ACT Neuro Flashcards by Euan Mckeating

Describe a stroke and its common aetiology

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

How well did you know this?

Not at all

Perfectly

What are the criteria for a Total Anterior Circulation Stroke

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

How well did you know this?

Not at all

Perfectly

What are the criteria for a Partial Anterior Circulation Stroke

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

How well did you know this?

Not at all

Perfectly

What are the criteria for a Lacunar Circulation Stroke

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

How well did you know this?

Not at all

Perfectly

What are the criteria for a Posterior Circulation Stroke

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

How well did you know this?

Not at all

Perfectly

Describe Wernicke’s dysphasia

A receptive dysphagia: can speak but makes no sense

How well did you know this?

Not at all

Perfectly

Describe Broca’s dysphasia

An expressive dysphagia: Cannot form words with mouth

How well did you know this?

Not at all

Perfectly

How are strokes classified during examination

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

How well did you know this?

Not at all

Perfectly

Assessment and Investigation of suspected Stroke

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&amp;Es - ?dehydration 
LFTs - ?encephalopathy, 
Clotting - ?Haemorrhage
Troponin - ?MI 
Lipids - 2" Prevention

How well did you know this?

Not at all

Perfectly

What criteria are included in the ROSIER score

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

How well did you know this?

Not at all

Perfectly

Management of ischaemic stroke;

haemorraghic ruled out on CT

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

How well did you know this?

Not at all

Perfectly

What are the contraindications for thrombolyisis of ischaemic stroke

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

How well did you know this?

Not at all

Perfectly

Management of haemorrhagic stroke, confirmed on CT

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

How well did you know this?

Not at all

Perfectly

Complications of stroke

Aspiration pneumonia,
Further episodes,
Dependancy, 
Pressure sores, 
Contractures, 
Constipation, 
Depression

How well did you know this?

Not at all

Perfectly

Secondary prevention of ischaemic stroke

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

How well did you know this?

Not at all

Perfectly

Describe Parkinsons disease and its aetiology

Loss of dopaminergic nerve cells in the substantia nigra

Tremor
Rigidity
Bradykinesia
Loss of postural reflexes

History of parkinson disease

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.

Management of Parkinon’s disease

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

Describe Multiple Sclerosis and its risk factors

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

Symptoms of Multiple Scleorsis

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

Investigation of suspected Multiple Sclerosis

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)

Management of Acute attack of Multiple Sclerosis

Oral Methylprednisolone for 5 days

Reduce duration and severity of attack but not recovery

Long term management of Multiple Sclerosis

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

Description and aetiology of subarachnoid haemorrhage

A bleed into the subarrachnoid space

Aneurysm
Arteriovenous malformation
Clotting disorder

Assessment and investigation of suspected subarachnoid haemorrhage

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)

Management of subarachnoid haemorrhage

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

Aetiology of Delirium

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

Describe Delerium

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

Assessment and investigation of suspected Delirium

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

Management of Delirium

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

Brainscape's Knowledge GenomeTM

ACT Neuro Flashcards

Brainscape's Knowledge Genome^TM