ground)

MCA- upper > lower

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16
Q

Barthes index

A

Measure a persons daily functioning post-stroke (AODL & mobility)

Level 1- mild dependent

Level 2- moderate dependent

Level 3- severe dependent

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17
Q

Ischaemic vs haemorrhagic stroke

A

Very difficult to differentiate, but if symptoms progress (get worse), could be haemorrhagic

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18
Q

Stroke mimic

A

Seizure- post ictal paresis (can be a dense hemiparesis)

Hypoglycaemia (BM is most important initial test)

Functional

TIA

Migraine

NB- difference is that the patient loses consciousness beforehand (unlikely with stroke/TIA)

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19
Q

Drugs that can induce Parkinsonism

A

Chlorpromazine, haloperidol (anti psychotics), risperidone, olanzapine, metoclopramide (anti emetic/GORD), prochloperazine (schizophrenia, anxiety, BPPV), cyclizine (depression)

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20
Q

Vascular Parkinson’s

A

Predominant lower body signs

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21
Q

Dementia with Lewy bodies

A

Dementia, Parkinson’s, and visual hallucinations (hallucinations first)
Cognition may fluctuate (like delirium), in contrast to other forms of dementia

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22
Q

Multi system atrophy

A

Prominent early autonomic features eg. Hypotension, bladder instability, erectile dysfunction
Cerebellar signs

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23
Q

PSP

A

Early falls, truncal rigidity, vertical gaze palsy

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24
Q

Normal pressure hydrocephalus

A

Dementia, gait disorder, bladder instability

Wet wobbly wacky

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25
Q

Corticobasal degeneration

A

Asymmetrical Parkinsonism and dyspraxia, dementia, and aphasia

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26
Q

Parkinson’s disease with dementia

A

Dementia comes after initial Parkinsonism

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27
Q

Drug induced Parkinsonism

A

Rapid onset and bilateral
Rigidity and rest tremor are uncommon

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28
Q

Differentiate IPD and Parkinson’s plus syndromes

A

Poor response to levodopa

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29
Q

PD and neuroleptic malignant syndrome

A

If medication isn’t taken or absorbed regularly (eg. Due to vomiting illness/ forgetfulness etc.)

Patients need to be advised on the importance of regularly taking medication and how to spot symptoms of NMS

NB- don’t give Drug holidays for this reason/ mess with patients drugs whilst they are in hospital

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30
Q

Neuroleptic malignant syndrome

A

Hyper pyrexia, mental status changes, muscular rigidity, autonomic dysfunction

NB- raised creatinine, leukocytosis seen. AKI may develop secondary to rhabdomyolysis

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31
Q

Management of a tremor patient

A

Parkinson features- refer to movement disorder clinic

Non Parkinson features;

Review meds and check TFT’s
Propranolol
Safety net (come back if PD features develop)

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32
Q

Symptoms to ask in stroke or TIA history

A

Face
Arms
Speech

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33
Q

Features of narcolepsy

A

Hypersomnolence
Cataplexy (sudden loss of muscle tone triggered by emotion)
Sleep paralysis
Vivid hallucinations

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34
Q

Investigations and management of narcolepsy

A

Multiple sleep latency EEG

Give daytime stimulants (modafinil), and nighttime sodium oxybate

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35
Q

Neurofibromatosis 1

A

Cafe au lait spots
Axillary/groin freckles
Peripheral neurofibromas
Iris hamatomas
Scoliosis
Phaeochromayctoma

Mnemonic CRABBING;

C – Café-au-lait spots (6 or more) measuring ≥ 5mm in children or ≥ 15mm in adults
R – Relative with NF1
A – Axillary or inguinal freckles
BB – Bony dysplasia such as Bowing of a long bone or sphenoid wing dysplasia
I – Iris hamartomas (Lisch nodules) (2 or more) are yellow brown spots on the iris
N – Neurofibromas (2 or more) or 1 plexiform neurofibroma
G – Glioma of the optic nerve

36
Q

Neurofibromatosis 2

A

Bilateral vestibular schwannomas
Multiple intracranial schwannomas, meningiomas, ependyomas

37
Q

Treatment of neuropathic pain

A

Either amitriptyline, duloxetine, gabapentin, or pregabalin (if it doesn’t work, stop and try another one- all used as mono therapy)
Tramadol as a rescue therapy

38
Q

Causes of delirium

A

PINCH ME Stroke
Pain
Infection (UTI, pneumonia, cellulitis, meningo-encephalitis)
Nutrition (hypercalcaemia, hyperglycaemia, hyponatraemia, (any electrolyte disturbance) alcohol withdrawal, B12 & folate deficiencies)
Constipation
Hydration
Medication
Environment
Stroke (acute infarct/bleed)

39
Q

Features of delirium

A

Memory disturbance
Agitated or withdrawn (hyper or hypoactive delirium)
Disorientated
Mood change
Visual hallucinations
Disturbed sleep cycle
Poor attention

40
Q

Factors favouring delirium over dementia

A

Impaired consciousness
Fluctuating symptoms (worse at night, periods of normality)
Abnormal perceptions (illusions and hallucinations)
Agitation
Fear
Delusions

41
Q

Risk factors for falls

A

Lower limb muscle weakness
Vision problems
Previous falls
Balance or gait disturbance (diabetes, PD, RA)
Poly pharmacy
Incontinence
65+
Postural hypotension
Arthritis
Psychoactive drugs
Cognitive impairment

42
Q

Medications that cause postural hypotension

A

Nitrates
Diuretics
Anticholinergic medications
Antidepressants
Beta blockers
Levodopa
ACE-inhibitors

43
Q

Medications that can cause falls for other reasons

A

Benzodiazapenes
Antipsychotics
Opiates
Anticonvulsant
Codeine
Digoxin
Sedative agents

44
Q

What tools are used to assess frailty

A

Evaluation of gait speed
Self reported health status
PRISMA7 questionnaire (age, sex, health problems, assistance required, walking aid use)

45
Q

STOPP START

A

STOPP- identifies medications where their risk outweighs therapeutic benefits

START- identifies medications that may provide additional benefits eg. PPI for gastroprotection

46
Q

Investigations for a confused/delirious patient

A

History (collateral (family, staff), notes), cognitive assessment (AMT10), thorough clinical examination (A-E with observations)

Confusion screen
-urinalysis with culture
-bloods: FBC, UE, LFT, coagulation INR, TFT,Ca, B12, folate, haemanitics, glucose, blood cultures, bone profile
-imaging: CT head if concerned about intracranial pathology, CXR (pneumonia, PE, pulmonary oedema)

47
Q

Management of delirium

A

Supportive- same staff, gentle re orientation, clear and regular introductions, access to hearing aids and glasses, encourage independence, clocks, familiar objects and photographs, ensure lighting and noise are adequate, ask family and friends to visit

Medication- avoid where necessary, haloperidol 0.5mg IM is first line, then benzos (0.5mg lorazepam). Avoid haloperidol in PD patients (always check)- use lorazepam

Tell family and carers on discharge that delirium may never diss appear (some will be left with a degree of cognitive impairment)

48
Q

How long after stroke will you see signs on CT

A

12 hours

49
Q

Assess stroke symptoms in an acute setting (eg. AE)

A

ROSIER

50
Q

Parkinson’s disease and inhibition

A

Dopamine receptor agonists are associated with inhibition eg. Ropinirole

51
Q

Thrombectomy guidelines

A

Acute ischaemic stroke
6-24 hours, if limited infarct core volume demonstrated on scans

52
Q

Levodopa side effects

A

Dyskinesia
On off effect
LESS EFFECTIVE OVER TIME
Postural hypotension
Cardiac arrhythmias
Nausea and vomiting
Psychosis
Reddish discolouration of urine upon standing

53
Q

What to check for in a man with osteoporosis

A

Testosterone

54
Q

Management of osteoporosis

A

Offer bone protection if T score less than -2.5
Offer prophylactic bisphosphonates to those with a T-score < -1.5 if they are on steroids / going to be on steroids for 3 or more months (even if <65 years-old)

NB- if they cannot tolerate alendronate, try risedronate

NB- no bisphoshpanates below eGFR 35, try denosumab instead

55
Q

Cabergoline (dopamine agonist)

A

Associated with pulmonary fibrosis

56
Q

3 H’s when classifying a stroke

A

High function (speech, apraxia, neglect)
Hemianopia
Hemi loss (sensory or motor)

57
Q

TACS

A

3/3 H’s

58
Q

PACS

A

2/3 H’s

59
Q

Lacunar stroke (Lacunar)

A

1/3 H’s

60
Q

Posterior circulation stroke (POCS)

A

Occipital- isolated CONTRALATERAL homonymous field defect
Cerebellar- IPSILATERAL cerebellar signs
Brain stem- IPSILATERAL cranial nerve palsy

61
Q

ACA occlusion

A

Contralateral arm and leg hemiplegia and sensory loss
Apraxia

62
Q

MCA occlusion

A

Contralateral lower facial, arm, leg hemiplegia and sensory loss
Contralateral homonymous hemianopia
Dysphasia (dominant hemisphere)
Contralateral neglect (non dominant hemisphere)

63
Q

Initial management for a patient who becomes unresponsive several hours after a fall/head injury

A

Insert an oropharyngeal airway and call anaesthetics for definitive airway management

64
Q

What investigation can aid IPD diagnosis

A

single photon emission computed tomography (SPECT), especially if trying to distinguish ET and IPD

65
Q

Management of PD

A

Refer to movement disorder clinic/ neurologist (don’t start treatment before they have seen the movement disorder specialist- will remove any signs and Sx)
Conservative- physiotherapy, support groups, SALT assessment, occupational therapy
Medical;
-If the motor symptoms are affecting the patient’s quality of life: levodopa (usually combined with a decarboxylase inhibitor eg. carbidopa (co-carbeldopa) or benserazide (co-benyldopa)) and a MAO-B inhibitor (sometimes a dopamine agonist too)
-If the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived eg. bromocryptine), levodopa or monoamine oxidase B (MAO‑B) inhibitor (selegiline)
Surgical- DBS

NB- drooling: glycopyrronium, orthostatic hypotension (midodrine), nausea- domperidone

66
Q

COMT inhibitor

A

entacapone

67
Q

Dopamine receptor agonists

A

bromocriptine, ropinirole, cabergoline, apomorphine

Pulmonary fibrosis, hallucinations, impulse control, daytime somnolence

68
Q

MAO-B inhibitor

A

selegilline

69
Q

Antimuscarinics

A

procyclidine, benzotropine, trihexyphenidyl (benzhexol)

block cholinergic receptors
now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson’s disease
help tremor and rigidity

70
Q

Amantadine

A

SE- ataxia, slurred speech, confusion, dizziness and livedo reticularis

71
Q

Discontinuing benzodiazepines

A

Switch to diazepam slowly
Reduce dose by 1/8 every 2 weeks
When 1mg reached, stop completely

72
Q

Features of a benign essential tremor

A

Fine tremor
Symmetrical
More prominent on voluntary movement
Worse when tired, stressed or after caffeine
Improved by alcohol
Absent during sleep

73
Q

Differentials for a tremor

A

Benign essential tremor
Parkinson’s disease
Multiple sclerosis
Huntington’s Chorea
Hyperthyroidism
Fever
Medications (e.g. antipsychotics, lithium, salbutamol)
DT’s

74
Q

Areas a benign essential tremor affects

A

Voluntary muscles

Hand tremor
Head tremor
Jaw tremor
Vocal tremor

75
Q

Investigations for a tremor

A

Bedside- thyroid, neuro, and PD exams
Bloods- FBC UE TFT’s folate B12
Imaging- not needed, SPECT if I wanted to differentiate BET and PD

76
Q

Vertebral wedge fracture investigation

A

X ray

77
Q

Ondansetron

A

5-HT3 antagonists used mainly in the management of chemotherapy-related nausea. It mainly acts in the chemoreceptor trigger zone area of the medulla oblongata.

Adverse effects- constipation, prolonged QT interval

78
Q

Bisphosphonate treatment holiday

A

Repeat DEXA scan and FRAX score now and stop the bisphosphonate if low risk, T score is now >-2.5, and review in two years

The duration of bisphosphonate treatment varies according to the level of risk. Some authorities recommend stopping bisphosphonates at 5 years if the following apply:
patient is < 75-years-old
femoral neck T-score of > -2.5
low risk according to FRAX/NOGG

79
Q

Weber’s stroke syndrome

A

affects medial portion of midbrain

ipsilateral III palsy
contralateral limb weakness (not sensory loss)

80
Q

DVT and subsequent stroke

A

Do an echocardiogram to rule out ASD/VSD (that’s the only way you can have an embolic stroke following a DVT, if the thrombus can get into the opposite side of the circulation)

81
Q

Anti-emetics in PD

A

domperidone

82
Q

AF post stroke

A

following a stroke or TIA, warfarin or a direct thrombin or factor Xa inhibitor should be given eg. apixaban

Antiplatelets should only be given if needed for the treatment of other comorbidities (eg. clopidogrel)

83
Q

3 stroke syndromes

A

Weber’s
Wallenberg’s (lateral medullary)
Lateral pontine

84
Q

Respiratory secretions and bowel colic

A

Hyoscine bromide and glycoporronium

85
Q

Agitation and confusion at the end of life

A

Underlying causes of confusion need to be looked for and treated as appropriate, for example hypercalcaemia, infection, urinary retention and medication. If specific treatments fail then the following may be tried:
first choice: haloperidol
other options: chlorpromazine, levomepromazine

In the terminal phase of the illness then agitation or restlessness is best treated with midazolam

86
Q

Anticholinergics and dementia meds

A

work in opposite ways to one another so will reduce each others efficacy

Year 4 Additional Notes (17 decks)

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