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Year 3 > MedEd acute neuro > Flashcards

MedEd acute neuro Flashcards

1
Q

what is a stroke?

A

a sudden onset, focal neurological deficit of vascular origin lasting more then 24 hrs

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2
Q

what are the 2 types of stroke and how do they differ?

A

ischaemic- due to vascular occlusion or stenosis

haemorrhagic- due to vascular rupture

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3
Q

what type of stroke is more common?

A

ischaemic

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4
Q

what are the 2 types of ischaemic stroke and how do they differ?

A 
thrombotic= atherosclerotic plaque formation
embolic= blood clot from elsewhere
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5
Q

what is the difference between a thrombus and an embolus?

A 
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
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6
Q

what are rf for stroke?

A 
hypertension
old age
diabetes
hyperlipidaemia/ hypercholesterolaemia
smoking 
obesity
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7
Q

what are signs and symptoms of a stroke?

A 
acute onset
facial and limb weakness
slurring of speech
loss of coordination and balance 
dizziness
depends on what area of the brain is affected
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8
Q

what is the difference between aphasia and apraxia?

A 
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
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9
Q

define aphasia?

A

inability to use or comprehend words- language problem

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10
Q

define apraxia?

A

difficulty initiating and executing the voluntary movements needed to produce speech- speech problem

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11
Q

out of deficits in brocas and wernicke’s area what causes aphasia and what causes apraxia?

A

brocas region deficit causes apraxia

wernickes region deficit causes aphasia

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12
Q

what parts of the brain does the anterior cerebral artery supply?

A

medial and superior frontal lobe

anterior parietal lobe

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13
Q

what are associated signs of an anterior cerebral artery stroke?

A

contralateral hemiparesis- more the legs than the arms and face
behavioural changes

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14
Q

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?

A

anterior cerebral artery

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15
Q

what does the middle cerebral artery supply?

A

lateral parts of the frontal, temporal and parietal lobes

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16
Q

what are associated symptoms for a stroke of the middle cerebral artery?

A 
contralateral hemiparesis more so of the face and arms than the legs 
aphasia
apraxia 
contralateral hemisensory loss
quadrantopia
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17
Q

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?

A

middle cerebral artery

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18
Q

if contralateral hemiparesis is more significant in the face/arms than the legs and vice versa after a stroke what arteries were affected?

A

more in the face/arms than the legs= middle cerebral artery

more in the legs than in the arms/face= anterior cerebral artery

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19
Q

a lesion where will cause a contralateral homonymous inferior quadrantopia?

A

parietal upper optic radiation

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20
Q

a lesion where will cause a contralateral homonymous superior quadrantopia?

A

temporal lower optic radiation

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21
Q

what does the posterior cerebral artery supply?

A

occipital lobe

inferior temporal lobe

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22
Q

what are associated signs of a posterior cerebral artery stroke?

A

contralateral homonymous hemianopia

agnosia (inability to recognise familiar faces and objects)

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23
Q

if someone has a contralateral homonymous hemianopia and agnosia post stroke what artery is likely affected?

A

posterior cerebral artery

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24
Q

how can you distinguish cerebellar lesions from other strokes?

A

they give ipsilateral signs whereas other stroke signs are contralateral signs

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25
Q

what acronym is used to remember cerebellar signs and what does it stand for?

A 
DANISH:
dysdiadochokinesia
ataxia
nystagmus
intention tremor
slurred speech
hypotonia
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26
Q

where is damage in a posterior circulation stroke?

A

in the brainstem

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27
Q

what is the difference between a posterior circulation and posterior cerebral artery stroke?

A

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

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28
Q

what ix are done for stroke, why and what is GS?

A

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

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29
Q

what ix must be done immediately in stroke and within how long?

A

non contrast head CT

must be done within an hr

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30
Q

does normal CT rule out ischaemic stroke?

A

NO

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31
Q

what score can be used in stroke when someone is waiting and what does it calculate?

A

rosier score while the CT is being arranged= risk of stroke in the emergency room

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32
Q

how is ischaemic stroke managed? give names and doses of drugs

A

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

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33
Q

what are contraindications for thrombolysis in stroke patients?

A

presentation after 4.5 hrs
haemorrhagic stroke
other haemorrhage eg subarachnoid
prolonged PT, APTT, high INR

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34
Q

what is done in a stroke unit?

A

swallow assess
early mobilisation and rehabilitation
VTE prophylaxis
MDT approach with lots of staff involved

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35
Q

how is secondary antiplatelet prevention of a stroke done in patients with AF?

A

warfarin prophylaxis

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36
Q

how is secondary antiplatelet prevention of a stroke done in non AF patients?

A

75mg aspirin for 2 weeks

lifelong clopidogrel 75mg daily

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37
Q

what is the difference between antiplatelet stroke prophylaxis in AF vs non AF patients?

A

AF= warfarin

non AF= 75mg aspirin for 2 weeks then lifelong 75mg clopidogrel daily

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38
Q

how is haemorrhagic stroke managed?

A

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

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39
Q

what score must be used when someone has a TIA and what does it calculate

A

ABCD2 score, it used to estimate risk of stroke in someone with a TIA

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40
Q

how is ABCD2 score interpreted?

A

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

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41
Q

how is a TIA managed when it presents?

A

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

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42
Q

how is secondary prevention carried out after TIA?

A

75 mg clopi OD
high intensity statin eg atorvastatin OD
antihypertensive if BP needs to be controlled

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43
Q

what 3 medications and doses are given for secondary prevention after TIA?

A

75 mg clopi OD
atorvastatin OD
antihypertensive if needed

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44
Q

what are complications of stroke?

A

aspiration pneumonia
DVT
death

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45
Q

what ix are done in TIA?

A

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

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46
Q

what artery is most commonly ruptured in an extradural haemorrhage and why?

A

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

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47
Q

what artery runs right under the pterion?

A

middle meningeal artery

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48
Q

what is the sequelae of events in and extradural haemorrhage?

A

trauma
LOC
lucid interval (where the patient is ok)
rapid deterioration with headache, decreasing mental status and signs of raised ICP developing

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49
Q

what ix is done for extradural haemorrhage? what is seen and how do you remember this?

A

urgent non contrast head CT- you see a lemon/lenticular white shape on one side with midline shift
might do an MRI

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50
Q

how is extradural haemorrhage managed?

A

urgent referral to neurosurgery who will do burrholes or craniotomy

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51
Q

what is ruptured in a subdural haemorrhage?

A

bridging veins

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52
Q

what is the difference between blood in an extradural vs subdural haemorrhage?

A 
extradural= arterial blood
subdural= venous blood
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53
Q

what is the difference between an acute, subacute and chronic subdural haemorrhage?

A 
acute= presents after trauma within 72 hrs
subacute= presents within 3-20 days 
chronic= presents after 3 weeks
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54
Q

how long might it take a subdural haemorrhage to present and what do you need to consider?

A

it can take up to 9 weeks and the patient may have forgotten about the trauma that caused it

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55
Q

in what haemorrhage are bridging veins ruptured?

A

subdural

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56
Q

in what haemorrhage is the middle meningeal artery ruptured?

A

extradural

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57
Q

what are rf for subdural haemorrhage?

A 
elderly 
head trauma
falls
alcoholics 
anticoagulation
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58
Q

what are rf for extradural haemorrhage?

A

trauma
road traffic accidents
young people (under 20/30 yrs)

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59
Q

what will headache in subdural haemorrhage be like?

A

continuous and gradual

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60
Q

what are signs and symptoms of a subdural haemorrhage?

A

gradual and constant headache
fluctuating consciousness
confusion
symptoms of raised ICP

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61
Q

what ix is done for subdural haemorrhage and what will you see?

A

urgent non contrast head you see a banana shape on one side of the head- white if its acute and dark if its chronic

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62
Q

how is subdural haemorrhage managed?

A 
if small (<10mm) and no neuro deficits admit and observe
if large (>10mm) or significant neuro deficits burrhole/ craniotomy
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63
Q

what size is a small v large subdural haemorrhage?

A

small: <10mm
large: >10mm

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64
Q

what ruptures in a subarachnoid haemorrhage?

A

saccular aneurysm

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65
Q

what are rf for subarachnoid haemorrhage?

A 
polycystic kidney disease 
alcohol
hypertension
smoking
hypertension
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66
Q

what haemorrhage is polycysctic kidney disease a rf for?

A

subarachnoid

67
Q

what are signs and symptoms of subarachnoid haemorrhage?

A

sudden onset thunderclap headache- worst pain in their life in the occipital region
meningism (neck stiffness, photophobia, headache)

68
Q

what ix do you do for subarachnoid haemorrhage- include what you might have to do if they present late? what will you see

A

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

69
Q

what is xanthochromic CSF seen in and when?

A

after 12 hrs in a subarachnoid haemorrhage

70
Q

what is present in xanthochromic CSF? what does it look like compared to normal haemoglobin

A

xanthochromia and oxyhaemoglobin

looks more yellow then normal clear CSF

71
Q

how is subarachnoid haemorrhage mananged?

A

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

72
Q

why is nimodipine given in SAH?

A

to prevent delayed cerebral ischaemia

73
Q

how are the different head heamorrhages managed?

A 
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
74
Q

what surgery can be done for SAH?

A

endovasular coiling or clipping

75
Q

what is epilepsy?

A

recurrent tendency to have unprovoked seizures

76
Q

what triggers seizures in epilepsy?

A

they are unprovoked in nature

triggers can be lack of sleep, flashing lights, stress, alcohol

77
Q

what is a seizure?

A

an abnormal paroxysmal discharge of cerebral neurons

78
Q

out of glutamate aspartate and GABA what is excitatory and what is inhibitory?

A

glutamate aspartate= excitatory

GABA= inhibitory

79
Q

in a seizure what happens to the balance between glutamate aspartate and GABA?

A

glutamate aspartate= upregulated= more excitation

GABA= downregulated= less inhibition

80
Q

what do you need to ask in an hx if someone has a seizure?

A

what happened before, during and after specifically

was there a witness

81
Q

what signs and symptoms might you get before a seizure?

A

aura- strange feeling in stomach, deja vu, strange smells or tastes, visual disturbance eg zigzag lines

82
Q

what signs and symptoms might you get during a seizure?

A

duration under 3 mins
tongue biting
incontinence
jerking movements

83
Q

what signs and symptoms might you get after a seizure?

A

slow recovery
post ictal headache
post ictal confusion
post ictal myalgia

84
Q

in terms of what areas of the brain are involved what are different types of seizures?

A

localised

generalised

85
Q

what are the types of localised seizures?

A

focal seizure with impaired awareness
focal aware seizure
focal seizure with secondary generalisation

86
Q

what are some characteristics of focal frontal lobe seizures?

A

motor symptoms eg jacksonian march, post ictal weakness, involuntary actions

87
Q

what are some characteristics of focal temporal lobe seizures?

A

aura eg epigastric discomfort
automatisms eg lip smacking, playing with fingers
hallucinations

88
Q

what are some characteristics of focal parietal lobe seizures?

A

sensory disturbance eg pain, numbness, tingling

89
Q

what are some characteristics of focal occipital lobe seizures?

A

visual distrubance eg spots, lines, flashes

90
Q

what type of seizures are more common in kids?

A

absence

91
Q

what some types of generalised seizure?

A 
myoclonic
tonicclonic
clonic
atonic 
myoclonic
absence
92
Q

how do you remember which types of seizure are generalised?

A

anything with ‘tonic’ in + absence seizures

93
Q

what might be raised on bloods in a seizure?

A

prolactin

94
Q

what ix are done for seizures? why

A

EEG

bloods- check glucose to exlcude hypoglycaemia, UEs to exclude electrolyte abnormalities, prolactin may be raised

95
Q

how many seizures are needed for a diagnosis of epilepsy and how far apart do they have to be?

A

at least 2 (or more) seizures 24 hrs

96
Q

what is seen on EEG in focal vs generalised seizures?

A 
focal= normal activity then craziness in just a few leads 
generalised= normal activity then craziness in all leads
97
Q

how are seizures managed?

A 
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

98
Q

what medications are given for generalised seizures?

A

carbamazepine

lamotrigine

99
Q

what medications are given for focal seizures?

A

first line sodium valproate

second line carbamazepine

100
Q

what antiepileptic do you give child bearing age women instead of sodium valproate?

A

lamotrigine

101
Q

what are general side effects of anti epileptics?

A

weight gain

psychiatric effects eg anxiety, depression

102
Q

what are specific side effects of carbamazepine?

A

neutropenia and osteoporosis

103
Q

what are specific side effects of lamotrigine?

A

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

104
Q

what antiepilaptic causes neutropenia and osteoporosis as a side effect?

A

carbamazepine

105
Q

what antiepileptic causes steven johnsons syndrome as a side effect?

A

lamotrigine

106
Q

how does steven johnsons syndrome present?

A

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

107
Q

what are dissociative seizures? how do you identify them and how are they managed?

A

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

108
Q

what is status epilepticus?

A

when a seizure lasts more then 5 mins or there are 2 seizures back to back without recovery or gain of consciousness in between

109
Q

what are triggers of status epilepticus?

A

non adherence to medication
alcohol abuse
overdose and drug toxicity

110
Q

how is status epilepticus managed?

A

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

111
Q

how do benzodiazepines work?

A

they bind to GABA A receptors and increase channel opening frequency. This increases chloride conductance and neuronal hyperpolarisation leading to increased inhibitory neurotransmission

112
Q

what is SUDEP and how can it be avoided?

A

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

113
Q

what are epilepsy complications?

A

SUDEP- sudden unexpected death from epilepsy
fractures from seizures
medication side effects
behavioural problems

114
Q

what is guillian barre syndrome?

A

an acute autoimmune demyelination of the peripheral nerves

115
Q

what often precedes guillian barre syndrome?

A

gastroenteritis caused by campylobacter jejuni

116
Q

what organism usually causes gastroenteritis before someone presents with guillian barre syndrome?

A

campylobacter jejuni

117
Q

what are signs and symptoms of guillian barre syndrome?

A 
ascending parasthesia and weakness of limbs 
flaccid paralysis 
hypotonia
symmetrical limb weakness
altered sensation/numbness 
fasciculations
118
Q

where might guillian barre progress to and cause death? what is it therefore important to do

A

the respiratory muscles- if they are paralysed

it is important to do spirometry

119
Q

what is miller fischer syndrome?

A

triad of opthalmoplegia, areflexia and atonia
NO muscle weakness
it occurs in 25% of people with guillian barre

120
Q

what is absent in miller fischer syndrome?

A

muscle weakness

121
Q

what is the diagnostic definitive ix for guilian barre? what is seen?

A

nerve conduction studies- reduced conduction (do on arms/hands)

122
Q

what ix are done for guillian barre? what is seen

A

nerve conduction studies- reduced conduction is seen
spirometry
lumbar puncture- high protein, normal glucose and WCC
bloods- anti ganglioside antibody in miller fischer variant

123
Q

what is seen on bloods in miller fischer syndrome?

A

anti ganglioside antibodies

124
Q

in what condition are anti ganglioside antibodies seen?

A

miller fischer syndrome

125
Q

how is guillian barre syndrome managed?

A 
conservative= respiratory support, DVT prophylaxis 
medical= IV immunoglobulins (IVIG) or plasma exchange (if theres IgA deficiency or renal failure)
126
Q

what are causes of spinal cord compression in young vs elderly?

A 
young= more commonly trauma
old= cancer, osteoporosis, corticosteroids, disc herniation
127
Q

what are symptoms of spinal cord compression

A 
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
128
Q

in spinal cord compression where are UMN symptoms seen?

A

below the level of the lesion

129
Q

in spinal cord compression where are LMN symptoms seen?

A

at the level of the lesion

130
Q

what are the 3 categories of symptoms seen in spinal cord compression?

A

motor
autonomic
sensory

131
Q

what ix are done in spinal cord compression and why? what is GS

A

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

132
Q

what are the 2 main ix for multiple myeloma and what is seen?

A

urine- bence jones proteins

immunoglobulin electrophoresis- one band is seen instead of multiple

133
Q

what is cauda equina syndrome?

A

compression of the nerve roots forming the cauda equina

134
Q

what are symptoms of cauda equina syndrome?

A 
LMN symptoms (hypotonia, hyporeflexia) 
bilateral sciatica
perianal parasthesia
leg weakness
reduced anal tone 
bladder retention
135
Q

what bladder symptom do you get in cauda equina syndrome?

A

urinary retention

136
Q

what is radiculopathy?

A

symptoms that rise due to compression of a nerve at or near its root as it exites the spinal cord

137
Q

what symptoms do you get in radiculopathy?

A

LMN symptoms for muscles innervated by this spinal root

Dermatomal pattern of pain and numbness

138
Q

what are signs and symptoms of sciatica?

A

pain radiating from buttock down the ipsilateral leg

weakness of calf muscles

139
Q

how is sciatica diagnosed?

A

by doing the straight leg test- there will be pain in the distribution of the sciatic nerve when the leg is passively flexed

140
Q

what is the straight leg test done to diagnose?

A

sciatica

141
Q

what is lasegue’s sign?

A

positive straight leg test

142
Q

how is spinal cord compression managed?

A

A-E approach
insert catheter if needed
high dose corticosteroids in malignancy (alongside PPI)
urgent referral to neurosurgery for surgical decompression

143
Q

how is spinal cord compression managed if due to malignancy?

A

high dose corticosteroids (alongside PPI)

urgent referral to surgery for surgical decompression

144
Q

what ix is done for cauda equina syndrome?

A

MRI spine

145
Q

how is cauda equina managed?

A

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)

146
Q

what are complications of cauda equina syndrome?

A

chronic sexual dysfunction
chronic urinary retention or bowel incontinence
paraplegia

147
Q

what ix are done for sciatica?

A

urgent MRI spine if neurological deficit present or mass is suspected
lumbosacral spine x ray to evaluate fractures

148
Q

how is sciatica managed?

A 
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
149
Q

what is hydrocephalus?

A

excessive accumulation of CSF in the brain’s ventricular system

150
Q

what happens to ICP in hydrocephalus?

A

it is raised

151
Q

how is more likely to get hydrocephalus?

A

young and elderly (bimodal age distribution)

152
Q

what are the 2 types of hydrocephalus?

A

communicating

non communicating

153
Q

what is communicating hydrocephalus?

A

when CSF can freely flow through the ventricular system

the issue is in that there may be decreased reabsorption or increased production of CSF

154
Q

what is non communicating hydrocephalus?

A

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)

155
Q

what is the key difference between communicating and non communicating hydrocephalus?

A

in communicating CSF can flow freely through the ventricles

in non communicating it can’t

156
Q

what is normal pressure hydrocephalus?

A

chronic dilation of the ventricles causing hydrocephalus WITHOUT raised ICP

157
Q

in what type of hydrocephalus is ICP not raised? explain why

A

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

158
Q

what is hydrocephalus ex vacuo?

A

hydrocephalus where ventricles enlarge due to chronic brain conditions that cause atrophy eg alzheimer’s

159
Q

what is the triad for normal pressure hydrocephalus and how do you remember it?

A

wet, wacky and wobbly:
urinary incontinence
cognitive impairment
gait apraxia

160
Q

what are signs and symptoms of acute onset hydrocephalus?

A

signs of raised ICP:
papilloedema
headache
nausea and vomitting

161
Q

what are signs and symptoms of chronic onset hydrocephalus?

A

wet wacky wobbly
double vision
CN palsy

162
Q

what are some signs you might see in children with hydrocephalus?

A 
sunset eyes (papilloedema and iris pushed to bottom and half visible like a sunset) 
enlarged skull
163
Q

what ix are done for hydrocephalus? what will you see

A

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

164
Q

how is hydrocephalus managed?

A 
conservative= stop smoking, increase exercise, reduce salt intake 
medical= BP medications and statins if needed 
surgical= ventriculoperitoneal shunting to drain CSF (GS)

Year 3 (104 decks)

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