Neuro Flashcards
1
Q
define infarction
A
obstruction to the blood suply
2
Q
what is a TIA
A
transient neurological dysfunction secondary to ischaemia without infarction, resolves within 24hrs
3
Q
what is crescendo TIA
A
2 or more TIAs within a week
4
Q
typical symptoms of a stroke
A
UNILATERAL
- sudden limb weakness
- sudden facial weakness
- sudden onset dysphasia
- sudden onset visual or sensory loss
5
Q
what are the risk factors for a stroke/TIA
A
- CVD (angina/MI/PVD)
- previous TIA/stroke
- AF
- DM
- HTN
- Carotid artery disease
- Vasculitis
- thrombophilia (group of conditions where blood clots more easily)
- Smoking
- Combined contraceptive pill
6
Q
What risk tool is used in the community to identify stroke
A
FAST
7
Q
What risk tool is used in A&E to identify stroke
A
ROSIER - recognition of stroke in emergency room
8
Q
what risk score is used for a pt with a TIA
A
ABCD2
9
Q
what does ABCD2 risk score assess
A
assess a pts risk of having a subsequent stroke after having a TIA
10
Q
What does ABCD2 stand for
A
A - age (>60=1)
B - BP (>140/90=1)
C - clinical features (unilateral weakness =2, dysphasia without weakness = 1)
D - duration (>60mins=2, 10-60mins =1, <10mins=0)
D - diabetes (=1)
11
Q
what result in ABCD2 indicate high risk
A
a high score = higher risk of pt having a stroke in the following 48hrs
<4 = specialist assessment within 1wk >3 = specialist assessment within 24hrs
12
Q
what is the gold standard Ix for ?stroke
A
diffusion-weighted MRI
13
Q
define stroke
A
disruption of blood supply to the brain, characterised by rapidly developing signs of focal or global disturbance of cerebral functions, lasting for more than 24 hours or leading to death
14
Q
what are the two types of stroke
A
- haemorrhagic
- ischaemic
15
Q
what are the three types of ischaemic stroke
A
- Cerebral hemisphere infarcts
- Posterior circulation ischaemia
- Lacunar infarcts
16
Q
what are the typical presenting symptoms for a cerebral hemisphere infarct
A
- Contralateral hemiplegia which is initially flaccid (floppy limb, falls like a dead weight when lifted) and then becomes spastic.
- Contralateral sensory loss.
- Homonymous hemianopia.
- Dysphasia.
17
Q
what are the typical presenting symptoms for a posterior circulation infarct
A
- Motor deficits
- ‘Crossed’ syndromes: ipsilateral cranial nerve dysfunction and contralateral long motor or sensory tract dysfunction.
- Sensory deficits
- Homonymous hemianopia.
- Ataxia, imbalance, unsteadiness, or disequilibrium.
- Vertigo, with or without nausea and vomiting.
- Diplopia (ophthalmoplegia).
- Dysphagia or dysarthria.
- Isolated reduced level of consciousness can result from bilateral thalamic or brain stem ischaemia.
18
Q
what motor deficits are seen in posterior circulation infarcts
A
- weakness
- clumsiness
- paralysis
19
Q
what sensory deficits are seen in posterior circulation infarcts
A
numbness, including loss of sensation or paraesthesia in any combination of extremities, sometimes including all four limbs or both sides of the face or mouth.
20
Q
what can a complete infarct affecting the pons cause
A
‘locked-in syndrome’
-quadriparesis, loss of speech, but preserved awareness and cognition, and sometimes preserved eye movements
21
Q
which arteries are commonly affected by strokes in the cerebral hemisphere
A
- anterior cerebral artery
- middle cerebral artery
- posterior cerebral artery
22
Q
typical symptoms of a stroke in the anterior cerebral artery
A
- contralateral leg weakness and sensory loss
- mild/no upper extremity involvement
- balance problems
- L-sided = aphasia
23
Q
typical symptoms of a stroke in the middle cerebral artery
A
- contralateral face and arm weakness and sensory loss
- mild/no leg weakness
- head+eyes deviate toward side of stroke
L-sided = aphasia R-sided = deficits of spatial perception, apraxia
24
Q
typical symptoms of a stoke in the posterior cerebral artery
A
- visual problems
- prosopagnosia (unable to recognise faces)
- alexia (inability to read)
- aphasia
25
typical symptoms of a vertebrobasilar system stroke
- vertigo
- nystagmus
- visual problems
- facial weakness
- dysphasia
- dysarthria
- loss of pain and temp
- ipsilateral horner's syndrome (ptosis, miosis, anhidrosis)
26
what are the typical differential dx for stroke
- hypoglycaemia
- TIA
- brain tumour
- Subdural haematoma
- Todd's palsy
27
what is Todd's palsy
condition experienced by pts with epilepsy where a seizure is followed by brief period of paralysis (typically unilateral)
28
acute Mx of stroke
thrombolysis within 4.5hrs
thrombectomy within 6hrs
29
what medication is used in thrombolysis
alteplase
30
how does alteplase work
- tissue plasminogen activator
rapidly breaks down clots
31
what medication is given for strokes
aspirin 300mg STAT (within 24hrs) and continued for 2wks
32
what other treatments are used in the secondary prevention of stroke
- clopidogrel 75mg OD
- atorvastatin 80mg
- treat modifiable risks
- carotid endarterectomy or stenting (if carotid disease present)
33
who is involved in the stroke rehabilitation MDT
- SALT
- nutrition and dieitics
- physio
- OT
- social services
- ophthalmology
- psychology
34
when are statins prescribed in stroke pts
Do not start statin treatment immediately after an acute stroke but continue statin treatment for people with acute stroke who are already taking statins
35
what risk assessment is used in the primary prevention of strokes
Qrisk3
36
what does the Qrisk 3 score assess
calculates a persons risk of developing a heart attack of stroke in the next 10 years
37
what does GCS assess
level of consciousness
38
what responses are assessed in the GCS
- eyes (4)
- verbal (5)
- motor (6)
39
GCS eye response levels
4 - spontaneous
3 - voice
2 - pain
1 - none
40
GCS verbal response levels
```
5 - orientated
4 - confused
3 - inappropriate words
2 - groans/incoherent sounds
1 - none
```
41
GCS motor response levels
```
6 - voluntary movement
5 - localise to pain
4 - normal flexion
3 - abnormal flexion
2 - extension
1 - none
```
42
what score is the GCS out of
15
43
what GCS score indicates intubation
8
44
what are the different types of intracranial haemorrhage
- subdural
- extra-dural
- subarachnoid
45
what are the three layers of the meninges
- dura (outer layer)
- arachnoid
- pia (inner layer)
46
where is the subdural space
between the dura matter and the arachnoid matter
47
where is the arachnoid space
between the arachnoid matter and the pia matter
48
what are the different stages of a subdural haemorrhage
- An acute SDH.
- A subacute SDH (this phase begins 3-7 days after the initial injury).
- A chronic SDH (this phase begins 2-3 weeks after the initial injury).
49
what are the main causes of a subdural haemorrhage
- tearing of bridging veins
| - damaged cortical artery bleeding
50
which groups are at high risk of subdural haemorrghage
- infants (tearing of bridging veins ?shaken baby syndrome)
- elderly (cerebral atrophy)
- alcoholics (cerebral atrophy)
51
acute presentation of subdural haemorrhage
- headache
- wound from trauma
- LoC (not always present acutely)
52
chronic presentation of subdural haemorrhage
- progressive symtpoms
- n+v
- neurological deficit such as focal limb weakness, speech difficulties, increasing drowsiness/confusion or personality changes
- progressive headache
53
when ?subdural haemorrhage what information is vital to get from the Hx
- anticoagulant use
- PMHx of bleeding disorders/coagulopathies
- alcohol intake
54
differentials for ?subdural haemorrhage
- progressive stroke
- SAH
- infection (meningitis/encephalitis)
- tumour
if pt presents confused all the differentials for that!
55
Ix for subdural haemorhage
- FBC, U&E, LFTs
- Coagulation screen
- Group and save/cross-match
- CT head
56
what Ix are included in FBC
- Hb
- WBC count
- Platelet count
- RBC count
- Haematocrit
- MCV
- Mean cell haemoglobin
can also include differential white cell count
- neutrophils
- lymphocytes
- monocytes
- eosinophils
- basophils
57
complications of a sub-dural haemorrhage
- seizures
- Raised ICP
- Death
- cerebral oedema
- coma (coning due to midline shift)
- permanent neurological damage
58
Mx of subdural haemorrhage
- If small, asymptomatic, acute SDH = observation, serial examinations and serial CT scanning
- Surgery is needed if there are focal signs, deterioration, a large haematoma, raised intracranial pressure or midline shift
59
what surgery is used in the tx of subdural haemorrhage
- emergency craniotomy and clot evacuation
| - burr holes may be considered if there is rapid deterioration
60
what is a extra-dural haemorrhage
a bleed into the potential space between the skull and the dura matter
61
which artery is typically affected in an extra-dural haemorrhage
middle meningeal artery
62
which region of the brain is typically affected in an extra-dural haemorrhage
temporo-parietal region
63
where else can an extra-dural haemorrhage occur
in the spinal column
64
which age group is more likely to have an extra-dural haemorrhage
adolescents and young adults
65
on a CT scan what shape are subdural haemorrages
concave
66
on a CT scan what shape are extra-dural haemorrages
convex
67
what is the most common cause of extra-dural haemorrhage
trauma (to the skull or spine)
68
what is the typical presentation of a extra-dural haemorrhage
Hx of trauma followed by a lucid period followed by a rapid deterioration in the pt & the conscious level
69
what are the possible signs/symptoms of an extra-dural haemorrhage
- N+V
- headache
- Seizures.
- Bradycardia with or without hypertension, indicates raised intracranial pressure.
- Evidence of skull fractures, haematomas, or lacerations.
- Cerebrospinal fluid (CSF) otorrhoea or rhinorrhoea resulting from skull fracture with a tear of the dura.
- Alteration in level of consciousness with deterioration of the Glasgow Coma Scale (GCS) score.
- Unequal pupils.
- Facial nerve injury.
- Weakness of limbs.
- Other focal neurological deficits include aphasia, visual field defects, numbness and ataxia
70
how may an extra-dural haemorrhage in the spinal column present
- Weakness.
- Numbness.
- Alteration in reflexes.
- Urinary incontinence.
- Possibly both urinary and faecal incontinence
71
what reflex happens in response to a raised ICP
Cushings Reflex
72
what is Cushings triad
- Hypertension
- Bradycardia
- Irregular breathing pattern
73
Ix for an extra-dural haemorrhage
- head CT
| - baseline FBC, U&E (?abnormalities in coagulopathy)
74
Mx of an extra-dural haemorrhage
ABCDE
- maintain airway and oxygenation
- IV fluids to maintain circulation
Mx depends on the size of the haemorrhage and the stability of the pt
75
Mx of a small extra-dural haemorrhage
conservative
76
Mx of a large extra-dural haemorrhage
burr holes to allow for evacuation of the bleed
77
pharmacologically what can be given for raised ICP
IV mannitol
78
what drug class is mannitol in
osmotic diuretics
79
how does mannitol work
increases plasma osmotic pressure leading to brain dehydration and a decrease in ICP
80
complications of an extra-dural haemorrhage
- permanent or temporary neurological deficits
- death
- post-traumatic seizures
- post-concussion syndrome
81
complications of a spinal extra-dural haemorrhage
- spasticity
- urinary complications
- neuropathic pain
82
what is a subarachnoid haemorrhage
bleeding into the subarachnoid space between the pia matter and arachnoid matter
83
what is typically found in the subarachnoid space
cerebrospinal fluid (CSF)
84
what is the most common cause of a subarachnoid haemorrhage
rupture of a berry aneurysm
85
which area of the brain does the anterior cerebral artery supply
anteromedial portion of the cerebrum
86
which area of the brain does the middle cerebral artery supply
lateral parts of the cerebrum
87
which area of the brain does the posterior cerebral artery supply
posterior cerebrum
88
risk factors for SAH
- smoking
- hypertension
- cocaine use
- alcohol
- marfan's syndrome
- FHx
89
what is the characteristic symptom of SAH
thunder-clap headache
90
differentials for SAH
- meningitis
- encephalitis
- migraine
- ischaemic stroke
91
when are SAH most likely to occur
during strenuous activity
- weight lifting
- sex
92
what are the other features associated with SAH
- neck stiffness
- photophobia
- visual changes
- weakness
- seizures
- LoC
93
Ix for SAH
- CT head
- LP (raised RCC & Xanthochromia (yellow colour to the CSF caused by bilirubin))
- angiography (used to locate source of bleeding once SAH confirmed)
94
early Mx of SAH
- ABCDE
- stop bleeding with endovascular obliteration by coiling (1st) or clipping (2nd)
- nimodipine
95
what is nimodipine
a calcium channel blocker
96
why is nimodipine given in SAH Mx
prevents vasospasm which is a common complication of SAH that can cause brain ischaemia
97
what other Mx may be needed following a SAH
- LP or insertion of a shunt to treat hydrocephalus
| - anti-epileptic mediciation (if seizures)
98
How is nimodipine prescribed
60mg four-hourly
99
what else needs to be managed after/during a SAH
Blood pressure
100
How is blood pressure maintained after a SAH
- Nitroprusside
- labetolol
BP level should be low enough to prevent re-bleeding and high enough to maintain cerebral perfusion
101
what mean arterial pressure is the aim in raised ICP control
MAP 50
