Acute neuro Flashcards
GCS
Eye opening 4 - spontaneously 3 - to speech 2 - to pain 1 - no response
Verbal 5 - orientated to time, person, place 4 - confused 3 - inappropriate words 2 - incomprehensible words 1 - no reponse
Motor 6 - obeys command 5 - moves to localised pain 4 - flex to withdraw from pain 3 - abnormal flexion 2 - abnormal extension 1 - no response
3 = lowest, 15 = highest
Causes of blackout
Syncopal
- vasocagal; stress, sweaty, wake up fine
- arrhythmia; sitting in chair, pass for 10 mints, wake up fine/palpitations
- dehydration + drugs; postural hypotension, get up and pass out
- Stokes-Adams; complete heart block, absent pulse, lost seconds, facial flush
- carotid sinus hypersensitivity; turn their head, tight collar trigger
Non-syncopal
- metabolic; hypoglycaemia
- non-epileptic seizure; Hx of psych disorder, rapid recvoery, unprovoked
- epileptic seizure; jerking, loss of bladder control, tongue biting, auras, post-ictal state
Causes of strokes/TIAs
RFs
- smoking, clotting disorders, COCP, hyperlipidaemia, HTN, FHx, little exercise, DM, cardiac diseases, high BP, old age, male
Ischaemic (80%)
- thrombosis, embolism (AF, CHA2DS2-Vasc), hypotension
Haemorrhagic (20%)
- AV malformations, amyloid angiopathy, hypertenion, Charcot-Bouchard microaneurysm
Young people
- cocaine, vasculitis
Clinical features of strokes/TIAs
SUDDEN ONSET Impaired coordination Head/neck pain Memory often intact AF Sensory/visual/speech impairment Weakness Pointers to bleeding (meningism/headache) or ischaemia (carotid bruits) Signs depend on part of brain is affected
Compare UMN and LMN sx
UMN
=> hyperreflexia, upgoing plantars, pronator drift, weakness in arm extensors and leg flexors, spasticity, no muscle wasting, no fasiculations, concentrated signs
LMN
=> unilateral signs, fasiculations, muscle wasting, hypotonia, weakness, hyporeflexia, normal plantar response
MRC grading
0 = no muscle contraction I = flicker of contraction II = some active movement III = active movement against gravity IV = active movement against resistance V = normal power allowing for age
Anterior cerebral artery stroke sx
Confusion Abulia Gait aprexia Frontal release sign Contralateral hemiparesis; lower limb > upper limb
Posterior cerebral artery stroke sx
Visual agnosia Homonymous hemianopia (w/ macular sparing)
Basilar artery stroke sx
Impaired consciousness
Cerebellar pathology
Visual impairments
Cranial nerve pathology (III-XII)
Middle cerebral artery stroke sx
Hemineglect
Apraxia
Contralateral hemiparesis; upper limb/face > lower limb
Contralateral hemisensory loss
Expressive/receptive aphasia (if left MCA)
Quadrantopia
=> Meyer’s; inferior optic radii damage causes superior quad.
=> Baum’s; superior optic radii damage causes inferior quad.
Difference between expressive and receptive aphasia
Expressive => Broca’s area
- linked to speech production (motor) so loss means pt still understands, just cannot express themselves
- left frontal lobe
Receptive => Wernicke’s area
- linked to speech understanding (sensory) so loss means pt cannot understand what you’re saying so speaks nonsense
- left parietal and temporal lobe
These two areas are connected by the arcuate fasciculus
- damage to this area causes conduction aphasia
Intracerebral haemorrhage stroke sx
Headache and meningism
Focal neuro signs and N&V
Signs of increased ICP
Seizures
Lacunar infarct sx based on region stroke occurs
Internal capsule => pure motor deficit
Basal ganglia => dyskinesia
Thalamus => affects consciousness
Pontine => dizziness/vertigo, bilateral effects
Cerebellar sx based on artery affected
Superior => dizzy
Anterior inferior => dizzy, deaf
Posterior inferior => dizzy, dysphagic, dysphonic, lateral medullary syndrome
What is lateral medullary syndrome?
Due to ischaemia in lateral medulla oblongata (posterior inferior cerebellar artery): Contralateral spinothalamic sensory loss Ipsilateral hemisensory loss Ipsilateral Horner's syndrome Ipsilateral ataxia Vertigo Dysarthria
Ix for strokes/TIA
CT Head** Bloods ECG, Echo CT angiogram, carotid doppler MRI, MRA
Hyperacute mx of stroke
CT head** 1st line
Protect airways
Maintain homeostasis (glucose, BP)
Therapeutic window (<4.5hr onset, ideal <90mins)
If not contraindicated (never for haemorrhagic):
=> thrombolyse IV alteplase (0.9mg/kg)
Acute mx of stroke
CT head already done Aspirin 300mg - prevent further thrombosis once haemorrhage ruled out Anticoagulation; heparin Formal swallow assessment GCS monitoring Thromboprophylaxis Admit for MDT care on stroke unit
Complications of strokes/TIAs
Cerebral oedema (increased ICP) Immobility Infections DVT Pscyhiatric/mood disturbances Seizures Cardiovascular events Death
Prevention of strokes
Primary
=> controls RFs
Secondary
=> 75 mg aspirin 2 weeks then lifelong clopidogrel/dipyramidole
=> lifelong anticoagulation
Surgery
=> carotid endartectomy if stenosis found >70% from carotid doppler
TIA presentation and mx
Episode lasted 10-15 minutes Amaurosis fugax (like a curtain descended to vision) Resolved before coming into GP
ABCD2 score to assess (age, BP, clinical features, duration of TIA + diabetes)
=> >/=4 refer to specialist
=> >/= 6 8.1% risk of stroke in 2 days, 35% in next week
*will lead to a stroke, driving inhibited for 1 month
Causes of epilepsy
> 2 seizures => epilepsy since means >70% of recurrence
70% idiopathic, 30% secondary to brain injury (tumour, stroke, infection, trauma, AI)
RFs/associations:
- FHx, childhood infection, neurodevelopmental disorders (i.e. autism), metabolic disease (PKU, storage diseases)
Classifications of epilepsy
Partial => no LoC
Complex => LoC
Focal => may be secondary to generalisation
Generalised => tonic-clonic, absence, myoclonic, tonic, atonic
Focal seizure sx based on lobe affected
Temporal lobe
- begins w/ aura, period of unresponsiveness, automatisms (uncontrolled motor features), dysphagia
Frontal lobe
- jacksonian march, Todd’s palsy, leg motor disturbances
Parietal lobe
- sensory loss
Occipital love
- visual loss
Generalised seizure sx based on type
Tonic-clonic
- Prodrome (aura) => Tonic (ictal stiffness) => Clonic (contractions) => Drowsy (post-ictal state)
Absence
- cessation of activity, upward roll of eyes
Myoclonic
- jerking of specific muscle groups
Tonic
- bear hugging posture
Atonic
- complete loss of muscle tone
Signs + sx of a seizure
Tongue-biting
Incontinence
Limb jerking
Post-ictal; confusion, exhaustion
Ix for seizures
Bloods
EEG
CT/MRI
Ix based on suspected cause
Mx for seizure types
Focal
= carbamazepine, lamotrigine
Generalise
= sodium valproate
Mx of status epilepticus
Seizures > 30 mins
- Secure airway, high-concentrated oxygen, assess cardiac + resp. function, check blood glucose levels, secure IV access in TWO large veins
- IV lorezepam, buccal midazolam, IV phenytoin phenobarbital, general anaesthetics (midazolam)
- Seek advice from expert if not stopping
Complications of seizures
Sudden death in epilepsy; brain fails to 'reset' Status epilepticus Fractures Developing behavioural problems Drug side effects
What are dissociative seizures?
No identifiable organic cause
Psychological related behavioural disturbances mistaken for epilepsy
Clinical diagnosis
= pt can recall event, asynchronous motor movements, lasts longer and variable in presentation
Mx often psychotherapy
Causes of hydrocephalus
Enlargement of cerebral ventricular system => obstruction (non-communicating) - posterior cranial fossa tumour - cerebral aqueduct stenosis - 3rd/4th ventricle lesion
=> non-obstruction (communicating)
- normal pressure hydrocephalus
- meningitis
- subarachnoid aneurysm haemorrhage
Presentation for hydrocephalus
Acute decreased consciousness, palsy, diplopia, behavioural changes, seizures, increased ICP
- neonates: sunset sign, increased head circumference
- normal pressure: wet, wobbly, wacky (Hakim’s triad)
Ix and mx of hydrocephalus
Ix: CT scan, CSF, LP (therapeutic in normal pressure)
Mx: intraventricular shunts
Spinal cord compression causes + features
Affects any age
- trauma, abscess, Pott’s (TB), inflammatory disease (spinal steonsis leads to cauda equina syndrome)
Features
- incontinence, sensory loss, back pain, spastic paresis bilaterally in lower limbs
RFs
- bone disease, vertebral disk disease
Cauda equina sx
Flaccid paresis Loss of bowel and bladder control Saddle paraesthesia Radicular back/leg pain Areflexia
Ix for spinal cord compression
MRI; definitive
Radiology
Blood
- FBC, ESR, B12, syphilis serology, U&Es, LFTs, PSA< serum electrophoresis
Guillian-Barre syndrome presentation
Appears post-infection, 2-3 weeks later, affects all ages = acute inflammatory demyelinating polyneuropathy
Progressive ascending paraesthesia and paresis, eventually involves resp. muscles, involves cranial nerves
Miller-Fischer variant (rare); opthalmoplegia, ataxia and areflexia
Ix for GBS
LP
- increased protein, normal cell content and glucose
Nerve conduction study
- decreased conduction velocity, normal at early stages
Bloods
- anti-ganglioside in Miller-Fischer variant + 25% GBS cases
Spirometry
- decreased fixed vital capacity due to ventilatory weakness
ECG
- arrhythmias may develop
A patient is rushed into hospital having collapsed on the street. After assessing airways, breathing and circulation you now assess their disability. They have not opened their eyes since arriving and only mumble incoherently when told to open their eyes. They do not respond to vocal commands to move however when you squeeze the patient’s trapezius muscle, they move to the appropriate shoulder to slap your hand away and briefly open their eyes.
What is their GCS score?
A 2 B 5 C 8 D 9 E 13
D 9
An 85-year-old woman presents to A+E struggling to talk. Her husband brought her in 30 minutes ago after she was unsteady on her feet and fell over. You assess her consciousness and find she has a GCS of 15. On examination you find she has right-sided hemiparesis with positive Babinski sign. You assess her blood pressure and find it to be 170/100.
What is the most appropriate next step?
A ACEi IV B Alteplase IV C Urgent CT head scan D Aspirin 300mg oral E Urgent carotid doppler
C Urgent CT head scan
A 65-year-old man presents with sudden onset left sided weakness. He is obese, type II diabetic and has high cholesterol. On examination you find a left-sided hemiparesis with his arm more affected than the leg. There is also an equal hemisensory loss. He is unable to see anything at the bottom of his vision on his left-hand side.
Which vascular territory has likely been affected?
A Right middle cerebral artery B Right anterior cerebral artery C Left middle cerebral artery D Right carotid artery E Right posterior cerebral artery
A Right middle cerebral artery
A 25 year old woman has an episode of altered consciousness lasting a few minutes. She has no memory of the event but just beforehand she developed a sense of déjà vu and had a rising feeling in her stomach.
What is the most likely cause?
A Absence seizure B Vasovagal episode C Complex partial seizure D Simple partial seizure E Cardiac arrhythmia
C Complex partial seizure
A 15 year old girl who is a known epileptic has arrived at hospital having a seizure. The seizure started over 30 minutes ago while she was having dinner and has not regained consciousness since. Her mother says she has had 3 seizures over the past 3 months before being diagnosed with and treated for epilepsy, but none were as bad as this. Life support examination reveals that the airways are open, patient is breathing and pulse is 110 bpm. Her GCS is 8/15. You set up two IV lines ready for the patient to be managed.
What is the most appropriate next step?
A Perform an EEG B Check glucose C Perform CT scan D Give IV lorazepam E Give IV thiopentone
B Check glucose
A 26-year-old man was admitted for severe food poisoning and put on antibiotics, a week later in his hospital bed he’s started to notice pins and needles across his lower limb, and he’s been feeling weak in that region also. What’s the most likely diagnosis?
A: Guillain Barre Syndrome B: Meningism C: Anti Biotic Abcess D: E: B-12 Deficiency E: Stokes-Adams attack
A: Guillain Barre Syndrome
A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. On examination, power is 2/5 in his right arm, 4/5 in his right leg and 5/5 in his left arm and leg. A CT head scan is performed and an ischaemic stroke is diagnosed.
What type of stroke is it? A Left total anterior circulation stroke B Right anterior cerebral artery stroke C Left middle cerebral artery stroke D Right middle cerebral artery stroke E Left brainstem stroke
C Left middle cerebral artery stroke
Mrs Smith, an 85-year-old woman, is brought to A & E by her
husband. When she woke up this morning her husband
noticed that Mrs Smith’s smile looked strange and that she
was unable to move her right arm. She seemed fine last
night going to bed after watching the news as normal. On
examination she had right sided hemiparesis and a positive
Babinski sign. A CT-head done at the A & E excluded a
hemorrhage.
What is the next most appropriate step in her
management?
A Carotid doppler B 300mg aspirin, orally C 75 mg clopidogrel, orally D ECG E IV alteplase
B 300mg aspirin, orally
Sx of cerebellar damage
D ysdiadochokinesia A taxia (gait and posture) N ystagmus I ntention tremor S lurred, staccato speech H ypotonia/Heel-shin test
*cerebellar lesions lead to ipsilateral lesions
A 16-year-old boy presents to A & E after collapsing on a cricket game. According to his cricket coach, the boy was unconscious for about one minute during which time, he was moving his arms and legs around. Further review revealed that he had experienced a similar episode a month before.
What is the most appropriate drug for this patient?
A Sodium valproate B Carbamazepine C Lamotrigine D Lorazepam E Phenytoin
A Sodium valproate
*generalised epileptic seizure
A 62-year-old woman presents back pain and difficulty walking. On examination there is increased tone and hyper-reflexia in both legs. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier.
Which is the most likely diagnosis?
A Guillain-Barré syndrome B Spinal cord compression C Spondylolesthesis D Cauda equina syndrome E Lumbosacral radiculopathy
B Spinal cord compression
A 20-year-old woman presents with pins and needles in both legs. Her symptoms rapidly progress over 4 days to include lower extremity weakness to the point that she is unable to mobilise her lower extremities. She reports gastrointestinal symptoms 2 weeks ago. Lumbar puncture reveals mildly elevated protein with no cells and normal glucose.Given the most likely neurological diagnosis which organism is most likely to have caused the gastroenteritis?
A Salmonella B Campylobacter Jejuni C E. Coli 0517 D Rotavirus E Entamoeba histolytica
B Campylobacter Jejuni
*30% of GBS occur after infection of this bacteria
A 21-year-old woman presents to A & E with acute onset of left-sided body twitching, lasting for 5 minutes, after a minor accident in which she hit her head. She reports 3 similar episodes in the past month, after her boyfriend broke up with her. Past-medical history includes IBS for which she takes laxatives. Physical examination, laboratory investigations and imaging studies are normal.
What is the most likely diagnosis?
A Dissociative seizure B Simple partial seizure C Vasovagal episode D Todd’s palsy E Myoclonic seizure
A Dissociative seizure
