Dizziness

Question 1

vertigo causes ?

Answer 1

Viral labyrinthitis
vestibular neuronitis
BPPV
meniere’s disease
verteberobasilar ischemia
acoustic neuroma

Question 2

viral labyrinthitis clinical features ?

Answer 2

follows after a viral infection
associated with nausea and vomiting
sudden onset and hearing may be affected

Question 3

clinical features of vestibular neuritis ?

Answer 3

Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss

Question 4

Menniere’s disease clinical features ?

Answer 4

hearing loss
tinnitus
association with fullness or pressure of both ears

Question 5

verteberobasilar ischemia ?

Answer 5

dizziness of extension of the neck

Question 6

acoustic neuroma clinical features ?

Answer 6

unilateral sensorineural hearing loss,
unilateral tinnitus
vertigo
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

Question 7

other causes of dizziness ?

Answer 7

drugs such as gentamicin, diuretics for ototoxicity

posterior circulation stroke

multiple sclerosis

Question 8

Tests for posterior circulation stroke ?

Answer 8

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

Question 9

Total anterior circulation infarcts- BAMFORD CLASSIFICATION

Answer 9

middle and anterior cerebral arteries

1. Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Question 10

Partial anterior circulation infarcts - BAMFORD CLASSIFICATION

Answer 10

upper or lower division of middle cerebral artery

2 of the above criteria are present

Question 11

lacunar infarcts (LACI, c. 25%)

Answer 11

perforating arteries around the internal capsule, thalamus and basal ganglia

strong association with hypertension

presents with 1 of the following:

1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis

Question 12

Lateral medullary syndrome/ Wallenberg’s syndrome
(posterior inferior cerebellar artery)

Answer 12

Ipsilateral: facial pain and temperature loss

Contralateral: limb/torso pain and temperature loss

Ataxia, nystagmus

dysphagia,

cranial nerve palsy e.g. Horner’s

Question 13

Weber’s syndrome
(branches of the posterior cerebral artery that supply the midbrain)

Answer 13

ipsilateral III palsy
contralateral weakness

Question 14

clinical features of anterior cerebral artery

Answer 14

Contralateral hemiparesis and sensory loss, lower extremity > upper

Question 15

Middle cerebral artery

Answer 15

Contralateral hemiparesis and sensory loss, upper extremity > lower

Contralateral homonymous hemianopia

Aphasia

Question 16

investigations for stroke ?

Answer 16

,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

==========

later on ECHO !!!!!

Carotid doppler scan -
carotid endarterectomy is recommend as soon as possible within 7 days

Question 17

treatment for stroke

Answer 17

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 )

==========

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

==========
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.

Question 18

contraindications for thrombolysis ?

Answer 18

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

Question 19

secondary prevention of stroke ?

Answer 19

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

==========

Statin therapy should be started at 48 hours after stroke onset

Question 20

other treatment for stroke ?

Answer 20

early rehabilitation

=====

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

Question 21

What is TIA ?

Answer 21

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

Question 22

referral for TIA ?

Answer 22

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

Question 23

imaging for TIA ?

Answer 23

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

Question 24

management of TIA ?

Answer 24

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*

===================

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*

Question 25

how does stroke get alerted

Answer 25

ambulance clinicians must place a pre-alert to hyperacute stroke units

not every hospital has a hyperacute stroke unit

designated thrombectomy centre for consideration of mechanical thrombectomy

specialist stroke clinician determines if patient is eligible for the stroke pathway

Acute stroke services should receive this alert and
have continuous (24/7) access to brain imaging including CT or MR angiography and perfusion when necessary

should provide specialist medical, nursing, and rehabilitation staffing levels, even via telemedicine during on call thing

Question 26

they want to make a complaint because this wasn’t picked up on her initial visit to A+E earlier in the week. How would you manage this?

Answer 26

I would also ask them if they wanted to speak to one of the senior clinicians on my team who may be able to further address their concerns.

To finish our conversation, I would again empathise with them with regards to the situation that they find themselves in and

let them know that I am available to speak to again in case they have any further questions or issues with the complaints process.

Question 27

NIHSS score for STROKE ?

Answer 27

: no stroke * 1–4: minor stroke * 5–15: moderate stroke * 16–20: moderate/severe stroke * 21–42: severe stroke

Question 28

differentials fro stroke ?

Answer 28

SOL
TIA
paraplegic migraines
HYPOGYCEMIA
aortic or carotid artery dissection
delirium