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5th Year > ACT Neuro > Flashcards

ACT Neuro Flashcards

1
Q

Describe a stroke and its common aetiology

A

A sudden onset loss of neurological function that lasts >24hrs due to hypoperfusion of the brain.

Ischaemic: AF, Carotid stenosis, Endocarditis, Shock

Hemorrhagic: Hypertension, Trauma, Aneurysm, Anticoagulation

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2
Q

What are the criteria for a Total Anterior Circulation Stroke

A

TACS = All 3 of:
Motor/sensory deficit in 2 or more of legs, arms and face
Homonymous Hemianopia
Higher cortical dysfunction eg. Dsyphasia, low GCS

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3
Q

What are the criteria for a Partial Anterior Circulation Stroke

A

PACS = 2 of the following:
Motor/sensory deficit in 2 or more of legs, arms and face
Homonymous Hemianopia
Higher cortical dysfunction eg. Dsyphasia, low GCS

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4
Q

What are the criteria for a Lacunar Circulation Stroke

A 
LACS = one of the following
Pure sensory stroke
Pure motor stroke
Senori-motor stroke
Ataxic hemiparesis
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5
Q

What are the criteria for a Posterior Circulation Stroke

A

POCS = one of the following
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia

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6
Q

Describe Wernicke’s dysphasia

A

A receptive dysphagia: can speak but makes no sense

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7
Q

Describe Broca’s dysphasia

A

An expressive dysphagia: Cannot form words with mouth

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8
Q

How are strokes classified during examination

A 
Oxford classification:
Total Anterior Circulation Stroke - TACS
Partial Anterior Circulation Stroke - PACS
Lacunar Stroke - LACS
Posterior Circulation Stoke - POCS
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9
Q

Assessment and Investigation of suspected Stroke

A

A to E
ROSIER score - 0 or less means stroke unlikely
Order CT head ASAP

Bedside: ECG - ?AF
Bloods: Glucose! - essential for good outcomes
FBC - ?infection, 
U&Es - ?dehydration 
LFTs - ?encephalopathy, 
Clotting - ?Haemorrhage
Troponin - ?MI 
Lipids - 2" Prevention
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10
Q

What criteria are included in the ROSIER score

A

Loss of consciousness or syncope = -1
Seizure activity = - 1

Asymmetrical Facial weakness = +1
Asymmetrical Arm weakness = +1 
Asymmetrical Leg weakness = +1
Speech disturbance = +1
Visual field defect  = +1
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11
Q

Management of ischaemic stroke;

haemorraghic ruled out on CT

A

Thrombolysis with Alteplase / mechanical thrombectomy

  • within 4.5hrs of onset of symptoms and no CI
  • repeat CT at 24hrs for haemorrhagic transformation
  • then Aspirin 300mg PO or PR for 2 weeks +/- PPI

No Thrombolysis = Give Aspirin 300mg stat

Admit to stroke ward
Assess swallow - ? NBM, refer SALT
IV fluids if NBM
Treat Fever - salvaging the ischaemic penumbra
Monitor Glucose - sliding scale, tight control 4-11mmol
Monitor BP - do not treat without senior input
No LMWH - incase of haemorrhage transformation
Modify risk factors eg. Statin after 48hrs

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12
Q

What are the contraindications for thrombolyisis of ischaemic stroke

A

Absolute:

  • Previous intracranial haemorrhage
  • Seizure at onset of stroke
  • Intracranial neoplasm
  • Suspected subarachnoid haemorrhage
  • Stroke or traumatic brain injury in preceding 3 months
  • Lumbar puncture in preceding 7 days
  • Gastrointestinal haemorrhage in preceding 3 weeks
  • Active bleeding
  • Pregnancy
  • Oesophageal varices
  • Uncontrolled hypertension >200/120mmHg

Relative:

  • Concurrent anticoagulation (INR >1.7)
  • Haemorrhagic diathesis
  • Active diabetic haemorrhagic retinopathy
  • Suspected intracardiac thrombus
  • Major surgery / trauma in preceding 2 weeks
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13
Q

Management of haemorrhagic stroke, confirmed on CT

A

Refer to Neurosurgeons
If anticoagulated then reverse
- prothrombin complex concentrate and IV vitamin K

Assess swallow - ? NBM, refer SALT
IV fluids if NBM
Monitor BP - do not treat without senior input
Monitor Glucose - sliding scale, tight control 4-11mmol
Admit to stroke ward
Modify risk factors

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14
Q

Complications of stroke

A 
Aspiration pneumonia,
Further episodes,
Dependancy, 
Pressure sores, 
Contractures, 
Constipation, 
Depression
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15
Q

Secondary prevention of ischaemic stroke

A

After 2 weeks of Aspirin 300mg switch to:
1st: Clopidogrel 75mg

2nd: Aspirin 7mg + MR dipyridamole 200mg BD
3rd: MR dipyridamole 200mg BD

If AF consider Anticoagulation after 2 weeks of Aspirin

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16
Q

Describe Parkinsons disease and its aetiology

A

Loss of dopaminergic nerve cells in the substantia nigra

Tremor
Rigidity
Bradykinesia
Loss of postural reflexes

17
Q

History of parkinson disease

A

Activities of daily living: buttons, laces, micrographic,
Difficulty getting in and out of car, turning over in bed

Poverty of facial expression
Tremor - resting, 5hz
Rigidity - cog wheeling in wrist, synkinesis to reinforce
Bradykinesia - Thumb finger test
Extrapyramidal posture - Simian, gunslinger
Parkinson’s gait: Loss of arm swing, Hesitency, Shuffling, Hurrying (festination), Retropulsion (falling backward), Clock face turning.

18
Q

Management of Parkinon’s disease

A

Patient explanation - incurable, progressive
Assess disability with Unified PD Rating Scale (UPDRS)
MDT approach - Neurologist, nurse, social worker, physio
Postural exercises

Early: L-dopa with decarboxylase inhibitor
- if less disabled consider DA agonists
Late: DA agonists, COMT inhibitors, MAO-B inhibitors
Advanced: Apomorphine, Deep brain stimulation

19
Q

Describe Multiple Sclerosis and its risk factors

A

T cell mediated autoimmune demyelination of the CNS, causing plaque formation and multiple neurological deficits, separated in time and location.

Relapsing-remitting disease - 85%
- acute attacks (last 1-2 months) then periods of remission
Secondary progressive disease
- 65% of RRMS become SPMS within 15 years
Primary progressive disease - 10%, common in older
Progressive-relapsing disease

Female 3:1
HLA D2
Higher latitudes - Vitamin D deficiency

20
Q

Symptoms of Multiple Scleorsis

A

Motor:
Spastic weakness - most commonly seen in the legs
Clumsiness - ataxia

Sensory:
Optic neuritis - common presenting feature
Internuclear ophthalmoplegia
- failure of adduction on the side of the lesion
Numbness and parasthesia

Autonomic:
Urinary incontinence
Sexual dysfunction

Symptoms worsen in a hot bath or with exercise

21
Q

Investigation of suspected Multiple Sclerosis

A

Mainly clinical Dx
- 2 separate attack affecting different parts of the CNS

MRI - periventricular and juxtacortical plaques

LP - CSF oligoclonal bands (60% at 1 attack, 90% at 2)

22
Q

Management of Acute attack of Multiple Sclerosis

A

Oral Methylprednisolone for 5 days

Reduce duration and severity of attack but not recovery

23
Q

Long term management of Multiple Sclerosis

A

Patient education
Smoking cessation
Vaccination - discuss risks
Supervised exercise and physiotherapy

Fatigue - Mindfullness, CBT, Amantadine
Spaticity - Baclofen or Gabapentin
Oscillopsia- Gabapentin
Emotional liability - Amitriptyline
Pain - Pain ladder or neuropathic
Bladder dysfunction - USS assess bladder emptying
- If residual volume = intermittent self-catheterisation
- if no residual volume = anticholinergics

24
Q

Description and aetiology of subarachnoid haemorrhage

A

A bleed into the subarrachnoid space

Aneurysm
Arteriovenous malformation
Clotting disorder

25
Q

Assessment and investigation of suspected subarachnoid haemorrhage

A

Imaging: urgent HIGH RESOLUTION CT head

If CT negative - LP after 12 hours for xanthochromia

if SAH confirmed - CT intracranial angiogram
- to identify a vascular lesion e.g. aneurysm or AVM

Bedside: ECG - raised ICP characteristics
Bloods: FBC, Coag,
U&Es (control K+ to avoid arrhythmias)

26
Q

Management of subarachnoid haemorrhage

A

Refer to neurosurgery as soon as SAH is confirmed
Nurse flat, consider transfer to ICU
Protect the airway + Oxygen
Regular neuro observations

Analgesia - 5mg Morphine IV
Anti-emetic - Metoclopramide 10mg IV/IM
Nimodipine 60mg 4 hourly to prevent vasospasm
Keep systolic blood pressure < 130mmHg
- use B blockers unless lethargic (suggests vasospasm)

Endovascular coiling
Neurosurgical clipping

27
Q

Aetiology of Delirium

A

DELIRIUMN
Drugs/Dehydration - withdrawal or toxicity - TCAs, BDZs, digoxin, diuretics, lithium, steroids, opiates, alcohol (+ withdrawal = delirium tremens)
Electrolyte Disturbances – low Na, high Ca
Level of Pain – not enough analgesia
Infection/Inflammation
Respiratory Failure – hypoxia, hypercapnia
Impaction of Faeces
Urinary Retention
Metabolic Disorder/MI – hypoglycaemia, liver/renal failure
Neurological conditions – epilepsy, SOL, encephalitis, stroke, SAH

Risk factors: Elderly, male, pre-existing dementia, previous episode, sensory impairment, immobility

28
Q

Describe Delerium

A 
1. Acute onset mental status change or fluctuating course
\+
2. Inattention 
\+ 
3. Disorganised thinking 
or
4. Altered level of consciousness
29
Q

Assessment and investigation of suspected Delirium

A

Collateral Hx
Cognitive assessment - AMTS
Ex - Neurological exam + Septic screen

Bedside: MSU for dipstick + MC&S, ECG, PR
Bloods: FBC, ESR, CRP, U&E, Glucose, LFT, TFT, Calcium, Haematinics
Imaging: CXR + CT/MRI Head if indicated due to focal neurology
Unusual – syphilis, HIV, TB

30
Q

Management of Delirium

A

Treat underlying cause
Environment modification
- Quiet side room with good lighting
- Clock + calendar
- All sensory aids in good condition e.g. clean glasses
- Regular routine, including mobilisation
- Clear communication
- Smaller number of staff interacting with patient
- Involve family at the bedside

Sedate only if staff or patient safety under threat
- Haloperidol 0.5mg – 1mg QDS PO, double if IM
If alcohol/seizure/Parkinson’s - Lorazepam 0.5- 1mg PO/IM

5th Year (10 decks)

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