Neurology Flashcards
What is a TACS, and what features must be present for diagnosis?
= a large cortical stroke affecting the areas of the brain suppled by both the middle & anterior cerebral artery territories.
- All three of the following must be present for a TACS diagnosis:
- Unilateral weakness (and/or sensory deficit) of the face, arm, and leg
- Homonymous hemianopia
- Higher cerebral dysfunction → dysphasia, visuospatial disorder.
What is a PACS & what must be present for a diagnosis?
= a less severe form of TACS, in which only part of the anterior circulation has been compromised.
- Two of the following need to be present for a PACS diagnosis:
- Unilateral weakness (and/or sensory deficit) of the face, arm, and leg
- Homonymous hemianopia
- Higher cerebral dysfunction → dysphasia, visuospatial disorder
What is a lacunar stroke (LACS) and what needs to be present for a diagnosis?
= a subcortical stroke that occurs secondary to small vessel disease. There is no loss of higher cerebral functions.
- One of the following needs to be present for LACS diagnosis:
- Pure sensory stroke
- Pure motor stroke
- Sensori-motor stroke
- Ataxic hemiparesis
How does a stroke involving the Anterior Cerebral Artery present? What is the key feature?
- Leg weakness is key !! Leg>arm/face weakness due to arrangement of the motor homunculus
- Sensory weakness → less common
- Motor aphasia → difficulty initiating speech, comprehension
- Urinary incontinence
How does a stroke involving the Middle Cerebral Artery present? What is the key feature?
-
Face/upper limb weakness
- Arm/Face > leg weakness
- Expressive aphasia → if lesion is on the dominant hemisphere, typically the left, due to Broca’s area being on the dominant side.
- Receptive aphasia → if lesion is on dominant hemisphere, due to Wernicke’s area being affected.
- Contralateral hemineglect → if the lesion is on the non-dominant side
What antiplatelet therapy is giving to people following an ischaemic stroke? What preparation can these be given?
Aspirin 300mg for 2 weeks (or until discharge).
- Change to 75mg clopidogrel OD after 2 weeks or once discharged.
- Oral, rectal, via NG tube
When can a patient be thrombolysed in the event of a stroke?
Alteplase can be used within 4.5hrs of symptom onset & once a haemorrhagic stroke has been ruled out on CT.
What secondary prevention is given following an ischaemic stroke long term?
- Clopidogrel 75mg OD
- Atorvastatin 20-80mg (after 48hrs)
- Blood pressure & diabetes control
- Address modifiable risk factors → smoking, obesity, exercise
When is an endarterectomy done following an ischaemic stroke?
If there is >50% occlusion on the affected side, and it can be done within a week
How does an extradural haematoma present?
- Often have immediate LOC, followed by period of lucidity, then a progressive decline in consciousness over the next few hours.
- Headache
- Nausea & vomiting
- Confusion
How does an extradural haematoma appear on a CT scan?
- Bi-Convex, lemon-shaped mass
- Midline shift
- Brainstem herniation
How does a subdural haematoma present?
- Drowsiness or poor balance & graduate deterioration following head trauma
- Headache
- Nausea & vomiting
How does a subdural haematoma show on CT scan?
- Crescent, banana-shaped mass
- Acute SDH → hyperdense (bright white) appearance
- Chronic SHD → hypodense (black/grey) appearance
How does a subarachnoid haemorrhage present?
- Sudden onset, severe headache (thunderclap)
- Nausea & vomiting
- Photophobia
- Kernig’s Sign → inability to extend the knee due to pain when the patient is supine & the hip & knee are flexed to 90 degrees
How does a subarachnoid haemorrhage show up on CT scan
- Hyperdensity around the Circle of Willis
- Hyperdensity in the subarachnoid space
What are the risk factors for idiopathic intracranial hypertension?
- Obesity
- Female
- Medications → COCP, tetracyclines, retinoids, lithium
What are the signs & symptoms of Idiopathic Intracranial Hypertension?
Symptoms → Chronic & progressive:
- Headache → non-specific, diffused, sometimes associated with nausea & vomiting. Typically worse in the morning or after bending forwards, or valsalva manoeuvres
- Transient visual loss / blurring of vision → lasts <30 seconds
- Pulsatile tinnitus → exacerbated by lying flat
- Visual disturbance → photophobia, flashes, transient visual darkening or loss
Signs:
- Bilateral papilloedema seen on fundoscopy
- Peripheral visual field defects
- Horizontal diplopia → due to a sixth nerve palsy in some cases
What is the key finding on lumbar puncture for Idiopathic Intracranial Hypertension?
elevated opening pressure >250mmH2O
How is Idiopathic Intracranial Hypertension managed?
Conservative Management:
- Weight loss
- Stop/change any medications which may be causing or worsening the IIH.
Medical Management:
- Considered in those with Mild-Moderate symptoms.
- Acetazolamide → carbonic anhydrase inhibitor which reduces the rate of CSF production
- If not tolerated, then topiramate or furosemide can be used.
- Serial lumbar punctures can be used short-term to preserve vision in patients with IIH awaiting a surgical procedure.
Surgical Management:
- Essential for IIH patients with rapidly declining visual function or those who failed medical therapy.
- CSF diversion procedures
What are the features of an essential tremor?
- Fine tremor (6-12Hz)
- Symmetrical
- Most notable in hands, but can affect the head, jaw, voice, tongue, face, lower limbs
- More prominent with voluntary movement
- Worse when tired, stressed or after caffeine
- Improved by alcohol
- Absent during sleep
How can an essential tremor be medically managed?
- Propranolol → first line, if patient is bothered by symptoms
- Primidone
What is clinically/radiologically isolated syndrome?
- Clinically IS = an otherwise unexplained clinical episode of neurologic dysfunction
- Radiologically IS = evidence of white matter pathology on neuroimaging not attributable to any other pathology in the absence of clinical symptoms.
What are the 3 main patterns of MS?
- Relapsing-Remitting MS
- Most common form of disease at presentation
- = unpredictable attacks of neurological dysfunction (>24hrs in absence of fever), followed by relief of symptoms, though patients may not return fully to baseline.
- Secondary Progressive MS
- Initially presents as relapsing-remitting, then later declines steadily & progressively without remission.
- Primary Progressive MS
- Steady, progressive worsening of disease severity from the onset without remission.
What is Lhermitte’s sign?
an electric shock sensation that travels down the spine & into the limbs when flexing the neck, indicating disease in the cervical spinal cord, caused by stretching the demyelinated dorsal column.
What are the two key investigations when diagnosing MS?
- MRI brain & spinal cord with gadolinium contrast
- MS lesions will be apparent as white matter plaques in T2.
- Need to be disseminated in space & space
- Oligoclonal bands in CSF & high protein content
- Reflect various immunoglobulins seen on CSF electrophoresis
How is an acute episode of MS managed?
- High-dose steroid therapy → methylprednisolone
- Plasmapheresis → if exacerbation is refractory to steroids
- Exclude any infections
