Neurological Flashcards
Tx of subdural Hematoma
if less 10mm and less 5mm midline shift - observation, monitoring and follow up,
Prophylactic anti epileptic,
correction coagulopathy,
intracranial pressure-lowering regimen
greater 10mm and greater 5mm midline shift - surgery + as above.
Irrigation/evacuation eg drill
Craniotomy
RF for sub dural hematoma
recent trauma
Coagulopathy
advanced age >65
anticoagulant use
RF for Subarachnoid Haemorrhage
smoking alcohol misuse HTN Bleeding disorders, mycotic aneurysm (SBE) Post menopausal decreased oestrogen FmHx - 3-4 fold
Presentation of subarachnoid
Clinical presentation
Elderly with no traumatic history
PmHx of HTN, AVM, Aneurysms or Diabetes mellitus
Symptoms
sudden severe headache - described as thunder clap
+/- vomiting collapse, seizures and coma
Signs
Neck stiffness
Kernig’s signs - 6 hr to develop.
Brudzinski’s sign
Retinal haemorrhages
+/- focal neuropathy - indicate site of aneurysm
Pupil change = CN3 palsy with a posterior communicating artery aneurysm or intracerebral bleed.
Mx of subarachnoid
Refer to neurosurgery Senior help Reexam often for Neuro and GCS First line - Cardiopulmonary support 2 rd Maintain cerebral perfusion - Hydration, aim BP >/= 160 and only tx if severe. Sugical clipping or coil embolisation Calcium channel blocker - Nimodipine - to reduce risk of poor outcome by reducing vasospasm and secondary ischaemia after aneurysmal SAH. Stool softeners Antitussive - if coughing Analgesia - if headache Coagulopathy correction Sodium replacement - hyponatraemia
Complication of Subarachnoid haemorrhage
Rebreeding 20%
cerebral ischaemia
Hydrocephalus
Hyponatraemia
Symptoms and signs of Extradural
Clinical sign progress
1 trauma - severe enough to cause fracture of temporal or parietal bone
2 Loss of consciousness = concussion
3 Regains after a few minute = Lucid interval
may get up and walking around
4 Loss of consciousness again = hepatoma compression on brain
other
severe headache
vomiting
confusion
fets
hemiparesis with brisk reflexes and up going plantar reflexes
Ipsilateral pupil dilates
coma deepens
bilateral limb weakness develops
breathing becomes deep and irregular = brainstem compression
Mx of extradural
Call for help
watch for deterioration - Cheyne-Stokes breathing and unilateral fixed dilated pupil
Intubate
Urgent CT
Neurosurgical tea referral
IV fluids to maintain euvolemia to provide adequate cerebral perfusion pressure
Tx ICP by
- osmotic diuretics
- Hyperventilation to prevent hypocapnia which may cause vasoconstriction and ischema.
- elevate head 30 degrees.
Surgical evacuation.
Difference between concussion, contusion and laceration
Concussion mild short unconscious, spontaneous recovery
Contusion is moderate. Bruise which include, coup and contra coup and diffuse axonal injury
Laceration is severe - visible tear in brain tissue
Stroke Management
DRS ABCDEFGlucose
CT to rule out haemorrhage
Aspirin
ischemic - Thrombolysis - IV recombinant tissue plasminogen activator within 4.5 hr
Haemorrhage - need surgical referral.
Regulate CO and O2 levels with ETT and ventilator
Surgery to decrease intracranial pressure
Coagulation and electrolyte correction
Stroke unit referral
Manage RF - Long term antiplatele drugs, statins, oral anticoagulation, antihypertensive
NBM until SP swallow assessment
Carotid USS look for source
Carotid endarterectomy and angioplasty.
Echo, CXR, ECG
Canadian CT head rule
CT is required for patients with minor head injuries (minor head injury is defined as witnessed LOC, definite amnesia, or witnessed disorientation in patients with a GCS score of 13 to 15) with any one of the following: [8]
High risk (for neurological intervention):
- GCS less 15 at 2 hours after injury
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (haemotympanum, raccoon eyes [periorbital ecchymosis], CSF otorrhoea/rhinorrhoea, Battle’s sign [ecchymosis of the mastoids])
- 2 or more episodes of vomiting
- Aged 65 years or above
Medium risk (for brain injury on CT):
- Amnesia more than 30 minutes before impact (retrograde amnesia)
- Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height greater 1 metre [3 feet] or greater 5 stairs).
Contraindications for Thrombolysis
Major infarct or haemorrhage on CT
Mild (non disabling) deficits
Recent surgery, trauma, or obstetric delivery
Past CNS haemorrhage
AVM or aneurysm
Severe liver disease, varices or portal HTN
Seizures at presentation
Recent arterial or venous puncture at a non-compressible site
Anticoagulants or PTT greater then 15s
PLT less then 100
BP greater then 220/130
Test to do in a patient that had a stroke
HTN
Echo
CXR
Carotid doppler
Hypoglycaemia, hyperglycaemia, hypolipidaemia, hyperhomocysteinaemia
Vasculitis - ESR, ANA+ve,
Prothrombitc states, Thrombophilia, antiphospholipid syndrome
Hyper viscosity eg polycythaemia, sickle cell disease
Thrombocytopenia
