Consolidation slides Flashcards
Types of Intracranial Haemorrhage
1) Epidural haemorrhage
2) Subdural haemorrhage
3) Subarachnoid haemorrhage
4) Intraparenchymal haemorrhage
The cause of Epidural haemorrhage
Head trauma -> skull fracture from blunt trauma-> laceration of arterial vessels (most commonly meningeal artery)
more tremendous force is required than subdural haemorrhage
The cause of subdural haemorrhage
Head trauma -> rupture of bridging veins
Elderly/ alcoholics are more susceptible, can occur with minor head trauma
Anticoagulation meds
The cause of subarachnoid haemorrhage
Rupture of saccular, or berry, aneurysum (80%); and rupture of arteriovenous malformation (AVM) (10%)
Known risk factor of aneurysm rupture (4)
- Tobacco use
- Alcohol abuse
- Hypertension caused by cocaine and other stimulants
- Large aneurysm size
The cause of Intraparenchymal haemorrhage
Damaged blood vessels due to:
- HTN
- Cerebral amyloid angiopathy
- Head trauma
- Ruptured aneurysm
- Blocked vessels
Presentation of EDH
Triphasic Presentation
S&S of EDH
Brief LOC -> Lucid interval -> headache, progressive obtundation (altered level of consciousness), hemiparesis (contralateral) -> “ blown pupil” (ipisilateral) secondary to uncal herniation
Presentation/ signs and symptoms of SDH
Non-specific clinical signs including
Headache, altered mental status, hemiparesis
Non-convulsive seizure may occyr in 20% of patients with acute SDH
Can be subacute or chronic
Gradual change in mental status may present as delirium or dementia in elderly, careful history will reveal remote fall
Presentation of SAH
Aneurysmal SAH is typically characterised by explosive or “thunderclap headache” instantaneously maximal at onset, “worst”
Normally associated with activities
Presentation of ICH
FAST + headache
occur without warning
s&s depend on location affected
Weakness of the left arm, leg and face (damage to?)
Damage to the motor area of the right cerebral hemisphere
Speech problem damage to the ?
Broca’s area
Small stroke in the ________ can cause severe problems as many __________ pass through here from the brain to the spinal cord
brain stem, nerves
loss of co-ordination in the right arm and leg is caused by the damaged to
left parietal lobe
difficulty in understanding speech, reading, naming object is caused by the damage to the
wernicke’s area
Unsteadiness and poor co-ordination is the damage to the
cerebellum
TIA vs Established stroke
TIA pathogensiesis vs Established stroke
Transient Ischemic Attacks
(TIA)
- Any neurological dysfunction that lasts for a few seconds to a few minutes
- Should recover within 24
hours - Pathogenesis of TIA
- Low-flow states in vascular
obstruction - Small emboli which get
dissolved later - Recognition of TIA helps in
prevention of major stroke
Established stroke
- Infarction of brain tissue occurs due lack of blood. Deficit is permanent
- Increasing obstruction may
involve a proximal branch of the artery and increase the deficit: stroke-in-evolution - Edema occurs in surrounding tissue
- Resolution of edema after the acute stage may restore some function
Non modifiable risk factor of ischemic stroke (8)
- Age
- Race
- Sex
- Ethnicity
- History of migraine headaches
- Sickle cell disease
- Fibromuscular dysplasia
- Heredity
Modifiable risk factor of ischemic stroke
- HTN
- DM
- Hypercholesterolemia
- TIA
- Carotid stenosis
- Oral contraceptive use
- Cardiac disease
1) AF
2) Valvular disease
3) Prosthetic valve
4) Mitral stenosis
-Lifestyle issues:
1) Excessive alcohol intake
2) Tobacco and illicit drug use
3) Obesity and physical inactivity
Lumbar puncture indication
CNS infection – meningitis
Thunderclap headache to rule out SAH when CT/MRI is normal or beyond 3
days
Lumbar puncture is to evaluate _____________________.
To evaluate for normal pressure hydrocephalus
Contra-indication of Lumbar puncture
Presence of infection in the tissues near the puncture site
- Presence of SOL (space occupying lesion)
- Bleeding tendencies (plt < 80 or INR > 1.4)
Types of epileptic seizures (6) Generalised seizures
Generalized tonic-clonic
Absence
Myoclonic
Clonic
Tonic
Atonic
Generalised tonic-clonic symptoms
Unconsciousness, followed by body stiffening (tonic phase), violent jerking
(Clonic phase), does into a deep sleep after (Postictal phase).
Absence seizure symptoms
Brief loss of consciousness, interrupts an activity and stares blankly. May occur several time a day
Myoclonic symptoms
Sporadic jerks, both side of body jerking movements , clustered, no LOC
Describe the jerks as electrical shocks
Clonic symptoms
Rhythmic jerks of both side of the body
Tonic symptoms
Muscle stiffness, rigidity
Atonic symptoms
Loss of muscle tone in four limbs
Types of epileptic seizure (3)
Partial seizures (Produced by small area of the brain)
- Simple
a. simple motor
b. simple sensory
c. simple psychology - complex
- partial seizure with secondary generalisation
symptoms of simple motor
Jerking, muscle rigidity, spasms, head-turning
symptoms of simple sensory
Unusual sensations affecting either the vision, hearing, smell taste, or touch
symptoms of simple psychological
Memory or emotional disturbances
symptoms of complex (impairment of awareness)
Automatisms such as lip smacking, chewing, fidgeting,
walking and other repetitive, involuntary but
coordinated movements
Symptoms of partial seizure with secondary generalization
Symptoms that are initially associated with a preservation of consciousness that then evolves into a
loss of consciousness and convulsions.
Pathology of PD
Degeneration of pigmented dopaminergic neurons in the pars compacta of
the substantia nigra
- There is loss of cells
- Dying cells may show inclusion bodies (Lewy bodies)
- Less degree of cell loss in other structures, globus pallidus, putamen etc.
Loss of neurons results in less amount of dopamine in the striatum.
There is an imbalance of dopamine and Acetylcholine
This imbalance results in loss of inhibition by direct pathway and
stimulation by indirect pathway
Clinical features of PD (11)
Tremor
* Present at rest (resting tremor)
* 4 to 6 Hz (cps)
* Decreased by action
* Increased by stress
* Common in arms
(pill-rolling movements)
* Can affect head, jaw and legs
* Can be unilateral or bilateral
Rigidity
* Increase in tone of muscles
* Affects both flexor and extensor groups of muscles, but flexors are affected
more
* Known as ‘lead-pipe’ rigidity - increased resistance in whole range of movement (cf spasticity)
* Rigidity superimposed with resting tremor can produce a ‘cog-wheel’
phenomenon
Bradykinesia
* Less movement (hypokinesia or akinesia)
* Delay in initiation of movement (freezing)
* Once started, movements are slow (bradykinesia)
* E.g loss of facial expression, blinking, arm swinging
Postural and gait abnormality
* Flexed posture (legs, arms, trunk
and neck)
* Slow, short, shuffling gait
(‘festinant gait’, ‘chasing their
center of gravity’)
* Unable to stop when pushed
forward (propulsion). Unable to
stop when pushed backward
(retropulsion)
- mask’ facies
- slow monotonus voice, micrographia
- Drooling of saliva
- Excessive sweating
- Urinary problems, urgency and incontinent
- mental depression
- dementia is very rare
Cause of headache (3)
- Migraine
- Tension-type headache
- Cluster headache
Migraine duration
Typically lasts from 4 to 72 hours if untreated.
Pain characteristics of migraine
Pain Characteristics: Often unilateral (one side of the head), but can be bilateral. The pain is usually
throbbing or pulsating.
Migraine intensity
Intensity: Moderate to severe; often debilitating.
Associated symptoms of migraine
Associated Symptoms: Nausea, vomiting, sensitivity to light (photophobia), and sensitivity to sound
(phonophobia). Some patients also experience visual disturbances known as aura (e.g., flashing lights, zigzag
lines, or temporary loss of vision) before the headache
Mechanism of migraine
Neurally induced dilatation and inflammation of intracranial
and extracranial vessels
Duration of tension-type of headache:
Can last from 30 minutes to several days.
Pain characteristics of tension type headache
Pain Characteristics: Typically bilateral (affecting both sides of the head), with a steady, pressing, or
tightening quality rather than throbbing. The pain is often described as a band-like pressure around the head.
Intensity of tension type headache
Intensity: Mild to moderate; not usually as severe as migraines or cluster headaches.
Associated Symptoms of tension-type headache
Generally, there is no associated nausea or vomiting, and sensitivity to light or sound
is not as pronounced. There may be mild tenderness in the neck, shoulders, or scalp.
Mechanism of tension type headache
Unknown; may be increased sensitivity of pain-mediating
systems in brain
Duration of cluster headache:
Attacks typically last from 15 minutes to 3 hours.
Pain Characteristics of cluster headache:
Severe, excruciating, and usually unilateral, focused around one eye or temple. The pain is often described as sharp or burning.
Intensity of cluster headache
Extremely severe; often described as the most intense headache a person can experience.
Associated Symptoms of cluster headache
Ipsilateral (same side) symptoms such as nasal congestion, rhinorrhea (runny nose), ptosis (drooping of the eyelid), and lacrimation (tearing).
The patient may also experience agitation or
restlessness.
Mechanism of cluster headache
Neurally induced inflammation and edema of internal carotid artery
Cause
Intracranial Mass Lesion:
e,g, Brain Tumor,
Hydrocephalus
Mechanism
Displacement (traction) of pain- sensitive vessels
Cause of headache
Low Intracranial Pressure
State: e.g Post-Lumbar
puncture
Traction through brain sagging on dural attachments; intracranial
vasodilatation
Cause of Headache
Meningitis, Subarachnoid
Haemorrhage
Mechanism
Inflammation of vessels in
meninges and of perivascular dura
Cause of headache
Temporal Arteritis,
Intracranial Vasculitis
Mechanism
Inflammation of scalp and
intracranial vessels
Criteria for diagnosing migraine without Aura (common migraine)
At least 5 attacks fulfilling the following criteria
Each attack, untreated or unsuccessfully treated, lasts 4-72 hrs
- The attack has at least 2 of the following characteristics:
Unilateral location; pulsating quality; moderate or severe intensity; pain aggravated by exertion or routine physical activity
- During an attack at least 1 of the following symptoms should be present:
Nausea / vomiting; photophobia, phonophobia
No evidence from history or physical examination of any other disease that might cause headaches
Criteria for Diagnosing Migraine with Aura
About 15% of migraineurs experience an aura
May occur with only a few, most, or all attacks
Typically precede headache, last 20-60 min and then clears before headache begins
Aura may trespass into the first few min of headache
Most auras are visual
Criteria for diagnosis : same as those for migraine without aura, but include symptoms of neurological dysfunction occurring before or during the attack
