Neurology

Question 1

What percentage of strokes are due to intracranial bleeds?

Answer 1

10-20%

Question 2

What are some risk factors for intracranial bleeds?

Answer 2

Hypertension
Head injury 
Aneurysms
Ischaemic stroke --> haemorrhage
Brain tumours
Anti-coagulations ie Warfarin

Question 3

How might a patient with an intracranial bleed present?

Answer 3

Sudden onset headache
Seizures
Reduced consciousness
Weakness
Vomiting
Sudden onset neurological symptoms

Question 4

What causes a subdural haemorrhage?

Answer 4

Rupture of bridging veins

Question 5

How does a subdural haemorrhage appear on a CT?

Answer 5

Crescent shape not limited by cranial sutures

Question 6

In what population groups are subdural haemorrhages most likely to occur?

Why?

Answer 6

Elderly
Alcoholics

Brain more atrophied –> bridging vessels more likely to rupture

Question 7

A subdural haemorrhage occurs between which layers of the meninges?

Answer 7

Dura mater

Arachnoid mater

Question 8

What usually causes an extradural haemorrhage?

Answer 8

Rupture of the middle meningeal artery

Often associated with fracture of the temporal bone

Question 9

Between what layers of the cranium, does an extradural haemorrhage occur?

Answer 9

Skull and dura mater

Question 10

How does an extradural haemorrhage appear on a CT?

Answer 10

Bi-convex shape

Limited by sutures

Question 11

How does an intracerebral haemorrhage present?

Answer 11

Similarly to an ischaemic stroke

Question 12

What are the principles of managing a patient who has an intracerebral haemorrhage?

Answer 12

A-E assessment
Urgent head CT
FBC and clotting (correct any clotting abnormalities)
Management in a stroke unit
? neurosurgical input
Consider intubation, ventilation and ITU if drop GCS
Correct severe hypertension

Question 13

Where does a SAH occur?

Answer 13

Subarachnoid space between the Pia mater and the arachnoid membrane

Question 14

What symptoms are associated with a SAH?

Answer 14

Sudden onset occipital headache “thunder clap”
Neck stiffness
Photophobia
Neurological symptoms - visual changes, speech changes, weakness, seizures, LOC

Question 15

What are risk factors for SAH?

Answer 15

HTN
Smoking
Excessive alcohol consumption
Cocaine
FHx

Question 16

in what groups of people are SAH most common in?

Answer 16

Black people
Females
45-70 years

Question 17

What is SAH particularly associated with?

Answer 17

Cocaine use
Sickle cell anaemia
Connective tissue disorders (E-D, Marfans)
Neurofibromatosis

Question 18

What investigations should be performed in patents with ?SAH?

Answer 18

Urgent Head CT (hyperattenuation in the subarachnoid space)

If CT negative, after 12 hours –> LP (raised RBC, xanthochromia)

CT/MRI angiography - located site of bleed

Question 19

What ECG changes may be seen in SAH?

Answer 19

Inverted T waves

Elevated ST

Question 20

How should a patient with SAH be managed?

Answer 20

Neurosurgically

• Endovascular coiling
• Neurosurgical clipping

MDT approach (SALT, physio, OT, nursing)

Question 21

What drug should be prescribed to patients with SAH to prevent further complications?

Answer 21

Nimodipine (Ca channel blocker - prevents vasospasm)

Question 22

Define a TIA

Answer 22

Transient neurological dysfunction secondary to ischaemia without infarction

Question 23

What is a crescendo TIA?

Answer 23

Two or more TIAs occurring within a week - carries a high risk of progressing to a stroke

Question 24

How does a stroke present?

Answer 24

Sudden onset of neurological symptoms which are asymmetrical 
Sudden weakness of limbs
Sudden facial weakness
Sudden dysphagia
Sudden visual/sensory changes

Question 25

Give some risk factors of stroke

Answer 25

Cardiovascular disease - angina, MI, PVD
Previous stroke, TIA
AF
Carotid artery disease
DM
Vasculitis
Thrombocytopenia

Modifiable:
HTN
Smoking
OCCP

Question 26

What scoring tool can be used in hospital to determine the likelihood of a patient having a stroke?

Answer 26

ROSIER

Question 27

What scoring tool can be used to assess the likelihood of a patient with a suspected TIA having a subsequent stroke?

Answer 27

ABCD2

Question 28

Define the ABCD2

Answer 28

A = Age (>60 = 1 pt)
B = BP (>140/90 = 1 pt)
C = Clinical features (unilateral weakness = 2 pt; dysphagia without weakness = 1 pt)
D = Duration (> 60 min = 2 pt; 10-60 min = 1 pt; <10 min = 0 pt)
D = Diabetes = 1 pt

Question 29

What is the significance of a ABCD2 score in terms of need to see a specialist?

Answer 29

<3 = specialist assessment within 1 week 
>3 = specialist assessment within 1 week

Question 30

How should a stroke be managed?

Answer 30

A - E assessment
Exclude hyperglycaemia
Urgent Head CT (exclude haemorrhagic cause)
Aspirin 300mg (only if no haemorrhage) - continue for 2 weeks
Admit to specialist Stroke Unit

Question 31

What is the timeframe for potential thrombolysis treatment in the management of ischaemic stroke?

Answer 31

Within 4.5 hours of symptoms

Question 32

What is the timeframe for potential thrombectomy in the management of ischaemic stroke ?

Answer 32

Within 6 hours

Question 33

How should a TIA be managed?

Answer 33

300mg Aspirin
Perform ABCD2 score
Secondary prevention

Question 34

What are the secondary prevention methods in TIA management?

Answer 34

Aspirin for 2 weeks then…
Clopidogrel 75mg OD (dipyridamole + aspirin)
Atorvastatin 80mg
Assess for carotid artery disease –> stenting or carotid endartectomy
Treat modifiable risk factors

Question 35

Who makes up the MDT in a stroke patient?

Answer 35

Nurses
SALT
OT
Physios
Social services
Dieticians
Optometery and ophthalmology
Psychology
Orthotics