Emergency Neurological Conditions Flashcards
1
Q
Between what layers is a SAH and what is the space called?
A
Pia mater and Arachnoid
Subarachnoid space
2
Q
What are the two broad causes of SAH? Give some specifics.
A
Traumatic - eg RTA (may be other cranial bleeds as well)
Spontaneous - Rupture of cerebral aneurysm, AV malformation, Vasculitis
3
Q
Give two modifiable and non modifiable risk factors for Subarachnoid Haemorrhage
A
Modifiable - Hypertension, Smoking, excess alcohol, cocaine use
Non Modifiable - Female, FHx
4
Q
What are some conditions associated with SAH?
A
- Cocaine use
- Sickle cell anaemia
- Connective tissue disorders such as Marfan syndrome, Ehlers-Danlos
- Neurofibromatosis
- ADPKD
5
Q
What patients are SAH common in?
A
Black patients
Female patients
Age 45-70
6
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
7
Q
Name symptoms of Subarachnoid Haemorrhage
A
Thunderclap Headache
Photophobia
Neck Stiffness
Nausea and Vomiting
Vision changes
Neurological symptoms (speech changes, weakness, seizures, LOC)
8
Q
Name four signs of Subarachnoid Haemorrhage
A
Neck Stiffness
Cranial Nerve Palsy
Reduced Consciousness
Diplopia
9
Q
What is the first line investigation for SAH and what will be seen?
A
CT Head (if within 6h - 99% sensitivity)
Blood will cause hyperattenuation in sub arach space
10
Q
When should an LP be done for SAH? What would be a negative LP?
A
After ≥12 hours after symptom onset if CT is non-diagnostic and there is a high index of suspicion
must rule out raised intracranial pressure first
If clear or if Oxyhaemaglobin alone (suggests trauma or traumatic tap)
11
Q
Name four findings you would expect from a positive Lumbar Puncture for SAH
A
- Opening Pressure (elevated)
- Red Cell Count (elevated)
- Xanthochromia (seen after 12 hours)
- Bilirubin
12
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)
Also can locate source of bleeding
13
Q
Name some medical managements of SAH
A
- IV fluids and monitoring
- GCS<8 requires intubation
- Nimodipine to prevent vasospasm (4 hours for 3 weeks)
- Analgesia and Antiemetics to prevent ValSalva
- Antiepileptics to treat seizures
14
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)
15
Q
Name three possible surgical managements of SAH
A
Coiling
Clipping
External Ventricular Drain (if Hydrocephalus)
16
Q
Name three complications of SAH
A
Rebleeding
Vasospasm
Hydrocephalus
17
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)
18
Q
Strokes can be either Ischaemic or Haemorrhagic. How can Ischaemic strokes be classified?
A
By the Bamford/Oxford Classification
TACS, PACS, LAC, POC
19
Q
Strokes can be either Ischaemic or Haemorrhagic. How can Haemorrhagic strokes be classified?
A
Intracerebral or Subarachnoid
20
Q
Describe the pathophysiology of an Ischaemic Stroke
A
Either due to Thrombosis, Embolism or Dissection
21
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)
22
Q
Describe the TAC classification of Ischaemic Stroke
A
Unilateral Sensory/Motor Weakness
Homonymous Hemianopia
Higher Cerebral Dysfunction
Requires 3/3
23
Q
Describe the PAC classification of Ischaemic Stroke
A
Unilateral Sensory/Motor Weakness
Homonymous Hemianopia
Higher Cerebral Dysfunction
Requires 2/3
24
Q
Describe the LAC classification of Ischaemic Stroke
A
Can be:
Pure Sensory, Pure Motor, Sensorimotor, Ataxic
25
Describe the POC classification of Ischaemic Stroke
One of the following:
Brainstem Cerebellar Syndrome
Conjugate Eye Movement Disorder
Isolated Homonymous Hemianopia
Bilateral Sensorimotor Loss
Cranial Nerve Palsy and Contralateral Sensory/Motor
26
Name two Posterior Stroke Syndromes
Locked In Syndrome - Basilar Artery
Wallenberg Syndrome - Posteroinferior Cerebellar Artery (Nystagmus, Vertigo, Horners, Diplopia, Dysphagia)
27
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
28
Name 5 investigations for a suspected stroke
CT head
ECG
Echo
Bloods
Carotid Doppler
29
How is a Haemorrhagic Stroke Managed?
Depends on the extent of the bleed and suitability for intervention
Large bleeds - decompressive hemicraniotomy or suboccipital craniotomy
30
How is an Ischaemic Stroke managed ideally?
Thrombolysis with Alteplase (synthetic tPA)
If within 4.5 hours and NIHSS is between 5 and 26
31
Name three contraindications to Thrombolysis
Ischaemic stroke within the past 3 months
Active Bleeding
Intracranial Neoplasm
Previous Haemorrhagic Stroke
32
If Thrombolysis is contraindicated in terms of Ischaemic Stroke management, what is the next line?
300mg Asparin for 2w followed by 75mg Clopidogrel lifelong
33
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
34
Name two early and two late complications of Stroke
Early - Haemorrhagic transformation, Cerebral Oedema (eg Malignant MCA)
Late - Mobility and Sensory Issues, Fatigue
35
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
36
Other than the medical team, name three professions involved in Post Stroke care
SALT
Phsyiotherapists
Palliative care
37
What are some causes of Raised Intracranial Pressure?
* Neoplasms
* Abscess
* Haemorrhage
* CSF disturbance - hydrocephalus
* IIH
* Meningitis
* Cerebral oedema
38
What are the normal ranges for intracranial pressure
* Adults - **1-15mmHg**
* Children - **5-7mmHg**
* Term infants - **1.5-6mmHg**
* **general rule = \>20mmHg** is raised
39
What is Cushing's triad/reflex/response?
**HYPERTENSION** - increased MAP to maintain cerebral perfusion pressure
**BRADYCARDIA** - increased MAP detected by baroreceptors which stimulate bradycardia via increased vagal activity
**APNEA** - compression of brainstem damages respiratory centres
40
Raised ICP is initially compensated by shunting blood and CSF out. When it begins to decompensate, what are the symptoms?
Classic Triad - **Headache**, **Papilloedema**, **Vomiting** (projectile)
Pupillary changes, third nerve palsies, hypertension, bradycardia,
41
What features of a headache are suspicious of raised intracranial pressure?
* Constant
* Worse in morning
* Worse on bending/straining
42
Name three investigations for raised ICP
```
CT/MRI
Bloods (renal function, electrolytes, osmolality)
ICP monitoring (only if abnormal scan or low GCS)
```
43
First line managements for raised ICP
* Airway and breathing
* maintain sats
* Circulation
* maintain MAP and therefore CPP
* Sedation, analgesia, paralysis
* decreases metabolic demand
* prevents cough, shivering (may increase ICP)
* Head tilt
* improves cerebral venous drainage
* Temperature
* prevent hyperthermia
* may by therapeutic hypothermia
* Anticonvulsants
* prevent seizures, reduce metabolic demand
* Nutrition and PPI
* improve healing and prevent stomach ulcer from increased vagal activity
* Mannitol or hypertonic saline - osmotic diuresis
44
Name three second line managements of raised ICP
Barbiturate Coma
Hypothermia
Decompressive Hemicraniectomy
45
What is the 'Traditional' definition of Status Epilepticus?
Single Seizure lasting over 30 minutes, or two seizures in succession without recovery in between
46
What is the 'Practical' definition of Status Epilepticus?
Single Seizure lasting over 5 minutes or recurrent seizures without recovery
47
What are the three broad classifications of Seizures?
Focal
Generalised (both hemispheres)
Unknown
48
What are the subclassifications of Focal Seizures?
Can be aware or impaired awareness
Sensory or motor depending on first presenting symptom
49
What are the subclassifications of General Seizures?
Tonic Clonic
Tonic
Myoclonic
Atonic
Absence
50
Name four prehospital managments for Status Epilepticus
Note Time
Turn on side and cushion head
Don't restrain
Buccal Midazolam/Rectal Diazepam if available
51
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
52
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
53
How is refractory Status Epilepticus managed?
ITU for General Anaesthesia with Thiopentone
54
Name three complications of Status Epilepticus
Hyperthermia
Arrhythmia
Long term Neuro Damage
55
How should suspected Meningococcal Sepsis be managed in the community?
IM Benzyl Penicillin
56
What is the first line management for Meningitis at UHL?
IV Ceftriaxone (Meropenem if PA) and Dexamethasone (unless immunosupressed)
Notify PHE
57
What is the first line management for Meningitis at UHL if over 60/immunocompromised?
Ceftriaxone + Amoxicillin + Dexamethasone
58
Who requires PEP for Meningitis?
If prolonged contact with affected in the last 7 days
Single dose Ciprofloxacin
59
What is GCA?
Sight threatening vasculitis characterised by inflammation of medium and large sized arteries
Preferential involvement of temporal/opthalmic/occipital
60
Describe the pathophysiology of GCA
Granulomatous inflammation, vessel wall damage and release of angiogenic factors leads to narrowing and ischaemia
61
Name four symptoms of GCA
Unilateral Temporal Headache
Scalp Pain
Jaw Claudication
Visual Blurring
62
Name four signs of GCA
Abnormal Temporal Artery (thickened, tender)
Scalp Tenderness
Transient/Permanent Visual Loss
Optic Disc Changes (pale and swollen)
63
How is GCA diagnosed?
3/5 of
Age\>50
New Headache
Temporal Artery Abnormality
Elevated ESR
Abnormal Biopsy
64
Name four investigations for GCA
ESR/CRP
Temporal Artery Biopsy
Duplex USS (halo occlusions and stenosis)
Opthalmological assessment
65
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
66
Name three complications of GCA
Visual Loss
Arterial Aneurysm
Arterial DIssection
67
Name 5 causes of Spinal Cord Injury
Trauma
Tumours
Prolapsed Disc
Haematoma
Inflammatory DIsease
68
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
69
How does a Spinal Cord Injury present?
Cervical Spine - Quadraplegia
Thoracic Spine - Paraplegia
Root pain in legs
May have loss of autonomic activity
70
What is Spinal Shock?
Physiological loss/depression of function lasting hours to weeks
Flaccid areflexia and paralysis before becoming hypertonic
71
What is Neurogenic Shock?
Damage to descending motor pathways resulting in loss of vasomotor tone and cardiac innervation
72
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)
73
Name five signs of a LMN lesion
Weakness
Wasting
Hypotonia
Areflexia
Fasciculations
74
Name four signs of an UMN lesion
Weakness
Hypertonia
Hyperreflexia
Upgoing plantars
75
What is Central Cord Syndrome?
Central Cord Compression and oedema resulting in more upper limb weakness than lower
76
What is Anterior Cord Syndrome?
Damage to spinal artery, lower limbs affected more than upper
77
How is Spinal Cord Injury Investigated?
Spine MRI
U and Es
Hb and Haematocrit
78
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
79
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
80
How can Cauda Equina be investigated?
Normally diagnosed from a good examination and history
MRI (40% show no abnormalities)
Urodynamic Studies (post surgery)
81
Name two differentials for Cauda Equina
Conus Medullaris Syndrome (less prominent pain, more urinary retention and constipation)
Mechanical Back Pain
82
How is Cauda Equina managed?
Urgent Surgical Decompression
Treat underlying cause
83
What is Cerebral Perfusion Pressure?
The available blood for brain tissue
CPP = MAP - ICP
Aim for \>90
84
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
85
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)
86
Describe a Tonsilar Herniation
Cerebral Tonsils pushed through Foramen Magnum, compressing brainstem
87
Name 5 worrying features following a Head Injury
Vomiting
Reduced GCS
Confusion
Signs of a Basal Skull Fracture
Cushings triad
88
What are the three branches of GCS?
Eye Opening
Verbal Response
Motor
Best response out of each side is used
89
Describe the scoring of Eye Opening with GCS
4 - Spontaneously
3 - To Voice
2 - To Pain
1 - None
90
Describe the scoring of Verbal Response with GCS
5 - Conversation
4 - Confused
3 - Words
2 - Sounds
1 - None
91
Describe the scoring of Motor Response with GCS
6 - Obeys Commands
5 - Localises
4 - Withdraws
3 - Flexes
2 - Extends
1 - None
92
Name four indicaions for Head CT post Head Injury according to NICE
GCS\<13 initially
Suspected Skull #
Focal Neurological Signs
\>1 episode of vomiting
93
Describe the severity of Head Injury in terms of GCS
Mild (13-15)
Mod (9-12)
Severe (3-8)
94
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
95
What is a Bulbar Palsy
Features as a result of diseases affecting the lower cranial nerves (VII - XII)
96
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
97
Name four presenting features of Bulbar Palsies
Weak and wasted tongue
Drooling
Absent palatal movements
Dysphonia
98
Name five causes of Bulbar Palsy
Diptheria
Poliomyelitis
MND
Syringobulbia
Guillaine Barre Syndrome
99
What is Pseudobulbar Palsy?
Disease of the corticobulbar tracts causing an UMN lesion
May have UMN signs in limbs
100
Name three causes of Pseudobulbar Palsy
MS
Internal Capsule Infarcts
Neurosyhphilis
101
How is Bulbar Palsy investigated?
Speech Assessment (Electromagnetic Articulography)
Routine Bloods
CT/MRI
102
How is Bulbar Palsy Managed?
Admission if dysphagia
Treat underling cause
Anticholinergics for drooling
Baclofen for Spasticity
103
Name four diseases affecting the NMJ and causing Respiratory Distress
Lambert Eaton
Myasthenia Gravis
Clostrodium Botulinim
Organophosphates
104
Name four diseases affecting the Muscle and causing Respiratory Distress
MND
Acid Maltase Deficiency
Electrolyte Disturbance (hypokalaemia)
Polymyositits
105
Name one diseases affecting the nerves and causing Respiratory Distress
Guillaine Barre Syndrome
