Neurology Flashcards
What is a TIA?
- sudden onset
- brief episode of neurological deficit
Pathophysiology of TIA
- temporary, focal cerebal ischaemia
- lack of O2 and nutrients to brain
- without infarction → no irreversible cell death
Features of a TIA
- symptoms are maximal at onset
- usually lasts 5-15 mins
- classical definition = lasts <24hrs
Risk factors for TIA
- age
- HTN
- smoking
- diabetes
- a fib
- the pill
- males
- black people
Causes of a TIA
atherothromboembolism from carotid artery
cardioembolism
- in a fib
- after an MI
- valve disease/prosthetic valve
hyperviscosity
hypoperfusion
Presentation of a TIA
- amaurosis fugax
- aphasia
- hemiparesis
- hemisensory loss
- hemianopic visual loss
What symptoms do not indicate a TIA on their own?
- syncope
- dizziness
- temporary loss of consciousness
- temporary memory loss
- gradual onset
What scoring tool measures the risk of a stroke after a TIA?
ABCD2 score
- age
- BP
- clinical features
- duration of TIA
- DM
- gives 2 day risk
Investigations for TIA
- diffusion weighted MRI/CT brain
- carotid imaging → doppler US then angiography if stenosis found
- bloods
- ECG
- echo
Management of TIA
- loading dose 300mg aspirin
- control BP/cholesterol
- no driving for 1 month
- antiplatelet therapy = daily 75mg aspirin
- anticoagulation if AF
- carotid endarterectomy
What is a stroke?
- rapid onset neurological deficit
- lasting over 24hrs
- poor blood flow to brain → cell death
What are the 2 types of stroke?
ischaemic 85%
- blood clot in blood vessel to brain
haemorrhagic 15%
- bleed in small blood vessel in/around brain
urgent CT/MRI to determine type → guides treatment
Risk factors for ischaemic stroke
- age
- male
- HTN
- smoking
- diabetes
- recent/past TIA
- IHD/AF
- the pill
- black/asian
- PVD
Causes of ischaemic stroke
- small vessel occlusion by thrombus
- atherothromboembolism
- cardioembolism
- hyperviscosity
- hypoperfusion
- vasculitis
- fat emboli from long bone fracture
- venous sinus thrombosis
Presentation of cerebral infarcts
depends on site
ACA
- contralateral weakness and sensory loss of lower limb
MCA
- contralateral motor weakness/sensory loss
- speech issues
- contralateral hemiplegia
- UMN facial weakness
- dysphagia
- homonymous hemianopia
- visuo-spatial deficit
Presentation of brainstem infarcts
depends on site
- quadriplegia
- facial numbness/paralysis
- vision disturbances
- speech impairment
- vertigo → N&V
- locked-in syndrome
What are lacunar infarcts?
- small infarcts
- occlusion of a single perforating artery supplying a subcortical area
occurs in
- internal capsule
- basal ganglia
- thalamus
- pons
Presentation of lacunar infarcts
depends on site → one of:
- sensory loss
- unilateral weakness
- ataxic hemiparesis
- dysarthria
Management of ischaemic strokes
- exclude haemorrhagic stroke
- loading dose 300mg aspirin
- antiplatelet therapy → 300mg aspiring daily for 2 weeks then clopidogrel
- anticoagulation if AF
- thrombolysis → IV alteplase within 4.5hrs
- mechanical thrombectomy
acute stroke unit
- rehabilitation
- swallowing/feeding support
What are the 4 types of haemorrhagic stroke?
- intracerebral haemorrhage
- subarachnoid haemorrhage
- extradural haemorrhage
- subdural haemorrhage
What is an intracerebral haemorrhage?
- sudden bleeding into brain tissue
- rupture of blood vessel in brain
- leads to infarction (O2 deprivation)
- pooling blood increases ICP
Risk factors for intracerebral haemorrhage
- HTN
- age
- alcohol
- smoking
- diabetes
- anticoagulation
- thrombolysis
- secondary to ischaemic stroke
Pathophysiology of increased ICP
- pressure on skull/brain/blood vessels
- CSF obstruction
- midline shift
- tentorial herniation
- coning
Presentation of intracerebral haemorrhage
similar to ischaemic stroke
pointers to haemorrhage
- sudden loss of consciousness
- severe headache
- meningism
- coma
Investigations for intracerebral haemorrhage
- same as ischaemic stroke
- CT/MRI brain = essential
Management of intracerebral haemorrhage
- stop anticoagulants immediately → reverse effects with clotting factor replacement
- BP control
- reduce ICP → mechanical ventilation, IV mannitol
What is a subarachnoid haemorrhage?
spontaneous bleeding into subarachnoid space
Risk factors for SAH
- HTN
- known aneurysm
- previous aneurysmal SAH
conditions associated with berry aneurysms
- PKD
- coarctation of aorta
- connective tissues diseases
Causes of SAH
- aneurysmal rupture → Berry aneurysms
- ateriovenous malformations
- idiopathic
- traumatic injury
Pathophysiology of SAH
- tissue ischaemia
- raised ICP
- space-occupying lesion → puts pressure on brain
- blood irritates meninges → can obstruct CSF outflow
- vasospasm
Complications of SAH
- rebleeding
- hyponatraemia
Symptoms of SAH
- sudden onset excruciating headache → thunderclap, occipital
- N&V
- collapse
- loss of consciousness
- vision changes
- coma
Signs of SAH
signs of meningeal irritation
- neck stiffness
- Kernig’s sign
- Brudzinski’s sign
- retinal, subhyaloid, vitreous bleeds
- focal neurological signs
- high BP
Investigations for SAH
ASAP brain CT
- star shaped sign
lumbar puncture
- only if normal ICP
- xanthochromia → yellowish CSF
MR/CT angiography to find source of bleeding
Management of SAH
- IV fluids
- ventricular drainage if hydrocephalus
- nimodipine reduces vasospasm
- surgery if aneurysm → endovascular coiling/surgical clipping
What is a subdural haematoma?
- bleeding into subdural space
- rupture of bridging vein
- usually due to head trauma
- massive latent interval
Risk factors of subdural haematoma
- babies → traumatic injury
- brain atrophy → dementia, elderly, alcoholics
- prone to falls
- anticoagulants
Pathophysiology of subdural haematoma
- bleeding forms haematoma then stops
weeks/months later
- haematoma autolyses → increase in oncotic/osmotic pressure → water sucked in → haematoma enlarges
- rise in ICP
- midline structures shifted away from side of clot
Symptoms of subdural haematoma
- fluctuating levels of consciousness
- drowsiness
- headache
- confusion
- insidious physical/intellectual slowing
Signs of subdural haematoma
- raised ICP
- seizures
- localising neurological signs
Investigations for subdural haematoma
CT scan
- haematoma → banana shaped
- midline shift
MRI
Management of subdural haematoma
surgery
- remove haematoma → clot evacuation
- craniotomy
- burr hole washout
IV manittol
reverse clotting abnormalities
address cause
What is an extradural haematoma?
- bleeding into extradural space
- after trauma to temple → fracture → rupture of MMA
- lucid interval
Risk factors for extradural haematoma
- young people
- male
Pathophysiology of extradural haematoma
after lucid interval
- rise in ICP
- pressure on brain
- midline shift → tentorial herniation/coning
Presentation of extradural haematoma
after lucid interval
- rapidly declining GCS
- headache
- vomiting
- seizures
- coma
- deep/irregular breathing → coning
- death → respiratory arrest
Investigations for extradural haematoma
CT scan
- haematoma → lemon shaped
- midline shift
skull xray → fracture lines
Management of extradual haematoma
- stabilise
- urgent surgery → clot evacuation/ligation of bleeding vessel
- IV mannitol
- airway care
What are the red flags for headaches?
- worst headache ever
- other neurological signs
- onset >50
- severe, quick onset
- abnormal pattern of migraine
What is a migraine?
- recurrent throbbing headache
- often preceded by an aura
- associated with N&V, visual changes
most common cause of episodic headache
Risk factors for migraines
- family history
- female
- age → first in adolescence
Causes of migraines
CHOCOLATE
- chocolate
- hangovers
- orgasms
- cheese
- oral contraceptives
- lie-ins
- alcohol
- tumult
- exercise
Presentation of migraine
prodrome
- yawning
- craving
- mood/sleep changes
aura
- precedes attack, variety of symptoms
- visual disturbances
- parasthesia
Diagnosis of migraine
2+ of:
- unilateral pain
- throbbing-type pain
- moderate to severe intensity
- motion sensitivity
and 1+ of:
- N&V
- photo/phonophobia
Investigations for migraine
- bloods
- CT/MRI → look for red flags
- lumbar punture
Management of migraines
conservative = avoid triggers
mild
- NSAIDs → naproxen/ipubprofen
- antiemetic
severe = oral triptans eg sumatriptan
- not if IHD, uncontrolled HTN
- SE → arrythmias, angina
Prophylaxis of migraines
- beta blockers
- acupuncture
- amitriptyline = TCA
- topiramate = anticonvulsant
What are cluster headaches?
- episodic headaches with pain free periods
- most disabling primary headache
Risk factors for cluster headaches
- smoking
- alcohol
- male
- 20-40
- autosomal dominant gene
Presentation of cluster headaches
pain
- rapid onset excruciating
- classically around the eye
- can be temples and forehead
- unilateral, localised to one area
- rises to a crescendo over few minutes
- lasts 15-160mins, 1/2 x a day
- watery bloodshot eye
- facial flusing
- rhinorrhoea
- miosis +/- ptosis
Management of cluster headaches
- 15L 100% O2 for 15mins via non-rebreather mask
- triptans → sumatriptan
Prevention of cluster headaches
- verapamil CCB
- prednisolone
- stop smoking/drinking