ACT Neuro Flashcards
(30 cards)
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
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
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
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
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
Describe Wernicke’s dysphasia
A receptive dysphagia: can speak but makes no sense
Describe Broca’s dysphasia
An expressive dysphagia: Cannot form words with mouth
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
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&Es - ?dehydration LFTs - ?encephalopathy, Clotting - ?Haemorrhage Troponin - ?MI Lipids - 2" Prevention
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
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
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
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
Complications of stroke
Aspiration pneumonia, Further episodes, Dependancy, Pressure sores, Contractures, Constipation, Depression
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
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
