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Neurology, Opthalmology and ENT Core Conditions > Ischemic/Hemorrhagic stroke, TIA, Bells Palsy, Ramsay Hunt > Flashcards

Ischemic/Hemorrhagic stroke, TIA, Bells Palsy, Ramsay Hunt Flashcards

1
Q

Stroke
-subtypes

A

Sudden interruption of blood supply in brain
Ischemic (85%)
-thrombosis of large vessels (carotid)
-embolic from clot/fat/air/septic

Haemorrhagic (15%)
-intracerebral
-subarachnoid

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2
Q

Risk factors for stroke and TIA
-ischemic
-hemorrhagic

A

General
-HTN
-age
-hypercoagulability - APS, migraine with aura, postpartum, sickle cell

Ischemic
-smoking
-hyperlipidemia, carotid artery disease
-DM
-AF, infective endocarditis

Hemorrhagic
-AVM
-ADOKD
-AC

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3
Q

Symptoms of stroke

A

ACUTE SUDDEN FOCAL NEURO LOSS
-unilateral weakness/paraesthesia in face, arm, leg
-dysarthria, expressive/receptive dysphasia
-vision problems
-headache (sudden, severe, unusual)
-ataxia
-vertigo/loss of balance

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4
Q

Symptoms of stroke mimics

A

Neuro symptoms that are gradual in onset, progressive, migratory
-POSITIVE neurological symptoms (flashing lights, tingling, jerking, shaking limbs)
-cognitive impairment
-resp, abdominal or other abnormal signs

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5
Q

Stroke and TIA mimics

A

Migraine with aura - positive marching in minutes

Epilepsy - focal, acute, positive sensorimotor spread in minutes.
Stereotypic attacks

TGA - short term acute anteroretrograde amnesia, resolves in hours

Bells palsy

Facial palsy

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6
Q

Facial palsy/Bells palsy
-presentation
-how does this differ from a stroke

A

Weakness/paralysis of facial muscles

Forehead sparing in UMN/stroke
Forehead not spared in facial palsy

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7
Q

Bells palsy
-presentation
-investigations
-management

A

Idiopathic, but related to recent viral infections/stress

Painless unilateral LMN facial weakness, in hours
-cannot close eyes or cry
-increased sensitivity to sound
-metallic taste

Clinical diagnosis
-serology to rule out RHS

Supportive eye care - eye pathc, lubricating drops
Medical - PO steroids within 72hrs + antivirals
Surgical if no change or not Bells

If no change within 3wks => urgent neuro referral

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8
Q

Ramsay Hunt Syndrome
-pathophysiology
-presentation
-investigations
-management

A

Reactivitation of HZV

Ear pain => facial palsy, ipsilateral vertigo, increased sensitivity to sound, blisters on VII region

Clinical diagnosis

Medical - PO pred (5 days) + aciclovir (7 days)

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9
Q

Stroke patterns - Anterior cerebral artery

A

CL M+S loss
L limbs > U limbs

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10
Q

Stroke patterns - Middle cerebral artery

A

CL M+S loss
U limb > L limbs

CL HH
Aphasia if dominant hemisphere affected
Spatial neglect if non dominant hemisphere affected

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11
Q

Stroke patterns - Posterior cerebral artery

A

CL HH with macular sparing
Visual agnosia

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12
Q

Stroke patterns - Branches of PCA that supply midbrain

A

Weber’s syndrome

IL CN3 palsy
CL UL, LL weakness

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13
Q

Stroke patterns - Posterior inferior cerebellar artery

A

Lateral medullary syndrome
Wallenburg syndrome

Spinothalamic - temp/pain loss
IL facial
CL limb/torso

Ataxia, nystagmus

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14
Q

Stroke patterns - Anterior inferior cerebellar artery

A

Lateral pontine syndrome

Spinothalamic - temp/pain loss
IL facial
CL limb/torso

IL FACIAL PARALYSIS and DEAFNESS

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15
Q

Stroke patterns - retinal artery

A

Amaurosis fugax

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16
Q

Stroke patterns - basilar artery

A

Locked in syndrome

17
Q

Difference between TIA and stroke

A

TIA - brief neurological deficit due to focal brain, spinal cord, retinal ischemia without acute infarction

Stroke - acute infarction of focal, brain, spinal cord, retinal ischemia => neurological deficit

18
Q

Management of suspected ischemic stroke
-secondary management

A

Carotid endarterectomy if
-stroke/TIA in carotid region and not severely disabled
-stenosis 50 or 70%+ depending on criteria used

19
Q

Presentation of hemorrhagic strokes (SAH)

A

Thunderclap occipital headache
-peak severe pain almost instantly
-may be history of less severe headaches leading up to presentation

N+V

Meningism - photophobia, neck stiffness

Seizures

May have ST elevation on ECG
-from autonomic neural stimulation from hypothalamus/elevated levels of circulating catecholamines

20
Q

TIA
-what is it

A

Transient neurological deficit caused by focal cerebral ischemia without CT evidence of infarction

Symptoms last U24hrs, bit similar to stroke

21
Q

Bamford and Oxford classification of strokes
POCS

A

Posterior circulation infarct - cerebellum and brainstem

-homonymous hemianopia
-dizzy
-drowsy
-dysarthria
-diplopia
-dysphagia

22
Q

Bamford and Oxford classification of strokes
TACS vs PACS

A

Total anterior circulation infarct - ACA + MCA

INVOLVEMENT OF WEAKNESS/SENSORY LOSS + VISION + SPEECH

All 3 of
-unilateral weakness/sensory deficit of face, arm, leg
-homonymous hemianopia
-higher cerebral dysfunction (aphasia or spatial neglect)

PACS - smaller arteries of anterior circulation involved

2 of the 3 criteria from above

23
Q

Bamford and Oxford classification of strokes
Lacunar

A

Lacunar infarct - no loss of higher cerebral function

1 of
-pure sensory
-pure motor
-sensorimotor
-ataxic hemiparesis

24
Q

Stroke differentials
-acute
-chronic

A

Acute
-seizure
-migraine + aura
-peripheral neuropathy - Bells
-trauma
-hypoglycemia, hypoxia
-syncope
-meningitis, encephalitis, vasculitis
-delirium
-drug, alcohol, Wernicke’s

Chronic
-tumour
-subdural
-asbcess

25
Q

Initial investigations for suspected stroke or TIA

A

History
Clinical examination
-neuro
-cardiovascular
-RULE OUT HYPOXIA AND HYPOGLYCEMIA

Quick screening tools
-FAST
-ROSIER

Suspect stroke if
-sudden onset focal neurological deficit, ongoing/persisted for longer than 24hrs

Suspect TIA if
-sudden onset neurological deficit has resolved within 24hrs

Blood glucose
ECG - AF?
CT HEAD TO ASSESS FOR HEMORRHAGE

26
Q

Managament of ischemic stroke
-immediate
-secondary prevention

A

A-E stabilisation
ASPIRIN 300mg for 2 weeks

Non contrast CT head
-may not see anything
-may have hypodense tissue + (hyperdense artery sign from clot)

U4.5hrs since onset - alteplase thrombolysis

U6hrs since onset - mechanical thrombectomy for proximal anterior circulation
-can use with thrombolysis if applicable

6-24hrs => thrombectomy if there is potential to salvage brain tissue
-Yes = proximal anterior circ
-Maybe = proximal posterior circ

2 week follow up
1st line - long term clopidogrel 75mg + PPI
2nd line - aspirin 75mg + MR dipyridamole 200mg BD
3rd line - aspirin 75mg OD
4th line - MR dipyridamole 200mg BD

Lifestyle changes
-smoking cessation
-reduce alcohol
-increase physical activity
-diet modification

27
Q

Management of hemorrhagic stroke

A

STOP AC, AP
Rapid reduction in high BP => target 130-140 within 1 hour of treatment, maintain for 7 days

UNLESS
-underlying structural cause - tumour, AVM, aneurysm
-GCS U6
-early neurosurgery to evacuate hematoma
-massive hematoma with poor prognosis

Surgery
SAH - coil, craniectomy and clipping
ICH - craniotomy/craniectomy with evacuation of hematoma

Hydrocephalus - temporary ext ventricular drain or long term ventriculoperitoneal shunt
LowNa from SIADH
Seizures

28
Q

Investigations and management
-subarachnoid hemorrhages

A

Non contrast CT head immediately to assess for ischemic or haemorrhagic
If U6hrs + normal => alt diagnosis
If 6hrs+ + normal => LP at least 12hrs from onset
-xanthochromia = identify true SAH from traumatic tap
-normal/high opening pressure

Evidence of hemorrhagic stroke
-hyperdense blood surrounded by hypodense edema
=> NEUROSURGERY REFERRAL and CT intracranial angio to identify cause

Fluid resuscitation
PO nimodipine => prevent vasospasm
Reduce BP!

29
Q

Management of TIA
-initial
-ongoing

A

Referrals
-Current => emergency admission, imaging to exclude hemorrhagic
-Multiple TIAs => discuss admission with stroke specialist
-Within week => assessment within 24hrs
-More than 1 week => assessment within the week

Immediate
300mg aspirin unless
-has bleeding disorder or on AC/AP => immediate admission for imaging to exclude haemorrhage
-can’t take aspirin
-TIA caused by AF => take DOAC/warfarin

Imaging - MRI
-determine ischemic area/hemorrhage

Aspirin for 2 weeks => clopidogrel 75mg
Statin 40mg
Lifestyle modification

Do not drive until driving advice given by specialist team

Carotid doppler - if candidate for carotid endarterectomy (stenosis 70%+)

If U55
-thrombophilia and AI screening (ANA, APL. ACL, LA)
-coagulation factors
-ESR
-homocysteine
-syphilis

Neurology, Opthalmology and ENT Core Conditions (22 decks)

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