Emergency Neuro Presentations

Question 1

As the brain and ventricles are enclosed by a rigid skull, they have a limited ability to accommodate additional volume. Additional volume (e.g. haematoma, tumour, excessive CSF) will therefore lead to a rise in intracranial pressure (ICP).

What is normal range for ICP?

Answer 1

7-15 mmHg in adults in the supine position

Question 2

What is cerebral perfusion pressure?

Answer 2

cerebral perfusion pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain
CPP = mean arterial pressure - ICP

Question 3

What causes raised intracranial pressure?

Answer 3

idiopathic intracranial hypertension
traumatic head injuries
infection e.g. meningitis
tumours
hydrocephalus

Question 4

What features may raised ICP present with?

Answer 4

headache
vomiting
reduced levels of consciousness
papilloedema
Cushing’s triad

Question 5

What is Cushing’s triad of raised ICP?

Answer 5

widening pulse pressure
bradycardia
irregular breathing

Question 6

How can raised ICP be investigated?

Answer 6

neuroimaging : CT/MRI

invasive ICP monitoring:
catheter placed into the lateral ventricles of the brain to monitor the pressure
may also be used to take collect CSF samples / drain CSF
a cut-off of > 20 mmHg is often used to determine if further treatment is needed to reduce the ICP

Question 7

What is the initial management of raised ICP?

Answer 7

investigate and treat the underlying cause
head elevation to 30º
IV mannitol may be used as an osmotic diuretic
controlled hyperventilation
removal of CSF

Question 8

What is the purpose of controlled hyperventilation in the mx of raised ICP?

Answer 8

aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP

leads to rapid, temporary lowering of ICP

caution needed as may reduce blood flow to already ischaemic parts of the brain

Question 9

What are the methods for removing excess CSF?

Answer 9

drain from intraventricular monitor
repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
ventriculoperitoneal shunt (for hydrocephalus)

Question 10

What are the 4 different types of intracranial haemorrhage?

Answer 10

Extradural haemorrhage (bleeding between the skull and dura mater)

Subdural haemorrhage (bleeding between the dura mater and arachnoid mater)

Subarachnoid haemorrhage (bleeding in the subarachnoid space)

Intracerebral haemorrhage (bleeding into brain tissue)

Question 11

What is a subarachnoid haemorrhage?

Answer 11

bleeding in the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane

very high mortality (around 30%) and morbidity

may be traumatic or spontaneous

Question 12

What are the causes of spontaneous subarachnoid haemorrhage?

Answer 12

intracranial aneurysm (saccular ‘berry’ aneurysms): 85% of cases
associated with hypertension, adult PCKD, Ehlers-Danlos and coarctation of the aorta

arteriovenous malformation

pituitary apoplexy

mycotic (infective) aneurysms

Question 13

In which patient group are subarachnoid haemorrhages more common?

Answer 13

Aged 45 to 70
Women
Black ethnic origin

Question 14

Give some risk factors for subarachnoid haemorrhage

Answer 14

Family Hx
Hypertension
Smoking and alcohol
Cocaine use
Sickle cell anaemia
Connective tissue disorders (e.g., Marfan syndrome or Ehlers-Danlos syndrome)
Neurofibromatosis
Autosomal dominant polycystic kidney disease

Question 15

How does subarachnoid haemorrhage typically present?

Answer 15

sudden onset occipital ‘ thunderclap’ headache

often comes on during strenuous activity, such as heavy lifting or sex

nausea and vomiting
meningism (photophobia, neck stiffness)
seizures
coma

ECG changes including ST elevation may be seen

Question 16

How should a suspected subarachnoid haemorrhage be investigated?

Answer 16

non-contrast CT head is the first-line investigation of choice : blood appears hyperdense/bright on CT

if CT head is done within 6 hours of symptom onset and is normal: do NOT do lumbar puncture
consider an alternative diagnosis

if CT head is done more than 6 hours after symptom onset and is normal: do a lumber puncture (LP) to confirm / exclude diagnosis

SAH seen on CT / confirmed on LP:
CT angiography is used after confirming the diagnosis to locate the source of the bleeding

Question 17

What findings would you expect on an LP for a patient with SAH?

Answer 17

Raised red cell count (a decreasing red cell count on successive bottles may be due to a traumatic procedure)

Xanthochromia (a yellow colour to the CSF caused by bilirubin)

Question 18

How can you manage subarachnoid haemorrhage?

Answer 18

bed rest, analgesia

oral nimodipine to prevent vasopasm

discontinuation of antithrombotics (reversal of anticoagulation if present)

intracranial aneurysms require prompt intervention (within 24 hours):
most treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon

Question 19

What are the complications of aneurysmal SAH?

Answer 19

re-bleeding

hydrocephalus

hyponatraemia

ventriculoperitoneal shunt

vasospasm (also termed delayed cerebral ischaemia)

seizures

Question 20

What is the risk of rebleeding after aneurysmal SAH?
How should it be managed?

Answer 20

happens in 10% of cases
most common in the first 12 hours

if rebleeding is suspected then a repeat CT should be arranged
associated with a high mortality (up to 70%)

Question 21

Hydrocephalus refers to increased cerebrospinal fluid, causing expansion of the ventricles.

Treatment options include:

Answer 21

Lumbar puncture

External ventricular drain (a drain inserted into the brain ventricles to drain CSF)

Ventriculoperitoneal (VP) shunt (a catheter connecting the ventricles with the peritoneal cavity)

Question 22

When does vasopasm most commonly present post SAH?

How should it be managed?

Answer 22

also termed delayed cerebral ischaemia, typically 7-14 days after onset

ensure euvolaemia (normal blood volume)
consider treatment with a vasopressor if symptoms persist (e.g. vasopressin, adrenaline, noradrenaline)

Question 23

Which are the most important prognostic factors in SAH?

Answer 23

conscious level on admission
age
amount of blood visible on CT head

Question 24

Meningitis is defined as inflammation of the meninges (lining of the brain and spinal cord).

What are the common causative organisms?
How does it present?

Answer 24

Neisseria meningitidis and Streptococcus pneumoniae
GBS in neonates

Presentation:
fever, neck stiffness, vomiting, headache, photophobia, altered consciousness and seizures

meningococcal septicaemia = non-blanching rash

Question 25

How may meningitis present differently in neonates?

Answer 25

Neonates and babies can present with very non-specific signs and symptoms poor feeding, lethargy, hypotonia, hypothermia and a bulging fontanelle

Question 26

What are the common causes of meningitis in the 0-3 month age group?

Answer 26

Group B Streptococcus (most common cause in neonates) E. coli Listeria monocytogenes

Question 27

What are the common causes of meningitis in the 3 month - 6 year age group?

Answer 27

Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenzae

Question 28

What are the common causes of meningitis in the 6 - 60 year age group?

Answer 28

Neisseria meningitidis Streptococcus pneumoniae

Question 29

> 60 age group are more at risk of meningitis caused by which organism?

Answer 29

Listeria monocytogenes

Question 30

What are the 2 special tests that you can use to assess for meningeal irritation?

Answer 30

Both tests create a slight stretch in the meninges Kernig’s test: lying the patient on their back, flexing one hip to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. +ve = spinal pain or resistance to movement Brudzinski’s test : lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest +ve = patient involuntarily flexes their hips and knees

Question 31

How do bacterial v viral meningitis present on an LP? (consider appearance, protein, glucose, WCC and culture)

Answer 31

Appearance Cloudy V Clear Protein High V Normal Glucose Low V Normal White Cell Count Neutrophils V Lymphocytes Culture Bacteria Present V Negative

Question 32

What is the pre-hospital mx of suspected bacterial meningitis?

Answer 32

IM benzylpenicillin urgently

Question 33

How can meningitis be investigated?

Answer 33

Bloods: FBC, CRP, U&Es glucose lactate clotting profile Additional tests that may be helpful include: blood gases throat swab for meningococcal culture Consider LP + CSF analysis

Question 34

When should a LP not be performed for suspected bacterial meningitis?

Answer 34

signs of severe sepsis or a rapidly evolving rash severe respiratory/cardiac compromise significant bleeding risk signs of raised intracranial pressure

Question 35

How should patients with suspected bacterial meningitis and no contraindications to LP be managed?

Answer 35

IV access → take bloods and blood cultures Lumbar puncture to confirm dx IV antibiotics 3 months - 50 years: ceftriaxone (or cefotaxime) > 50 years: ceftriaxone + amoxicillin IV dexamethasone avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised CT scan is not normally indicated

Question 36

When an LP is taken for suspected bacterial meningitis, what should the CSF be tested for?

Answer 36

glucose, protein, microscopy and culture lactate meningococcal and pneumococcal PCR enteroviral, herpes simplex and varicella-zoster PCR consider investigations for TB meningitis

Question 37

How should patients with suspected bacterial meningitis and signs of raised ICP be managed?

Answer 37

get critical care input secure airway + high-flow oxygen IV access → take bloods and blood cultures IV dexamethasone alongside abx (cefotaxime +/- amoxicillin) Arrange neuroimaging

Question 38

How should patients with suspected bacterial meningitis and sepsis / rapidly evolving rash be managed?

Answer 38

get critical care input secure airway + high-flow oxygen IV access → take bloods and blood cultures IV fluid resuscitation IV antibiotics (cefotaxime +/- amoxicillin)

Question 39

What should be offered to household members and close contacts of an individual with confirmed bacterial meningitis?

Answer 39

oral ciprofloxacin or rifampicin prophylaxis if they have have contact with the individual in the 7 days before sx onset

Question 40

Viral meningitis is more benign condition than bacterial meningitis and is much more common. What can cause it?

Answer 40

non-polio enteroviruses e.g. coxsackie virus, echovirus mumps, measles herpes simplex virus (HSV), cytomegalovirus (CMV), herpes zoster viruses HIV

Question 41

What are the risk factors for developing viral meningitis?

Answer 41

patients at the extremes of age (< 5 years and the elderly) immunocompromised, e.g. patients with renal failure, with diabetes intravenous drug users

Question 42

How can viral meningitis be managed?

Answer 42

If there is any question of bacterial meningitis while waiting for LP results the patient should be commenced on broad-spectrum abx with CNS penetration e.g. ceftriaxone and aciclovir IV viral meningitis is generally self-limiting, with symptoms improving over the course of 7 - 14 days and complications are rare in immunocompetent patients aciclovir may be used if the patient is suspected of having meningitis secondary to HSV

Question 43

What complications may arise as a result of meningitis?

Answer 43

sensorineural hearing loss (most common) seizures focal neurological deficit infective: sepsis, intracerebral abscess pressure: brain herniation, hydrocephalus

Question 44

Patients with meningococcal meningitis are at risk of developing what condition?

Answer 44

Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)

Question 45

Encephalitis is inflammation of the brain tissue itself, that is primarily caused by HSV-1 in adults. What features does it present with?

Answer 45

fever, headache, psychiatric symptoms, seizures, vomiting focal features e.g. aphasia peripheral lesions (e.g. cold sores) have no relation to the presence of HSV encephalitis

Question 46

How can suspected encephalitis be investigated?

Answer 46

PCR for HSV, VZV and enteroviruses CSF: high WCC and protein MRI medial temporal and inferior frontal changes (e.g. petechial haemorrhages) EEG lateralised periodic discharges at 2 Hz

Question 47

How can encephalitis be managed?

Answer 47

IV aciclovir

Question 48

A stroke represents a sudden interruption in the vascular supply of the brain. What are the different types of stroke?

Answer 48

ISCHAEMIC: 85% Thrombotic stroke - from large vessels e.g. carotid Embolic stroke - AF is an important risk factor HAEMORRHAGIC: 15% Intracerebral haemorrhage Subarachnoid haemorrhage

Question 49

Give some risk factors for developing an ischaemic stroke

Answer 49

General risk factors for cardiovascular disease: age smoking hypertension hyperlipidaemia diabetes mellitus Risk factors for cardioembolism: atrial fibrillation

Question 50

Give some risk factors for developing a haemorrhagic stroke

Answer 50

age hypertension arteriovenous malformation anticoagulation therapy

Question 51

What features may someone present with when they are having a stroke?

Answer 51

motor weakness dysphasia, dysphagia visual field defects (homonymous hemianopia) balance problems

Question 52

How may cerebral hemisphere infarcts present?

Answer 52

contralateral hemiplegia: initially flaccid then spastic contralateral sensory loss homonymous hemianopia dysphasia

Question 53

What system can be used to classify strokes based on their presenting symptoms?

Answer 53

The Oxford Stroke Classification (also known as the Bamford Classification)

Question 54

Which part of the circulation is involved in a Total anterior circulation stroke (TACS)?

Answer 54

involves middle and anterior cerebral arteries

Question 55

What are the diagnostic criteria for a Total anterior circulation stroke (TACS) according to the Oxford Stroke Classification System?

Answer 55

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

Question 56

Which part of the circulation is involved in a Partial anterior circulation stroke (PACS)?

Answer 56

involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery

Question 57

What are the diagnostic criteria for a Partial anterior circulation stroke (PACS) according to the Oxford Stroke Classification System?

Answer 57

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

Question 58

What part of the circulation is involved in a Lacunar Infarct?

Answer 58

involves perforating arteries around the internal capsule, thalamus and basal ganglia

Question 59

What are the diagnostic criteria for a Lacunar infarct (LACS) according to the Oxford Stroke Classification System?

Answer 59

presents with 1 of the following: 1. pure motor stroke 2. pure sensory stroke 3. ataxic hemiparesis

Question 60

What part of the circulation is involved in a Posterior Circulation Stroke?

Answer 60

vertebrobasilar arteries

Question 61

What are the diagnostic criteria for a Posterior Circulation Stroke (POCS) according to the Oxford Stroke Classification System?

Answer 61

presents with 1 of the following: 1. cerebellar or brainstem syndromes (e.g. vertigo, nystagmus, ataxia) 2. loss of consciousness 3. isolated homonymous hemianopia

Question 62

What is the likely site of the lesion for a stroke patient presenting with: Contralateral hemiparesis and sensory loss, lower extremity > upper

Answer 62

Anterior cerebral artery

Question 63

What is the likely site of the lesion for a stroke patient presenting with: Contralateral hemiparesis and sensory loss, upper extremity > lower Contralateral homonymous hemianopia Aphasia

Answer 63

Middle cerebral artery (MCA supplies Wernicke's and Broca's areas)

Question 64

What is the likely site of the lesion for a stroke patient presenting with: Contralateral homonymous hemianopia with macular sparing Visual agnosia

Answer 64

Posterior cerebral artery (PCA supplies area that contains visual cortex in the occipital lobe)

Question 65

What is the likely site of the lesion for a stroke patient presenting with: Ipsilateral CN III palsy Contralateral weakness of upper and lower extremity

Answer 65

branches of the posterior cerebral artery that supply the midbrain - Weber's syndrome

Question 66

What is the likely site of the lesion for a stroke patient presenting with: Ipsilateral: facial pain and temp loss Contralateral: limb/torso pain and temp loss Ataxia, nystagmus, double vision Horner's syndrome

Answer 66

Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)

Question 67

What is the likely site of the lesion for a stroke patient presenting with: Ipsilateral: facial paralysis and deafness Contralateral: limb/torso pain and temperature loss

Answer 67

Anterior inferior cerebellar artery (lateral pontine syndrome)

Question 68

What is the likely site of the lesion for a stroke patient presenting with: Amaurosis fugax

Answer 68

Retinal/ophthalmic artery

Question 69

What is the likely site of the lesion for a stroke patient presenting with: 'Locked-in' syndrome

Answer 69

Basilar artery

Question 70

How do lacunar strokes present?

Answer 70

present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia strong association with hypertension common sites include the basal ganglia, thalamus and internal capsule

Question 71

Whilst symptoms alone cannot be used to differentiate haemorrhagic from ischaemic strokes, patients who've suffered haemorrhages are more likely to have:

Answer 71

decrease in the level of consciousness: seen in up to 50% of patients with haemorrhagic stroke headache is also much more common nausea and vomiting seizures occur in up to 25% of patients

Question 72

What scoring tools can be used to identify strokes quickly in the community and in ED?

Answer 72

FAST tool: F – Face A – Arm S – Speech T – Time (act fast and call 999) ROSIER Tool: The ROSIER tool (Recognition Of Stroke In the Emergency Room) gives a score based on the clinical features and duration stroke is possible in patients scoring one or more

Question 73

How should suspected strokes be investigated?

Answer 73

Urgent non-contrast CT head scan to exclude haemorrhage acute ischaemic strokes: 'hyperdense artery' sign corresponding with the responsible arterial clot - this tends to visible immediately may show areas of low density in the affected territory once ischaemia has set in acute haemorrhagic strokes: typically show areas of hyperdense material (blood) surrounded by low density (oedema)

Question 74

How should a confirmed ischaemic stroke be managed?

Answer 74

aspirin 300mg orally or rectally should be given as soon as possible (continued daily for 2 weeks) Thrombolysis with alteplase should be given if: * it is administered within 4.5 hours of onset of stroke symptoms * haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Question 75

What is recommend for patients with an acute ischaemic stroke who present within 4.5 hours?

Answer 75

A combination of thrombolysis AND thrombectomy

Question 76

What are the absolute contraindications to delivering thrombolysis?

Answer 76

Previous intracranial haemorrhage Uncontrolled hypertension >200/120mmHg Seizure at onset of stroke Intracranial neoplasm Suspected subarachnoid haemorrhage Stroke or traumatic brain injury in preceding 3 months Lumbar puncture in preceding 7 days Active bleeding Oesophageal varices Pregnancy

Question 77

How may you investigate for an underlying cause of stroke?

Answer 77

Patients with a TIA or stroke are investigated for carotid artery stenosis and atrial fibrillation with: Carotid imaging (e.g., carotid ultrasound, or CT or MRI angiogram) ECG or ambulatory ECG monitoring

Question 78

What secondary prevention should be offered to patients who have had a stroke?

Answer 78

Clopidogrel 75mg once daily (alternatively aspirin plus dipyridamole) Atorvastatin 20-80mg (not started immediately – usually delayed at least 48 hours) Blood pressure and diabetes control Addressing modifiable risk factors (e.g., smoking, obesity and exercise)

Question 79

How can you measure someone's functional status post-stroke?

Answer 79

Barthel index (BI): an outcome measure for stroke Describes 10 tasks, and is scored according to amount of time or assistance required by the patient for each given task Tasks: feeding, moving from wheelchair to bed, personal toileting, getting on/off toilet, bathing, walking on level surface, ascending/descending stairs, dressing, controlling bowels and controlling bladder The total score is from 0 to 100, with 0 being completely dependent, and 100 being completely independent

Question 80

Cauda equina syndrome (CES) is a serious condition in which the lumbosacral nerve roots that extend below the spinal cord are compressed. What may cause it?

Answer 80

the most common cause is a central disc prolapse this typically occurs at L4/5 or L5/S1 other causes include: tumours: primary or metastatic infection: abscess, discitis trauma haematoma

Question 81

What features may CES present with?

Answer 81

low back pain bilateral sciatica: around 50% of cases reduced sensation/pins-and-needles in the perianal area decreased anal tone urinary dysfunction incontinence is a late sign that may indicate irreversible damage

Question 82

How should CES be investigated and managed?

Answer 82

urgent MRI whole spine surgical decompression

Question 83

How may a primary brain injury be classified?

Answer 83

focal (contusion/ haematoma) or diffuse (diffuse axonal injury) Diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons

Question 84

How may cerebral contusions be classified?

Answer 84

adjacent to (coup) or contralateral (contre-coup) to the side of impact

Question 85

What is secondary brain injury?

Answer 85

When cerebral oedema, ischaemia, infection, or herniation exacerbates the original injury The normal cerebral auto regulatory processes are disrupted following trauma, making the brain more susceptible to blood flow changes and hypoxia

Question 86

What is shown here?

Answer 86

Extradural haematoma Bleeding into the space between the dura mater and the skull Most occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery

Question 87

What is shown here? What are the risk factors?

Answer 87

Subdural haematoma Bleeding between the dura mater and the arachnoid mater Risk factors include old age, alcoholism and anticoagulation Slower onset of symptoms than a epidural haematoma, +/- fluctuating consciousness

Question 88

What is shown here?

Answer 88

Subarachnoid haemorrhage

Question 89

Which patients with head injuries require a CT head within 1 hour?

Answer 89

GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture any sign of basal skull fracture post-traumatic seizure focal neurological deficit more than 1 episode of vomiting

Question 90

Give some signs of basal skull fracture

Answer 90

haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign

Question 91

If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, what should you do?

Answer 91

perform a CT head scan within 8 hours of the injury

Question 92

How should traumatic head injuries be managed?

Answer 92

Life threatening rising ICP : consider IV mannitol/ furosemide while theatre is being prepped Diffuse cerebral oedema may require decompressive craniotomy Depressed skull fractures: open = formal surgical reduction and debridement closed injuries may be managed nonoperatively

Question 93

Which patients should receive ICP monitoring following head injury?

Answer 93

ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.

Question 94

What is the most likely cause of hyponatraemia in a patient with a traumatic head injury?

Answer 94

SIADH

Question 95

What is the minimum cerebral perfusion pressure in children and adults?

Answer 95

Minimum of cerebral perfusion pressure of 70mmHg in adults and between 40 and 70 mmHg in children.

Question 96

Unilaterally dilated pupil that is sluggish to respond to light (or fixed) =

Answer 96

3rd nerve compression secondary to tentorial herniation

Question 97

Bilaterally dilated pupils that are sluggish to respond to light (or fixed) =

Answer 97

Poor CNS perfusion Bilateral 3rd nerve palsy

Question 98

Unilaterally dilated pupil that is cross reactive (Marcus - Gunn) in response to light =

Answer 98

Optic nerve injury

Question 99

Bilaterally constricted pupils =

Answer 99

Opiates Pontine lesions Metabolic encephalopathy

Question 100

Unilaterally constricted pupil with preserved light reflex =

Answer 100

Sympathetic pathway disruption (e.g. Horner's)

Question 101

What is temporal arteritis? (also known as giant cell arteritis)

Answer 101

a vasculitis of unknown cause that affects medium and large-sized vessels peak incidence is in 70yr olds requires early recognition as may be sight threatneing

Question 102

Which patient group is at risk of developing temporal arteritis?

Answer 102

patients with Polymyalgia Rheumatica around 50% of TA patients have features of PMR such as aching and morning stiffness in proximal limb muscles

Question 103

What features does temporal arteritis typically present with?

Answer 103

typically patient > 60 years old usually rapid onset (e.g. < 1 month) headache jaw claudication tender, palpable temporal artery also lethargy, depression, low-grade fever, anorexia, night sweats

Question 104

How should temporal arteritis be investigated?

Answer 104

vision testing is a key investigation in all patients inflammatory markers : raised ESR (> 50 mm/hr) and raised CRP temporal artery biopsy: skip lesions may be present

Question 105

What are the potential ocular complications of temporal arteritis?

Answer 105

anterior ischemic optic neuropathy is most common: occlusion of the posterior ciliary artery (branch of the ophthalmic artery) → ischaemia of the optic nerve head swollen pale disc and blurred margins on fundoscopy diplopia temporary visual loss - amaurosis fugax permanent visual loss may develop suddenly

Question 106

How should temporal arteritis be managed?

Answer 106

urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy no visual loss = high-dose prednisolone evolving visual loss = IV methylprednisolone prior to starting high-dose prednisolone there should be a dramatic response, if not the diagnosis should be reconsidered urgent ophthalmology review patients with visual symptoms should be seen the same-day by an ophthalmologist

Question 107

What is bulbar palsy ?

Answer 107

signs and symptoms linked to the impaired function of the lower cranial nerves arising from the brainstem Glossopharyngeal (9), vagus (10), accessory (11) and hypoglossal (12) are affected due to the lower part of cranial nerves or their lower motor neurones being damaged

Question 108

What symptoms might someone present with if they have a bulbar palsy?

Answer 108

dysphagia (glossopharyngeal nerve damage) difficulty chewing lack of gag reflex nasal regurgitation difficulty in handling secretions / aspiration of secretions slurred speech, dysphonia and dysarthria

Question 109

What may cause someone to develop a bulbar palsy?

Answer 109

Brainstem stroke Brainstem tumour Degenerative diseases e.g. ALS Autoimmune diseases e.g. Guillain Barre Genetic Conditions

Question 110

How can bulbar palsies be investigated and managed?

Answer 110

consider CSF testing to rule out multiple sclerosis (may present similarly) MRI to investigate for brainstem strokes and tumours treat the underlying cause manage sxs - NG tube for feeding, SALT team input, medications to reduce drooling

Question 111

Name 4 conditions that are stroke mimics. How are they differentiated from an acute stroke?

Answer 111

HEMI: - Hypoglycaemia - Epilepsy - Migraine (hemiplegic) - Intracranial tumours/infections The Recognition of Stroke in the Emergency Room (ROSIER) scale

Question 112

Define TIA

Answer 112

TIA: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

Question 113

How are TIAs managed acutely?

Answer 113

Immediate antithrombotic therapy: give aspirin 300 mg immediately, unless contraindicated e.g. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging- CT head- to exclude a haemorrhage)

Question 114

If the patient has had more than 1 TIA ('crescendo TIA') or has a suspected cardioembolic source or severe carotid stenosis:

Answer 114

discuss urgently with a stroke specialist

Question 115

If the patient has had a suspected TIA in the last 7 days:

Answer 115

arrange assessment within 24 hours by a stroke specialist

Question 116

If the patient has had a suspected TIA which occurred more than a week previously:

Answer 116

refer for specialist assessment as soon as possible within 7 days

Question 117

In cases of stroke, thrombolysis with alteplase should only be given if:

Answer 117

it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial) haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Question 118

How is GCS scored?

Answer 118

In GCS, take the best response from each side! MoVE 654 Motor: 6. Obeys commands 5. Localises to pain 4. Withdraws from pain 3. Abnormal flexion to pain (decorticate posture) 2. Extending to pain 1. None Verbal: 5. Orientated 4. Confused 3. Words 2. Sounds 1. None Eye opening: 4. Spontaneous 3. To speech 2. To pain 1. None