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1
Q

Symptoms of extradural brain injury

A 
"Talk and die" - a brief loss of consciousness after injury followed by a lucid period
Headache
Vomiting
Confusion
Seizures
Focal neurology
Boggy scalp haematoma
Dilated pupils
Death can result from rapidly rising intra-cranial pressure
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2
Q

Causes of extradural brain injury

A

Blunt head trauma causing arterial bleeding e.g. MMA
RTA, fall, assault
Majority occur with associated skull fractures and scalp haematomas

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3
Q

Management of subarachnoid haemorrhage

A

Intracranial aneurisms - coil
Until treated: strict bed rest, well controlled BP, avoid straining
Main goal of surgery is to prevent re-bleeds

Vasospasm prevention:
21 day course of nimodipine 60mg 4hrly oral/NG (CCB)
Hypovolaemia
Induced-hypertension and haemodilution

Hydrocephalus:
External ventricular drain or LT VP shunt

Treat hyponatraemia with fluid restriction

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4
Q

Define primary brain injury

A

Intra-axial
Diffuse:
Shearing forces e.g. rotational, causing axon damage and rupture of small vessels
Focal:
As brain hits skull parenchymal contusion - coup is direct impact of brain of the skill at the site of injury, contre-coup is injury from brain rebounding off opposite side of skull

Laceration within the skull:
Brain impinges on sharp of bony edge within skull, e.g. sphenoid ridge

Extra-axial:
Bleeds

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5
Q

ABCD2 score

A

> 4 = risk of future stroke

Age - >60 = 1
BP - >140/90mmHg = 1
Diabetes - 1

Clinical features:
Unilateral weakness = 1
Speech disturbance without weakness = 1

Duration:
>60 mins = 2
10-60 mins = 1

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6
Q

Management of migraine

A

Abortive:
NSAIDs or sumatriptan

Prophylaxis:
Beta blocker, CCB, etc.
Topiramate, carbamazepine

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7
Q

Causes of subdural brain injury

A

Acute:
Trauma causing shearing of bridging veins e.g. acceleration/deceleration of RTA, falls, assaults

Chronic:
Trivial injury in elderly, patients on anticoagulation or alcoholic patients moths or weeks before causing a small tear in a cerebral vein (low-pressure venous bleed)

Paeds:
Shaken baby syndrome (fragile bridging veins)

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8
Q

Presentation of stroke

A

UMNL:
Pyramidal weakness, hyperreflexia, spasticity, upgoing plantars,

Focal neurology based on arterial supply:
MCA - eyes look at lesion

RHS stroke:
Sensory inattention, hemi-spatial neglect, LSW and hemisensory loss

LHS stroke:
Dysphagia, RSW and hemisensory loss

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9
Q

Symptoms of venous sinus thrombosis

A

Young women
Sudden headache
Visual loss or change

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10
Q

Investigations for trigeminal neuralgia

A

MRI necessary to exclude secondary cause

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11
Q

Management of tension headache

A

Stress relief and rest
Paracetamol/NSAIDs
Prevention with amitriptyline

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12
Q

Thrombectomy in stroke

A

<6hr onset
Often do thrombolysis then consider surgical removal of thrombus via catheter in groin

Criteria:
Patients with ischaemic stroke due to proximal MCA, carotid T, distal MCA & basilar occlusion
Patients presenting within 6 hours
Patients with significant neurological deficit (NIHSS ≥ 6)
Minimal ischaemia visible on brain imaging at time of presentation

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13
Q

Management of subdural brain injury

A

Acute:
Release of clot through craniotomy

Chronic:
Release of clot or fluid collection through burr-holes

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14
Q

Define stroke

A

Sudden interruption in vascular supply to the brain
Resulting in rapidly developing focal neurological deficit
>24h

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15
Q

Types of head injury

A

Closed (concessional)
Open (penetrating or blunt)
Acceleration, deceleration or rotational injury

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16
Q

Tension headache symptoms

A 
S - bilateral
O - chronic, usually at end of the day
C - tight band, non-pulsatile
R -
A - scalp muscle tednerness
T - chronic
E - stress
S - mild-to-moderate (able to continue with ADLs)
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17
Q

Management of trigeminal neuralgia

A

Carbamazepine

2nd line topimarate, gabapentin or ablative surgery

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18
Q

Pathophysiology of stroke

ischaemic vs. haemorrhagic

A

Ischaemic:
Arterial occlusion
Thrombotic (20%, rupture of atherosclerotic plaque in an ICA)
Embolic (80%, left heart if AF, or infective endocarditis, long bone fracures)

Haemorrhagic:
HTN, AVMs, aneurysmal, CAA, anticoagulation therapy, haemophilia, recreational drugs

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19
Q

Headache red flags

A

Specific:
Sudden onset -SAH
“Thunderclap” - SAH
First & worst - SAH
Unilateral with eye pain - glaucoma/cluster headache
Scalp tenderness in >50s - GCA
Worse on coughing/in the morning/bending forward -raised ICP

General headache red flags:
Neurological deficit
Meningism (photophobia, neck stiffness)
Decreased consciousness
Not usual pattern of headaches
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20
Q

Investigations for stroke

A 
Screening tools: FAST/ROSIER
ABCDE
Bloods
ECG
CXR
CT Head +/- CTA
MRI if ischaemic stroke 
Follow up: 
Bloods, carotid USS, echo
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21
Q

Investigations for venous sinus thrombosis

A

Bloods

MRI venogram to diagnose

22
Q

Cluster headache symptoms

A

S - unilateral, around one eye
O - quick develops, 1-2x/day, 15m-2hr
C - sharp stabbing pain
R -
A - facial/eyelid swelling/redness, Horner’s syndrome, runny nose, watery eyes, conjunctival injection/ redness, restlessness/agitation
T - clusters lasting several wks, clusters ~1yrly
E - ?alcohol may trigger, hyperbaric chamber relieves
S - severe (pt restless & agitated)

23
Q

Causes of subarachnoid haemorrhage

A

Traumatic:
Trauma, skull fractures, TBI

Non-traumatic:
Arterial aneurysm rupture

Congenital “weak area”
Atherosclerosis
Local high flow
Infection (mycotic aneurisms)

Associations:
PKD, Ehler’s Danlos, CoA

24
Q

Investigations for cluster headache

A

CT can be done to rule out SOL

Exclude acute glaucoma differential

25
Describe decerebrate posturing
Central tegmental tract damage/damage to upper brain stem (midbrain, pons) Arms adducted, extended, internally rotated Wrists pronated and fingers flexed Legs stiffly extended Ankles plantar flexed
26
Migraine symptoms
``` S- Unilateral O - Sudden or ~1hr onset, lasts 4-72hrs C - Throbbing pain R - Back of head & down neck (rule out meningism - infection, SAH) A - N&V, photophobia, phonophobia, aura T - Some constant, some wax & wane E- physical activity, improved with rest S - severe ```
27
Investigations for intracranial pressure headaches
CT head LP LP raised lymphocytes (normal glucose and protein) - viral LP raised neutrophils (low glucose and high protein) - bacterial
28
Investigations for migraine
None required CT if uncertain
29
Define secondary brain injury
``` Cerebral oedema Ischaemia Infarction Herniation Hydrocephalus TBI SAH ```
30
Define transient ischaemic attack
Transient episode of neurological dysfunction caused by ischaemia, without infarction Emergency - high risk of stroke in the first few days after
31
Intracerebral brain injury symptoms
``` Progression over minutes to hours Impaired consciousness Focal neurology (e.g. hemiplegia) Headache N&V ```
32
Causes of head injury
Falls Assault RTA Alcohol
33
Management of cluster headache
100% oxygen Sumatriptan Prophylaxis with verapamil (CCB)
34
Medical optimisation post-stroke
Aspirin 300mg PO asap or 24hrs after thrombolysis if a haemorrhage is excluded, for 2wks Statin after 48hrs if cholesterol >3.5 mmol/L (risk of haemorrhagic transformation) Anticoagulants (clopidogrel 75mg daily) after 2wks (minimise risk haemorrhagic transformation)
35
Thrombolytic therapy in stroke
<4.5hrs onset (<3hr if diabetic) No haemorrhage on CT BP <185/110 Alteplase (tPA) recommended by NICE Risks: Haemorrhage, hypotension (monitor) Benefits: No effect on mortality, but effect on disability 1 in 8 cured, 1 in 3 get better, 1 in 18 get worse No antiplatelets for 24 hours following IV thrombolysis to avoid bleeding complications
36
Intracerebral brain injury causes
``` HTN damage to blood vessels e.g. perforating lenticulostriate arteries Cerebral amyloid angiopathy Micro-aneurysms Anticoagulation Bleeding disorder Tumours Trauma No underlying cause ```
37
Management of extradural brain injury
Neurosurgical emergency Bone flap or burr hole over suspected site Evacuate clot Control bleeding (diathermy, silver clips, under running) Mannitol IVI while being transferred
38
Management for TIA
Aspirin 300mg daily (unless bleeding disorder/on anticoagulants/already taking aspirin regularly, CI) Admit for assessment / observation if >1 TIA (crescendo TIA) Secondary prevention: Clopidogrel 74mg OD (as 1st line as in stroke) (or aspirin + dupyridamole if cannot tolerate) Carotid endarterectomy if >50% stenosis (some people say >70%)
39
Symptoms of trigeminal neuralgia
Stabbing, shooting pain down face/jaw line | Triggered by chewing/talking
40
Describe decorticate posturing
Damage to one or both corticospinal tracts Flexors predominate in upper limb (rubrospinal) Arms adducted, flexed, internally rotated to lie across chest Wrists and fingers flexed Legs stiffly extended Ankles plantar flexed
41
Intracerebral haemorrhage management and prevention of complications
Emergency management: Reverse anticoagulants Neurosurgical referral Resus and ABCDE Medical management: BP lowering Reversal of anticoagulants (warfarin, dibigatran) Prevention of complications: IPC Nutrition Monitor for expansion of haematoma and oedema
42
Secondary prevention of stroke
Clopidogrel 75mg OD for life (dipyridamole and aspirin, or apixaban / DOAC if stroke and AF) Lifestyle: Smoking diabetic control, HTN, high cholesterol and AF Correction of medical RFs: BP, cholesterol, AF, DM Carotid endarterectomy and angioplasty
43
Classification of headaches
``` Acute: Trauma Cerebrovascular (SAH/ICH/infarction) Meningitis Systemic infection Acute angle-closure glaucoma ``` ``` Chronic/recurrent: Tension Migraine Cluster Raised ICP (SOL, hydrocephalus) Temporal arteritis Drugs ```
44
Venous stroke symptoms
Raised ICP due to obstruction or focal neurological deficits Seizures due to venous infarction and venous haemorrhage
45
Intracerebral injury management
Optimise physiology ``` Surgical treatment if: Young Superficial bleed Critically raised ICP Major deficit ```
46
Symptoms of subdural brain injury
``` Slowly progressive and fluctuating symptoms (also delayed in chronic subdural bleeds) Progressive mental deterioration Drowsiness progressing to coma Focal neurology (e.g. hemiplegia) Headache Vomiting ```
47
Investigations for TIA
CTH if on warfarin/DOAC/bleeding disorder to rule out ICH
48
Symptoms of subarachnoid haemorrhage
``` Acute onset thunderclap headache (occipital or unilateral) LOC, then wake (arterial rupture but when ICP > systolic BP bleeding is tamponaded) N&V Seizures Meningism Positive Kernig's sign Focal neurology Cerebral salt wasting - hyponatraemia ```
49
# Define primary and secondary headaches Give examples of each
Primary: Disturbance of pain networks in absence of damage Migraine, tension, cluster, analgesia overuse Secondary: Underlying cause identifiable on LP, scans SAH, meningitis, GCA, idiopathic intracranial HTN, low pressure headaches, malignant HTN, sinusitis
50
Differentials of stroke
``` Hypoglycaemia Migraine Epilepsy MS Tumours Syncope CNS infections Head injury ```
51
Investigations for tension headache
None required
52
Venous stroke causes
``` Infective Inherited or acquired thrombophilia Dehydration Inflammatory (Behcet's, Wegener's, SLE) Haematology (sickle cell, PRV, thrombocytopenia, PNH), Malignancy Head injury Neurosurgery LP Combined OCP ```

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