Headache and stroke Flashcards
What score is used to determine the severity of stroke?
NIHSS
Differentials for weakness - i.e. stroke mimics
Stroke/TIA Seizure Sepsis Toxic/metabolic Space occupying lesion Syncope
How to clinically differentiate between stoke and seizure?
Seizure will be postical and drowsy
What is the most important investigation
CT Head
White - haemorrhage
Dark - ischaemia - unlikely to see new infarct
Describe the Bamford Classification
TACS:
All three
1. Unilateral weakness (and/or sensory deficit) of face, arm, legs.
2. Homonymous hemianopia
3.. Higher cerebral cerebral dysfunction (dysphasia, visuospatial disorder)
PACS:
Two of:
1. Unilateral weakness (and/or sensory deficit) of face, arm, legs.
2. Homonymous hemianopia
3.. Higher cerebral cerebral dysfunction (dysphasia, visuospatial disorder)
POC: One of 1. Cerebellar or brainstem syndromes 2. LOC 3. Isolated homonymous hemianopia
LACS:
Subcortical stroke due to small vessel disorder. No evidence higher cerebral dysfunction
One of
Unilateral weakness (and/or sensory) of face and arm, arm and leg or all three.
Pure sensory stroke
Ataxic hemiparesis
Describe blood supply to brian
- Internal carotid → anterior circulation
* Veterbral artery → posterior circulation
Mgmt of acute ischaemic stroke
ABCDE
Thrombolysis - 4.5 hrs and not CI
or
Aspirin 300mg 14 days
Bloods: FBC, U&Es, coagulation, HbA1c and cholesterol
How to manage BP - how dif in iscahemic and haem strokes
BP < 180 for ischaemic
BP < 140 for haemorrhagic
Oral/BG amlodipine or labetolol infusions
Causes of haemorrhagic stroke
HTN (majority!!)
Aneurysms/ AV malformation
Anticoagulation
Recreational drugs
Causes ischaemic stroke
AF - emboli
Atherosclerosis
Dissection - young person for message
What medications to give - embolic (AF) vs thrombotic
Embolic: NOAC/warfarin
Thrombotic: Clopidogrel 75mg
Why do you NOT give LMWH in the acute mgmt of ischaemic or haemorrhagic stroke?
Risk of haemorrhagic tranformation
Long term Ischaemic stroke mgmt
admit to stroke ward
Clop/NOAC/warfarin (unless ↑ hasbleed) Atorvastatin 80mg IPC stocking - as use LMWH SALT PHYSIO
What next investigation of choice 24 hours?
Diffuse weighted MRI head
Common complication
Aspiration pneumonia
Seizures (15%)
Depression, anxiety, pseudobulbar effect
DVTs
After 24 hours in anterior stroke
- ECHO
- Carotid doppler if anterior circulation
- Consider 24 hour tape if AF
CT criteria
GCS < 13 on injury < 15 2 hours after admission Open or depressed skull fracture Basal skull fracture post-tramutic seizure Focal neurological deficit > 1 episode vomiting
Describe Extradural haem Where and how? Presentation? Mortality What type of person How does the CT criteria help you?
Head injury + LOC
‘Lucid internal’ → pt degeriates
30% mortality
Acute (60%), subacute (30%), Chronic (10%)
Temopral or parietal bone fracture → damages meningeal artery
Less common in small children and ppl > 60 years.
Blood between dura mata and skill
→ think about cervical spine
→ the associated symptoms can be any of the CT criteria
Mgmt extradural
Complications?
- ABCDE + imaging
- Reverse coagulopathy + cushing’s response
- Small → asymptomatic - regular obs + scans
- Surgery: focal signs, large, ↑ICP, midline shift
Surgery - emergency craniotomy or clot evacuation
Complications: Death - cerebellar herniation ↑ ICP cerebral oedema Seizures Permanent neurological or cognitive deficit due to pressure effects on brian coma
Subdural haematoma
Aetiology and cause :
Time courses:
Tearing of bridging veins in subdural space
• Blunt trauma (most common)
• Spontaneously
Acute, subacute (3-7 days), chronic (2-3 weeks) Blunt trauma (most common)
Which high risk group
Infants - physical abuse
elderly - cerebral atrophy causes tension on veins. Consider anticoagulation
Alcoholics - RF for thrombocytopenia, ↑bleeding time, ↑head injury, cerebral atrophy
Mgmt and complications for subdural
Same as extradural
Subarachnoid Causes Mean age Risk factors Associated disorder
Berry aneurysm otherwise traumatic brain injury
Mean 50 years
RF: HTN, cocaine, smoking, alcohol XS
associated: Ehlers-danlos, NFM1
CF
Sudden onset headache
Pulses to occiput
Ass vomiting, seizure delirum
Neck stiffness → late sign
What do 10-15% experience before the SAH
Common CF
Sentinel bleeds - small bleed or expansion of aneurysm
Headache, dizzy, orbital pain, diplopia, vision loss, ↓consciousness
Inv
CT without contrast - positive in 95% - do ASAP
LP at 12 hours for xanthachromia
MGMT
- CT angiography - find bleeding site
- start nimodipine (prevent vasospasm)
- Surgical Tx - endovascular embolisation or surgical clipping
Comps → the same as other bleeds
Red flags for headache
What headaches do you always wanna rule out
Worsening of headache Sudden-onset reaching max intensity in 5 mine New neurological deficit New onset cognitive deficit change in personality ↑ consciousness Head trauma painful or red eye - acute angle glaucoma ↓ vision - temporal arteritis jaw claudication vomiting
• Bleeds, giant cell arteritis, acute angle glaucoma, meningitis/encephaltiis
Things in the pmhx to son cider
↓ immunity
cancer Hx
Giant cell arteritis
- Typically patient
- CF
- Investigation
60 , europeans
recent onset temporal headache, myalgia, malaise fever, jaw claudication
+- systemic symptoms = fever, anorexia, wt loss, sweats, malaise, temporal artery maybe prominent, tender and pulseless
Bloods: ESR + anaemia
Biopsy → shows vasculitis
Tx for giant cell
40mg prednisaoline (60mg if claudication present)
IV methylpred if vision loss
75mg aspirin + PPI
Complication
Loss of vision
Aneurysm, dissection and stenosis of the aorta due to vasculitis
Steroid related complications → osteoporosis + cushing’s
Acute closure glaucoma
What is it?
RF?
CF?
Obstruction of anterior chamber angle (lens catches on cornea) → ↑ pressure in anterior chamber
RF: ↓ Age (lens grows with age), genetics, hyperopia (long-sightedness)
CF • Pain (severe and rapid progressive) • blurred vision, visual loss • Coloured haloes • Systemic malaise (N+V)
3 most common primary headaches
Migrane
Tension
Cluster
What is the most common recurring headache - describe it
How many do you have to have a month for it to be considered chronic
Tx
Tension headache, bilateral, feels tight, not aggravated by routine activities.
- episodic <15 days a month,
- chronic > 15 a month
Tx: headache diary, ensure not medication induced or associated with depression analgesia
Migrane Features Tiggers Mgmt - when to give prophylaxis
• unilateral, pulsating, moderate-severe, aggravated by routine activities, sensitive to light/sound +- vomiting
Trigger: choco, wine, alcohol, exercise, COCP
Prophylaxis if 2/3 attacks producing disability for 3+ days
1) BB +-Amitryptalline - if associated with pain, depression or insomnia
2) Topiramate or sodium valoprate
3) Pitozifen
Acute - NSAIDS + antiemetics → if these fail triptans
Cluster headache CF When do these typically occur? Triggers? How many must you have for a diagnosis? Tx?
Unilateral, sharp, burning, severe, restless, red/watery eye, nasal congestion, swollen eyelid
Occur at night, 1-2 hour after falling asleep
Lasts for 45-90 mins
trigger alcohol, heat, exercise, sleep deprivation
Must have 5 for diagnosis.
Episodic (7D in 1 year)
Chronic (1 year or more with remission < 1 month)
Tx actually with triptans and oxygen
Most common presentation of metastasis
Seizure
What is a UBO
unidentified bright object associated with migrant
What is the cushing’s triad
Response to ↑ICP - ↑BP, irregular, ↓HR
