Neurology and neurosurg Flashcards
Difference between a stroke and a TIA
TIA: episode <24hours without brain damage on imaging or neurological deficits
Stroke: brief episode with brain injury or neurological deficits still existing at 72 hours.
When do you call a code stroke and what does this mean?
If <4.5hours from symptom onset -> thrombolysis (if ischaemic)
What does fast stand for?
Facial weakness (can they smile? Any mouth or eye droop?)
Arm weakness (can they raise both arms and hold it there)
Speech difficulity
Time to act fast!
What are some DDX that can mimic stroke? (list 5)
Seizure
Sepsis
Syncope/pre-syncope
Space occupying lesion (haemmhorage or tumour)
Toxic/metabolic derangement (hypoglycaemia, hyponatraemia)
Initial management (in ED) of stroke
ABCs and vitals BSL, FBE, UEC CODE STROKE -> mobilise stroke team ECG (AF?) CT brain Medications (aspirin 100mg, ACEi, statin)
What are the 2 main types of stroke and their sub categories?
- Ischaemic
- intracerebral
- subarachnoid - Haemmhoragic
- Large artery thromboembolism
- Cardiogenic embolism (AF)
- Lacunar infarct
Which type of stroke is most lethal?
Intracerebral
What is the hallmark of a SA haemmhorage?
What is this due to?
CT findings
Thunderclap headache
-ruptured berry
Aneurism (around circle of willis) or AV malformation
CT: Hyperdense blood in fissures, commonly around COW.
What type of stroke is associted w HTN?
Deep intracerebral haemmhorage (putamen, thalamus, brainstem, cerebellum)
Should patients be able to recall what they were doing at the moment their stroke SX began, or is this is a sign of a mimic?
Yes they should with a stroke.
In stroke MX, what agent do you use for thrombolysis? What is the aim of thrombolysis?
Recominant tpa
Aim to salvage the ischaemic penumbra (tissue surrounding the dead core, not yet but will die if left without treatment)
Contraindications for thrombolysis (4)
Haemmhorage (stroke or elsewhere)
Recent surgery
Known aneurysm
Stroke mimics (must rule these out first!)
What further investigations would you do if the stroke is ischaemic?
ECG +/- echo (AF/clot of cardiac origin?)
Carotid doppler U/S +/- CTA (internal carotid stenosis?)
What medications do you give in ED for stroke?
ASPIRIN 100mg
ACE inhibitor
Statin
+/-Warfarin/NOAC if in AF
Primary prevention of stroke (before any stroke has occurred)
- Reduce stroke risk factors
-weight loss (diet and exercise)
-smoking cessation
Statin (reduce cholesterol)
Good blood sugar control
ACE-inhibitior (BP control)
What is the CHADS2 score?
Stroke risk for people in AF:
- Congestive cardiac failure (1 point)
- HTN (1)
- Age (>75) (1)
- Diabetes (1)
- Prior TIA or stroke (2 points)
□ 0 = very low risk -> antiplatelet
□ 1 = 1 low risk -> anticoag or antiplatelet
□ >2 = mod-high risk -> anticoag
Secondary prevention of stroke (after stroke/TIA)
- Antiplatelet (Aspirin) is FIRST LINE
- BP lowering (ACEi, thiazide diuretics)
- Cholesterol: Statins
- If in AFIB: CHADS2 score to determine antiplatelet and/or anticoagulant
+/- Carotid revascularisation (endarterectomy and stenting if symptomatic and stenosis >70%)
MX of haemmhoragic stroke
Keep BP low (SBP 120-130
Control raised ICP
Admit to neurosurg -> may need craniotomy
What are the different types of brain bleeds?
Which is associated w old age and alcoholism?
Which with trauma?
Which with ruptured berry aneurysm?
Which with HTN?
Epidural -> trauma
Subdural -> old age, alcohol, anticoag
Subarachnoid -> ruptured berry aneurysm/AVM
Intracranial -> HTN (aneurysm/AVM to lesser degree)
Characteristic présentation of an epidural haematoma and CT finding
Lucid interval before altered conscioussness
Hyperdense lenticular (lemon shaped) mass limited by suture lines
Characteristic présentation of an subdural haematoma and CT finding
No lucid period
Altered consciousness
Pupil irregularities
Hemiparesis
Hyperdense concave crescentic (crescent moon shaped) mass
Crosses suture lines
How do intracranial bleeds present?
TIA like SX and signs of raised ICP
DDX for headache
Tension-type
Migraine
Cluster
Analgesic overuse
Encephalitis/meningitis SAH Subdural haemmhorage Giant cell arteritis Raised ICP Glaucoma Stroke/TIA Space occupying lesion - tumour of abscess Systemic disorders -thyroid, THN, pheochromocytoma
Clinical presentation of meningitis vs encephalitis
Meningitis: severe headache
+/- neck stiffness, photophobia, rash, fever, systemic illness
Encephalitis: confusion, drowsiness, altered LOC, focal neurological signs, seizures, headaches, signs of systemic illness and fever