Neurology Flashcards
What is the difference between Conus Medullaris Syndrome and Cauda Equina?
Conus Medullaris- Upper Motor Neurone signs- Hyperreflexia and Hypertonia
Cauda Equina- Lower Motor Neurone signs- Hyporeflexia and Hypotonia
What are the 4 causes of Cauda Equina?
Lumbar Disc Herniation
Trauma (Fall)
Spinal Tumour
Lumbar Spine Stenosis (narrowing of the spinal canal)
What are the 5 signs of Cauda Equina?
Lower Back pain and Sciatica (Back and Leg Pain)
Saddle Anaesthesia- numbness in the Peri-anal Region, Groin and Inner Thighs
Urinary Retention and Incontinence (Palpable Bladder due to Urinary Retention)
Leg Weakness and Difficulty Walking
Erectile Dysfunction
What 2 investigations should be done if Cauda Equina is suspected?
Urgent MRI of the Spine
CT Myelography if an MRI is not possible
What is the management of Cauda Equina?
Emergency Decompressive Laminectomy Surgery
What are Cluster Headaches and what is their pahtophysiology?
They are Unilateral, Periorbital Headaches with Autonomic Dysfunction that presents with (4) Conjunctival Infection, Lacrimation, Rhinorrhoea and Nasal Congestion
They are a form of Trigeminal Autonomic Cephalgia that occur due to the Hypersensitivity of the Trigeminal Autonomic Reflex Arc- they consist of Vascular Dilation and Trigeminal Nerve Stimulation
What are the 3 main forms of Trigeminal Autonomic Cephalgia?
Cluster Headaches
Paroxysmal Hemicranial
Short-lived Unilateral Neuralgiform Headaches with Conjunctival Injection and Tearing (SUNCT)
What are the 8 signs of Cluster Headaches?
Clusters of Headaches that occur due to certain precipitants (Alcohol, Volatile smells, Warm temperatures, Sleep)
Unilateral, Periorbital or Temporal headaches that last between 15 mins to 3 hours
Ipsilateral Autonomic Symptoms (6)
- Lacrimation
- Conjunctival Infection
- Nasal Congestion
- Rhinorrhoea
- Ptosis
- Miosis
What investigation should be conducted if a Cluster Headache is suspected?
ESR- to rule out Giant Cell Arteritis
What is the management of Cluster Headaches? (3)
What 4 things should be avoided? (4)
Triptans for Symptomatic Relief
High flow Oxygen
Verapamil for Prophylaxis
Avoid
- Paracetamol
- NSAIDs
- Opioids
- Oral Triptans
What is the most common cause of Encephalitis?
Herpes Simplex Virus 1
causing Frontal and Temporal Lobe Encephalitis
What is the main risk factor for Encephalitis?
Being Immunocompromised (HIV, being Very Old or Very Young, Medication)
What are the 6 signs of Encephalitis?
Reduced GCS
Fever
Headache (Excruciating)
Confusion
Focal Neurological Deficit (3)
- Aphasia
- Hemiparesis
- Cerebellar signs
Behavioural Changes (3)
- Memory disturbances
- Psychotic behaviour
- Withdrawal or changes in personality
What 3 investigations should be ordered if Encephalitis is suspected?
MRI- would show inflammation of Frontal and Temporal Lobes in Herpes Simplex Virus 1
Cerebrospinal Fluid- Lymphocytosis with Raised Protein in Viral Aetiology
EEG- Periodic Lateralised Discharges at 2Hz
What is the 3 step management plan for Encephalitis?
Aciclovir
Ganciclovir- If it is a Herpes Virus that is Not HSV1
Ganciclovir and Foscarnet- If it is Cytomegalovirus
What is the pathophysiology of Guillain-Barre Syndrome?
It is an autoimmune demyelinating condition of the Peripheral Nervous System- triggered by an Infection
- This is due to a pathogenic antigen being very similar to Myelin Gangliosides in the Peripheral Nervous System
- So the Myelin Sheath is attacked by the Immune System
What are the 2 types of Guillain-Barre Syndrome and what are some facts about them?
Acute-Inflammatory Demyelinating Polyneuropathy (ADIP) is the most common
Miller-Fischer Syndrome (3)
- Ataxia, Areflexia and Opthalmoplegia
- In this form, the Eyes are affected first- not the Legs like Normal
- It is a Descending Paralysis
What are the two main risk factors for Guillain-Barre Syndrome?
Malignancies- Lymphoma may increase risk of Guillain-Barre Syndrome
Respiratory or Gastrointestinal Infections-
Bacterial (2)
- Campylobacter Jejuni
- Mycoplasma Pneumoniae
Viral (4)
- Zika virus
- Influenza
- Epstein-Barr Virus
- Cytomegalovirus
What are the 6 signs of Guillain-Barre Syndrome
Symmetrical Muscle weakness affecting the Legs first and then the Arms (Ascending Weakness)
Tingling in hands and feet which is followed by muscle weakness
Unsteady when Walking- Ataxia with Hyporeflexia or Areflexia in Affected Limb
Back and Leg Pain
Shortness of Breath- due to weakness of Respiratory Muscles
Facial Weakness and Speech Problems- Cranial Nerve Involvement and Bulbar Dysfunction (Diplopia or Facial Droop)
What 6 investigations should be conducted if Guillain-Barre Syndrome is suspected?
Progressive Weakness and Areflexia (hyporeflexia) typically means Guillain-Barre Syndrome
Check B12 and Folate as their deficiencies are associated with Neurological Features
TFTs- to exclude Hypothyroidism as a cause of Weakness
LFTS- elevation of Hepatic Enzymes is associated with a more Severe Disease
Anti-Ganglioside Antibodies- as AntiGQ1b is associated with Miller-Fisher Syndrome
Lumbar Puncture- shows Raised Protein with Normal WBC Count (However a Normal Protein Level does NOT Exclude Guillain-Barre Syndrome)
What is the 5 step management for Guillain-Barre Syndrome?
IV Immunoglobulins
Plasma Exchange
Thromboprophylaxis to Prevent Venous Thromboembolisms
Physiotherapy
Intensive Care Support
What are the 3 complications of Guillain-Barre Syndrome?
Type 2 Respiratory Failure
Pulmonary Complications (such as infections due to Intubation or Pulmonary Emboli due to immobility and a pro-inflammatory state
Autonomic Dysfunction of Bowel (ileus) and Bladder (retention)
What are the 8 red flags for a Headache?
Recent Head Trauma (within past 3 months)- check for Subdural Haematoma
Headache worse when standing- check for a CSF leak
Headache worse when lying down- check for a raised ICP (such as due to a Space-Occupying Lesion)
Household contact has similar symptoms (check for CO poisoning)
Headache with a Fever or a Change in Consciousness (check for Meningitis or Encephalitis)
Headache with Visual Disturbance (check for Acute Closed Glaucoma)
Headache with Vomiting (check for a Space-occupying Lesion, Abscess or CO Poisoning)
Headache during Pregnancy (check for Pre-Eclampsia)
What 4 conditions can a Lumbar Puncture help diagnose?
Multiple Sclerosis
Guillain-Barre Syndrome
Sub-Arachnoid Haemorrhage
Meningitis
What are the 6 contraindications for a Lumbar Puncture?
Raised ICP (Papilloedema) Change in Consciousness Shock Bradycardia and Hypertension (part of Cushing's Triad) Issues with Pupils After a Convulsion
What are the 2 most common causes of Bacterial Meningitis?
Streptococcus Pneumoniae and Neisseria Meningitidis
What is the most common cause of Viral Meningitis?
Coxsackievirus
What are the 9 signs of Meningitis?
Meningism (Headache, Stiffness, Photophobia)
Fever
Nausea and Vomiting
Seizures
Petechial or Purpuric Non-blanching Rash- due to Neisseria Meningitidis
Kernig’s Sign- unable to extend knee when the hip is flexed
Brudzinski Sign- hips and knees flex when the neck is also flexed
Reduced GCS
Bulging Anterior Fontanelle (Top of baby’s head where there is a gap in the skulls usually is bulging)
Which 6 investigations should be ordered if Meningitis is suspected?
FBC- check for Leukocytosis
Coagulation Screen before Lumbar Puncture
Check Blood Glucose in ALL Patients too compare with CSF Glucose
Perform a whole blood PCR for Neisseria Meningitidis
Perform a CSF PCR for Herpes Simplex Virus and Varicella Zoster Virus
Perform a CSF Gram Stain- Streptococcus Pneumoniae is a Gram Positive Cocci and Neisseria Meningitidis is a Gram Negative Diplococci
What is the 5 step management for Meningitis?
IV or IM Benzylpenicillin
Do NOT offer antibiotics in Primary Care as this will delay the transfer to the hospital
Steroids- Dexamethasone is ideally given With or Before the Antibiotics
Antibiotics (2)
- Cefotaxime (add Amoxicillin if they are <3 months or >50 years old)
- Give Chloramphenicol if they are allergic to Penicillin
For Viral Meningitis- give Aciclovir
What are the 4 complications of Meningitis?
Hydrocephalus
Cerebral Oedema
Sensorineural Hearing Loss
Waterhouse-Friderischsen Syndrome- Adrenal Gland Failure due to a Haemorrhage caused by Neisseria Meningitidis
What are 6 things to note in the CSF interpretation of Meningitis?
The Pressure is only normal in Viral Meningitis, but it may be elevated or normal in Bacterial and Fungal Meningitis and Tuberculosis
The Fluid Appearance is only Clear in Viral Meningitis, it is Cloudy in Bacterial and Fungal Meningitis and Tuberculosis
If the White Cell Count in the CSF is over 1,000, this is Bacterial Meningitis, although the White Cell Count may be normal in Bacterial Meningitis as well
The main cells visible in the CSF in Bacterial Meningitis and early stages of other Meningitis are Neutrophils, and Lymphocytes in the later stages of Viral and Fungal Meningitis and Tuberculosis
The Protein in the CSF would only be less than 1g/L in Viral Meningitis
The Glucose in the CSF would only be greater than 60% in Viral Meningitis
What is the most likely cause of Meningitis in Neonates and the most likely cause of Meningitis in Very Old People and Very Young People?
Group B Streptococcal Bacteria are the most common cause of Meningitis in Neonates
Listeria Monocytogenes is the most common cause of Meningitis in Very Old and Very Young Patients
What should be offered to people who have been in close contact with patients diagnosed with Meningitis ? (3)
Ciprofloxacin (first line)
Rifampicin (second line)
Meningococcal Vaccination
What is the pathophysiology of a Migraine?
It is thought to occur due to the Hyperexcitability of the Trigeminal Nerve which dilates the Meningeal Blood Vessels and causes Sensitisation of Surrounding Nerve Fibres which causes the Pain
What are the triggers of a Migraine? (CHOCOLATE +3)
Chocolate Oral Contraception Alcohol Anxiety Travel Exercise
Bright Lights
Lack of Food and Water
Menstruation
What are the 4 signs of a Migraine?
Unilateral Pulsing Headache (commonly Bilateral in Children)
Photophobia and Phonophobia
Typical Aura (up to 1 hour) (3)-
- Visual Symptoms
- Paresthesia
- Speech Disturbances
Atypical Aura (more than 1 hour) (4)
- Poor Balance
- Diplopia
- Motor Weakness
- One eye only affected
What 2 investigation should be ordered if a Migraine is suspected?
CT or MRI to rule out other causes such as a Subarachnoid Haemorrhage
ESR to rule out Giant Cell Arteritis
What is the management plan for Acute (4) and Chronic (7) Migraine?
Acute Migraine-
- Ibuprofen or Aspirin or Paracetamol
- Oral Sumatriptan (Alone or in combination with Paracetamol and NSAIDs)
- Antiemetic (Metoclopramide or Prochlorperazine)
- Avoid Opiates!!!
Chronic Migraine-
- Headache Diary
Prophylaxis-
- Propanolol (First Line)
- Topiramate (unless the patient is Pregnant)
- Amitriptyline
- Frovatriptan or Zolmitriptan if the patient is having Predictable Menstrual Migraines
- Otherwise Consider Mindfulness and Acupuncture
- Riboflavin may be good but avoid in Pregnancy
What are the 4 types of Motor Neurone Disease and state some facts about each of them?
Amylotrophic Lateral Sclerosis (ALS)-
- Mutations in SOD1
- Upper Motor Neurone Signs- Predominantly affects the Corticospinal Tracts
- Lower Motor Neurone Signs- also affects Anterior Horn Cells
Progressive Muscle Atrophy-
- Lower Motor Neurone Signs- Predominantly affects the Anterior Horn Cells
- Best Prognosis
Primary Lateral Sclerosis-
- Upper Motor Neurone Signs- Predominantly affects the Corticospinal Tracts
Progressive Bulbar Palsy-
- Affects the Suprabulbar Nuclei and Cranial Nerves- causes Speech and Swallowing Issues
- Worst Prognosis
What are the 5 signs of Motor Neurone Disease?
Falls
Progressive Weakness
Speech and Swallow Issues- Mainly in Progressive Bulbar Palsy
- Dysarthria and Dysphagia are mainly seen in Progressive Bulbar Palsy
Fasciculations (especially in the Tongue)- are also seen in Motor Neurone Disease
Muscle Wasting- look out for Atrophies
What 3 investigations should be ordered if Motor Neurone Disease is suspected?
Electromyography (evidence of Fibrillation Potentials)
Nerve Conduction Studies show Reduction in Amplitude
Pulmonary Function should be assessed as Motor Neurone Disease Patients are at risk of Respiratory Failure
What is the 5 step management of Motor Neurone Disease?
Riluzone
Respiratory Support in Patients with a Reduced FVC (like BiPAP)
Supportive treatments-
- Antispasmodics (Baclofen)
- Feeding support- from a PEG tube
- Speech and Language Therapy
- Physiotherapy
What are the 2 complications of Motor Neurone Disease?
Respiratory Failure
Aspiration Pneumonia and Bronchopneumonia
What is the pathophysiology of Multiple Sclerosis?
It is an autoimmune Demyelinating Disease of the Central Nervous System
What are the 2 patterns of Multiple Sclerosis?
Relapsing-Remitting- which is the most common
Primary/ Secondary Progressive- which has no remission associated with it
What are the 5 risk factors of Multiple Sclerosis?
Epstein-Barr Virus
HLA-DR2
Vitamin D Deficiency
Living in Northern Latitudes
Autoimmunity
What are the 8 signs of Multiple Sclerosis?
Optic Neuritis (3)-
- Blurred Vision and Red Desaturation
- Pale Optic Disc
- Unilateral or Bilateral Internuclear Opthalmoplegia (one eye doesn’t move as much to the left or right as the other)
Numbness and Tingling
Sensory Loss due to Demyelination of the Spinothalmic or the Dorsal Columns
Upper Motor Neuron Signs with Spastic Paraparesis
Bowel and Bladder Dysfunction
Uhtoff’s Phenomenon- The Symptoms get worse with an Increased Temperature- like in a Hot Bath
Lhermitte’s Phenomenon- Electric Shock Sensation on Neck Flexion
Cerebellar Signs- Ataxia and Tremor
What 3 investigations should be ordered if Multiple Sclerosis is suspected?
MRI of the brain and spine-
- Demyelinating plaques would be seen (Dawson’s Fingers are found Perpendicular to the Lateral Ventricles)
- High Signal T2 Lesions
Oligoclonal Bands on Lumbar Puncture, also an increased IgG
EEG= Visual-Evoked Potentials- Delayed Velocity but a Normal Amplitude
What is the management of Multiple Sclerosis? Relapsing (2) and Maintenance (4)
Relapsing-
- Steroids (Oral or IV Methylprednisolone) is first line
- Plasma Exchange if this does not work
Maintenance- DMARDs
- Beta Interferon (reduces the Relapse Rate but Not the Progression)
- Monoclonal Antibodies (Natalizumab and Alemtuzumab) reduce the Relapse Rate and the Progression
- Glatiramer Acetate- an immunomodulator which acts as a Decoy
- Fingolimod- which keeps the Lymphocytes in the Lymph Nodes
How should the complications of Multiple Sclerosis be managed? (5)
Fatigue- Investigate other causes (like Anaemia) and consider giving them Amantidine
Spasticity- Physiotherapy- Gabapentin and Baclofen are first line
Mental Health Issues- Amitryptilline
Bladder Dysfunction- Intermittent self-catheterisation if there is a Significant Residual Volume
Anticholinergics should be given if the Bladder Residual Volume is Insignificant
What is the pathophysiology of Myasthenia Gravis?
It is a Chronic Autoimmune Disorder of the Post-synaptic Membrane at the Neuromuscular Junction of Skeletal Muscles
This occurs due to antibodies against Nicotinic Acetylcholine Receptors
Some patients have antibodies against Muscle-Specific Kinase (MuSK) which is a post-synaptic protein
The number of available binding sites for Acetylcholine at the muscle is reduced and this causes weakness
What are the 2 risk factors of Myasthenia Gravis?
Thymoma/ Thymic Hyperplasia
Autoimmunity
What are the 9 signs of Myasthenia Gravis?
Fatigability
Diplopia- as the Extraocular Muscles are the first to be affected
A Muscle Weakness that is worse at the end of the day
Proximal Muscle Weakness with Fatigability
Ptosis which is exacerbated on an upward gaze (Bilateral or Unilateral)
Dysphagia
Myasthenia Snarl (Snarling expression when attempting to smile)
Head Drop- this is a rare sign which occurs due to a weakness of the Cervical Extensor Muscles
Complex Opthalmoplegia- which can not be attributed to one Cranial Nerve
What 4 investigations should be ordered if Myasthenia Gravis is suspected?
Antibodies (Against the Acetylcholine Receptors and Muscle-Specific Kinase)
Electrophysiological Studies- repetitive nerve stimulation shows a Decremental Muscle Response
CT to exclude a Thymoma
TFTs- as there is a prevalence of Autoimmune Thyroiditis
What is the 6 step management of Myasthenia Gravis?
Pyridostigime is first line (it is an Acetylcholinesterase Inhibitor)
Prednisolone is second line (if Pyridostigime doesn’t change the symptoms)
Azathioprine is third line (if Prednisolone does not work)
Use Methotrexate or Rituximab if the symptoms are uncontrolled by the first three medications
Perform a thymectomy if a thymoma is present
If the patient has Myasthenia Crisis (Myasthenia Gravis with weakened Respiratory Muscles)-
- IV Immunoglobulins or Plasmapheresis
- Intubation (if severe)
- Corticosteroids
What are the 2 complications of Myasthenia Gravis?
Myasthenic Crisis
Aspiration Pneumonia- as Dysphagia increases the risk of Aspiration
What 9 drugs should be avoided in Myasthenia Gravis?
Tetracyclines Ciprofloxacin Gentamicin Quinolones Azithromycin Beta Blockers Procainimide Lithium Phenytoin
What are 4 signs of Parkinsonism?
Bradykinesia
Tremor
Rigidity
Postural Instability
What 4 diseases are associated with Parkinsonism?
Parkinson’s Disease- Unilateral Symptoms which then become Bilateral as the Disease Progresses
Parkinson plus Syndrome (3)
- Multiple System Atrophy (Shy Drager Syndrome)
- Progressive Supranuclear Palsy (Vertical Gaze Palsy)
- Corticobasal Degeneration (Alien Limb Phenomenon)
Lewy Body Dementia
- Cognitive Impairment
- Visual Hallucinations
Wilson’s Disease
- Parkinsonism and Liver Failure with Kayser-Fleischer Rings
What are the 4 drugs and 3 other things that can causes Parkinsonism?
Antipsychotics
Metoclopromide (an antiemetic)
Domperidone (an antiemetic)
Lithium
Encephalitis
Illegal Drugs
Dementia Pugilistica
What is the pathophysiology of Parkinson’s Disease?
It is the loss of Dopaminergic Neurones in the Substantia Nigra Pars Compacta of the Basal Ganglia
It is associated with a Dysfunction in the genes associated with Alpha Synuclein and Ubiquitin Protease-
- This leads to a loss of transmission between the Basal Ganglia, Thalamus and Motor Cortex
- This results in an impaired Voluntary Movement
What is the protein found in Parkinson’s Disease?
Lewy Bodies- Eosinophilic Inclusion Bodies consisting of misfolded Alpha Synuclein in the Substantia Nigra Pars Compacta
What are the 7 signs of Parkinson’s Disease?
Bradykinesia
Tremor (Pill Rolling Tremor)
Rigidity (Cog Wheel Rigidity)
Anosmia (an early feature)
Sleep Disturbance
Constipation
Psychiatric Symptoms (Depression, Anxiety, Dementia which develops after the Motor Symptoms)
What 2 investigations should be ordered if Parkinson’s Disease is suspected?
MRI Brain- to exclude other possibilities
SPECT (DaT scan) to show Reduced Dopamine Uptake in Basal Ganglia
What is the 8 step management of Parkinson’s Disease?
If the Quality of Life is affected-
- Levodopa and Decarboxylase Inhibitor (Co-Beneldopa)
If Quality of Life is Not Affected (give One of These)
- Levodopa and Decarboxylase Inhibitor (Co-Beneldopa)
- Dopamine Agonist (Pramipexole or Ropinirole), Avoid Bromocroptine as it leads to Cardiac Fibrosis and Pulmonary Fibrosis
- Monoamine Oxidase B Inhibitor (Selegiline or Rasagiline)
If the Above don’t work-
- Entacapone- reduces Breakdown of Levodopa Peripherally meaning that More of it reaches the brain
- Amantidine- increases Dopamine Release and reduces Uptake
- Subcutaneous Apomorphine- Dopamine Agonist
- Deep Brain Stimulation
What is Status Epilepticus?
It is a Single Continuous Seizure lasting more than 5 minutes or 2 Consecutive Seizures
What are the 7 risk factors for Status Epilepticus?
Epilepsy
Poor compliance with Anti-epileptic Medication
Alcoholism
Recreational Drug Use (Cocaine)
Previous Neuronal Injury (5)
- Head Trauma
- Stroke
- Haemorrhage
- Brain Tumours
- CNS Infection
Electrolyte Imbalance- particularly Hyponatraemia and Hypocalcaemia
Medications (4) reduce their threshold-
- Buproprion
- Tramadol
- Theophylline
- Certain Antibiotics
What are the 5 signs of Status Epilepticus?
Tonic-clonic Seizure- Muscles stiffen and Jerking of Limbs occur
Tongue biting
Urinary Incontinence
Loss of Consciousness
Post Ictal- Confusions and Altered State of Consciousness After and Epileptic Seizure
What 5 investigations should be ordered if Status Epilepticus is suspected?
ECG- look for Cardiac Arrhythmias as these can Precipitate Seizures
Arterial or Venous Blood Gases- Metabolic Acidosis with Raised Lactate
Inflammatory Markers to identify a possible infection
Investigate Anti-epileptic Drug levels
Perform Toxicology Screen
What is the 6 step management for Status Epilepticus?
If the patient has Alcohol Excess= Give them Pabrinex or Glucose
If any two Benzodiazepines have been given- move on to the Established Status Treatment
Pre-Hospital=
- Rectal Diazepam or Buccal Midazolam
- If the seizure continues then proceed…
Early Status (<10 minutes)=
- IV Lorazepam is First Line in Hospital
- If this still continues, then proceed…
Established Status (10-60 minutes)= - Phenytoin and/ or Phenobarbital
Refractory Status (60-90 minutes)=
- General Anaesthesia with (3)
- Propofol
- Midazolam
- Thiopental
What are the 2 complications of Status Epilepticus?
Aspiration Pneumonia/ Respiratory Failure
Hyperkalaemia and Hypoglycaemia
What are the 3 types of Haemorrhagic Stroke?
Intracerebral- bleeding within the brain Parenchyma
Subarachnoid- bleeding into the Subarachnoid space
Intraventricular- bleeding within the Ventricles- Prematurity is a strong risk factor for this
What are the Cardiac (3), Vascular (2) and Haematological (3) causes of Ischaemic Stroke?
Cardiac
- Atherosclerotic Disease (4)- Smoking, Hypertension, Diabetes, Hypercholesterolaemia
- Atrial Fibrillation
- Embolism due to Septal Abnormality- such as Patent Foramen Ovale
Vascular
- Aortic Dissection
- Vertebral Dissection
Haematological
- Hypercoagulability- Antiphospholipid Syndrome
- Sickle Cell Anaemia
- Polycythaemia
What are the 4 causes of Haemorrhagic Stroke?
Trauma
Arteriovenous Malformation
Intracerebral Strokes in Particular (Hypertension and Cerebral Amyloid)
Subarachnoid Strokes in Particular (Berry Aneurysm)
What are the signs of Anterior Cerebral Artery Strokes?
Contralateral Hemiparesis and Sensory Loss in the Lower Limbs more than the Upper Limbs
What are the signs of Middle Cerebral Artery Strokes?
Contralateral Hemiparesis and Sensory Loss in the Lower Limbs more than the Upper Limbs
Homonymous Hemianopia-
- Aphasia if the Dominant Hemisphere is affected, as the Wernicke’s Area is Affected
- Hemineglect Syndrome- if Non-Dominant Hemisphere is affected
What are the signs of Posterior Cerebral Artery Strokes?
Contralateral Homonymous Hemianopia with Macular Sparing
Contralateral loss of Pain and Temperature due to Spinothalamic Damage
What are the signs of Vertebrobasilar Artery Strokes?
Cerebellar Signs
Reduced Consciousness
Quadriplegia or Hemiplegia
What are the signs of Weber’s Syndrome Strokes (due to a Midbrain Infarct)?
Oculomotor Palsy
Contralateral Hemiplegia
What are the signs of Lateral Medullary Syndrome Strokes (due to Posterior Inferior Cerebral Artery Occlusion)?
Ipsilateral Facial loss of Pain and Temperature
Ipsilateral Horner’s Syndrome (Ptosis, Miosis, Anhidrosis, Enophthalmos)
Ipsilateral Cerebellar Signs
Contralateral loss of Pain and Temperature
What 4 investigations should be ordered if a Stroke is suspected?
Non-Contrast CT Head to work out whether it is a Haemorrhagic or an Ischaemic Stroke (Ischaemic would not show up)
ECG for Atrial Fibrillation
Blood tests- Check for Risk Factors and Rule out the 2 Stroke Mimics (Hypoglycaemia and Hyponatraemia)
CT Angiogram for Artery Occlusion
What is the 6 step management for an Ischaemic Stroke?
Give them Aspirin ASAP
- but if they are treated with Thrombolysis then start Aspirin 24 hours after the Haemorrhage is excluded on the Non-Contrast CT Head
Start Thrombolysis if they are within 4.5 hours of Symptom onset and Haemorrhagic Strokes are excluded on imaging
Perform Thrombectomy if they are >5 on the NIH Scale and <3 on the Rankin Scale
Do NOT Start Anticoagulation if Atrial Fibrillation is the cause and give them Aspirin instead
Also Maintain their Blood Glucose levels
Secondary Prevention (3)-
- Clopidogrel is First Line
- Otherwise give them Aspirin with Dipyridamole
- All Patients should be started on a high-dose statin such as Atorvastatin
What is the management of a Haemorrhagic Stroke?
It depends on the subtype
For Subarachnoid Haemorrhage- Endovascular or Surgical Clipping
Admit Haemorrhagic Stroke Patients to Neurocritical Care and monitor for Raised Intracranial Pressure
(Consider Intubation with Hyperventilation, Head Elevation 30 degrees and IV Hypertonic Saline)
Decompression via Surgery may be needed
What 3 arteries are associated with the Anterior Circulation of the head and which 5 arteries are associated with the Posterior Circulation of the head?
Anterior Circulation-
- Anterior Choroidal Artery
- Anterior Cerebral Artery (ACA)
- Middle Cerebral Artery (MCA)
Posterior Circulation-
- Posterior Cerebral Artery (PCA)
- Basilar Artery
- Superior Cerebral Artery
- Anterior Inferior Cerebellar Artery
- Posterior Inferior Cerebellar Artery
What are Berry Aneurysms? (2)
Ruptures of Saccular Berry Aneurysms are the most common cause of spontaneous Subarachnoid Haemorrhages
They occur at points of Arterial Bifurcation within the Circle of Willis- such as the junction between the Anterior Communicating Artery and Anterior Cerebral Artery- which is the Most Common Location
What are Watershed Zones within the Head and give 2 examples of them?
These are areas that are Furthest away from Arterial Supply and are therefore vulnerable to Reduced Perfusion
1) Cortical Border Zone Infarction- border of the ACA/ MCA and the MCA/PCA
2) Internal Border Zone Infarction- borders of the penetrating MCA branches or borders of the deep branches of the MCA and ACA- deep white matter infarction
Which artery supplies the Wernicke’s and Broca’s Area?
The Middle Cerebral Artery
Why does Macular Sparing Occur in Strokes?
The Occipital Pole is responsible for supplying the Macula and this region has a rich Anastomoses of vessels- this region is supplied by the MCA
What is Locked-In Syndrome?
The patient is fully aware but can not move or communicate verbally due to almost complete paralysis
This may be caused by a Stroke affecting the Basilar Artery so that no blood is delivered to the Pons
What is the most common cause of a Subarachnoid Haemorrhage?
Trauma
What are the 4 Atraumatic Causes of a Subarachnoid Haemorrhage?
Berry Aneurysm- Most Common Cause of Spontaneous Subarachnoid Haemorrhage
- This arises at a point of Arterial Bifurcation within the Circle of Willis
- The junction between the Anterior Cerebral Artery and Anterior Communicating Artery is the most common location
- This is associated with Polycystic Kidney Disease, Coarctation of Aorta and Ehler’s-Danlos Syndrome
Arteriovenous Malformation
Mycotic Aneurysm- due to Bacterial Infection- like secondary to Emboli from Infective Endocarditis
Pituitary Apoplexy- Bleeding into the Pituitary Gland, associated with a Tumour
What are the 2 risk factors of a Subarachnoid Haemorrhage?
Polycystic Kidney Disease
Alcohol
What are the 7 signs of a Subarachnoid Haemorrhage?
Headache (Occipital, Thunderclap Headache and Sudden Onset)
Meningism- Photophobia and Neck Stiffness
Nausea and Vomiting
Confusion, Coma and Seizures
Reduced GCS
3rd Nerve Palsy- from Posterior Cerebral Artery Aneurysm pressing on the 3rd nerve- Dilated Pupil
6th Nerve Palsy- Increases ICP
What 4 investigations should be ordered if a Subarachnoid Haemorrhage is suspected?
Urgent non-contrast CT of head- Blood in Basal Cisterns
ECG should be done on ALL patients (Arrhythmias and ST Elevation)
If the CT is negative but you are still suspicious of a Subarachnoid Haemorrhage, then perform a Lumbar Puncture-
- Xanthochromia with Normal or Raised Opening Pressure (Xanthochromia is the yellow pigmentation of the CSF due to the degradation of Haemoglobin to Bilirubin)
CT Angiogram or DSA (Digital Subtraction Angiography)- to find the Source
What is the 5 step management for Subarachnoid Haemorrhage?
Nimlodipine should be offered immediately
Endovascular Clipping of the Aneurysm is the first line investigation
Surgical Clipping via Craniotomy is second line
If the ICP is raised- perform Intubation with Hyperventilation, Head Elevation to 30 degrees and IV Mannitol
Prescribe Antitussives and Stool Softeners to prevent patient straining and reduces risk of rebleeding
What are the 3 main complications with Subarachnoid Haemorrhage?
Vasospasm (Treat with induced Hypervolaemia, Hypertension, Haemodilution)
Hydrocephalus- manage via External Ventricular Drain
Hyponatraemia due to SIADH
