Acute Neuro Flashcards
Stroke and TIA definition?
Sudden onset focal neruological deficit of presumed vascular origin lasting >24 hours
TIA is same but <24hrs
Stroke 3rd leading cause of death. World is 2nd after IHD
Cause of ischaemic stroke?
Atehrsoclerosis and thrombosis
Embolism (AF)
Pathologies that lead to intracerebral hemorrhage?
HTN, Charcot-bouchard microaneurysm rupture, amyloid angiopathy, AV malformation
trauma, tumour, vasculitis
Score for stroke in AF patients?
CHA2DS2VASc
CHF, HTN, AGE >75, DM, Stroke/tia/TE, Vascular disease, Age > 65, Sex Female
Score for bleeding if anticoagulated?
HAS-BLED
HTN, Abnormal renal or liver function (1 each), stroke, bleeding, labile INRS, elderly >65, drugs or alcohol (1 each)
> 2 Chad for anticoag unless Has >3
Stroke/TIA RFS?
HTN, DM, obesity, old age, hypercholesterolaemia, smoking, AF
Presentation of Stroke?
Sudden onset, Weakness/numbness face,arm, leg Vision change Dizziness, loss of coordination/balance Speech problems Sepcific to brain AREA
ACA stroke presentation?
Contralateral hemiparesis
Lower>upper
behavioural changes
MCA stroke?
Contralater hemiparesis Upperface/limb>lower Contralateral hemisensory loss apraxia Aphasia Quadrantopias
PCA stroke?
Homonymous contralateral hemianopia
Visual agnosia
Posterior circulation stroke?
Brainstem stroke = decreased consciousness and CN pathology
Cerebellar = DANSISH Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia/heel-shin test
Cerebellar is ipsilateral
Features of lacunar infarcts?
Affecting internal capsule = pure motor deficit
Pontine = dizziness/vertigo/bilateral affects
Thalamus = cosnciousness
Basal ganglia = dyskinesias
Features of intracerebral haemorrhage?
headache and menigism
Focal neurological signs N+V
Signs of ICP
Seizures
Oxford stroke classification?
TACS = All3 of motor/sensory deficit, homonymous hemianopia, higher cortical dysfunction
PACS = 2 of above
POCS = isolated homonymous hemianopia, bainstem signs, cerebrellar ataxia
LACS = pure motor, pure sensory, senosrimotor deficits
Ix for strokes/TIAs?
Urgent non contrast CT head 1st
Bloods, ecg, vitals and maintain BP, hydration, sats and temp
Mx for hyperacute stroke?
<4.5 hours = IV alteplase
>4.5 hours of thrombolysis contraindicated = aspirin 300mg oral
What is further stroke management?
Swallowing assessment, VTE prophylaxis, GCS monitoring, early mobilisation adn rehab, MDT approach
Other IX for stroke?
CTA, MRI/MRA, carotid doppler
What is secondary prevention for stroke?
AF = warfarin prophylaxis
Non AF = continue aspiring for 2 weeks then lifelong clopidogrel
management of haemorrhagic stroke?
ICU/stroke unit for monitoring and support
Surgery
Complication of stroke?
Aspiration pneumonia, cerebral oedema (ICP), immobility, depression, dvt, seizures, death
Complication of TIA?
Stroke = ABCD2 Age BP Clinical presentation Duration DM
Causes of non-syncopal collapse?
Epileptic seizures, non-epileptic sezures and others e.g. hypoglycaemia, alcohol and drugs
Features of reflex syncope?
Vasovagal: young, with precipitating factor, sweating, pale, quick recovery. May have brief clonic jerking of limbs
Carotid sinus hypersensitivity: tight collar and head turning
Situational syncope = micturation
Features of cardiac sncopes?
Arrhythmias: chesrt pain, palpitations, seconds and rapid spontaneous attack
Stokes-adams attach = pallor, seconds, facial flush
Outlet obstruction e.g. HOCM or AS
Massive PE
Orthostatic causes of syncope?
Collapse on standing up from stress, lack of sleep, dehydration, drugs e.g. antihypertensives, ANS instability and baroreceptor dysfunction
Cerebrovascular causes of syncope?
Vertebrobasilar insuffiiency, subclavian steal and aortic dissection
Features of epileptic seizures?
Aura or no warning, <3 mins, tongue biting, twitching, incontinence, slow recovery and confusion
Feature of non-epileptic seizure?
Background Hx of depression
Definition of epilepsy?
A recurrent tendency to have unprovoked seizures.
Seizure = an abnormal paroxysmal discharge of cerebral neurons
Aetiology of epilepsy?
Primary epileptic syndrome = idiopathic and seizures unprovoked
Secondary seizures = tumours, infection, inflammation and trauma
Triggers for epilepsy?
Anything that alters cerebral excitability e.g. lack of sleep, flickering lights, alcohol and stress
There may be no trigegr
Describe an aura?
Strainge feeling in gut, deja vu, strange smells and flashing lights, tingling, stiffness and twitching
Features post-seizure?
Slow recovery, post-ictal headache, confusion and myalgia
Todds paresis is syndrome with wakness of paralysis of area of focal onset for seizure
What are the generalised epileptic seizure types?
Tonic clonic (LOC -> limbs stiffen = tonic and limb jerking = clonic)
myoclnic (repetitive myoclonic jerks and common in puberty)
clonic, tonic,
atonic (loss of muscle tone and in children
Absence seizures ( brief episodes with behaviorudal arrest 5-10 sec but maintained posture and in chldren
WHat are the epileptic focal seizures?
Focal impaired awareness seizure, focal aware seizures and focal seizures with secondary generalisation
Features of frontal lobe epilepsy?
Motor symptoms
Jacksonian march : muscular spasm spreads from distal part of limb to wider body area
Todds paresis
Involuntary actions
Temporal lobe epilepsy features?
Aura
Automatisms (playing with fingers, lip smacking)
Hallucinations
Features of parietal lobe epilepsy?
Sensory disturbances e.g. pain, tingling, numbness
Features of occipital lobe epilepsy?
Visual phenomena e.g. spots, lines and flashes
Ix for epilepsy?
Need 2 or more unprovoked seizures >24 hours apart
EEG
Bloods (hypo, FBC, Electrolyte, serum prolactin elevated post seiuzure)
CT/MRI (structural lesions)
Mx for seizures?
Generalised :
1) Sodium valproate
2) carbamazepine
Focal:
1) Carbamazepine
2) Lamotrigine
Others = phenytoin, levetiracetam, cobazam
Pregnancy = avoid valproate and use lamotrigine
SEs of seizure management?
Psychiatric (depression)
Weight gain
Carbamezepine = neutropaenia and osteoporosis Lamotrigine = TENS/Steven-johnsons
AED MOA?
Benzos via enhanced GABA inhibition
Levitarecem b reduced glutamate excitation (pre)
Lamotrigine, phenyotin and CBZ via block action potential deplaisation
What is status epilepticus and triggers?
Seizure lasting >5mins and repeated seixures without recovery or consciousness regain
Trigger: non adherence to meds, alcohol abuse and OD & toxicivity
Mx for status epilepticus?
ABC Airway, IV access and monitoring -> IV lorazepam (repeat after 10mins) -> IV phenytoin -> ICU
Complications of epilepsy?
Sudden death in epilepsy
Behavioural problems
Fractures
Complications from drugs
What is GUillain-Barre syndrome?
Acute autoimmune demyelination polyneuropathy affecting the PNS
AI attacks the myelin in peripheral nerves. Mechanism is molecular mimicry
Presentation of GBS?
URTi, gastroenteritis (Campylobacter, CMV, HIV)
- > 2-3 wees = peripheral neuropathy with acute progression, ascending aprasthesia and pain, symetrical limb weakness
- > can progress to affect resp muscles = resp paralysis
Other RFs = cancer (lymphoma and immunisation)
What signs are in GBS?
Hypotonia, flaccid paralysis, altered sensation and numbness, weakness, fasciculations
What is Miller-FIscher syndrome?
Triad of opthalmoplegia, areflexia and ataxia but NO muscle weakness
Ix for GBS?
Nerve conduction studies can be confirmatory (decreased velocity)
CSF = albuminocytological dissociation with increased protein and nirmal glucose and cell count
Spirometry
Bloods = anti-ganglioside Abs n Miller-fisher variant and 25% GBS
What is hydrocephalus?
Excessive accumulation of CSF in the ventricular system in the brain
Bimodal distribution
Types of hydrocephalus?
Non-communication/obstructive = stenosis of cerbral aqueduct, lesions in 3rd/4th ventricle, psoterior fossa lesions compressing 4th ventricle
Communication hydrocephalus = decreased absoprton and increased production of CSF = tumours, meningitis (TB), normal pressure hydrocephalus )idiopathic ventricular enlargement with out elevated CSF pressure)
hydrocephalus ex vacuo = ventricular expansion secondary to brain atrophy e.g. alzheimers
Presentation of hydrocephalus?
Acute = features of ICP e.g. n+V, headache, pappilloedema
Gradual = cognitive impairement, unsteady gait, double vision, CN palsies
NPH = 1) cognitive impairement, gait apraxia, hyperreflexia (wet, wacky, wobbly)
Kids = sunset eyes and large head
hydrocephalus Ix?
1st = CT/MRI head
CSF = ventricular drain may show infection
LP is contraindicated in hih ICP
Causes of cord compression?
Trauma = young Chronic = old e.g. tumours, osteoporosis, corticosteroids, intervertebral disease e.g. disc herniation
Cord compression symptoms?
Depends on the level
Motor = limb weakness, UMN symptoms below level of the lesion and LMN at level of lesion
Sensry = loss below a specific level and back pain
Autonomic = constipation, urinary retention, erectile dysfunction
Ix for cord compression?
Radiology with MRI definitive
Bloods = FBC, U&Es, caclcium and immunoglobulins for MM
Urine for bence jones for MM
What is cauda equine syndrome and causes?
Lumbosacral nerve roots that from the cauda equine in the spinal canal become compressed
Commonly by disc compression and stenosis of the spinal canal
Presentatio of cauda equina syndrome?
LMN symptoms, perianal anaesthesis, bladde retention and leg weakness
What is radiculopathy and example?
Range of symptoms from compression of nerve at or near root where it exits the spinal cord
E.g. sciatica = lumbosacral and pain and tingling radiating from the lower back to ipsilateral leg. Weakening in calf msucles
Causes of radiculopathy?
Degenerative disc disease, osteoarthritis, tumours, infection e.g. spondylithesis
Presentation and IX for radiculopathy?
Motor = LN symptoms from nerve Sensory = dermatomal with pain and numbness
CT/MRI for herniation
Laegues sign for Sciatic
What is a dissociative seizure?
Cam resemble epileptic seizure but have NO biological correlate
Prlonged duration
Hx of abuse, psychological or emotional precipitant
Mx involves psychotherapy
