Neuro3 Flashcards
Acute Neurology
What is the scoring for the “eyes” in the GCS?
4- spontaneous movement
3- eyes open to vocal
2- eyes open to pain
1- no response
What is the scoring for the “verbal” in the GCS?
5- speaks coherently 4- confused 3- mumbles random words 2- makes random noises 1- no response
What is the scoring for the “motor” in the GCS?
6- normal movement 5- moves towards localised pain 4- extends away from localised pain 3- abnormal flexion 2- abnormal extension 1- no response
What is the definition of a stroke?
A sudden onset focal neurological deficit of presumed vascular origin which lasts longer than 24 hrs
What is the definition of a transient ischaemic attack?
A sudden onset focal neurological deficit of presumed vascular origin which resolves fully within 24 hrs
What are the two types of strokes?
Ischaemic (80%)
Haemorrhagic (20%)
What are the causes of ischaemic stroke?
Thrombosis
Embolic (eg. AF)
Hypotension
What are the causes of haemorrhagic stroke?
Hypertension
Charcot-Bouchard microaneurysm
Amyloid angiopathy
AV malformations
What are some non-common causes of strokes?
Vasculitis
Cocaine use
Trauma
Tumour
What are the risk factors for a stroke?
Age BP Cardiac disease DM Exercise FHx Hyperlipidaemia Smoking (ABCD...)
What is the epidemiology of a stroke?
3rd commonest cause of death after heart attack and cancer
M>F
Age >70
Hx of TIA
What are the clinical features of a cerebrovascular accident (CVA)?
Sudden onset Weakness Sensory/visual/speech impairment Impaired co-ordination Head/neck pain Memory often intact
What are the UMN lesion signs?
Spasticity/clonus Weak arm extensors, leg flexors Hyper-reflexia Upgoing plantars Pronator drift No fasciculations, muscle wasting
What are the LMN lesion signs?
Hypotonia General weakness Hyporeflexia Normal plantar response Fasciculations, muscle wasting
What are the signs of an anterior cerebral artery infarct?
Contralateral hemiparesis Lower limb > upper limb Abulia (absence of willpower to act decisively) Confusion Gait apraxia Frontal release sign
What are the signs of a middle cerebral artery infarct?
Contralateral hemiparesis
Upper limb > lower limb
Contralateral hemisensory loss
Apraxia
Hemineglect
Receptive/expressive dysphagia (if left sided)
Quadrantanopia (if Meyer’s/Baum’s loop affected)
What is the presentation if Meyer’s loop is affected?
Contralateral homonymous superior quadrantanopia
What is the presentation if Baum’s loop is affected?
Contralateral homonymous inferior quadrantanopia
What are the signs of a posterior cerebral artery infarct?
Macular sparing homonymous hemianopia
Visual agnosia
What are the signs of a basilar artery infarct?
Cranial nerve pathology (III-XII)
Visual impairments
Cerebellar pathology
Impaired consciousness
What are the signs of a superior cerebellar artery infarct?
Dizziness
What are the signs of an anterior inferior cerebellar artery infarct?
Dizziness
Deaf
What are the signs of a posterior inferior cerebellar artery infarct?
Dizziness
Dysphagic
Dysphonic
(Lateral medullary syndome)
What are the signs of a lacunar infarct?
Internal capsule- pure motor deficit
Pontine- dizziness/vertigo, bilateral affects
Thalamus- affects consciousness
Basal ganglia- dyskinaesia
What are the signs of an intracerebral haemorrhage?
Headache and meningism
Focal neurological signs
Raised ICP
Seizures
What are the characteristics of a TIA?
Usually lasts 10-15 minutes
By definition can last up to 24hr
Amaurosis fugax
Global events like syncope/dizziness is atypical
What are the investigations for a stroke?
CT head Bloods ECG CTA Carotid Doppler MRI MRA (gold standard, way too expensive)
What is the hyperacute management for a Pt with an ischaemic stroke presenting <4.5 hrs?
ABCDE
-maintain airway
-maintain BP (to prevent brain hypoperfusion)
-maintain glucose
CT Head
IV alteplase (0.9mg/kg) thrombolysis (if no contraindication)
What are the contraindications for thrombolysis?
Haemorrhagic stroke Recent trauma/surgery Varices/portal hypertension GI bleeds Known clotting disorder BP >180/105
What is the acute management for a Pt with an ischaemic stroke?
Conservative: -SALT assessment -GCS monitoring Medical: -300mg aspirin daily -heparin (VTE prophylaxis)
What is the primary prevention for a stroke?
Control risk factors
- stop smoking
- lower hypertension
- control diabetes/hyperlipidaemia
What is the secondary prevention for a stroke?
75mg aspirin for 2 weeks
Switch to clopidogrel/dipyramidole
Give lifelong anticoagulation (aspirin)
What is the surgical prevention for a stroke?
Carotid endarterectomy
When would you perform a carotid endarterectomy?
If the carotid stenosis is >70% on Doppler scanning
What is the general management of haemorrhagic strokes?
Refer to ICU/stroke unit Monitor glucose/GCS etc Antipyretic- paracetamol BP monitor- labetalol/nicardipine Coagulopathy- reverse warfarin/heparin/dabigatran DVT prophylaxis- heparin/enoxaparin
How is warfarin reversed?
Phytomenadione
Fresh frozen plasma/prothrombin complex concentrate
Platelet transfusion
How is heparin reversed?
Protamine sulphate
Platelet transfusion
How is dabigatran reversed?
Idarucizumab
How are thrombolytic agents reversed?
Fresh frozen plasma/prothrombin complex concentrate
Crypoprecipitate
Platelet transfusion
What are the complications of CVAs?
Aspiration Cerebral odemea Immobility Infection DVT Seizures Cardiovascular events Death
What is the prognosis of a CVA?
10% mortality in 1 month
10% recurrence in 1 year
Haemorrhagic has a worse prognosis
What is used to calculate the risk of a TIA progressing into a stroke?
ABCD2 score
What should you do if the ABCD2 score is >=4?
Refer to a stroke specialist
What does an ABCD2 score >=6 indicate?
- 1% risk of stroke in 2 days
35. 5% risk of stroke in 1 week
What is a seizure?
Abnormal excessive synchronised discharge of cerebral neurons
What is epilepsy?
Tendency for recurrent unprovoked seizures
>2 seizures to be classed as epilepsy
What is the aetiology of epilepsy?
70% idiopathic
30% secondary to brain injury, tumour, stroke, infection, head injury, autoimmune
What are the risk factors for epilepsy?
FHx
Childhood infections
Neurodevelopmental disorders eg. autism
Metabolic disease eg. storage disorders, PKU
What is the classification of epilepsy?
Focal
Generalised
What is the difference between a partial and complex seizure?
Partial- no LoC
Complex- LoC
What are the types of generalised seizures?
Tonic-clonic Absence Myoclonic Tonic Atonic
What is the description of a tonic-clonic seizure?
Prodrome- auras
Tonic- stiffening of muscles
Clonic- contractions
Post-ictal- drowsy state
What is the description of a absence seizure?
Loss of consiousness
Cessation of activity
Brief upward rolling of eyes
What is the description of a myoclonic seizure?
Jerking of specific muscle groups
What is the description of a tonic seizure?
Bear hugging posture
What is the description of a atonic seizure?
Complete loss of muscle tone
What is the presentation of a temporal focal seizure?
Automatisms
Hallucinations
Dysphagia
What is the presentation of a frontal focal seizure?
Jacksonian march
Todd’s palsy
Leg motor disturbance
What is the presentation of a parietal focal seizure?
Sensory deficits
What is the presentation of a occipital focal seizure?
Visual deficits
What are the investigations for epilepsy?
Bloods -glucose (severe hyper/hypoglycaemia) -WCC (CNS infx) EEG CT/MRI head
What is the management for a focal seizure?
Carabamazepine/lamotrigine
What is the management for a generalised seizure?
Sodium valproate
What is status epilepticus?
A continous seizure lasting >30 minutes
What is the management for status epilepticus?
Secure airway High flow O2 Assess cardiac and resp function Check blood glucose Secure IV access in both arms
IV lorazepam
IV phenytoin/phenobarbital
General anaesthetic eg. midazolam
Seek expert advice
What are the complications of epilepsy?
SUDEP (sudden death in epilepsy)
Status epilepticus
Fractures
Drug SEs
What is a dissociative seizure?
Seizure with no identifiable organic cause
Often last much longer than epilepsy
Variable in presentation
Patients most likely able to recall event
Clinical diagnosis
What is hydrocephalus?
Enlargement of the cerebral ventricular system
What are the types of hydrocephalus?
Communicating/non-obstructive
Non-communicating/obstructive
Hydrocephalus ex vacuo
What are the causes of communicating hydrocephalus?
SAH
Meningitis
Normal pressure hydrocephalus
What are the causes of obstructive hydrocephalus?
3/4th ventricle lesion
Cerebral aqueduct stenosis
Posterior cranial fossa tumour
What is hydrocephalus ex vacuo?
Compensatory enlargement of the ventricles due to parenchymal atrophy
What are the clinical features of hydrocephalus?
Acute drop in consciousness Diplopia Palsy Behavioural changes Seizure Raised ICP
What are the clinical features of hydrocephalus in neonates?
Increased head circumference
Sunset sign
What is seen in normal pressure hydrocephalus?
Hakim’s triad
- wet (urinary incontinence)
- wacky (dementia)
- wobbly (gait disturbance)
What are the investigations for hydrocepalus?
CT scan
CSF
LP (therapeutic in NPH)
What is the management for hydrocephalus?
Interventricular shunts
What is spinal cord compression?
Injury to the spinal cord with neurological symptoms dependant on the site and extent of injury
What are the common causes of spinal cord compression?
Trauma Metastases Inflammatory disease Spinal stenosis -> cauda equina Spinal abscess Pott's disease
What are the risk factors of spinal cord compression?
Bone disease
Vertebral disc disease
Cancer
What are the clinical features of spinal cord compression?
Back pain
Spastic paresis (bilateral, lower limbs)
Sensory loss
Incontinence
What are the clinical features of cauda equina?
Flaccid paresis Loss of bowel/bladder control Saddle paraesthesia Radicular back/leg pain Areflexia
What are the clinical features of Brown-Sequard syndrome?
Ipsilateral proprioception loss
Ipsilateral light sensation loss
Ipsilateral paralysis
Contralateral pain loss
What are the investigations for spinal cord compression?
Bloods
-FBC, ESR, B12, syphilis serology, U+E, LFT, PSA
Radiology
MRI- definitive
What is Guillain-Barre syndrome?
Acute inflammatory demyelinating polyneuropathy
What is the aetiology of GBS?
Unclear
Link with campylobacter jejuni and lymphoma
What are the clinical features of GBS?
Progressive ascending paraesthesia and paresis
Can lead to respiratory distress
Can involve cranial nerves
What is the Miller-Fisher variant?
GBS with the following triad:
Ophthalmoplegia
Ataxia
Areflexia
What are the investigations for GBS?
Lumbar puncture
-high protein, normal cell count and glucose
Nerve conduction studies
-reduced conduction velocity
Bloods
-Anti-ganglioside antibodies in MF variant + 25% of GBS
Spirometry
-fixed vital capacity: ventilatory weakness
ECG
-may develop arrhythymia
A patient is rushed into hospital having collapsed on the street. After assessing airways, breathing and circulation you now assess their disability. They have not opened their eyes since arriving and only mumble incoherently when told to open their eyes. They do not respond to vocal commands to move however when you squeeze the patient’s trapezius muscle, they move to the appropriate shoulder to slap your hand away and briefly open their eyes.
What is their GCS score?
A. 2 B. 5 C. 8 D. 9 E. 13
C. 8
E- 3
V- 2
M- 5
An 85-year-old woman presents to A+E struggling to talk. Her husband brought her in 30 minutes ago after she was unsteady on her feet and fell over. You assess her consciousness and find she has a GCS of 15. On examination you find she has right-sided hemiparesis with positive Babinski sign. You assess her blood pressure and find it to be 170/100.
What is the most appropriate next step?
A. ACEi IV B. Alteplase IV C. Urgent CT head scan D. Aspirin 300mg oral E. Urgent carotid doppler
C. Urgent CT head scan
A 65-year-old man presents with sudden onset left sided weakness. He is obese, type II diabetic and has high cholesterol. On examination you find a left-sided hemiparesis with his arm more affected than the leg. There is also an equal hemisensory loss. He is unable to see anything at the bottom of his vision on his left-hand side.
Which vascular territory has likely been affected?
A. Right middle cerebral artery B. Right anterior cerebral artery C. Left middle cerebral artery D. Right carotid artery E. Right posterior cerebral artery
A. Right middle cerebral artery
A 25 year old woman has an episode of altered consciousness lasting a few minutes. She has no memory of the event but just beforehand she developed a sense of déjà vu and had a rising feeling in her stomach.
What is the most likely cause?
A. Absence seizure B. Vasovagal episode C. Complex partial seizure D. Simple partial seizure E. Cardiac arrhythmia
A. Absence seizure
A 15 year old girl who is a known epileptic has arrived at hospital having a seizure. The seizure started over 30 minutes ago while she was having dinner and has not regained consciousness since. Her mother says she has had 3 seizures over the past 3 months before being diagnosed with and treated for epilepsy, but none were as bad as this. Life support examination reveals that the airways are open, patient is breathing and pulse is 110 bpm. Her GCS is 8/15. You set up two IV lines ready for the patient to be managed.
What is the most appropriate next step?
A. Perform an EEG B. Check glucose C. Perform CT scan D. Give IV lorazepam E. Give IV thiopentone
D. Give IV lorazepam
A 26-year-old man was admitted for severe food poisoning and put on antibiotics, a week later in his hospital bed he’s started to notice pins and needles across his lower limb, and he’s been feeling weak in that region also. What’s the most likely diagnosis?
A. Guillain Barre Syndrome B. Meningism C. Antibiotic allergy D. B-12 deficiency E. Stokes-Adams attack
A: Guillain Barre Syndrome
