Neuro Core Conditions 2 Flashcards
How is Status Epilepticus defined?
Either:
Single seizure persisting >30mins
Multiple seizures of shorter duration without a full neuro recovery in between
What is the pathophysiology of a seizure?
Rapid abnormal electrical discharges from cerebral neurones.
Arise from an imbalance between excitatory & inhibitory neurotransmitters (GABA & Glutamate)
Leading to failure of inhibitory process
What are the signs & symptoms of a prolonged seizure?
Tachycardia Hypertension Hyperglycaemia Lactic acidosis >30mins: Cerebral auto regulation & perfusion impairment From surge of catecholamines
What are the causes of status epilepticus?
1/3: Chronic epilepsy
1/3: New onset epilepsy
1/3: No past/future epilepsy
Other: OH/drug withdrawal, Stroke, SAH, CNS infection
How is a seizure investigated?
Bloods: U&E, FBC, LFT, Mg, Ca, Glucose, clotting, drug levels Blood cultures Depending on situation: CT Brain CXR (aspiration) LP EEG- In acute setting- Refractory S.E
How is status epilepticus managed?
STAGE 1: EARLY STATUS 0-10mins
- Secure airway & 15L/min Oxygen
- IV access & assess CV function
- IV Lorazepam 4mg bolus repeated at 10mins
STAGE 2: 0-30mins
- Glucose (50ml of 50%) +/- IV Thiamine if OH- abuse
- IV Phenytoin 15-18mg/kg at 50mg/min alt Phenobarbital or Fosphenytoin
- Monitor ECG
STAGE 3: ESTABLISHED 0-60mins
-Call ITU/ anaesthetist
STAGE 4: REFRACTORY: 30-90mins
- ITU transfer w/EEG monitoring
- GA with one of the following: 1-2mg/kg bolus Propofol, Thiopentone, Midazolam
- Anaesthetic continued for 12-24hrs after last seizure effect
What are the causes of epilepsy?
Primary generalised epilepsy Developmental abnormalities Brain trauma & surgery Intracranial mass/lesion CNS infection Metabolic disturbance Vascular abnormalities Pyrexia in children Drugs: Lidocaine, Ciclosporin, Lithium, Cocaine, OH withdrawal
What are the triggers for a seizure in epilepsy?
Sleep deprivation Alcohol (intake & withdrawal) Drug misuse Physical/mental exhaustion Flashing lights (PGE only) Infection/metabolic disturbance
How is partial epilepsy classified?
Simple partial: JACKSONIAN, Normal consciousness, isolated limb jerking/head turning away from seizure, isolated parasthesia, Todd’s paralysis
Complex partial: May impair consciousness, lip smacking, tachy, emotional disturbance, drowsy after, Déjà vu, vertigo, hallucinations, automatism
Secondary generalised: Partial that becomes general, tonic-clonic
How is generalised epilepsy classified?
Brainstem/ midbrain
Absence: PETIT MAL, childhood onset, unresponsive but conscious, staring, pale, some muscle jerking, multiple attacks on the same day, can affect school, normal after attack, likely to develop tonic-clonic later in life, generally <15s
Tonic-Clonic: GRAND MAL, aura, Tonic 10-60s: tongue biting, rigid, incontinence, hypoxic/cyanotic, epileptic cry, Clonic: secs-mins, eye rolling, tachy, convulsions, no/random breathing, usually self-limiting, headache afterwards
Tonic
Myoclonic: Clonic symptoms only
Atonic: Looks like fainting
How is epilepsy diagnosed?
ECG Neuro exam Bloods: Ca, Glucose, U&Es, LFTs, CK, Prolactin CT/MRI/PET scan EEG Sleep recordings/ 24hr EEG
How is epilepsy managed?
Inform DVLA
Partial: 1) Carbamezepine, 2)Sodium Valproate, Phenytoin
Generalised: 1) Sodium Valproate, 2) Lamotrigine
Absence: Sodium Valproate
Myoclonic: Sodium Valproate
What are the causes of a stroke?
Cerebral infarction 85% (ischaemic stroke)
Primary haemorrhage
Subarachnoid haemorrhage
What are the causes of cerebral infarction?
Large artery atherothromboembolism
Small vessel disease
Embolism from cardiac source
Which arteries would be affected in stroke if:
- Leg > arms affected
- Greatest deficit in the face & arms
- Legs: Anterior cerebral artery
- Face: Middle cerebral artery
What cortical symptoms can be seen in a stroke?
Agnosia
Dysphasia
Sensory inattention
Visual field defects
Where do the lacunar vessels supply?
Internal capsule (posterior= only motor signs)
Thalamus (Pure sensory signs)
Basal ganglia
What is the ROSIER tool?
Recognition of stroke in the ED Score: -2 - +5 -1: LOC, convulsive fit \+1: Face/arm/leg weakness, visual field defect, speech disturbance Score >1= stroke likely
How is a stroke investigated?
CT
<1hour if: on anticoags, bleeding tendency, GCS <13, indications for thrombolysis, papilloedema/neck stiffness, severe headache at stroke onset, unexplained progressive symptoms
<24hours of symptom onset if above criteria not met
MRI
Bloods: FBC, U&E, Coag, Glucose
ECG
What is the treatment for ischaemic stroke?
Thrombolysis within 4.5hours: Alteplase infusion over 60mins
Oxygen if sats not maintained
Nil by mouth
250-500ml bolus normal saline if dehydrated
Aspirin: 300mg STAT (withheld for 24hours for those given Alteplase)
Endovascular therapy
What is the NIHSS Score?
Calculate the severity of a stroke
1) Level of consciousness
2) Correct month & age
3) Blink eyes & squeeze hands
4) Horizontal extra ocular movements
5) Visual fields
6) Facial palsy
7) Left & Right arm & leg motor drift
8) Limb ataxia
9) Sensation
10) Language/ aphasia
11) Inattention
12) Dysarthria
What are the causes of haeorrhagic stroke?
Chronic hypertension
Vascular malformation
Cerebral amyloid angiopathy
Impaired coagulation
What is the treatment for haemorrhagic stroke?
Neurosurgical care
Neuro ICU
BP Control: Labetalol/ Nicardipine
DVT prophylaxis: Heparin/ Enoxaparin
What are the causes of confusion & delirium?
Vascular: CVA, TIA, dementia
Infection & inflammation: UTI, pneumonia, meningitis, ulcers
Trauma
Autoimmune: Thyroid
Metabolic: AKI, electrolytes, SIADH
Iatrogenic: Meds, OH, poisoning
Neoplastic: Cancer
Congenital: Seizures
Degenerative & developmental: learning, dementia
Endocrine: Glucose, constipation, dehydration
Functional: Visual, hearing
What investigations should be done for someone with delirium or confusion?
ECG Urinalysis Bloods ABG CXR CT LP
How is confusion assessed?
Confusion Assessment Method:
- Acute onset & fluctuating course
- Inattention (easily distracted, difficulty focusing)
- Disorganised thinking (incoherent, rambling, irrelevant to conversation)
- Altered level of consciousness (anything less than alert)
- Cognitive function altered (slow responses , worsening concentration)
- Perception
- Physical function impaired (reduced mobility, movement, restless, agitated, change in appetite, sleep altered)
- Social behaviour (lack of cooperation, withdrawal, mood)
What are the restrictions with epilepsy & driving?
MUST inform DVLA
- Seizures while awake w/LOC: Licence revoked, reapply if no attack for >1yr
- Seizure because Dr changed/reduced meds, reapply when: Seizure >6m ago, previously meds for 6m, no more seizures
- One off seizure & LOC: Licence revoked, reapply when following are true: No seizure in 6m & deemed medically fit
- Seizures asleep & awake: Licence fine if only attack in <3yr has been asleep
- Seizures asleep: Licence fine if >12m since 1st seizure
- Seizure w/ no LOC: Licence fine if >12m since 1st seizure
What are the contraindications of thrombolysis in stroke?
ABSOLUTE: Prev intracranial haemorrhage Seizure at stroke onset Intracranial neoplasm Suspected SAH Stroke/traumatic brain injury past 3m GI bleed past 3w LP past 7d Active bleed Pregnancy Oesophageal varices Uncontrolled HTN >200/120
RELATIVE: Concurrent anticoag (INR >1.7) Haemorrhagic diathesis active DM haemorrhage retinopathy Major trauma/surgery past 2w suspected intracardiac thrombus
What is the secondary prevention after a stroke?
Clopidogrel
Aspirin
Cholesterol >3.5 commence statin (delay for 48hrs)
