Neuro emergency Flashcards
SAH:
- Definition + most common cause
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
- Complications
- Prognostic factors (3)
SAH:
- Definition + most common cause : trauma, ruptured aneurysm, avm, htn
- Risk factors: ehlers, marfans, scd, pckd, htn, fx
- Symptoms: thunderclap headache occipital, photop, neck stiff, n+v, reduced conscious, seizures
- Investigations: non contrast ct (blood is white), if ct done >6 hours after onset then lp 12 hours post = xanthrochromia + inc bilirubin, ct ang for cause, clotting/fbc
- Management: maintain hydration, intubate if gcs <8, surgery in 72 hours endovasc coiling/neurosurg clipping, nimodipine, phenyotoin, anag, vte, rev anticoags
- Complications: hydroceph, rebleed, siadh, vasospasm, seizure, torsades
- Prognostic factors (3); conscious level, age, amount blood on ct
Meningitis:
- Definition
- Organism causes - neonates, child, elderly, viral
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
- Complications - acute, bacterial, viral
Meningitis:
- Causes:
neonates: ecoli, group strep b
child: haem influ, neisseria
elderly: strep peneum
immunosupp: listeria monocytogenes
viral: hsv, enterov, varicella
- Risk factors: ear implants, spinal procedure, endocarditis, splenectomy, crowded house
- Symptoms: nuchal rigidity, fever, altered mental status - photophobia, headache, seizures
- Signs: non blanching rash if meningococcal septicaemia, kernig (ext knee = resis), brudzinski (flexion neck = flex knees + hips)
- Complications: sepsis, cerebral oedema, siadh, hearing loss sensor, dic, seizures, waterhouse friderrichsen syndrome (haemorrhage causing adrenal insuff)
- Investigations: fbc/crp/u+es/lfts, cultures, LP for bacterial culture/viral pcr/cell count/protein/glucose, lp not needed if rash just meningococcal pcr
No LP if: papiloedma, gcs<12, bleed risk, resp/cardio compromise, signs sepsis
bacterial: cloudy, inc wcc (neuts), dec glucose, inc protein, + gram stain
viral: inc wcc (lymph), normal or inc protein
TB: fibrin web, dec glucose, inc protein, inc wcc (lymph)
- Management: if in gp 1M benzylpenicillin. dexameth within 12 hours abx + >6 months old, analgesia, single dose cipro if contact within 7 days, acyclovir
<3 months : cefotxime + amoxicillin (+ gentamicin if <28 days)
3 months - 50yrs: cefotaxime
>50: cefotaxime + amoxicillin
If meningococcal: iv benzylpenicllin + cefotaxime
Status epilepticus:
- Definition
- Complications
- Management
- Causes
Status epilepticus:
- Definition : seizure >5 mins (10 mins for focal) or 2 or more without regaining consciousness
- Complications : cerebral oedema, hyperthermia, shock, arrhythmia
- Management : 10mg buccal midazolam, 10mg PR diazepam, 4mg IV lorazepam and can repeat after 10 mins, iv phenytoin/levetiracetam/na valp, intubate + GA if still none
- Causes: epilepsy, head injury, alc consumption, uraemia
Stroke:
- Definition
- Causes
- Risk factors
- Symptoms
- Investigations
- Management
Stroke:
- Definition: a cerebrovascular accident where neurological deficit for >24 hours
- Causes: due to ischaemic (thrombus, embolus) or haemorrhagic (subarach due to avn malform or aneurysm, intracerebral due to htn)
- Risk factors: smoking, obesity, htn, dyslipid, previous, AF
- Symptoms: face drooping (forehead spared), arm contralat sensory loss or motor weaknesss, slurred speech, homonymous hemianopia, seizures
- Assessment tools: exclude hypoglycemia, ROSIER in a&e to work out if stroke or mimic (>0 = stroke likely), neuro ex
- Ix: ecg (af), fbc/clotting/lipids/glucose/u+es/lfts, carotid doppler uss, first line CT head non contrast where if black is isch and if white is blood
- Initial management: after ct admit to stroke centre, if <4.5 (or 9 if sleeping) hours iv thrombolysis altepase (not if prev haem/tumour/seiz/preg), then 24 hours after 300mg aspirin for 2 weeks OR straight away if no thrombolysis, thrombectomy in addition if large vessel/nihss >5 within 24 hours
- Management + supportive: SALT, physio, botulin if spasticity, no driving for 1 month, start 75 mg clopidogrel 2 weeks after aspirin + a statin if >3.5 48 hours after. Can also do carotid endartectomy if stenosis >50% within 7 days
NIHSS determines severity hence prognosis so if >22 bad and if <4 good. ASPECTs score is via CT findings
Monitor cbg, hydration, sats, temp, bp throughout, dvt - Complications: becomes haemorrhagic, cerebral oedema, seizures, bowel/bladder dysfunction, aspiration pneumonia, spasticity, immobility/ulcers, cognitive impairment
- Stroke mimics:
1. excluded via brain imaging: sol, ms, subdural haematoma
2. differences in symptoms: bppv, vestib neuronitis, syncope, transient global amnesia
3. further ix needed: migraine w aura, focal seizure, functional neurolog disorder
unlike these stroke should be stereotyped epsidoes, sudden, focal, and symptoms fit into a vascular territory
capsular warning syndrome are recurrent episodes of m/s signs without cortical signs (aphasia/apraxia/agnosia) which inc risk stroke - Bamford classification:
- TACs: 3 of homonymous hemianopea, contalat motor/sensory weakness, higher cerebral dysfunction (dysphasia, visuospatial dis, reduced conscious - proximal mca (upper limbs affected more)
- PACs: 2 of - mca branch
- LACs: 1 of pure sensory, pure motor or ataxic gait - lenticulostriate
- POCs: 1 of loss conciousness, homonymous hemian w macular sparing, cerebellar dysfunction, bstem dysfunction (m/s deficit with cranial nerve deficit) - vertebral/basilar/cerebellar artery
- Lateral medullary artery (wallenbergs syndrome): contralat limb sensory loss, ipsit (ataxia/facial numbness/dysphagia/cranial nerve palsy) - post inferior cerebellar art (supplies lateral medulla in bstem hence lateral spinothalamic tract controlling temp/pain)
- lateral pontine syndrome: same as wallenburgs but ipsat facial paralysis + deafness
- Webers: ipsilat cn3 palsy, contralat weakness
- amaurosis fugax - ophthalmic artery
- locked in syndrome - basilar artery
Other intracranial haemorrhages:
- Extradural: definition, cause, investigation, symptoms, complication
- Subdural: definition, cause, investigation
- Intracerebral: definition, strokes, causes
- general symptoms
- general risk factors
- management
- extradural: meningeal layer skull + dura. middle meningeal artery. CT shows biconvex (lentiform lemon). loss conscious, lucid then rapid decline. Causes supratentorial herniation hence cn3 palsy. craniotomy if neuro deficit.
- subdural: acute if <48 hours, chronic if >48. Bridging veins in elderly/alcoholics. Headache, confusion, focal neuro deficits, behaviour change, papilloedema, cn3 palsy, gait abnorm. Crescent shape CT (if chronic then hypodense. Surgical decompression with burr holes.
Encephalitis:
- Definition
- Causes - viral, bacterial and other things
- Symptoms
- Investigations
- Management
Encephalitis:
- Definition : infection of brain parenchyma
- Causes - viral, bacterial and other things: hsv1 (typically temporal + inferior frontal), cmv, vzv, rabies, polio, autoimmune
- Symptoms: dec consciousness, behaviour change, seizures, vomiting, headache, sensory/m deficits, aphasia, fever
- Investigations : urine dip, eeg (pleds, slowing delta waves), fbc/crp/hiv/cultures, mri head, lp (inc lymphocytes + protein)
- Management: ceftriaxone, iv aciclovir, anticonvulsants, dexameth if inc icp
Increased ICP:
- Normal ICP level in adult + child
- Causes
- Symptoms + signs
- Investigations
- Management
Increased ICP:
- Normal ICP level in adult + child: 15-20 (5-20)
- Causes: SOL, HIE, hydrocephalus, IIH, infection
- Symptoms + signs: dec conscious, headache, n+v, papilledema, dilated pupils (cn3 comp), cushings triad (irreg breathing, bradycardia, widening pulse pressure)
- Investigations: ct/mri, intraventricular catheter, intraparenchymal fibrooptic catheter
- Management : elevate, iv mannitol, controlled hypervent, drain
Temporal arteritis:
- Definition
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
- Complications
Acute bulbar palsy:
- Definition
- Causes
- Symptoms
- Management
Acute bulbar palsy:
- Definition : damage to cranial nerves 9-12
9 glossopharngeal: sens oropharynx, psns parotid, taste ant 2/3, carotid afferent
10 vagus: sens larynx, psns heart, motor larynx pharynx soft palate
11 accessory : motor tongue
12 hypoglossal: motor scm + trapezius - Causes: stroke, tumour, als, gbs
- Symptoms : dysphagia, dysphonia, drooling, dysarthria
- Management : glycopyronium bromide, ng tube, salt
- pseudobulbar palsy: umn signs onl
Idiopathic intracranial hypertension IIH:
- Definition
- Risk factors
- Symptoms
- Investigations
- Management - meds, surgical, lifestyle
Idiopathic intracranial hypertension IIH:
- Definition: no obvious cause but chronic inc ICP (should be 10-15). inc icp dec cerebral blood flow which can lead to oedema and dec blood flow even more
- Risk factors : overweight, female, fertile/preg, cocp use
- Symptoms: tinnitus, retrobulbar pain, papilloedema, headache, visual field loss, cn6 palsy
- Investigations: lp shows inc opening pressure
- Management - meds, surgical, lifestyle: carbonic anhydrase inhibitors acetazolamide dec csf production + furosemide, weight loss inc topiramate, surgery optic nerve sheath decompression + fenestration
SC compression + cauda equina:
- Causes
- symptoms
- UMN signs
- mx
- Complications
- lmn signs
- Cauda equina definition
- Symptoms
- Investigations
- Management
- Complications
SC compression (myelopathy) + cauda equina:
- Causes : fracture, prolapsed disc, malignancy, abscess/infection, stenosis, ankylosing spondylitis
- Symptoms: clumsiness, numbness, hoffman sign, umn signs
- UMN signs: hyperreflexia, hypertonia, spasticity, + babinski response (extensor plantar), clonus
- mx: nsaids, physio, decomp
- Complications: autonomic dysreflexia when impacted/retention (extreme htn, sweaty, agitation) if injury above t6
- LMN signs: hyporeflexia, hypotonia, flaccid muscle weakness, fasciculations, atrophy/weakness, flexor plantars
- Cauda equina definition: compression of cauda equina l1-s5 (lmn
- Symptoms: lower back pain, bilateral lower limb siatica pain, saddle anaesthesia, urin retention/incontinence, ed, weakness, reduced anal tone, lmn sign
- Investigations: urgent mri lumbar spine
- Management : urgent lumbar decompression within 48 hours onset (mets - radio, steroids if ankle)
- Complications: bladder, bowel, limb dysfunction
Head injury:
- Investigations
Head injury:
- Investigations:
ct within 1 hour if gcs <13 or <15 2 hours post injury, suspected skull fracture, seizure, focal neurolog deficit, vomiting.
CT within 8 hours if some loss conscious or anmesia +: >65, bleeding disorder/anticoags, dangerous injury, >30 mins amnesia
in paeds: immediate ct: loss conscious >5 mins, amnesia >5 mins, abormally drowsy, 3 or more episodes of vomiting, nai, seizure, gcs <14, suspicion skull fracture, neurolog deficit, if <1 w >5cm bruising, dangerous mech injury
Brown sequard syndrome:
- causes
- ix
- symptoms
Brown sequard syndrome:
- causes: sc hemisection lesion via fracture/knife/tumour/inflammatory
- ix: mri
- symptoms
1. dorsal column: decussates at medulla hence ipsilat fine touch, proprioception, vibration, 2D point discrimination
2. spinothalamic: decussates at spinal level hence contralat crude touch, pain, temp
3. corticospinal: ipsilat spastic paralysis (umn signs)
TIA:
- definition
- causes
- symptoms
- mx
- ix
TIA:
- Definition: focal neurolog deficit caused by focal brain/sc/retinal isch without acute infarction
- Causes: atherosclerosis
- Symptoms: m/s loss, aphasia, hemispatial neglect, dizzy, weak, amaurosis fugax
- Management: 300mg aspirin until seen, specialist within 24 hours (or within 1 weeks if >7 days). then dual antip therapy: clopidogrel 300mg intial dose then 75mg indef , aspirin 75mg 21 days + ppi (if cont then ticagrelor + clopidogrel)
if recurrent no driving for 3 months - Investigations: rule out hypoglyc fbc/gluc/lipids/coag, carotid duplex uss within 24 hours, mri brain with diffusion weighted imaging
Brain abscess
- symptoms
- ix
- mx
- symptoms: headache, fever, focal neurology due to inc icp, nausea, papilledema, seizures
- ix: ct with contrast: rim enhancing lesion w central cavity + surrounding oedema. mri contrast: lesion is diffusion restricting
- mx: surgery craniotomy + debridement, iv cephalosporin + metronidazole, dexameth if inc icp
