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Year 4 Neuro and Special Senses > Emergency Neurological Conditions > Flashcards

Emergency Neurological Conditions Flashcards

1
Q

Subarachnoid Haemorrhage is bleeding between the arachnoid and pia mater. What are the two broad causes? Give some specifics.

A

Traumatic - eg RTA (may be other cranial bleeds as well)

Spontaneous - Rupture of cerebral aneurysm, AV malformation, Vasculitis

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2
Q

Give two modifiable and non modifiable risk factors for Subarachnoid Haemorrhage

A

Modifiable - Hypertension, Smoking

Non Modifiable - Female, ADPCKD

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3
Q

Where are Berry Aneurysms normally located?

A

Located at branching points of major blood vessels (points of maximum haemodynamic stress)

30-40% ACA
25% PCA
20% MCA
10% Bifurcation

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4
Q

Name four symptoms of Subarachnoid Haemorrhage

A

Thunderclap Headache
Photophobia
Neck Stiffness
Nausea and Vomiting

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5
Q

Name four signs of Subarachnoid Haemorrhage

A

Neck Stiffness
Cranial Nerve Palsy
Reduced Consciousness
Diplopia

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6
Q

What is the first line investigation for Subarachnoid Haemorrhage?

A

CT Head (if within 6h - 99% sensitivity)

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7
Q

When is a Lumbar Puncture for Subarachnoid Haemorrhage required?

A

If more than 6 hours from onset

If strong clinical suspicion but no findings on CT

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8
Q

When should an LP be done for SAH? What would be a negative LP?

A

After 12 hours

If clear or if Oxyhaemaglobin alone (suggests trauma or traumatic tap)

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9
Q

Name four findings you would expect from a positive Lumbar Puncture for SAH

A

Opening Pressure (elevated)
Red Cell Count (elevated)
Xanthochromia
Bilirubin

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10
Q

Once an SAH has been diagnosed, what further investigation can be done?

A

CT Angiogram (to determine any underlying pathology, can be therapeutic - coil or clip at same time)

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11
Q

On initial presentation of an SAH you would calculate GCS. What two grading systems can be used?

A 
Modified World Federation of Neuro Societies (based on GCS)
Modified Fisher (risk of vasospasm based on thickness of SAH and any IVH)
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12
Q

Name four medical managements of SAH

A
  • IV fluids and monitoring
  • GCS<8 requires intubation
  • Nimodipine every 4h for 3w
  • Analgesia and Antiemetics to prevent ValSalva
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13
Q

Name three possible surgical managements of SAH

A

Coiling
Clipping
External Ventricular Drain (if Hydrocephalus)

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14
Q

Name three complications of SAH

A

Rebleeding
Vasospasm
Hydrocephalus

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15
Q

Define Stroke

A

Clinical syndrome characterised by sudden onset of rapidly developing focal/global neurological disturbance, lasting more than 24h/leading to death (secondary to cerebral bloody supply disruption)

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16
Q

Strokes can be either Ischaemic or Haemorrhagic. How can Ischaemic strokes be classified?

A

By the Bamford/Oxford Classification

TACS, PACS, LAC, POC

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17
Q

Strokes can be either Ischaemic or Haemorrhagic. How can Haemorrhagic strokes be classified?

A

Intracerebral or Subarachnoid

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18
Q

Describe the pathophysiology of an Ischaemic Stroke

A

Either due to Thrombosis, Embolism or Dissection

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19
Q

Describe the pathophysiology of a Haemorrhagic Stroke

A

Usually due to Hypertension (but can also be due to vascular malformations, tumours, or bleeding disorders)

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20
Q

Describe the TAC classification of Ischaemic Stroke

A

Unilateral Sensory/Motor Weakness
Homonymous Hemianopia
Higher Cerebral Dysfunction

Requires 3/3

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21
Q

Describe the PAC classification of Ischaemic Stroke

A

Unilateral Sensory/Motor Weakness
Homonymous Hemianopia
Higher Cerebral Dysfunction

Requires 2/3

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22
Q

Describe the LAC classification of Ischaemic Stroke

A

Can be:

Pure Sensory, Pure Motor, Sensorimotor, Ataxic

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23
Q

Describe the POC classification of Ischaemic Stroke

A 
One of the following:
Brainstem Cerebellar Syndrome
Conjugate Eye Movement Disorder
Isolated Homonymous Hemianopia
Bilateral Sensorimotor Loss
Cranial Nerve Palsy and Contralateral Sensory/Motor
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24
Q

Name two Posterior Stroke Syndromes

A

Locked In Syndrome - Basilar Artery

Wallenberg Syndrome - Posteroinferior Cerebellar Artery (Nystagmus, Vertigo, Horners, Diplopia, Dysphagia)

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25
FAST is the tool in the community used to screen for Stroke. What is the Hospital Tool called?
NIHSS - Good Score is <4 - Score>22 high risk of haemorrhagic transformation with thrombolysis - Score>26 means thrombolysis is contraindicated
26
Name 5 investigations for a suspected stroke
``` CT head ECG Echo Bloods Carotid Doppler ```
27
How is a Haemorrhagic Stroke Managed?
Depends on the extent of the bleed and suitability for intervention Large bleeds - decompressive hemicraniotomy or suboccipital craniotomy
28
How is an Ischaemic Stroke managed ideally?
Thrombolysis with Alteplase (synthetic tPA) If within 4.5 hours and NIHSS is between 5 and 26
29
Name three contraindications to Thrombolysis
Ischaemic stroke within the past 3 months Active Bleeding Intracranial Neoplasm Previous Haemorrhagic Stroke
30
If Thrombolysis is contraindicated in terms of Ischaemic Stroke management, what is the next line?
300mg Asparin for 2w followed by 75mg Clopidogrel lifelong
31
What is a Thrombectomy?
Removal of the thrombus done in specialist centres by interventional neuroradiology Can be combined with Thrombolysis Location specific and depends on brain tissue viability
32
Name two early and two late complications of Stroke
Early - Haemorrhagic transformation, Cerebral Oedema (eg Malignant MCA) Late - Mobility and Sensory Issues, Fatigue
33
What are the DVLA rules surrounding driving after a stroke?
Cars and Motocycles - stop for a month and inform if further symptoms after this time
34
Other than the medical team, name three professions involved in Post Stroke care
SALT Phsyiotherapists Palliative care
35
Name four causes of Raised Intracranial Pressure
Neoplasms Abscess CSF disturbance IIH
36
Raised ICP is initially compensated by shunting blood and CSF out. When it begins to decompensate, what are the symptoms?
Classic Triad - Headache (worse on waking), Papilloedema, Vomiting (projectile) Pupillary changes, third nerve palsies, hypertension, bradycardia
37
Name three investigations for raised ICP
``` CT/MRI Bloods (renal function, electrolytes, osmolality) ICP monitoring (only if abnormal scan or low GCS) ```
38
Name 5 first line managements for raised ICP
``` Avoid Pyrexia Head Elevation at 30 degrees Sedation Mannitol (not if hyperosmotic or hypovolaemic) Analgesia ```
39
Name three second line managements of raised ICP
Barbiturate Coma Hypothermia Decompressive Hemicraniectomy
40
What is the 'Traditional' definition of Status Epilepticus?
Single Seizure lasting over 30 minutes, or two seizures in succession without recovery in between
41
What is the 'Practical' definition of Status Epilepticus?
Single Seizure lasting over 5 minutes or recurrent seizures without recovery
42
What are the three broad classifications of Seizures?
Focal Generalised (both hemispheres) Unknown
43
What are the subclassifications of Focal Seizures?
Can be aware or impaired awareness Sensory or motor depending on first presenting symptom
44
What are the subclassifications of General Seizures?
``` Tonic Clonic Tonic Myoclonic Atonic Absence ```
45
Name four prehospital managments for Status Epilepticus
Note Time Turn on side and cushion head Don't restrain Buccal Midazolam/Rectal Diazepam if available
46
Describe the hospital management of Status Epilepticus in terms of stages
Stage 1 - A to E, O2, IV access and bloods Stage 2 - AED therapy, Pabrinex/Glucose where relevant Stage 3 - Determine aetiology, further AEDs, ITU
47
Describe the Anti-Epileptic Drug Choice for Status Epilepticus
1) Lorazepam IV/Diazepam PR/Midazolam Buccal 2) Second Dose 3) IV Phenytoin and ECG monitoring
48
How is refractory Status Epilepticus managed?
ITU for General Anaesthesia with Thiopentone
49
Name three complications of Status Epilepticus
Hyperthermia Arrhythmia Long term Neuro Damage
50
How should suspected Meningococcal Sepsis be managed in the community?
IM Benzyl Penicillin
51
What is the first line management for Meningitis at UHL?
IV Ceftriaxone (Meropenem if PA) and Dexamethasone (unless immunosupressed) Notify PHE
52
What is the first line management for Meningitis at UHL if over 60/immunocompromised?
Ceftriaxone + Amoxicillin + Dexamethasone
53
Who requires PEP for Meningitis?
If prolonged contact with affected in the last 7 days Single dose Ciprofloxacin
54
What is GCA?
Sight threatening vasculitis characterised by inflammation of medium and large sized arteries Preferential involvement of temporal/opthalmic/occipital
55
Describe the pathophysiology of GCA
Granulomatous inflammation, vessel wall damage and release of angiogenic factors leads to narrowing and ischaemia
56
Name four symptoms of GCA
Unilateral Temporal Headache Scalp Pain Jaw Claudication Visual Blurring
57
Name four signs of GCA
Abnormal Temporal Artery (thickened, tender) Scalp Tenderness Transient/Permanent Visual Loss Optic Disc Changes (pale and swollen)
58
How is GCA diagnosed?
3/5 of ``` Age>50 New Headache Temporal Artery Abnormality Elevated ESR Abnormal Biopsy ```
59
Name four investigations for GCA
ESR/CRP Temporal Artery Biopsy Duplex USS (halo occlusions and stenosis) Opthalmological assessment
60
How is GCA managed?
Prompt high dose steroids (before investigations if clinical suspicion is high) With visual symptoms requires 3d IV Methylpred before switching to oral Vit D, PPI, Bisphosphonate
61
Name three complications of GCA
Visual Loss Arterial Aneurysm Arterial DIssection
62
Name 5 causes of Spinal Cord Injury
``` Trauma Tumours Prolapsed Disc Haematoma Inflammatory DIsease ```
63
Other than insiduous progression, name five red flags for spinal cord injury
``` Gait Disturbance Loss of Bladder/Bowel Function L'hermitte's sign UMN signs in lower limbs LMN signs in upper limbs ```
64
How does a Spinal Cord Injury present?
Cervical Spine - Quadraplegia Thoracic Spine - Paraplegia Root pain in legs May have loss of autonomic activity
65
What is Spinal Shock?
Physiological loss/depression of function lasting hours to weeks Flaccid areflexia and paralysis before becoming hypertonic
66
What is Neurogenic Shock?
Damage to descending motor pathways resulting in loss of vasomotor tone and cardiac innervation
67
What is Brown Sequard Syndrome?
Complete cord hemisection results in: - Ipsilateral dermatomal loss - Ipsilateral loss of DCML - Contralateral loss of spinothalamic below level (may be a few below due to Lissauers)
68
Name five signs of a LMN lesion
``` Weakness Wasting Hypotonia Areflexia Fasciculations ```
69
Name four signs of an UMN lesion
Weakness Hypertonia Hyperreflexia Upgoing plantars
70
What is Central Cord Syndrome?
Central Cord Compression and oedema resulting in more upper limb weakness than lower
71
What is Anterior Cord Syndrome?
Damage to spinal artery, lower limbs affected more than upper
72
How is Spinal Cord Injury Investigated?
Spine MRI U and Es Hb and Haematocrit
73
How is Spinal Cord Injury managed?
Referral to neurosurgeons (if metastatic see Onc notes) Steroids DVT and PE prophylaxis Can consider Vasopressors such as dopamine to maintain perfusion
74
Define Cauda Equina
Compression of nerve roots caudal to the level of spinal cord termination, causing one or more of: Bladder/Bowel Dysfunction, Saddle Anaesthesia, Sexual Dysfunction, Lower Limb Neuro Deficit
75
How can Cauda Equina be investigated?
Normally diagnosed from a good examination and history MRI (40% show no abnormalities) Urodynamic Studies (post surgery)
76
Name two differentials for Cauda Equina
Conus Medullaris Syndrome (less prominent pain, more urinary retention and constipation) Mechanical Back Pain
77
How is Cauda Equina managed?
Urgent Surgical Decompression Treat underlying cause
78
What is Cerebral Perfusion Pressure?
The available blood for brain tissue CPP = MAP - ICP Aim for >90
79
Describe a Subfalcine Herniation
Cingulate gyrus pushed under the free edge of the falx on the same side as mass Can cause compression of the ACA
80
Describe a Tentorial Herniation
Uncus herniates through Tentorial Notch Damages ipsilateral CNIII Occludes blood flow in Posterior Cerebral and Superior Cerebellar Can cause secondary brain stem haemorrhage (Duret)
81
Describe a Tonsilar Herniation
Cerebral Tonsils pushed through Foramen Magnum, compressing brainstem
82
Name 5 worrying features following a Head Injury
``` Vomiting Reduced GCS Confusion Signs of a Basal Skull Fracture Cushings triad ```
83
What are the three branches of GCS?
Eye Opening Verbal Response Motor Best response out of each side is used
84
Describe the scoring of Eye Opening with GCS
4 - Spontaneously 3 - To Voice 2 - To Pain 1 - None
85
Describe the scoring of Verbal Response with GCS
``` 5 - Conversation 4 - Confused 3 - Words 2 - Sounds 1 - None ```
86
Describe the scoring of Motor Response with GCS
``` 6 - Obeys Commands 5 - Localises 4 - Withdraws 3 - Flexes 2 - Extends 1 - None ```
87
Name four indicaions for Head CT post Head Injury according to NICE
GCS<13 initially Suspected Skull # Focal Neurological Signs >1 episode of vomiting
88
Describe the severity of Head Injury in terms of GCS
Mild (13-15) Mod (9-12) Severe (3-8)
89
How is secondary brain injury prevented after Head Trauma
Intubate if low GCS Avoid Hypoxia and Maintain pO2 >13 Use Vasopressors if required 30 degree head tilt
90
What is a Bulbar Palsy
Features as a result of diseases affecting the lower cranial nerves (VII - XII)
91
Name four broad classifications of Bulbar Palsies
Muscle Disorders Diseases of Motor Nuclei in Medulla and Lower Pons Diseases of Intramedullary Nerves of Spinal Cord Diseases of Peripheral Nerves supplying muscles
92
Name four presenting features of Bulbar Palsies
Weak and wasted tongue Drooling Absent palatal movements Dysphonia
93
Name five causes of Bulbar Palsy
``` Diptheria Poliomyelitis MND Syringobulbia Guillaine Barre Syndrome ```
94
What is Pseudobulbar Palsy?
Disease of the corticobulbar tracts causing an UMN lesion | May have UMN signs in limbs
95
Name three causes of Pseudobulbar Palsy
MS Internal Capsule Infarcts Neurosyhphilis
96
How is Bulbar Palsy investigated?
Speech Assessment (Electromagnetic Articulography) Routine Bloods CT/MRI
97
How is Bulbar Palsy Managed?
Admission if dysphagia Treat underling cause Anticholinergics for drooling Baclofen for Spasticity
98
Name four diseases affecting the NMJ and causing Respiratory Distress
Lambert Eaton Myasthenia Gravis Clostrodium Botulinim Organophosphates
99
Name four diseases affecting the Muscle and causing Respiratory Distress
MND Acid Maltase Deficiency Electrolyte Disturbance (hypokalaemia) Polymyositits
100
Name one diseases affecting the nerves and causing Respiratory Distress
Guillaine Barre Syndrome

Year 4 Neuro and Special Senses (8 decks)

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