NEUROLOGY Flashcards
Describe 3 things a Lacunar Stroke can present with?
- unilateral motor disturbance affecting the face, arm or leg or all 3.
- complete one sided sensory loss.
- ataxia hemiparesis.
Describe the 3 critierias for Oxford Stroke Classification?
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
What is Brown-Sequard Sydnrome a result of in the spinal cord?
Brown-Sequard syndrome is a result of lateral hemisection of the spinal cord
It causes **same sided weakness and proprioception/vibration loss and loss of pain/temperature on the opposite side to the hemisection. **
This is because the pathway for pain/temperature sensation decussates at the level of the nerve root.
How many doses of IV benzodiazepines can be administered during convulsive status epilepticus?
Maximum of Two
Stroke Management
Describe the management for a large artery acute ischaemic stroke?
INTRAVENOUS THROMBOLYSIS AND MECHANICAL THROMBECTOMY (mechanical clot retrieval)
NICE: thrombectomy should be offered asap within 6hrs of symptom onset and together with IV thrombolysis (if within 4.5hrs)
Stroke management
When should 300mg aspirin be given and when should anticoagulants be started with regards to AF in stroke setting?
With regards to AF: anticoagulants should not be started until brain imaging has excluded haemorrhage and usually not until 14 days have passed from onset of ischaemic stroke
Stroke Management
Describe thrombolysis for acute ischaemic stroke and include the Absolute and Relative Contraindications to thrombolysis?
Thrombolysis with Alteplase should only be given if: administered within 4.5hrs od onset of stroke symptoms and that haemorrhage has been DEFINITIVELY excluded
Contraindications:
Absolute
Previous intracranial haemorrhage
Seizure at onset of stroke
Intracranial neoplasm
Suspected SAH
Stroke or traumatic brain injury in preceding 3 months
LP in preceding 7 days
GI haemorrhage in preceding 3 weeks
Active bleeding/Pregnancy/Oesophogeal varicces/uncontrolled HTN (>200/120)
Relative
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
Stroke management
Describe thrombectomy for acute ischaemic stroke?
offer mechanical thrombectomy- within 6hrs of symptom onset togethet with IV thrombolysis (within 4.5hrs) to people who have acute ischaemic stroke and confirmed occlusion of proximal anterior circulation
consider thrombectomy with IV thrombolysis ASAP for people last known to be well for up to 24hrs (incl wake-up strokes) and have acute ischaemic stroke/confirmed occlusion of proximal posterior circulation (basilat or posterior cerebral artery)
Stroke managment
Describe secondary prevention of strokes?
Clopidogrel plus modifed release (MR) dipyridamole in poeple who have had an ischaemic stroke
Cartoid artery endartectomy: pt suffered stroke or TIA in carotid territory and not severely disabled
SAH
Describe the most common cause of SAH and different causes of spontaneous SAH?
- The most common cause of SAH is head injury and this is called traumatic SAH
- intracranial aneurysm (saccular ‘berry’ aneurysms)
accounts for around 85% of cases
conditions associated with berry aneurysms include hypertension,adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta - arteriovenous malformation
- pituitary apoplexy
SAH
Describe the classical presenting features of SAH?
- headache**
usually of sudden-onset (‘thunderclap’ or ‘hit with a baseball bat’)
* * severe (‘worst of my life’)
occipital
typically peaking in intensity within 1 to 5 minutes
there may be a history of a less-severe ‘sentinel’ headache in the weeks prior to presentation - nausea and vomiting
- meningism (photophobia, neck stiffness)
- coma
- seizures
SAH
Describe the investigations for SAH (why should an LP be performed 12 hours after symptom onset)?
-
non-contrast CT head is the first-line investigation of choice
acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system. - if CT head is done **within 6 hours of symptom **onset and is normal
new guidelines suggest not doing a lumbar puncture
consider an alternative diagnosis - if CT head is done more than 6 hours after symptom onset and is normal
do a lumber puncture (LP) - timing wise the LP should be performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown).
xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure)-CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure
SAH
After spontaneous SAH is confirmed- what investigation is done to indetify a causative urgent treatment?
CT Intracranial angiogram- identify vascular lesion (Aneursym or AVM) or catheter angiogram
SAH
Describe the management of confirmed anuerysmal SAH?
supportive: bed rest, analgesia, venous thromboembolism prophylaxis, discontinuation of antithrombotics (reversal of anticoagulant)
Vasospasm**: prevented using a course of oral nimodipine **
Intracranial anuerysms: risk of rebleeding and require prompt intervention within 24hrs (treated with a coil by IR and some reuire craniotomy/clipping
SAH
Describe the complications of anuerysmal SAH?
- Re-bleeding: common in first 12 hrs, if suspected (sudden worsening of symptoms)- repeat CT arranged
- Hydrocephalus: temporarily treated with external ventricular drain- CSF diverted inyo bag at bedside
- Vasospasm (delayed cerebral ischaemia), 7-14 days after onset, ensure euvolaemia and consider treatment with a vasopressor if symptoms persist
- Hyponatraemia: due to SIADH
- Seizures
