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FRCEM Final SAQ > Neurological emergencies > Flashcards

Neurological emergencies Flashcards

1
Q

What are the Indications to perform an immediate non-enhancing CT brain in patients presenting with acute stroke

Reference - NG 128 updated may 2019

A
  1. indications for thrombolysis or thrombectomy
  2. on anticoagulant treatment
  3. a known bleeding tendency
  4. a depressed level of consciousness (Glasgow Coma Score below 13)
  5. unexplained progressive or fluctuating symptoms
  6. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NG128)
  7. papilloedema, neck stiffness or fever
  8. severe headache at onset of stroke symptoms.
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2
Q

Which 2 conditions/criteria must be met before considering alteplase for treatment of acute ischaemic stroke

NG 128

A
  1. treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms
    AND
  2. intracranial haemorrhage has been excluded by appropriate imaging techniques.
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3
Q

You have performed an unenhanced CT brain and now are considering a thrombectomy - What imaging would you choose to perform now?

NG 128

A

If thrombectomy might be indicated, perform imaging with CT contrast angiography
following initial non-enhanced CT. Add CT perfusion imaging (or MR equivalent) if
thrombectomy might be indicated beyond 6 hours of symptom onset. [

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4
Q

How does blood pressure control differ for acute intracerebral haemorrage vs acute ischaemic stroke

NG 128

A

FOR ACUTE HAEMORRAGIC STROKE:

Offer anti-hypertensive control if presenting within 6 hours onset of symptoms AND systolic BP is between 150-220mmhg

FOR ACUTE ISCHAEMIC STROKE:

consider antihypertensive therapy only if there is an hypertensive emergency with one of the following concomittant medical emergencies

  • hypertensive encephalopathy
  • hypertensive nephropathy
  • hypertensive cardiac failure/myocardial infarction
  • aortic dissection
  • pre-eclampsia/eclampsia.
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5
Q

5 clinical findings on examinations to sugggest a diagnosis of MS?

A

o reduced visual acuity and painful eye movements in 1
eye

o double vision

o ascending sensory disturbance and/or weakness

o problems with balance, unsteadiness or clumsiness

o altered sensation travelling down the back and
sometimes into the limbs when bending the neck forwards (Lhermitte’s
symptom).

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6
Q

Features on history taking to suggest MS?

A

o are often aged under 50 and

o may have a history of previous neurological symptoms and

o have symptoms that have evolved over more than 24 hours and

o have symptoms that may persist over several days or weeks and
then improve.

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7
Q
  1. non-pharmacological treatment options for MS?

VS

treatment of acute relapse of MS?

A 
1. #supervised exercise programmes including moderate 
   #progressive resistance training
   #encourage to stop smoking

VS

2.
# treat acute relapse of MS
methylprednisolone 0.5g po daily for 5 days

#treat fatigue with amantidine
#treat spasticity with baclofen or gabapentin
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8
Q

What conditions are associated with cerebral venous sinus thrombosis?

A
  1. Infections
  2. trauma
  3. highly pregnant
  4. hypercoagulable state ( anti-phospoholipid syndrome
    & thrombophilia )
  5. haematological disorders ( TTP, sickle cell disease )
  6. malignancy
  7. vascular disease ( SLE, Wegners, Bechets disease )
  8. ulcerative colitis & crohns
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9
Q

According to NICE CG 128 ( may 2019 )

what are the 3 reperfusion therapy options in a patient wtih an acute ischaemic stroke

A
  1. thrombectomy
  2. intravenous thrombolysis with tPA( alteplase )
  3. intra-arterial thrombolysis
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10
Q

What is the hyperdense MCA sign and what other features on ct head would you look for that would make you suspect this is an acute event rather than an established infarct?

A

the hyperdense MCA sign is:

increased density within the M1 segment of the MCA ( rt or left ).

In addition -

  1. there may be no obvious hypodensity in the MCA territory to suggest an established infarct
  2. there would be no intracranial haemorage evident.
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11
Q

You examine a patient that has a confirmed MCA infarct on CT head. other than weakness, give 3 further neurological findings you would expect to be present on examination.

A

Think according to the categories:

higher cortical: Aphasia

eyes: homonomous hemianopia

Motor: contralateral weakness

sensory: contralateral sensory impairment

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12
Q

Can you name the 5 frailty syndromes as described by the british geriatric society?

A
  1. Delirium
  2. Polypharmacy & susceptibility to side effects of medication
  3. incontinence
  4. falls
  5. immobility
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13
Q

What medical causes of postural hypotension would you consider in an elderly patient presenting with a fall?

A

Think according to the following categories:

what will impair vascular tone in the peripheral circulation:

  • dm
  • parkinsons

when is vascular tone reduced?

  • dehydration
  • addisons

when cant the heart increase the oxygen delivery fast enough?

  • fixed A.S
  • severe heart failure
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14
Q

The 2008 SIGN Guideline (3) gives a list of red flag features for headache on history and examination, can you name them?

A
  1. new onset of headache
  2. headache that is worse on waking
  3. headache worse with change in position ( bending down/lying down)
  4. headache exacerbated by exertion or valsalve

( 1-4 are indicative of raised intracranial pressure possibly due to a cerebral tumour )

  1. new onset headache in a patient with HIV
  2. New onset headache in a patient with cancer
  3. new onset headache in patient over 50 years
  4. sudden onset thunderclap
  5. focal neurological symptoms
  6. non-focal beurological symptoms
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15
Q

Can you name 2 signs of mass effect on a non-contrast ct head?

A
  1. effacement of the anterior horns of the lateral ventricles
  2. and effacement of the sulci.
  3. loss of grey-white differentiation ( due to global brain ischaemia from reduced cerebral perfusion pressure from raised ICP )
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16
Q

what is the treatment of cluster headache, and what drug would you consider for prophylaxis?

A
  1. oxygen - treat with 15 litres nrbm Oxygen for 15- 20 minutes and
  2. Sumatriptan - 6mg s/c sumatriptan

prophylaxis considered with verapamil

17
Q

List 3 clinical features which are more likely in haemorrhagic than embolic strokes?

A
  1. vomiting
  2. persisten headache
  3. seizures
  4. reduced conciousness
18
Q

In a patient with heamorragic stroke how quickly can the effects of warfarin be reversed?

A

within 15 minutes - with the administration of IV prothrombin complex concentrate

19
Q

In a patient with massive upper GI bleeding - give the indications for transfusion of

  1. platelets,
  2. FFP’s and
  3. PCC?
A
  1. Give platelet transfusion to patients who are actively
    bleeding and have a platelet count of < 50 x 109
    /litre.
  2. Give fresh frozen plasma to patients who have either:
     a fibrinogen level of < 1g/litre, OR
     a prothrombin time (INR) or activated partial
    thromboplastin time >1.5 times normal.
  3. Give prothrombin complex concentrate to patients who are
    taking warfarin and actively bleeding
20
Q

in a patient that presents with an acute thrombo-embolic ( ischaemic ) stroke - what are the indications for thrombolysis with tPA ?

Resource:
NICE CG 128

A
  1. Onset of symptoms within 3 hours (3-4.5 hours if evidence of penumbra)
  2. 18-80years old
  3. National Institutes of Health Stroke Scale 4-25
  4. Stroke symptoms
    present for >30minutes

memory aid:
age between 18-80, started within last 3 hours and stroke symptoms lasting > 30 minutes with a NIHSS 4-25

21
Q

What is the mechanism of a 6th nerve palsy in a patient with an ischaemic stroke?

A

it is a false lateralizing sign

22
Q

according to NICE CG 128 : thrombolysis in patients with acute ischaemic stroke , which 2 conditions must be met before considering thrombolysis?

A
  1. treatment is started as soon as possible within 4.5 hours of onset of stroke symptoms
    and
  2. intracranial haemorrhage has been excluded by appropriate imaging techniques.
23
Q

AS per NICE cg 128 for thrombectomy in patient with acute ischaemic stroke -

  1. we should offer thrombectomy as soon as possible and within 6 hours of symptom onset,
    together with intravenous thrombolysis to people who have which 2 criteria/conditions?
  2. Offer thrombectomy
    [6]
    as soon as possible to people who were last known to be
    well between 6 hours and 24 hours previously (including wake-up strokes) - who meet which 2 criteria?
A
  1. acute ischaemic stroke and
    confirmed occlusion of the proximal anterior circulation demonstrated by computed
    tomographic angiography (CTA) or magnetic resonance angiography (MRA)
  2. who have acute ischaemic stroke and confirmed occlusion of the proximal anterior
    circulation demonstrated by CTA or MRA and
    if there is the potential to salvage brain tissue, as shown by imaging such as CT
    perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
24
Q

What are the clinical features of anterior cerebral artery territory stroke syndrome?

A

ANTERIOR CEREBRAL ARTERY TERRITORY STROKE FEATURES ARE:

1. Higher cortical functions :
#ACA = aphasia,change in behaviour and personality, limb apraxia
2. eyes: 
#homonomous hemianopia
  1. motor +/- sensory
#contralateral motor hemiparesis  of face, arm and leg  
( leg > arm )
#contralateral sensory loss
25
Q

What are the clinical features of middle cerebral artery territory stroke syndrome?

A

CLINICAL FEATURES OF MIDDLE CEREBRAL ARTERY TERRITORY STROKE:

1.Higher cortical functions:

Dysphagia ( expressive/ receptive )
( compared to ACA has Aphasia, Changed behaviour, Apraxia of limbs )

2.  eyes
# homonomous hemianopia
  1. motor +/- sensory
#contralateral motor hemiparesis of face, arm and leg ( face/arm > leg )
#contralateral sensory loss
26
Q
  1. What are the associated autonomic features of a cluster headache?
  2. and what drug would you use to treat it?
  3. What drug would you consider as prophylaxis for cluster headache?
A
  1. Autonomic features in cluster headache:
  2. ipsilateral ptosis
  3. ipsilateral miosis
  4. ipsilateral conjunctival injection
  5. ipsilateral lacrimation
  6. ipsilateral rhinorrheoa
  7. Drug therapy in cluster headache:
# high flow oxygen 15L/min tight fit mask
#6mg subcut sumatriptan 
3. Prophylactic therapy for cluster headache is calcium channel blocker 
# verapimil
27
Q

what are the Contra-indications to stroke thrombolysis?

A

contra-indications to thrombolysis for acute ischaemic stroke:

  1. any history of intracranial haemorage
  2. presence of intracranial haemorage on ct scan
  3. clinical presentation suggestive of SAH
  4. known bleeding diathesis
  5. any active internal bleeding
  6. uncontrolled hypertension sbp > 185mmhg or DBP > 110mmhg
28
Q

WHat is malignant hypertension?

A

severe hypertension ( bp> 180/110 ) with evidence of end organ damage e.g.

  • a focal neurological deficit
  • presence of encephalopathy
  • papilloedema
  • pulmonary oedema ( bibasal crackles )
  • 3rd heart sound
  • ankle oedema
  • nephropathy
29
Q

What is the 1st line management for Migraine attack?

CKS - NICE migraine management

A

*Offer simple analgesia such as:
Ibuprofen (400mg) or
Aspirin (900 mg) or
Paracetamol (1000mg).

*Offer a triptan, (alone or in combination with, paracetamol / NSAID) :

Oral sumatriptan (50–100 mg) is first choice

  • Consider offering an anti-emetic (such as metoclopramide 10mg or prochlorperazine 10mg) in addition to other acute medication even in the absence of nausea and vomiting.
30
Q

What prophylactic medication could you prescirbe for the following 2 conditions?

  1. migraine
  2. cluster headaches
    resource: CKS nice bites
A
  1. migraine -
    consider propanolol
    or topiramate ( although unliscenced for this use )
  2. cluster headaches -
    consider calcium channel blocking -verapimil
31
Q

What are the indications to perform a CT head in a patient that presents with a 1st seizure to the ED?

resource:
GEMNET- guideline for the management of lone acute severe headache

A
  1. History of head injury,anticoagulation/bleeding disorders, alcoholism, cancer, HIV, immunosupression
  2. fever or persistent headache
  3. focal seizure
  4. new focal deficit
  5. persistent altered mental state
32
Q

In a patient with a sudden onset of headache.

  1. what are the indications for CT head and
  2. what are the indications for IPPV?

resource:
GEMNET- guideline for the management of lone acute severe headache

A
  1. indications for CT head in suddden onset headache :
    * previous SAH
    * WOrst ever Headache
    * vomiting
    * neck stiffness
    * focal neurology
    * cranial nerve palsy
    * fits
  2. Indications for RSI intubation in sudden headache:
    * GCS < 8/15
    * inadequate respiration
    * hypoxia ( PO2 < 8kpa )
    * hypercapnoea ( PCO2 > 5.5kpa )
    * airway compromise
33
Q

In a patinet with TLOC - how will you diagnose a vasovagal syncope on your initial assessment?

A
  • there are no features that suggest an alternative diagnosis

AND

  • there are features suggestive of uncomplicated faint
    the 3 P’s
Posture ( prolonged standing )
Provoking factors ( pain )
Prodromal symptoms ( sweating or feeling warm just before)
34
Q

In a patient with a TLOC - when should you refer for a

  1. cardiovascular assessment within 24 hours?
  2. neuro specialist within 2 weeks

WHat investigation would you request if you suspect:

  1. a cardiac arrythmia?
  2. vasovagal syncope with recurrent episodes of TLOC
  3. SYncope during exertion
A

1.

  • FH of SCD in < 40 year old
  • TLOC during exertion
  • ECG abnormality
  • new murmur
  • heart failure
  • new unexplained breathlessness
  1. features suggestive of a seizure ( tongue biting, head turning to one side durin TLOC, unusual posturing, prolonged limb jerking )
  2. ambulatory ECG
  3. tilt test
  4. urgent ( within 7 days ) exercise testing
35
Q

What are the 3 indications to admit a patient with a suspected TIA?

https://cks.nice.org.uk/stroke-and-tia#!scenario:1

A
  1. crescendo TIA
  2. Has a suspected cardioembolic source or severe carotid stenosis.
  3. May be unable to attend for urgent review
                            or

lacks a reliable observer at home to contact emergency
services if further symptoms occur.

FRCEM Final SAQ (16 decks)

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