MM neuro tutorial Flashcards
What are the types of haemorrhages?
Subdural
Extradural/epidural
Subarachnoid
What effect would an extradural haemorrhage compressing the right motor cortex have?
Loss of motor function on the left side of the body
Where do the arteries in the brain run?
Under the arachnoid mater and pia mater
What are the meningeal layers from outer to innermost
Dura
Arachnoid
Pia
What does a subdural haemorrhage look like on a scan?
Like a crescent
What does an epidural haemorrhage look like on a scan?
Lenticular (like a half ball shape)
this is because its outside the brain under the skull
What does an subarachnoid haemorrhage look like on a scan?
Bright spots in the cisterns (spaces in the brain)
What are the risk factors for subdural haemorrhage?
Elderly and alcoholics
What are the risk factors for extradural haemorrhage?
Trauma
What are the risk factors for subarachnoid haemorrhage?
Burst aneurysm or trauma
How does extradural haemorrhages present?
Acute onset after lucid interval (accident occurs, unconscious for a few mins then fine and then rapid deterioration)
Deterioration of GCS
Syncope, nausea, vomiting
Severe pain
What is the main cause of extradural haemorrhage? What artery is usually involved?
Trauma, usually middle meningeal artery
What investigations are done for extradural haemorrhage?
Non contrast CT of the head straight away
MRI
What is the epidemiology for extradural haemorrhage?
Young, male
Why is non contrast CT used for extradural haemorrhage?
Blood appears bright when its fresh
What blood vessel is mainly associated with an extradural haemorrhage?
Middle meningeal artery
Where does the middle meningeal artery run?
Pterion
How is GCS calculated?
There are 3 categories: Eye opening (scored 1-4) Verbal response (scored 1-5) Motor response (scored 1-6) The higher the score the better (suggesting the patient is ok)
What is the max GCS?
15
How many GCS are there?
Adult and paediatric
What does localise pain mean on the GCS?
They move their hands/ legs towards where pain is inflicted
What is the minimum GCS?
3
At what GCS are patients intubated?
A score below 9
How does sub arachnoid haemorrhage present?
Sudden onset thunderclap headache at the back of their head (occipital region)
Neck may be stiff
May have meningeal symptoms
Syncope, nausea, vomiting
Very severe headache (worst in their life)
How should you report a GCS score
E 1-4
V 1-5
M 1-6
ie not just the total, report each section differently
What is epidemiology for subarachnoid haemorrhage?
50-55 year old woman
higher incidence in black people
What are causes of subarachnoid haemorrhage?
Rupture of sacular aneurysm (80%)- is spontaneous
Arterial venous malformation
Arterial dissections
What is a sacular aneurysm?
Not a full length aneurysm but it looks like a sac
What is arterial venous malformation?
When artery and vein blend together but they shouldn’t
What are risk factors of subarachnoid haemorrhage?
Smoking
hypertension
alcohol misuse
What is the first line investigation for subarachnoid haemorrhage and second line? What other investigations are done?
Non contrast head CT
if negative and you think they have it do a lumbar puncture
Serum electrolytes (they may be hyponatraemic if they have SIADH)
ECG
Serum glucose (1/3 are hypoglycaemic)
Which nerves are most affected by haemorrhages?
CN III and IV
When can you do a lumbar puncture? Why?
At least 12 hours post beginning of symptoms, you need to leave time for the haemoglobin to break down
How many tubes need to be filled in lumbar puncture?
3
What are cisterns?
Where CSF flows but not ventricles
What colour is CSF on CT?
Black
What syndrome is affected with head trauma?
SIADH
How will SIADH affect electrolytes?
Hyponatraemia
What test is done on all neuro patients?
ECG
How does subdural haemorrhage present?
Gradual onset
Fluctuating consciousness, personality change
Diminished response, nausea, vomiting
What are causes of subdural haemorrhage?
Trauma
What are risk factors for subdural haemorrhage?
Recent trauma
Coagulopathy/ anticoagulants
Over 65
Elderly and alcoholics
What is the epidemiology of subdural haemorrhages?
After falls, elderly patients, coagulopathy
Whats the main difference between subdural and extradural haemorrhage?
Subdural= gradual onset Extradural= sudden onset
Why must you be careful if you suspect someone has a change in behaviour due to a subdural haemorrhage?
Rule out whether this could be because of dementia etc as usually the patients are old
What are the 2 types of subdural haemorrhages?
Acute and chronic
How do you differentiate acute subdural and epidural
If there is trauma involved and if the person is young it is more likely epidural
What should you look for when examining eyes in a neuro patient?
Are their eyes responsive to light and can they follow a light (shows CN 1-4 are fine)
What medication may be given to those with subdural haemorrhage?
Anti epileptics
What are the 2 ways to treat a subdural haemorrhage?
Watchful waiting (they might just get better) Drill a burr hole and remove the haematoma
What are the 2 ways to treat a subdural haemorrhage?
Watchful waiting (they might just get better) Drill a burr hole and remove the haematoma
When should you use a burr hole to treat a subdural haemorrhage?
If it is starting to affect their memory
If they have a really poor GCS
What does plegic mean?
Paralysed/ can’t move
How do you differentiate between an acute and chronic subdural haemorrhage on CT?
Acute will show blood to be white
Chronic will show blood to be black
What is the biggest complication of a subdural haemorrhage? List some of the others too
Biggest= epilepsy Others= Coma, stroke, neuro deficits eg plegia
How do you treat a subdural haematoma?
Acute, below 10mm, below 5mm midline shift, no CNS dysfunction= observe and wait
Acute, above 10mm, above 5mm midline shift, CNS dysfunction= surgery burr holes and prophylactic antiepileptics
Chronic haematoma= anti epileptics
What anti epileptics may be given for prophylaxis in subdural haematoma?
Levitiracetam or phenytoin
What may levitiracetam also be called?
Cepra
What disease is subarachnoid haemorrhage associated with?
Polycystic kidney disease
What symptom will a brain bleed commonly present with?
Headache
What are the 2 types of stroke?
Ischaemic or haemorrhagic
Define stroke
A sudden onset focal neurological deficit of presumed vascular origin which lasts longer than 24 hours
Define TIA
A sudden onset focal neurological deficit of presumed vascular origin which lasts under 24 hours
What is an ischaemic stroke?
Loss of blood flow to a region of the brain due to stenosis or occlusion
What is a haemorrhagic stroke?
A burst blood vessel
How will a haemorrhagic stroke present?
Sudden onset
Loss of function
Vision changes
What are causes of haemorrhagic stroke?
Hypertension
Drugs (cocaine, amphetamines)
How should you investigate stroke?
CT head (exclude haemorrhage if its ischaemic)
What treatment do you need to start if someone comes in with an ischaemic stroke? Why would you not do this if the stroke is haemorrhagic?
Alteplase IV
If stroke is haemorrhagic this would make them bleed more
What is the epidemiology of haemorrhagic stroke?
Most are intracerebral, rest are subarachnoid
More common in men
More come in elderly
More common in asains
How is haemorrhagic stroke treated?
Refer them to neurosurgery
Go through ABCDE and protect airway etc
If weakness in a stroke is right sided which side will the bleed be on?
Left
What area has been affected if there is expressive aphasia?
Broca’s
What area has been affected if there is recepetive aphasia?
Wernicke’s
If the arm is more affected than the leg in stroke which artery is more likely affected?
Middle cerebral (supplies the lateral parts of the brain and this is what controls the arms)
How does ischaemic stroke present?
Sudden onset Loss of function Vision changes Headache Aphasia
What is the epidemiology of ischaemic stroke?
Older people Black people Hispanic people Lower levels of education Men more than women
What are causes of ischaemic stroke?
Those with vascular sclerosis or occulsion eg diabetics atrial fibrillation, high cholestrol
Cerebral venous thrombosis
What is the first line investigation for haemorrhagic stroke?
Non contrast CT head
How will ischaemic stroke appear on CT?
Hypo attenuated ie area is less intense than the surrounding area
What should you think when you see hypo attenuation on a CT?
Vascular occlusion
Ischaemia
What should you think when you see white on a CT?
Blood
How is ischaemic stroke treated?
Non contrast head CT to rule out haemorrhage THEN
Less than 4.5 hrs= alteplase IV, aspirin after 24 hrs of IV, supportive care, swallowing assessment, VTE prophylaxis (heparin)
Over 4.5 hrs= Aspirin 300 mg, supportive care, swallowing assessment, VTE prophylaxis
Central venous sinus thrombosis= antioagulate using heparin and supportive care
How is secondary prevention for ischaemic stroke carried out?
Continue with aspirin for 2 weeks, then switch to lifelong clopidogrel or diphyramidole
If they have AF offer lifelong anticoagulation
When is alteplase IV given for ischaemic stroke?
Only if you are completely sure they have prevented in under 4.5 hours of symptoms
How does presentation/risk factors/ epidemiology/ of TIA differ from stroke?
It doesn’t, everything is the same
What is the ABCD referral system?
It is a way of scoring patients to see how quickly they have to be referred for stroke eg score of above 2= refer within 24 hrs
How is TIA treated?
Depending on the cause
How is atherosclerotic TIA treated?
Antiplatelet (aspirin or clopidogrel)
Statin
Lifestyle modification
If carotid is obstructed over 50% do an enderartectomy
How is cardioembolic TIA treated?
Anticoagulation (warfarin or apixaban started in 2 weeks)
What is an enderartectomy?
When the plaque obstructing more than 50% of the carotid is surgically removed
What are complications of TIA?
Stroke
What are upper motor neurone signs?
Contralaterally: Weakness Higher spasticity Hyperreflexia Upgoing plantars
What signs are not present with upper motor neurone lesion?
No fasciculations or muscle wasting
What are the lower motor neurone signs?
Unilaterally: Fasciculations Muscle wasting Hyporeflexia Weakness Normal plantar response
How are strokes/TIAs graded?
MRC grading (0-5)
Describe MRC grading
0= no muscle contraction 1= flicker of contraction 2= some active movement 3= active movement against gravity 4= active movement against resistance 5= normal power considering their age
On the motor homunculus what organs are associated with the lateral regions?
Arm, face etc
On the motor homunculus what organs are associated with the medial regions?
Legs
Which artery is associated with the lateral areas of the brain?
Middle cerebral artery
Which artery is associated with the medial areas of the brain?
Anterior cerebral
If arms are more affected in stroke what artery is likely to be involved?
Middle cerebral
If legs are more affected in stroke what artery is likely to be involved?
Anterior cerebral
What vessels are associated with the posterior circulation in the brain?
They arise from the basilar artery and mainly include the posterior cerebral
What vessels are associated with the anterior circulation in the brain?
They arise from the internal carotid artery and mainly include middle and anterior cerebral arteries
How will stroke of the anterior cerebral artery present?
Contralateral hemiparesis (more so the lower limb)
Abulia
Confusion
Gait apraxia
How will stroke of the middle cerebral artery present?
Contralateral hemiparesis (more so the upper limb and face)
Contralateral hemisensory loss
Apraxia
Hemineglect
if the left MCA is affected: receptive/expressive aphasia
if meyer’s/baum’s loop is affected quadrantopia
If the left MCA is affected what stroke sign will occur?
Receptive or expressive aphasia
What is quadtrantopia?
A quarter of the visual field is lost
If someone is right hand dominant what side will their language center be dominant?
Left side
What visual symptoms arise after stroke affecting the posterior cerebral artery?
Homonymous hemianopia (macular sparing) Visual agnosia
What symptoms arise after stroke of the basilar artery?
Cranial nerve pathology (basilar artery is on the pons which also has the cranial nerves)
Visual impairments
Cerebellar pathology
Impaired consciousness
What does aneurysm of the superior cerebellar artery cause?
Trigeminal nerve neuralgia
Dizziness
What is amaurosis fugax?
A type of TIA
What are complications of stroke?
Loss of function of half of body will affect mood DVT (due to loss of movement) Immobility Seizures Infections Cardiovascular events Cerebral oedema Psychiatric/mood disturbance Death
