Neurology Flashcards
What is the immediate treatment of suspected bacterial meningitis (especially meningococcus)?
1.2g Benzylpenicillin
A patient arrives at the emergency department with a right-sided hemiplegia, facial weakness and is having difficulty with speech. You suspend a stroke. Which of the following is the recommended tool used to assess a patient in this situation?
(A) CHA2DS2VASC (B) ROSIER (C) ABCD2 (D) FAST (E) FRAX
(B) ROSIER
ROSIER is an acronym for a Recognition Of Stroke In the Emergency Room.
FRAX is an acronym for Fracture Risk Assessment Tool?
ABCD2 is used to assess a patient’s stroke risk after a transient ischaemic attack.
FAST (Face/Arms/Speech/Time) is a quick screening tool publicised by Public Health England. It teaches the general public about the signs of stroke so they can seek help quickly. It should not be used in the acute medical setting.
CHA2DS2VASC is a scoring tool used to assess risk of stroke in patients with atrial fibrillation.
ROSIER Score - first exclude hypoglycaemia then assess the following
Loss of consciousness or syncope = -1 point
Seizure activity = -1 point
New acute onset of: Asymmetrical facial weakness = +1 point Asymmetrical arm weakness = +1 point Asymmetrical leg weakness = +1 point Speech disturbance = +1 point Visual field defect = +1 point
A stroke is likely if the score is greater than 0.
Name some modifiable risk factors of Stroke.
Hypertension Smoking Diabetes Mellitus Heart disease (valvular, ischaemic, AF) Peripheral vascular disease Previous TIA Carotid bruit Contraceptive pill Hypercholesterolaemia Excess alcohol use Increased clotting Increased homocysteine Sylhylis
Name some signs of cerebral infarcts.
Depending on the site there may be some contralateral sensory loss or hemiplegia - initially flaccid but becoming spastic.
Dysphasia
Homonymous hemianopia
Visuospatial deficit
Name some signs of brain stem infarcts.
Wide range of effects.
Include quadriplegia, disturbance of gaze and vision
Locked-in syndrome (aware but unable to respond).
Name some signs of lacunar infarcts.
In basal ganglia, internal capsule, thalamus and pons. 5 syndromes (1) ataxic hemiparesis (2) pure motor (3) pure sensory (4) sensorimotor (5) dysarthria/clumsy hand
Cognition and consciousness are intact except in thalami stroke.
Once Haemorrhagic stroke has been excluded via urgent CT/MRI, what is the immediate treatment?
Give aspirin 300mg
Take to stroke unit with special nursing/physio to save life and to motivate.
Name some differential diagnoses of stroke.
Head injury Hypo/hyperglycaemia Subdural haemorrhage Intracranial tumour/Space occupying lesion Hemiplegic migraine Epilepsy (Todd’s palsy) CNS lymphoma Pneumocephalus (air entry via otitis or mastoid air cells) Wernicke’s encephalopathy Drug overdose (if coma) Hepatic encephalopathy Mitochondrial cytopathies Herpes encephalitis HIV/HTLV-1 toxoplasmosis Abscesses (e.g. typhoid)
An ischaemic stroke is presumed. Assuming an expert team is in place (neuroimaging and clinicians), and the patient is seen with 4.5 hours of the onset of symptoms and has no contraindications, what treatment should be considered with the utmost urgency?
Reperfusion with IV recombinant tissue plasminogen activator (alteplase 0.9mg/kg over 1 hour).
This reduces death and dependency despite a small increase in intracranial haemorrhage (usually small and asymptomatic).
Always do CT 24 hours post-thrombolysis to identify any bleeds.
Contraindications to this treatment include:
Major infarct or haemorrhage in CT
Mild/non disabling deficit
Recent birth/surgery/trauma or artery/vein puncture at an incompressible site
Previous CNS bleeds
Arteriovenous malformations or aneurysm
Severe liver disease, varies or portal hypertension
Seizures at presentation
On anticoagulants or INR >1.7
Platelets <100x10^9/L
Blood pressure > 220/130
