Dizziness Flashcards
vertigo causes ?
Viral labyrinthitis
vestibular neuronitis
BPPV
meniere’s disease
verteberobasilar ischemia
acoustic neuroma
viral labyrinthitis clinical features ?
follows after a viral infection
associated with nausea and vomiting
sudden onset and hearing may be affected
clinical features of vestibular neuritis ?
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss
Menniere’s disease clinical features ?
hearing loss
tinnitus
association with fullness or pressure of both ears
verteberobasilar ischemia ?
dizziness of extension of the neck
acoustic neuroma clinical features ?
unilateral sensorineural hearing loss,
unilateral tinnitus
vertigo
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2
other causes of dizziness ?
drugs such as gentamicin, diuretics for ototoxicity
posterior circulation stroke
multiple sclerosis
Tests for posterior circulation stroke ?
Cranial nerve examination - nystagmus (horizonal-abducens , vertical-occulomotor )
double vision
isolated homonymous hemianopsia asking them to cover one eye and assessing their peripheral vision
cerebellar or brainstem syndromes
ROMBERG TEST
Ataxia
walk in line test
past pointing and dysdiadochokinesis
Intention tremor - wide tremor during voluntary movements, such as holding out the hands
Total anterior circulation infarcts- BAMFORD CLASSIFICATION
middle and anterior cerebral arteries
- Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Partial anterior circulation infarcts - BAMFORD CLASSIFICATION
upper or lower division of middle cerebral artery
2 of the above criteria are present
lacunar infarcts (LACI, c. 25%)
perforating arteries around the internal capsule, thalamus and basal ganglia
strong association with hypertension
presents with 1 of the following:
- unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
- pure sensory stroke.
- ataxic hemiparesis
Lateral medullary syndrome/ Wallenberg’s syndrome
(posterior inferior cerebellar artery)
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
dysphagia,
cranial nerve palsy e.g. Horner’s
Weber’s syndrome
(branches of the posterior cerebral artery that supply the midbrain)
ipsilateral III palsy
contralateral weakness
clinical features of anterior cerebral artery
Contralateral hemiparesis and sensory loss, lower extremity > upper
Middle cerebral artery
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
investigations for stroke ?
,bedside
= ECG
routine bloods - with ESR vasculitis
coagulation screen!!!
group and save - incase if there is a haemorrhage in the brain !!!!
lipid profile
CT head
It may also pick up an infarct if it is established
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later on ECHO !!!!!
Carotid doppler scan -
carotid endarterectomy is recommend as soon as possible within 7 days
treatment for stroke
if it falls within 4.5 hours since the symptom onset then for thrombolysis
Patients should also be considered considered for thrombolysis with alteplase if:
treatment can be started between 4.5 and 9 hours of known onset,
AND
they have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue
Blood pressure should be lowered to 185/110 mmHg before thrombolysis.
(agents used is labetolol ,Nicardipine )
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Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)
Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously (including wake-up strokes):
who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
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If patient has had thrombolysis, delay aspirin initiation for 24 hours and ensure a follow up CT brain scan is done before aspirin is administered.
contraindications for thrombolysis ?
any previous history of Haemorrhage
Seizure at onset of stroke
stroke or traumatic brain injury the last 3 months
lumbar puncture in the last 7 days
gastrointestinal bleeding in the last 3 weeks
esophageal varicies
active bleeding
Uncontrolled hypertension >200/120mmHg
secondary prevention of stroke ?
if cardioembolic cause we can start them on just a DOAC
after aspirin 300 mg for two weeks :
Clopidogrel 75 mg daily LONG TERM OR aspirin 75 mg daily if intolerant
blood pressure often falls spontaneously over the first few days after stroke, so blood pressure lowering therapy for long term secondary prevention should be initiated at hospital discharge or at 1 - 2 weeks, whichever is later.
achieve a blood pressure below 130/80 except in severe bilateral carotid stenosis (over 70% stenosis) when the target is 150 - 160 systolic
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Statin therapy should be started at 48 hours after stroke onset
other treatment for stroke ?
early rehabilitation
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give advice for driving -
stroke or TIA: 1 month off driving, may not need to inform DVLA if no residual neurological deficit
multiple TIAs over short period of times: 3 months off driving and inform DVLA
What is TIA ?
a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
the features resolve, typically within 1 hour
referral for TIA ?
If a patient presents more than 7 days ago they should be seen by a stroke specialist clinician as soon as possible within 7 days
if resolved completely within 24 hours of onset (i.e. suspected TIA) should: assessed urgently within 24 hours by a stroke specialist clinician
imaging for TIA ?
NICE recommend that CT brains should not be done ‘unless there is clinical suspicion of an alternative diagnosis - for example concern of haemorrhage
MRI (including diffusion-weighted and blood-sensitive sequences) is preferred to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies
management of TIA ?
Minor ischaemic stroke (non- cardioembolic) with NIHSS score <=3
Definite/probable TIA
Aspirin 300 mg STAT AND clopidogrel 300 mg STAT
Aspirin 75 mg daily AND clopidogrel 75 mg daily* for THREE weeks**
Clopidogrel 75 mg daily LONG TERM*
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Possible TIA (uncertain diagnosis)
Aspirin 300 mg STAT (if not given already)
Clopidogrel 75 mg daily LONG TERM OR aspirin 75 mg daily LONG TERM*
