Neurology

Question 1

Strokes/cerebrovascular events are either:

Answer 1

Ischaemic
Intracranial haemorrhage

Question 2

Causes of an ischaemic stroke/disruption to blood supply

Answer 2

Thrombus/embolus
Atherosclerosis
Shock (hypotension)
Vasculitis

Question 3

What is a TIA?

Answer 3

transient neurological dysfunction secondary to ischaemia WITHOUT infarction

Question 4

what is the significance of a TIA?

Answer 4

often precede a full stroke

Question 5

what is a crescendo TIA?

Answer 5

2 or more TIAs within a week, high risk of developing into a full stroke

Question 6

presentation of a stroke

Answer 6

asymmetrical symptoms

sudden weakness of limbs
sudden facial weakness
sudden onset dysphasia
sudden onset visual or sensory loss

Question 7

presentation of a stroke

Answer 7

asymmetrical symptoms

sudden weakness of limbs
sudden facial weakness
sudden onset dysphasia
sudden onset visual or sensory loss

Question 8

what is the ROSIER tool?

Answer 8

need to exclude hypoglycaemia first ***

tool for recognition of stroke in the emergency room
score >0 = likely stroke

Question 9

first line radiological investigation for suspected stroke

Answer 9

non-contrast CT

Question 10

management of a stroke

Answer 10

300mg of aspirin as soon as haemorrhagic stroke has been excluded

thrombolysis with alteplase - no haemorrhage, within 4.5 hours

thrombectomy

Question 11

criteria for thrombectomy

Answer 11

offer as soon as possible and within 6 hours of symptom onset, as well as IV thrombolysis (if within 4.5 hours) to those with acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation
- via computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

offer as soon as possible to those who were last known to be well between 6-24 hours, have confirmed occlusion of proximal anterior circulation, potential to salvage brain tissue proven by CT perfusion or diffusion-weighted MRI showing limited core infarct volume

consider thrombectomy with IV thrombolysis (within 4.5 hours) as soon as possible for people last known to be well up to 24 hours previously who have acute ischaemic stroke and confirmed occlusion of proximal posterior circulation & potential to salvage brain tissue

Question 12

secondary prevention of stroke

Answer 12

clopidogrel 75mg (/aspirin plus modified release dipyridamole)

atorvastatin 80mg, but not started immediately due to the risk of haemorrhagic transformation

potential carotid endarterectomy or stenting in patients with carotid artery disease

Question 13

what is the regional blood supply to the brain?

Answer 13

anterior cerebral - anteromedial portion of cerebrum
middle cerebral - lateral portions
posterior cerebral - medial and lateral parts of posterior cerebrum

Question 14

MDT involved in stroke rehab

Answer 14

physiotherapists
nurses
speech and language
dieticians
occupational therapy
social services
psychology
optometry
orthotics

Question 15

risk factors for intracranial bleeds

Answer 15

anticoagulants
head injury
hypertension
aneurysms
brain tumours
ischaemic stroke can progress to haemorrhagic (exacerbated with re-perfusion of alteplase)

Question 16

presentation of intracranial bleed

Answer 16

sudden onset headache
seizures
weakness
nausea/vomiting
reduced consciousness
other sudden onset neurological symptoms

Question 17

causes of an extradural haematoma

Answer 17

rupture of the MMA in the temporo-parietal region e.g. fracture of the temporal bone

Question 18

what is an extradural haematoma

Answer 18

bleed that occurs between the skull and dura mater
bi-convex shape and don’t cross suture lines

Question 19

presentation of extradural haematoma

Answer 19

typical history is a young patient with a traumatic head injury that has an ongoing headache

period of improved neurological symptoms and consciousness (lucid interval) followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents
features of raised ICP

Question 20

what is a subdural haematoma

Answer 20

occur between dura and arachnoid layer
crescent shape, not limited by the cranial sutures

Question 21

causes of a subdural haematoma

Answer 21

rupture of the bridging veins in the outermost meningeal layer
more common in elderly or alcoholic patients (atrophy in brains making vessels more likely to rupture)

Question 22

presentation of a subdural haematoma

Answer 22

Slower onset of symptoms than a epidural haematoma

there may be fluctuating confusion/consciousness

Question 23

principles of management of intracranial bleed

Answer 23

CT head
check FBC and clotting, correct any clotting abnormality
admit to specialist stroke unit, potential surgery
consider intubation, ventilation and ICU care if they have reduced consciousness
correct severe hypertension but avoid hypotension

Question 24

what is a subarachnoid haemorrhage

Answer 24

involves a bleed into the subarachnoid space, between the arachnoid membrane and the pia mater

Question 25

cause of a subarachnoid haemorrhage

Answer 25

traumatic vs spontaneous

spontaneous = ruptured aneurysm (berry/saccular** or fusiform)
arteriovenous malformation
Pituitary apoplexy
Arterial dissection

can be particularly associated with cocaine use & sickle cell anaemia

Question 26

presentation of a subarachnoid haemorrhage

Answer 26

sudden onset occipital headache that occurs during strenuous activity e.g. sex, weight-lifting
‘thunderclap’ headache

neck stiffness
nausea & vomiting
photophobia
vision changes
neurological changes e.g. weakness, speech changes, reduced LOC
coma/seizures/sudden death

ECG ST elevation may be seen

Question 27

conditions associated with berry aneurysms

Answer 27

adult polycystic kidney disease
Ehlors-danlos syndrome
coarctation of the aorta

Question 28

risk factors for subarachnoid haemorrhage

Answer 28

hypertension
smoking
excessive alcohol consumption
cocaine use
FHx

more common in black patients, female, 45-70

Question 29

investigations for subarachnoid haemorrhage

Answer 29

CT head - hyperdense in basal cisterns
lumbar puncture if CT is negative, but still a strong suspicion

angiography (CT/MRI) can then be used once confirmed to locate source of bleeding e.g. aneurysm/arteriovenous malformation

Question 30

how does a lumbar puncture help with subarachnoid haemorrhage confirmation?

Answer 30

red cell count
xanthochromia

taken at least 12 hours after symptom onset to allow development of xanthochromia
**distinguish between true SAH and a traumatic tap

Question 31

management of subarachnoid haemorrhage

Answer 31

high risk of re-bleeding, need prompt intervention (within 24 hours)
most are now treated with a coil by interventional radiologists, minority require a craniotomy and clipping

until aneurysm is treated, need strict bed-rest, well controlled BP, avoid strenuous activity

vasospasm prevented with 21 day course of nimodipine (CCB targeting the brain vasculature), treated with hypervolaemia, induced hypertension, and haemodilution

hydrocephalus = external ventricular drain or long term ventriculo-peritoneal shunt

Question 32

complications of subarachnoid haemorrhage

Answer 32

re-bleeding** - 10% of cases, happens in first 12 hours
if re-bleeding suspected e.g. sudden worsening of neurological symptoms, repeat CT scan

vasospasm (delayed cerebral ischaemia) - 7-14 days after

hyponatremia (inappropriate SIADH)
seizures
hydrocephalus
death

Question 33

important predictive factors in SAH

Answer 33

level of consciousness on admission
age
amount of blood visible on a CT scan