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NEURO (Neurology) > Cerebrovascular Disease & Head Injury > Flashcards

Cerebrovascular Disease & Head Injury Flashcards

1
Q

1 Hour CT Cervical Spine Indications (3D).

A
  1. GCS < 13 on Initial Assessment.
  2. Intubated.
  3. Clinical Suspicion and
    3A. Age > 65.
    3B. High-Impact Injury.
    3C. Focal Neurological Deficit.
    3D. Paraesthesia in Upper/Lower Limbs.
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2
Q

8 Hours CT Scan Indications (5).

A

For adults who have experienced some loss of consciousness or amnesia since injury and :

  1. Above 65.
  2. History of Bleeding/Clotting Disorders.
  3. Dangerous Mechanism of Injury - High-Impact, Fall>1m, Fall>5 Stairs.
  4. On Warfarin.
  5. Retrograde Amnesia > 30 Minutes.
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3
Q

Basal Skull Fracture Signs (4).

A
  1. Panda Eyes (Periorbital Ecchymoses).
  2. Battle’s Sign (Postauricular Ecchymosis).
  3. CSF Nose/Ear Leakage.
  4. Haemotympanum.

Indication : Immediate CT Head Scan.

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4
Q

Clinical Features : Cerebral Hemisphere Infarction (4) vs. Brainstem Infarction (2).

A

Cerebral Hemisphere Infarct :

  1. Contralateral Hemiplegia (initially Flaccid and then Spastic Paralysis).
  2. Contralateral Sensory Loss.
  3. Homonymous Hemianopia.
  4. Dysphasia.

Brainstem Infarct (more severe symptoms) :

  1. Quadriplegia.
  2. Lock-in-Syndrome.
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5
Q 
Clinical Features of Artery Infarcts :-
A. Anterior Cerebral Artery (2).
B. Middle Cerebral Artery (4).
C. Posterior Cerebral Artery (3).
D. Anterior Inferior Cerebellar Artery (3).
E. Posterior Inferior Cerebellar Artery (3).
F. Retinal / Ophthalmic Artery (1).
G. Basilar Artery (1).
A

A. Anterior Cerebral Artery : (LOWER Extremities > UPPER Extremities)

  1. Contralateral Hemiparesis.
  2. Contralateral Sensory Loss.

B. Middle Cerebral Artery : (UPPER Extremities > LOWER Extremities)

  1. Contralateral Hemiparesis.
  2. Contralateral Sensory Loss.
  3. Contralateral Homonymous Hemianopia.
  4. Aphasia.

C. Posterior Cerebral Artery :

  1. Contralateral Homonymous Hemianopia with Macular Sparing.
  2. Visual Agnosia.
  3. Branches that supply Midbrain : Weber’s Syndrome : Ipsilateral CNIII Palsy + Contralateral Weakness of Upper and Lower Extremities.

D. Anterior Inferior Cerebellar Artery : Lateral Pontine Syndrome -

  1. Ipsilateral Facial Paralysis and Deafness.
  2. Contralateral Limb/Torso Pain and Temperature Loss.
  3. Ataxia and Nystagmus.

E. Posterior Inferior Cerebellar Artery : Lateral Medullary Syndrome / Wallenberg Syndrome -

  1. Ipsilateral Facial Pain and Temperature Loss.
  2. Contralateral Limb/Torso Pain and Temperature Loss.
  3. Ataxia and Nystagmus.

F. Retinal / Ophthalmic Artery :
1. Amaurosis Fugax.

G. Basilar Artery :
1. ‘Locked-In’ Syndrome.

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6
Q

Extradural Haematoma Profile :-

  • Definition.
  • Aetiology.
  • Clinical Features (3).
  • Investigation.
  • Management (3).
A

Definition : Collection of blood between the skull and the dura mater.

Aetiology : Rupture of Middle Meningeal Artery in the Temporo-Parietal Region (typically a head injury - pterion injury, followed by ongoing headache).
Low-Impact Trauma : Acceleration-Deceleration Trauma or Blow to Side of Head.

Clinical Features :

  1. Improved Neurological Symptoms and Consciousness.
  2. Rapid Decline over hours as Haematoma enlarges to compress intracranial contents.
  3. Raised ICP - Mass Effect on Brain - Uncal Herniation and a Fixed, Dilated Pupil due to CN III Compression.

Investigation :
CT - Hyperdense (Bright) Bi-Convex (Lentiform) Shape Limited by Cranial Sutures.

Management :
Definitive Management : Craniotomy and Evacuation of Haematoma.
Treat Raised ICP using Mannitol or Frusemide.
Treat Diffuse Cerebral Oedema using Decompressive Craniotomy.

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7
Q

Haemorrhagic Stroke Management Profile :-

  1. Short-Term Management (2).
  2. Long-Term Management (3).
A

Short-Term Management :
A. Within 6 hours - rapid BP lowering therapy if systolic BP > 150 unless underlying structural cause, GCS>6, or early neurosurgery (poor prognosis).
B. Stop and reverse anticoagulant therapy.

Long-Term Management :
A. Surgical Intervention to remove haematoma and relieve ICP.
B. BP Target : 130-140 within 1 hour of BP lowering therapy for at least 7 days.
C. Specialist Advice - Atrial Fibrillation or at risk of Ischaemic Strokes.

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8
Q

Haemorrhagic Stroke Profile :-

  • Risk Factors (2).
  • Epidemiology.
  • Aetiology (2).
A

Risk Factors : Arteriovenous Malformations and Anticoagulation Therapy. Common for all Strokes : Age and Hypertension.

Epidemiology : 15% of all Strokes.

Aetiology :

  1. Intracerebral Haemorrhages i.e. within the brain - presents similar to ischaemic stroke. This can be spontaneous or a result of bleeding into an ischaemic infarct, tumour or rupture of an aneurysm.
  2. Sub-Arachnoid Haemorrhages i.e. on the surface of the brain.
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9
Q

Immediate CT Scan Indications (6).

A
  1. GCS < 13 Initially.
  2. GCS < 15 After 2 Hours.
  3. 2+ Episodes of Vomiting.
  4. Focal Neurological Deficit.
  5. Post-Traumatic Seizure.
  6. Suspected Open/Depressed/Basal Skull Fracture.
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10
Q

Intraventricular Haemorrhage

  • Definition.
  • Aetiology (Adults, Children, Neonates).
  • Investigation.
  • Management.
A

Definition : Collection of blood within the ventricular system of the brain.

Aetiology :
Adults - Extension of SAH, Vascular Lesions, Tumours.
Children - Prematurity of Periventricular Vascular Structures.
Neonates - within 72 hours after birth (? birth trauma, combined with cellular hypoxia in delicate neonatal CNS).

Investigation : Hyperdensity within the dark CSF spaces within ventricles.

Management : Surgical CSF Diversion due to risk of Obstructive Hydrocephalus.

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11
Q

Ischaemic Stroke Management Profile :-

  1. Immediate Management (6).
  2. Short-Term Management (2).
  3. Long-Term Management (2).
A
  1. Immediate Management :
    A. Admit to Specialist Stroke Centre.
    B. Exclude Hypoglycaemia.
    C. Immediate CT Brain to exclude Intracerebral Haemorrhage (Haemorrhagic Stroke).
    D. Thrombolysis with Alteplase (tPA) or Thrombectomy.
    E. Aspirin 300mg (give immediately if no thrombolysis; give 24 hours later if thrombolysed).
    F. Consider importance of Anti-Hypertensives (lower BP - reduced perfusion so only indicated in hypertensive emergencies).
  2. Short-Term Management :
    A. Monitor for post-thrombolytic complications e.g. systemic/intracranial haemorrhage.
    B. ‘Young’ Stroke Blood Tests - Thrombophilia & Autoimmune Screening - in those with no obvious cause and under 55.
  3. Long-Term Management :
    A. Clopidogrel 75mg once > Aspirin + Clopidogrel > Modified Release Dipyramidole 200mg twice daily with Aspirin.
    B. Statin e.g. Atorvastatin (after 48 hours - due to risk of haemorrhagic transformation).
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12
Q

Ischaemic Stroke Profile :-

  • Risk Factors (5).
  • Epidemiology.
  • Aetiology.
  • Types (2).
A

Risk Factors : Smoking, Hyperlipidaemia, Diabetes Mellitus. Common to all Strokes : Age and Hypertension.

Epidemiology : 85% of Strokes.

Aetiology : Sudden occlusion of cerebral artery (most often due to atherosclerosis in Internal Carotid Artery - sudden rupture of a vulnerable plaque followed by thrombosis in the vessel lumen).

Types :

  1. Thrombotic Stroke (40% of strokes) - Thrombosis from Large Vessels e.g. Carotid Artery and occur at bifurcations.
  2. Embolic Stroke (20% of strokes) - Atrial Fibrillation and most commonly affecting the Middle Cerebral Artery.
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13
Q

LACI Profile :-

  • Definition.
  • Epidemiology.
  • Clinical Features (3).
A

Definition : Small infarcts involving perforating arteries around the internal capsule, basal ganglia, thalamus and pons.

Epidemiology : 25% of cases.

Clinical Features :

  1. Pure Motor;
  2. Pure Sensory;
  3. Mixed Motor and Sensory Signs of Ataxia.
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14
Q

PACI Profile :-

  • Definition.
  • Epidemiology.
  • Clinical Features (2).
A

Definition : Partial Anterior Cerebral Infarction, involving smaller arteries of the anterior circulation e.g. the upper/lower division of the Middle Cerebral Artery.

Epidemiology : 25% of cases.

Clinical Features : ANY 2 of TACI

  • Unilateral Hemiparesis;
  • Homonymous Hemianopia;
  • Higher Cognitive Dysfunction e.g. Dysphasia.
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15
Q

POCI Profile :-

  • Definition.
  • Epidemiology.
  • Clinical Features (3).
A

Definition : Posterior Circulation Infarcts, involving the Vertebrobasilar Arteries.

Epidemiology : 25% of cases.

Clinical Features :

  1. Cerebellar/Brainstem Syndromes.
  2. Loss of Consciousness.
  3. Isolated Homonymous Hemianopia.
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16
Q

Stroke Hospital Management :

  • Feeding (3).
  • Disability.
A

Feeding :

  1. Screen for safe swallow function (reduce risk of aspiration).
  2. Specialist assessment of swallowing if any concerns (within 24 hours) with NBM until assessed.
  3. Unsafe Swallow - NG (or Gastrostomy) tube feeding (within 24 hours) unless thrombolytic therapy.

Disability - Barthel Index (Stroke Outcome Measure).
10 basic tasks are scored with a total from 0 (completely dependent) to 100 (completely independent) based on amount of time and assistance required to determine functional status.

17
Q

Stroke Identification :-

  1. Community.
  2. Hospital.
A 
1. Community = FAST
F - Face;
A - Arm;
S - Speech;
T - Time (Act Fast and Call 999).
  1. Hospital = ROSIER
    ROSIER is based on clinical features and their duration in an emergency room. If a patient scores anything above 0, there is a likelihood of stroke.
18
Q

Stroke Pharmacology Profile :-

  1. Clopidogrel - M, C (2), A (1).
  2. Aspirin - M, C (3), A (3).
  3. Dipyramidole - M, I, C (3), A (5).
A
  1. Clopidogrel.
    Mechanism of Action - Thienopyridine : inhibition of platelet aggregation by modifying platelet ADP receptors, thereby preventing further strokes and MIs.
    Contraindications - Active Bleeding; 7 Days Before Surgery.
    Adverse Effects : Bleeding (GI, Intracranial).
  2. Aspirin.
    Mechanism of Action - irreversible inhibition of COX-1 to suppress Prostaglandin and Thromboxane Synthesis.
    Contraindications - Children (<16) : Reye’s Syndrome; Aspirin Hypersensitivity; 3rd Trimester of Pregnancy.
    Adverse Effects - GI irritation, hypersensitivity reactions, tinnitus.
  3. Dipyramidole.
    Mechanism of Action - increases intraplatelet levels of cAMP and reduces levels of Thromboxane A2 which inhibits platelet aggregation and blocks cellular uptake of Adenosine to cause vasodilation.
    Indication - 2nd line (if Clopidogrel is not tolerated).
    Contraindications : Caution with Ischaemic Heart Disease, Aortic Stenosis, Heart Failure.
    Adverse Effects : Vasodilation - Headache, Flushing, Dizziness, GI Symptoms. Antiplatelet - Increased risk of bleeding.
19
Q

Stroke Profile :-

  • Epidemiology.
  • Investigations (3).
  • Management for Types (2).
A

Epidemiology : 4th largest cause of death. One stroke every 3.5 minutes in the UK.

Investigations :
1. Non-Contrast CT Head (1st Line Radiology).
2. Diffusion-Weighted MRI (Gold-Standard Imaging Modality).
3. Carotid Ultrasound (Carotid Stenosis - Carotid Endarterectomies).
3*. If the patient is asymptomatic now, and there is >70% stenosis or if the patient is symptomatic now, and there is >50% stenosis, perform an endarterectomy. If not appropriate, conservative management e.g. Statins.

Management :

  1. Ischaemic Stroke - Thrombolysis/Thrombectomy.
  2. Haemorrhagic Stroke - Anticoagulation e.g. Warfarin and Antithrombotics e.g. Clopidogrel.
20
Q

Sub-Arachnoid Haemorrhage Profile :-

  • Risk Factors (6).
  • Epidemiology (3).
  • Aetiology (2).
  • Clinical Features (5).
  • Investigations (3).
  • Management (2).
A

Risk Factors :

  1. Cocaine Use.
  2. Excessive Alcohol Consumption.
  3. Sickle-Cell Anaemia.
  4. Connective Tissue Disorders e.g. Marfan’s, Ehlers-Danlos’.
  5. Neurofibromatosis.
  6. Autosomal Dominant Polycystic Kidney Disease (saccular ‘berry’ aneurysms).

Epidemiology : commoner in :

  1. Black Patients.
  2. Female Patients.
  3. Age = 45-70.

Aetiology :

  1. Traumatic SAH (Head Injury) - commonest.
  2. Spontaneous SAH - Intracranial Aneurysms (85% - Berry); AV Malformations; Mycotic Aneurysms; Pituitary Apoplexy.

Clinical Features :

  1. Sudden-Onset Occipital (‘Thunderclap’) Headache (during Strenuous Activity).
  2. Neck Stiffness.
  3. Photophobia and Meningism.
  4. Visual Changes.
  5. Neurological Symptoms.

Investigations :

  1. CT Head - Hyperattenuation in sub-arachnoid space (within cisterns of brain/sulci).
  2. Lumbar Puncture - CSF : Raised RCC and Xanthochromia (yellow - Bilirubin). If RCC decreases across samples, this is traumatic lumbar puncture (but Xanthochromia is absent in a traumatic tap.
  3. CT/MRI Angiography - Confirm source of bleeding.

Management :

  1. Neurosurgery : Coiling (Catheter into arterial system - place coil into aneurysm - seal off from artery) or Clipping (Cranial surgery and sealing aneurysm).
  2. Nimodipine (CCB) to prevent vasospasm complication due to brain ischaemia for 21 days.
21
Q

Subdural Haematoma Profile :-

  • Definition.
  • Risk Factors (4).
  • Pathophysiology.
  • Aetiology (2).
  • Clinical Features (3 + 3).
  • Investigations (1 +1).
  • Management (1 + 1).
A

Definition : Collection of blood that is under the layer of the dura mater of the meninges. It can be acute or chronic.

Risk Factors : due to fragility and/or predisposition of bridging veins to bleed.

  1. Elderly (brain atrophy increases risk of rupture).
  2. Alcoholics (brain atrophy increases risk of rupture).
  3. People on Anticoagulation.
  4. Infants (shaken baby syndrome).

Pathophysiology : Rupture of bridging veins in the outermost meningeal layer (between arachnoid and dura mater) mainly in frontal and parietal lobes.

Aetiology :
Acute = Trauma (High-Impact Injury).
Chronic = Slow Bleeding (Vascular Lesions e.g. AV Malformations).

Clinical Features :
Acute -
1. Fluctuating Level of Consciousness.
2. Insidious Physical/Intellectual Slowing.
3. Slower onset of symptoms than Extradural Haematoma.

Chronic = Weeks after a mild head injury with -

  1. Progressive Confusion.
  2. Loss of Consciousness.
  3. Weakness or Higher Cortical Dysfunction.

Investigations :
Acute CT - Hyperdense (Bright) Crescent Shape not limited by Cranial Sutures.
Chronic CT - Hypodense (Dark) Crescent Shape not limited by Cranial Sutures.

Management :
Acute - Decompressive Craniectomy.
Chronic (in Symptomatic Patients) - Burr Hole Drainage.

22
Q

TACI Profile :-

  • Definition.
  • Epidemiology.
  • Clinical Features (3).
A

Definition : Total Anterior Cerebral Infarction, involving anterior and middle cerebral arteries.

Epidemiology : 15% of cases.

Clinical Features :

  1. Unilateral Hemiparesis.
  2. Homonymous Hemianopia.
  3. Higher Cognitive Dysfunction e.g. Dysphasia.
23
Q

Thrombectomy :

  • <6 Hours (2).
  • 6-24 Hours (2).
  • 24+ Hours (3).
A
  1. Within 6 hours of symptom onset : OFFER
    A. With IV Thrombolysis (if within 4.5 hours).
    B. Confirmed occlusion of the proximal anterior circulation - CTA, MRA.
  2. 6 - 24 hours (including wake-up strokes) : OFFER
    A. Confirmed occlusion of the proximal anterior circulation - CTA, MRA.
    B. Potential to salvage brain tissue - CT perfusion or Diffusion-Weighted MRI.
  3. 24+ Hours : CONSIDER
    A. Acute Ischaemic Stroke.
    B. Confirmed occlusion of proximal posterior circulation (basilar/PCA) - CTA, MRA.
    C. Potential to salvage brain tissue - CT perfusion or Diffusion-Weighted MRI.
24
Q

Thrombolysis :

  • Indications (2).
  • Examples (3).
  • Mechanism of Action.
  • Contraindications (5).
  • Adverse Effects (2).
A

Indications :

  1. Within 4.5 hours of onset of stroke symptoms.
  2. Haemorrhage has been definitively excluded.

Examples : Alteplase, Tenecteplase, Streptokinase.

Mechanism of Action : tPAs activate Plasminogen into Plasmin which degrades fibrin to break up Thrombin.

Contraindications :

  1. Previous Intracranial Haemorrhage.
  2. Seizure during Stroke.
  3. Uncontrolled Hypertension.
  4. Pregnancy.
  5. Active Bleeding.

Adverse Effects :

  1. Haemorrhage.
  2. Streptokinase : Hypotension and Allergic Reactions.
25
Q

TIA Profile :-

  • Definition (and Crescendo TIA).
  • Aetiology.
  • Investigation.
A

Definition : Transient Ischaemic Attack is transient neurological dysfunction secondary to ischaemia without infarction (formerly : symptoms of a stroke that resolve within 24 hours). Crescendo - 2+ TIAs within 1 week.

Aetiology : Atherothromboembolism from the Carotid (or Cardioembolism - mural thrombus post-MI/AF/valve disease).

Investigation : ABCD2 - Assess risk of stroke.
A - Age > 60 (1).
B - BP = Hypertensive (1).
C - Clinical Features (2 - Weakness; 1 - Speech Disturbance).
D - Duration (2 - <60 minutes; 1 - 10-60 minutes).
D - Diabetes Mellitus (1).

NEURO (Neurology) (54 decks)

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