MedEd acute neuro Flashcards
what is a stroke?
a sudden onset, focal neurological deficit of vascular origin lasting more then 24 hrs
what are the 2 types of stroke and how do they differ?
ischaemic- due to vascular occlusion or stenosis
haemorrhagic- due to vascular rupture
what type of stroke is more common?
ischaemic
what are the 2 types of ischaemic stroke and how do they differ?
thrombotic= atherosclerotic plaque formation embolic= blood clot from elsewhere
what is the difference between a thrombus and an embolus?
thrombus= blood clot that forms in a vein embolus= blood clot from elsewhere that travels until it reaches a smaller vessel and becomes lodged in it
what are rf for stroke?
hypertension old age diabetes hyperlipidaemia/ hypercholesterolaemia smoking obesity
what are signs and symptoms of a stroke?
acute onset facial and limb weakness slurring of speech loss of coordination and balance dizziness depends on what area of the brain is affected
what is the difference between aphasia and apraxia?
aphasia= impaired ability to use or comprehend words apraxia= difficulty initiating and executing the voluntary movements needed to speak despite lack of paralysis to speech muscles
define aphasia?
inability to use or comprehend words- language problem
define apraxia?
difficulty initiating and executing the voluntary movements needed to produce speech- speech problem
out of deficits in brocas and wernicke’s area what causes aphasia and what causes apraxia?
brocas region deficit causes apraxia
wernickes region deficit causes aphasia
what parts of the brain does the anterior cerebral artery supply?
medial and superior frontal lobe
anterior parietal lobe
what are associated signs of an anterior cerebral artery stroke?
contralateral hemiparesis- more the legs than the arms and face
behavioural changes
if someone has contralateral hemiparesis (more so in the legs than the face/arms) and behavioural changes after a stroke what artery is it likely to have been in?
anterior cerebral artery
what does the middle cerebral artery supply?
lateral parts of the frontal, temporal and parietal lobes
what are associated symptoms for a stroke of the middle cerebral artery?
contralateral hemiparesis more so of the face and arms than the legs aphasia apraxia contralateral hemisensory loss quadrantopia
if someone has contralateral hemiparesis (more face/arms than legs), contralateral hemisensory loss, aphasia, apraxia, and a quadrantopia after a stroke what is the most likely artery affected?
middle cerebral artery
if contralateral hemiparesis is more significant in the face/arms than the legs and vice versa after a stroke what arteries were affected?
more in the face/arms than the legs= middle cerebral artery
more in the legs than in the arms/face= anterior cerebral artery
a lesion where will cause a contralateral homonymous inferior quadrantopia?
parietal upper optic radiation
a lesion where will cause a contralateral homonymous superior quadrantopia?
temporal lower optic radiation
what does the posterior cerebral artery supply?
occipital lobe
inferior temporal lobe
what are associated signs of a posterior cerebral artery stroke?
contralateral homonymous hemianopia
agnosia (inability to recognise familiar faces and objects)
if someone has a contralateral homonymous hemianopia and agnosia post stroke what artery is likely affected?
posterior cerebral artery
how can you distinguish cerebellar lesions from other strokes?
they give ipsilateral signs whereas other stroke signs are contralateral signs
what acronym is used to remember cerebellar signs and what does it stand for?
DANISH: dysdiadochokinesia ataxia nystagmus intention tremor slurred speech hypotonia
where is damage in a posterior circulation stroke?
in the brainstem
what is the difference between a posterior circulation and posterior cerebral artery stroke?
posterior circulation stroke= damage in brainstem= cerebellar DANISH signs
posterior artery stroke= lesion in posterior cerebellar artery supplying occipital lobe and inferior temporal lobe= contralateral homonymous hemianopia, agnosia
what ix are done for stroke, why and what is GS?
GS: urgent non contrast CT head within 1 hr to see if its ischaemic (dark area of old blood) or haemorrhagic (white area of fresh blood)
glucose- hypoglycaemia can mimic stroke
UEs- hyponatraemia
cardiac enzymes- troponin etc to rule out MI alongside stroke
FBC- check for thrombocytopenia prior to possible initiation of thrombolysis/anticoagulants
what ix must be done immediately in stroke and within how long?
non contrast head CT
must be done within an hr
does normal CT rule out ischaemic stroke?
NO
what score can be used in stroke when someone is waiting and what does it calculate?
rosier score while the CT is being arranged= risk of stroke in the emergency room
how is ischaemic stroke managed? give names and doses of drugs
always rule out haemorrhagic stroke with non contrast head CT first
if they present within 4.5 hrs- thrombolysis with IV alteplase (or r-TPA second line) then 300mg aspirin
if they present after 4.5 hrs- 300mg aspirin
what are contraindications for thrombolysis in stroke patients?
presentation after 4.5 hrs
haemorrhagic stroke
other haemorrhage eg subarachnoid
prolonged PT, APTT, high INR
what is done in a stroke unit?
swallow assess
early mobilisation and rehabilitation
VTE prophylaxis
MDT approach with lots of staff involved
how is secondary antiplatelet prevention of a stroke done in patients with AF?
warfarin prophylaxis
how is secondary antiplatelet prevention of a stroke done in non AF patients?
75mg aspirin for 2 weeks
lifelong clopidogrel 75mg daily
what is the difference between antiplatelet stroke prophylaxis in AF vs non AF patients?
AF= warfarin
non AF= 75mg aspirin for 2 weeks then lifelong 75mg clopidogrel daily
how is haemorrhagic stroke managed?
refer to neurosurgery for evaluation
they will either do surgery or put them in ITU for monitoring and support
discontinue anticoagulant medications and do not give aspirin or other thrombolysis
what score must be used when someone has a TIA and what does it calculate
ABCD2 score, it used to estimate risk of stroke in someone with a TIA
how is ABCD2 score interpreted?
if the score is 4 or over refer them to a stroke specialist
if the score is 6 or over there is an 8% risk of stroke in 2 days and 35.5% risk of stroke in a week
how is a TIA managed when it presents?
if suspected 300mg aspirin STAT
if presenting within 7 days of episode specialist review in 24 hrs
is presenting after 7 days of episode specialist review in 7 days
how is secondary prevention carried out after TIA?
75 mg clopi OD
high intensity statin eg atorvastatin OD
antihypertensive if BP needs to be controlled
what 3 medications and doses are given for secondary prevention after TIA?
75 mg clopi OD
atorvastatin OD
antihypertensive if needed
what are complications of stroke?
aspiration pneumonia
DVT
death
what ix are done in TIA?
only do a non contrast head CT if the patient is known to be taking an anticoagulant or bleeding disorder (to exclude haemorrhagic stroke)
ECG- may reveal AF or MI
bloods- FBC, UEs, clotting profile, cholesterol
what artery is most commonly ruptured in an extradural haemorrhage and why?
middle meningeal artery
this is because extradural haemorrhage is usually due to trauma and the pterion is the weakest point in the skull susceptible to fracture and the middle meningeal artery runs just under it
what artery runs right under the pterion?
middle meningeal artery
what is the sequelae of events in and extradural haemorrhage?
trauma
LOC
lucid interval (where the patient is ok)
rapid deterioration with headache, decreasing mental status and signs of raised ICP developing
what ix is done for extradural haemorrhage? what is seen and how do you remember this?
urgent non contrast head CT- you see a lemon/lenticular white shape on one side with midline shift
might do an MRI
how is extradural haemorrhage managed?
urgent referral to neurosurgery who will do burrholes or craniotomy
what is ruptured in a subdural haemorrhage?
bridging veins
what is the difference between blood in an extradural vs subdural haemorrhage?
extradural= arterial blood subdural= venous blood
what is the difference between an acute, subacute and chronic subdural haemorrhage?
acute= presents after trauma within 72 hrs subacute= presents within 3-20 days chronic= presents after 3 weeks
how long might it take a subdural haemorrhage to present and what do you need to consider?
it can take up to 9 weeks and the patient may have forgotten about the trauma that caused it
in what haemorrhage are bridging veins ruptured?
subdural
in what haemorrhage is the middle meningeal artery ruptured?
extradural
what are rf for subdural haemorrhage?
elderly head trauma falls alcoholics anticoagulation
what are rf for extradural haemorrhage?
trauma
road traffic accidents
young people (under 20/30 yrs)
what will headache in subdural haemorrhage be like?
continuous and gradual
what are signs and symptoms of a subdural haemorrhage?
gradual and constant headache
fluctuating consciousness
confusion
symptoms of raised ICP
what ix is done for subdural haemorrhage and what will you see?
urgent non contrast head you see a banana shape on one side of the head- white if its acute and dark if its chronic
how is subdural haemorrhage managed?
if small (<10mm) and no neuro deficits admit and observe if large (>10mm) or significant neuro deficits burrhole/ craniotomy
what size is a small v large subdural haemorrhage?
small: <10mm
large: >10mm
what ruptures in a subarachnoid haemorrhage?
saccular aneurysm
what are rf for subarachnoid haemorrhage?
polycystic kidney disease alcohol hypertension smoking hypertension
what haemorrhage is polycysctic kidney disease a rf for?
subarachnoid
what are signs and symptoms of subarachnoid haemorrhage?
sudden onset thunderclap headache- worst pain in their life in the occipital region
meningism (neck stiffness, photophobia, headache)
what ix do you do for subarachnoid haemorrhage- include what you might have to do if they present late? what will you see
urgent non contrast head CT- look for hyper attenuation around the circle of willis
if they present after 12 hs specificity is low so do a LP instead and you will see xanthochromic CSF
what is xanthochromic CSF seen in and when?
after 12 hrs in a subarachnoid haemorrhage
what is present in xanthochromic CSF? what does it look like compared to normal haemoglobin
xanthochromia and oxyhaemoglobin
looks more yellow then normal clear CSF
how is subarachnoid haemorrhage mananged?
same as haemorrhagic stroke- refer to neurosurgery who will either ICU and observe or surgery (endovascular coiling or surgical clipping)
give nimodipine to prevent delayed cerebral ischaemia
why is nimodipine given in SAH?
to prevent delayed cerebral ischaemia
how are the different head heamorrhages managed?
extradural= immediate referal to neurosurgery (burrholes and craniotomy) subdural= if small (<10mm) then ITU and observe, if large or significant neuro deficit (>10mm) then immediate neurosurgery referral (burrholes or craniotomy) subarachnoid= medically manage w nimodipine or refer to neurosurgery for endovascular coiling or clipping
what surgery can be done for SAH?
endovasular coiling or clipping
what is epilepsy?
recurrent tendency to have unprovoked seizures
what triggers seizures in epilepsy?
they are unprovoked in nature
triggers can be lack of sleep, flashing lights, stress, alcohol
what is a seizure?
an abnormal paroxysmal discharge of cerebral neurons
out of glutamate aspartate and GABA what is excitatory and what is inhibitory?
glutamate aspartate= excitatory
GABA= inhibitory
in a seizure what happens to the balance between glutamate aspartate and GABA?
glutamate aspartate= upregulated= more excitation
GABA= downregulated= less inhibition
what do you need to ask in an hx if someone has a seizure?
what happened before, during and after specifically
was there a witness
what signs and symptoms might you get before a seizure?
aura- strange feeling in stomach, deja vu, strange smells or tastes, visual disturbance eg zigzag lines
what signs and symptoms might you get during a seizure?
duration under 3 mins
tongue biting
incontinence
jerking movements
what signs and symptoms might you get after a seizure?
slow recovery
post ictal headache
post ictal confusion
post ictal myalgia
in terms of what areas of the brain are involved what are different types of seizures?
localised
generalised
what are the types of localised seizures?
focal seizure with impaired awareness
focal aware seizure
focal seizure with secondary generalisation
what are some characteristics of focal frontal lobe seizures?
motor symptoms eg jacksonian march, post ictal weakness, involuntary actions
what are some characteristics of focal temporal lobe seizures?
aura eg epigastric discomfort
automatisms eg lip smacking, playing with fingers
hallucinations
what are some characteristics of focal parietal lobe seizures?
sensory disturbance eg pain, numbness, tingling
what are some characteristics of focal occipital lobe seizures?
visual distrubance eg spots, lines, flashes
what type of seizures are more common in kids?
absence
what some types of generalised seizure?
myoclonic tonicclonic clonic atonic myoclonic absence
how do you remember which types of seizure are generalised?
anything with ‘tonic’ in + absence seizures
what might be raised on bloods in a seizure?
prolactin
what ix are done for seizures? why
EEG
bloods- check glucose to exlcude hypoglycaemia, UEs to exclude electrolyte abnormalities, prolactin may be raised
how many seizures are needed for a diagnosis of epilepsy and how far apart do they have to be?
at least 2 (or more) seizures 24 hrs
what is seen on EEG in focal vs generalised seizures?
focal= normal activity then craziness in just a few leads generalised= normal activity then craziness in all leads
how are seizures managed?
generalised= lamotrigine or carbamazepine focal= first line sodium valproate second line carbamazepine
NOTE= sodium valproate is teratogenic so avoid in women of child bearing age and give lamotrigine instead
what medications are given for generalised seizures?
carbamazepine
lamotrigine
what medications are given for focal seizures?
first line sodium valproate
second line carbamazepine
what antiepileptic do you give child bearing age women instead of sodium valproate?
lamotrigine
what are general side effects of anti epileptics?
weight gain
psychiatric effects eg anxiety, depression
what are specific side effects of carbamazepine?
neutropenia and osteoporosis
what are specific side effects of lamotrigine?
steven johnsons syndrome- starts with flu then rash develops which is individual blemishes that look like targets (darker in the middle and lighter on the outside) and can be in oral, mucosal and genital membranes
what antiepilaptic causes neutropenia and osteoporosis as a side effect?
carbamazepine
what antiepileptic causes steven johnsons syndrome as a side effect?
lamotrigine
how does steven johnsons syndrome present?
flu like symptoms
followed by a rash appearing which is individual blemishes that look like targets (dark in the middle and light on the outside) on the skin, mucous membranes, genitals etc
what are dissociative seizures? how do you identify them and how are they managed?
seizures that are not epileptic
they usually are prolonged in duration and there may be hx of abuse, psychological or emotional precipitants
management involves psychotherapy
what is status epilepticus?
when a seizure lasts more then 5 mins or there are 2 seizures back to back without recovery or gain of consciousness in between
what are triggers of status epilepticus?
non adherence to medication
alcohol abuse
overdose and drug toxicity
how is status epilepticus managed?
A-E approach
secure the airway and give high flow oxygen
IV lorazepam or PR diazepam, repeat in 10 mins if it doesnt help
IV phenytoin
refer to ITU
how do benzodiazepines work?
they bind to GABA A receptors and increase channel opening frequency. This increases chloride conductance and neuronal hyperpolarisation leading to increased inhibitory neurotransmission
what is SUDEP and how can it be avoided?
sudden unexpected death in epilepsy
get enough sleep, adhere to medication, avoid alcohol, avoid known triggers, train family in first aid, consider night time monitoring if needed
what are epilepsy complications?
SUDEP- sudden unexpected death from epilepsy
fractures from seizures
medication side effects
behavioural problems
what is guillian barre syndrome?
an acute autoimmune demyelination of the peripheral nerves
what often precedes guillian barre syndrome?
gastroenteritis caused by campylobacter jejuni
what organism usually causes gastroenteritis before someone presents with guillian barre syndrome?
campylobacter jejuni
what are signs and symptoms of guillian barre syndrome?
ascending parasthesia and weakness of limbs flaccid paralysis hypotonia symmetrical limb weakness altered sensation/numbness fasciculations
where might guillian barre progress to and cause death? what is it therefore important to do
the respiratory muscles- if they are paralysed
it is important to do spirometry
what is miller fischer syndrome?
triad of opthalmoplegia, areflexia and atonia
NO muscle weakness
it occurs in 25% of people with guillian barre
what is absent in miller fischer syndrome?
muscle weakness
what is the diagnostic definitive ix for guilian barre? what is seen?
nerve conduction studies- reduced conduction (do on arms/hands)
what ix are done for guillian barre? what is seen
nerve conduction studies- reduced conduction is seen
spirometry
lumbar puncture- high protein, normal glucose and WCC
bloods- anti ganglioside antibody in miller fischer variant
what is seen on bloods in miller fischer syndrome?
anti ganglioside antibodies
in what condition are anti ganglioside antibodies seen?
miller fischer syndrome
how is guillian barre syndrome managed?
conservative= respiratory support, DVT prophylaxis medical= IV immunoglobulins (IVIG) or plasma exchange (if theres IgA deficiency or renal failure)
what are causes of spinal cord compression in young vs elderly?
young= more commonly trauma old= cancer, osteoporosis, corticosteroids, disc herniation
what are symptoms of spinal cord compression
UMN signs below level of lesions LMN signs at level of lesion limb weakness (hemiplegia or paraplegia) sensory loss below the lesion back pain constipation urinary retention erectile dysfunction
in spinal cord compression where are UMN symptoms seen?
below the level of the lesion
in spinal cord compression where are LMN symptoms seen?
at the level of the lesion
what are the 3 categories of symptoms seen in spinal cord compression?
motor
autonomic
sensory
what ix are done in spinal cord compression and why? what is GS
GS= MRI spine
may so CT and lateral x rays
bloods= FBC, UEs, calcium, ESR, immunoglobulin electrophoresis to check for multiple myeloma
urine= bence jones proteins if due to multiple myeloma
what are the 2 main ix for multiple myeloma and what is seen?
urine- bence jones proteins
immunoglobulin electrophoresis- one band is seen instead of multiple
what is cauda equina syndrome?
compression of the nerve roots forming the cauda equina
what are symptoms of cauda equina syndrome?
LMN symptoms (hypotonia, hyporeflexia) bilateral sciatica perianal parasthesia leg weakness reduced anal tone bladder retention
what bladder symptom do you get in cauda equina syndrome?
urinary retention
what is radiculopathy?
symptoms that rise due to compression of a nerve at or near its root as it exites the spinal cord
what symptoms do you get in radiculopathy?
LMN symptoms for muscles innervated by this spinal root
Dermatomal pattern of pain and numbness
what are signs and symptoms of sciatica?
pain radiating from buttock down the ipsilateral leg
weakness of calf muscles
how is sciatica diagnosed?
by doing the straight leg test- there will be pain in the distribution of the sciatic nerve when the leg is passively flexed
what is the straight leg test done to diagnose?
sciatica
what is lasegue’s sign?
positive straight leg test
how is spinal cord compression managed?
A-E approach
insert catheter if needed
high dose corticosteroids in malignancy (alongside PPI)
urgent referral to neurosurgery for surgical decompression
how is spinal cord compression managed if due to malignancy?
high dose corticosteroids (alongside PPI)
urgent referral to surgery for surgical decompression
what ix is done for cauda equina syndrome?
MRI spine
how is cauda equina managed?
A-E approach
give analgesia when stable
insert a urinary catheter urgently
refer to neurosurgery for decompression by laminectomy (removal of lamina) or discectomy (removal of intervertebral disc)
what are complications of cauda equina syndrome?
chronic sexual dysfunction
chronic urinary retention or bowel incontinence
paraplegia
what ix are done for sciatica?
urgent MRI spine if neurological deficit present or mass is suspected
lumbosacral spine x ray to evaluate fractures
how is sciatica managed?
conservative= physiotherapy medical= NSAIDs, opioid analgesia, local corticosteroid injections surgical= if there is no improvement in pain after 6-8weeks refer to neurosurgery to assess disc herniation, epidural abscess and tumors etc
what is hydrocephalus?
excessive accumulation of CSF in the brain’s ventricular system
what happens to ICP in hydrocephalus?
it is raised
how is more likely to get hydrocephalus?
young and elderly (bimodal age distribution)
what are the 2 types of hydrocephalus?
communicating
non communicating
what is communicating hydrocephalus?
when CSF can freely flow through the ventricular system
the issue is in that there may be decreased reabsorption or increased production of CSF
what is non communicating hydrocephalus?
when the flow of CSF through the ventricular system is disrupted eg due to narrowing (posterior fossa lesion eg tumor or blood compress the 4th ventricle)
what is the key difference between communicating and non communicating hydrocephalus?
in communicating CSF can flow freely through the ventricles
in non communicating it can’t
what is normal pressure hydrocephalus?
chronic dilation of the ventricles causing hydrocephalus WITHOUT raised ICP
in what type of hydrocephalus is ICP not raised? explain why
normal pressure hydrocephalus
it occurs due to dilation of the ventricles so although there is accumulation of excess CSF the compensatory increase in ventricular volume means the pressure does not rise
what is hydrocephalus ex vacuo?
hydrocephalus where ventricles enlarge due to chronic brain conditions that cause atrophy eg alzheimer’s
what is the triad for normal pressure hydrocephalus and how do you remember it?
wet, wacky and wobbly:
urinary incontinence
cognitive impairment
gait apraxia
what are signs and symptoms of acute onset hydrocephalus?
signs of raised ICP:
papilloedema
headache
nausea and vomitting
what are signs and symptoms of chronic onset hydrocephalus?
wet wacky wobbly
double vision
CN palsy
what are some signs you might see in children with hydrocephalus?
sunset eyes (papilloedema and iris pushed to bottom and half visible like a sunset) enlarged skull
what ix are done for hydrocephalus? what will you see
CT/MRI head- shows ventricular enlargement or cause eg tumor
CSF analysis- may show infection
LP- only do if there isnt raised ICP
Levodopa challenge- no response
how is hydrocephalus managed?
conservative= stop smoking, increase exercise, reduce salt intake medical= BP medications and statins if needed surgical= ventriculoperitoneal shunting to drain CSF (GS)
