Neuro Flashcards
Symptoms of extradural brain injury
"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
Causes of extradural brain injury
Blunt head trauma causing arterial bleeding e.g. MMA
RTA, fall, assault
Majority occur with associated skull fractures and scalp haematomas
Management of subarachnoid haemorrhage
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
Define primary brain injury
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
ABCD2 score
> 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
Management of migraine
Abortive:
NSAIDs or sumatriptan
Prophylaxis:
Beta blocker, CCB, etc.
Topiramate, carbamazepine
Causes of subdural brain injury
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)
Presentation of stroke
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
Symptoms of venous sinus thrombosis
Young women
Sudden headache
Visual loss or change
Investigations for trigeminal neuralgia
MRI necessary to exclude secondary cause
Management of tension headache
Stress relief and rest
Paracetamol/NSAIDs
Prevention with amitriptyline
Thrombectomy in stroke
<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
Management of subdural brain injury
Acute:
Release of clot through craniotomy
Chronic:
Release of clot or fluid collection through burr-holes
Define stroke
Sudden interruption in vascular supply to the brain
Resulting in rapidly developing focal neurological deficit
>24h
Types of head injury
Closed (concessional)
Open (penetrating or blunt)
Acceleration, deceleration or rotational injury
Tension headache symptoms
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)
Management of trigeminal neuralgia
Carbamazepine
2nd line topimarate, gabapentin or ablative surgery
Pathophysiology of stroke
ischaemic vs. haemorrhagic
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
Headache red flags
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
Investigations for stroke
Screening tools: FAST/ROSIER ABCDE Bloods ECG CXR CT Head +/- CTA MRI if ischaemic stroke Follow up: Bloods, carotid USS, echo
Investigations for venous sinus thrombosis
Bloods
MRI venogram to diagnose
Cluster headache symptoms
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)
Causes of subarachnoid haemorrhage
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
Investigations for cluster headache
CT can be done to rule out SOL
Exclude acute glaucoma differential
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
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
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
Investigations for migraine
None required
CT if uncertain
Define secondary brain injury
Cerebral oedema Ischaemia Infarction Herniation Hydrocephalus TBI SAH
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
Intracerebral brain injury symptoms
Progression over minutes to hours Impaired consciousness Focal neurology (e.g. hemiplegia) Headache N&V
Causes of head injury
Falls
Assault
RTA
Alcohol
Management of cluster headache
100% oxygen
Sumatriptan
Prophylaxis with verapamil (CCB)
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)
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
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
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
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%)
Symptoms of trigeminal neuralgia
Stabbing, shooting pain down face/jaw line
Triggered by chewing/talking
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
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
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
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
Venous stroke symptoms
Raised ICP due to obstruction or focal neurological deficits
Seizures due to venous infarction and venous haemorrhage
Intracerebral injury management
Optimise physiology
Surgical treatment if: Young Superficial bleed Critically raised ICP Major deficit
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
Investigations for TIA
CTH if on warfarin/DOAC/bleeding disorder to rule out ICH
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
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
Differentials of stroke
Hypoglycaemia Migraine Epilepsy MS Tumours Syncope CNS infections Head injury
Investigations for tension headache
None required
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
