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Neurosciences Flashcards

1
Q

Clipping vs coiling aneurysmal SAH

A

ISAT 2005
coiling better short term outcomes, less invasive
coiling may require repeat procedures
less dependency and death at 1 year with coiling but higher rebleeding
surgical clipping - wide neck
improving coiling techniques

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2
Q

ICU management SAH

A
  • allow HTN first 21 days once porected
  • MAP > 90
  • ICP < 20 CPP > 60
  • treat seizures (avoid prophylaxis - worse outcomes)
  • repeat CT if change
  • feed
  • thromboprphylaxis
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3
Q

DCI vs vasospasm

A

vasospasm = narrowing of blood vessels
DCI = new neurological deterioration, may be due to basospasm
DCI management
- nimodipine
- euvolaemia, avoid anaemia
- end-vascular - coiling, angioplasty, IR vasodilator

HHH - hypertension, hypervolaemia, haemodilution - no longer recommended

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4
Q

Primary brain injury

A

neuronal dammage occurring immediately as a direct result of initial trauma. it is irreversible
impact - head striking object
inertial loading - he’d moving rapidly back / forward
penetrating
blast

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5
Q

Types of TBI

A

Fracture
- simple skull fracture
- depressed skull fracture - more likely to tear dura
Haematoma
- EDH
- SDH
- intraparenchymal
Other
- SAH
- Intraventricular haemorrhage
- contusion - coup / contrecoup
- diffuse axonal injury - shearing o axons

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6
Q

Secondary brain injury

A

neuronal damage due to sequelae of primary injury. hours - days after primary injury and main determent of outcome
causes
intracranial
- haematoma
- hydrocephalus
- vasopsasm
- infection
-seizures
extracrnial
- hypotension
- hyoxia
- hypo.hypercapnia
- hyponatraemia
- hypo/hyperglycaemia
- hyperthermia

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7
Q

Indications for CT head in head injury

A
  • GCS < 13 on initial assessment
  • GCS < 15 at 2 hrs
  • Seizures
  • Suspected open or depressed skull fracture
  • signs of BOS fracture
  • focal deficit
  • > 1 vomit
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8
Q

ICP monitoring indications

A

GCS 3-8 and abnormal CT head scan
GCS 3-8 and normal CT head scan if 2 of:
- Age > 40
- SBP < 90
- Abnormal motor posturing
(GCS < 12 and sedated)

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9
Q

Physiological principles of preventing secondary brain injury

A

Maintain cerebral oxygenation
- PO2 > 10
- CPP 60-70
- treat anaemia
Reduce CMRO2
- treat seizure
- normoglycaemia
- normothermia
- deep sedation
- NMB
- barbiturate infusion
Manage increased ICP
- ICP monitoring
- Blood
- CO2 4.5 - 5
- hyperventilate if extreme
- Head up 30 degrees
- avoid tube ties
- Brain - osmotherapy
- CSF - EVD
- Decompressive craniectomy - DECRA 2011 - significant more GOSE 1-4, no difference in death

ICU management = tiers

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10
Q

TBI outcomes

A

Extended glasgow outcome scale GOSE
1 - 8
8 = upper good recovery
1 = death

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11
Q

CRASH 1

A

steroids in head injury GCS < 14
significanty higher mortality with methyprednisolone

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12
Q

Cooling in TBI

A

Eurotherm / Polar - trend to poorter outcomes, increased short term morbidity. not recommended

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13
Q

Intracerebral haemorrhage

A

Bleeding into the brain parenchyma
15% of strokes
Arterial / venous disease, vascular malformations, haemostatic disorders
precipitated by hypertension, CVST, drugs
usually deep sites - cerebellum, pions, thalamus
correction of coagulopathy
intensive BP reduction to 140 systolic (jay prevent haematoma enlargement, end organ dysfunction from hypertension however may reduce cerebral blood flow

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14
Q

BAMFORD classification ischaemic stroke

A

TACS - all 3
- unilateral motor / sensory / both deficit
- homonymous hemianopia
- higher cerebral dysfunction
PACS - 2 out of 3
LACS
- pure motor / sensory face/arm/leg
- sensorimotor deficit
- dysarthria
- acute movement disorder
POCS
- isolate hemianopia
- brainstem signs
- cerebellar ataxia

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15
Q

Investigation of ischaemic stroke

A

validated tool for diagnosis e.g. rosier
exclude hypoglycaemia
history - onset, anticoagulation
NIHSS
Non-contrast CT
CTA if thrombectomy indicated
Perfusion scan if thrombectomy > 6hrs
risk factors - HBA1c, lipid profile, ECG

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16
Q

Management priorities ischaemic stroke

A

supportive care - O2
BP < 185/110 if thrombolysis
consider reduction if > 220/120 or organ dysfunction
aspirin 300mg 2 weeks
thrombolysis < 4.5hr
stroke ward

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17
Q

contraindications to thrombolysis

A
  • active bleeding
  • BP > 185/110
  • recent surgery
  • DOAC last 48hr, INR > 1.7, platelet < 100
  • ischemic stroke < 3 mo
  • intracranial malignancy
  • previous ICH
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18
Q

Malignant MCA syndrome

A

rapid neurological deterioration due to cerebral oedema following MCA territory stroke
inconclusive evidence of decompressive craniectomy
NICE
- MCA infarction NIHSS > 15
- reduced consciousness
- CT infarct > 50% MCA territory

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19
Q

CVST

A

Superior saggital, transverse, internal jugular, cortical veins
Risk factors
- those for thrombotic disorders plus
- head injury
- LP
- IJV CVCC

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20
Q

CVST pathophysiology

A

venous congestion upstream of occlusion
fluid extravasation into parenchyma
if venous pressure > arterial pressure ischaemia
CSF obstruction from swelling

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21
Q

CVST features

A

Headache - new, diffuse, severe, progressive
- seizures, paresis, papilloedema, altered mental state
- signs and symptoms of raised ICP
- focal neurology - visual disturbance

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22
Q

Consciousness

A

state of wakefulness and awareness
- wakefulness = eyes open, degree of motor arousal
- awareness - the ability to have experience of any kind

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23
Q

Disorders of consciousness

A

Confusional state - confusion, disorientation
Minimally conscious state
- plus - higher level responses e.g. following commands
- minus - lower level responses e.g. localising
vegetative state - reflexive and spontaneous movements only
- coma

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24
Q

Disorders of consciousness vs BSD

A

BSD = no wakefulness, no awareness, no consciousness. irreversible
coma = no wakefulness, no awareness, no consciousness. no response to environment or stimulation
VS = wakefulness but no consciousness or awareness
MCS = wakefulness, awareness and consciousness

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25
Locked in syndrome
upper motor neurone quadriplegia affected cranial nerves brain stem pathology consciousness maintained usually preserves eye movements in 1 or 2 axes
26
Prolonged disorders of consciousness
> 4 weeks permanent if no change in trajectory for 6 months - cause established - not related to medictions - reversible causes of loss of awareness treated - exclusion of other potentially reversible causes - coma recovery scale longer someone in APDOC, lesss likely to regain consciousness
27
Long term management of PDOC
- clinically assisted nutrition and hydration - pressure area relief - physiotherapy - prevent joint stiffnes - washing - bladder / bowel management Usually fully dependent MDT / court involvement in withdrawing nutrition and hydration
28
Convilsive status epilepticus
- seizure > 5 mins - recurrent seizures without complete recovery between - refractory = failure to respond to first line treatments - super-refractory = 24hrs
29
Complications of status epilepticus
- airway obstruction - aspiration - hypoxic ischaemic injury - dysrhythmias - lasting neurological dysfunction - trauma - rhabdomyolysis
30
Specific management principles in status epilepticus
- airway protection - rapid termination of seizures with AEDs - treat underling cause - treat complications Specific therapies - eclampsia - magnesium - toxicity - as indicated e.g. intralipid for LAs - Infection - abx, antivirals - alcohol withdrawal - glucose, thiamine
31
Investigations
- collateral history - bloods - glucose - U+E, Mg, TFTs - toxicology - bHCG - serum AED levels - TFTs - CT - EEG - LP - MRI
32
CSE manage,ent
0-5 mins - protect airway - oxygen - IV access - BM - treat if low - alcohol history - glucose, thiamine 5-15mins - Benzo - no response after 5 min - 2nd dose 15 mins - 2nd line - phenytoin 20mg/kg (max 2g) - valproate 40mg/kg (max 3g) - keprra 60mg/kg (max 4.5g) If ongoing seizures after infusion - consider 2nd or phenobarbital 15mg/kg 30 mins - GA - propofol / thio / ketamine / midazolam - propofol/midazolam maintenance - EEG monitoring 24hr (super-refractory) - thio coma - ketogenic, magnesium, IVIG - 24-48hr eeg control before waking
33
Meningitis definition
pathological inflammation of meninges
34
Causes of meningitis
bacteria - pneumococcus over 50s - meningococcus (n.meningitidis) - listeria over 60s - mycobacteria - TB Viral - HSV, enterovirus, VZV, HIV, influenza Fungal - crypto coccus parasitic - malaria, schistomsomiasis non-infectious - malignancy - inflammatory - SLE, sarcoid - medications
35
risk factors
- incomplete vaccination history - mmunocompromise - splenectomy (encapsulated bacteria) - malignancy - travel - shared accomonidation
36
clinical features
fever, meningism, altered mental state neuro - headache - seizures - cranial nerve palsy non-neuro - sepsis - rash - dic
37
Management priorties meningitis
supportive care - intubation if low gcs, seizure, agitation - seizure management LP ASAP but hold if severe spies,s DIC, rash Sepsis management - abx, cultures, cvs support 10mg dexamethasone with 1st dose abx, continue for 4 days. don't start after 12 hours infection prevention and control CT prior to LP - GCS < 12 - papilloedema - focal neurology - seizures
38
Specific investigations in meningitis
Laboratory - standard Micro - HIV, meningococcal PCR, pneumococcal PCR - urine pneumococcal angtigen Radiological - CT exclude differentials, complications LP - opening pressure - cell count - protein, glucose - gram stain - gram +ve diplococci - pneumococcal - gram -ve diplococci - meningococcal - gram +ve bacilli - listeria - culture - viral PCR - HSV, VZV - Autoimmune encephalitis panel - storage
39
Encephalitis
Inflammation of the brain parenchyma associated with neurological dysfunction
40
Causes of encephalitis
Viral - HSV, VZV, EBV, CMV - Measles - Rubella - Arboviruses - Japanese Encephalitis Bactierla - listeria - mycoplasma - TB Fungal - cryptococcal Protozoal - malaria Post-infectious autoiumme ADEM Non-infectious - Anti NMDA - Anti VGKC - Paraneoplastic limbic encephalitis
41
Encephalitis presentation
Neuro - altered mental state - seizures - headache - cranial nerve abnormalities Psychiatric - altered behaviour - altered personality Systemic - fever - rashes
42
Diagnosis of encepahalitis
Major - altered mental state for > 24hr with no alternative Minor (2 = possible, 3 = probable) - temperature > 38 - seizures - generalised, partial - new focal neurologicy - CSF WCC > 5 - abnormal brain parenchyma on imaging - EEG abnormality
43
Investigations for encephalitis
LP - viral PCR HIV serology MR - HSV encephalitis - hyper intensity of frontal temporal areas on T2 flair EEG - lateral periodic discharges
44
Tetanus
clostridium tetani tetanospasmin toxin irreversible binding to NMJ prevents inhibitory GABA release Stimulation of motor neurones spasm and autonomic instability Airway - trismus, laryngospasm Breathing - respiratory muscle rigidity CVS - autonomic instability Rhabdo, AKI, VTE Treatment - minimise toxin exposure - washout - bacterial eradication - metronidazol - neutralise toxin - human tetanus Ig - supportive care 4-6 weeks
45
botulism
clostridium botulinum wound / ingesttion / intestinal colonisation toxin cleaves SNARE proteins - - allowing Ach to fuse with presynaptic membrane ACH not release, flaccid paralysis, anticholinergic afebrile, descending, symmetrical flaccid paralysis loss of airway muscle tone, neck weakness T2RF postural hypotension diplopia, nystagmus ileus, urinary incontinence / retention supportive treatment wound debridement trivalent antitoxin
46
Guillain barre syndrome
Acute demyelinating polyneuropathy within 1 month of GI or resp infection Subtyprd - acute demyelinating polyradiculopathy (AIDP) - myelin sheaths - Acute motor axonal neuropathy (AMAN) - Acute motor sensory axonal neuropathy (AMSAN)
47
Diagnosis GBS
NINDS criteria - progressive bilateral weakness of arms and legs - absent / decreased tendon reflexes supportive features - < 2 weeks - symmetry - autonomic involvement - pain - CSF PROTEIN - Abnormal neurophysioology
48
DDX GBS
CNS - brain stem inflammation egg, sarcoid, spinal cord e.g. transverse myelitis anterior horn- myelitis e.g. polio nerve roots - compression, infection peripheral nerves - vitamin deficiencies, electrolytes NMJ - MG, neurotoxins Muscle - metabolic, myositis Other - functional
49
Critical care admission for GBS
rapidly progressing severe autonomic or bulbar features respiratory insufficiency (EGRIS > 4) - SOB at rest - Abnormal PO2, PCO2 - Vital capacity < 1L
50
Myasthenia gravis clinical features
- weakness and fatiguability of skeletal msucles - worse later in day - ocular weakness on presentation - craniocaudal progressioon Diagnosis - Serum ACHR antibodies - neurophysiological - tension test (cholingerigc crisis) - Thymus - CXR , CT - Resp function
51
Classification of myasthenia
- Occular - Generalised - mild - moderate - Severe generalised - Crisis - worsening of respiratory muscle weakness requiring intubation or NIV (infection, pregnancy)
52
Indications for sedation in critical care
- facilitate tracheal intubation - maintain tube tolerance - facilitate synchrony with ventilator - severe hyperactive delirium - reduce oxygen demand and prevent secondary injury - TBI, seizures - tolerance of invasive procedures
53
Why is depth of sedation important?
oversedation - worse delirium - increases LOS - Increased ventilator days Undersedation - hyper catabolism - increased sympathetic activity - risk of patient harm e.g. self extubation
54
Muscle relaxants in critical care
- facilitation of intubation - severe hypoxaemic respiratory failure - suppress high ventilatory drive - facilitate high pressure ventilation - suppress ICP - abdominal compartment syndrome - transfers
55
sedation hold
temporatory cessation of sedative infusions allow patient to wake, facilitate washout of drugs thought to reduce LOS and mechanical ventilation
56
Withdrawal syndromes in critical care
prexisting alcohol / opiate / benzo - can anticipate iatrogenic - cessation of prolonged sedation. 1/3 of over 7 days critical care opiod - adrenergic excitation and exaggerated nociception. prevention - titrate analgesia, use adjuncts, perform sedationn holds. clonidine and weaning (10-20% per day)
57
Multimodal cerebral monitoring
- clinical - ICP / CPP - CBF - Cerebral oxygenation - cerebral electrophysiological
58
ICP monitoring
- bolt - transduce sensed pressure in specific region (ipsilateral to pathology). allows coninous monitoring but local impression only and can't be recalibrated - EVD - intraventricular catheter connected to transducer via continual fluid column. diagnostic, therapeutic, medication, can recalibrate. infection more common and more invasive - optic nerve sheath diameter - intermittent and operator dependent - pupillometry - intermittent and operator dependent
59
CBF monitoring
- transcranial doppler - intracranial arteries, evaluate velocities - identify emboli, stenosis, vasospasm . pulsatilla index correlates with ICP > 20 - in SAH / vasospasm - increased velocity with narrower vessels or increased blood volume - lindegaard ratio. vasopsaspm LR > 3 - non-invasive, operator dependent, intermittent
60
Cerebral oxygenation monitoring
- NIRS - regional cerebral oxygen saturation - near IR high source and receiver - amount of light attenuation between the 2 measured. light spectra absorption between oxyHb and deoxyHb. non-invasive. - jugular bulb venous oxygen saturation - fibre optic catheter into IJ and thread superiorly. global measure of O2 supply-demand. 55-75% normal. < 55% may be poor supply or increased demand. >75% may be increased supply or poor demand. continuous monitoring, CVC related complications
61
cerebral metabolic monitoring
cerebral micro dialysis - catheter with semi permeable membrane in white mater, perfused with dialyse. small molecules diffuse in. measure - glucose - lactate and pyruvate - glutamate = glycerol
62
electrophysiology
continue EEG used in coma and target sedation e.g. burst suppression SSEP evoked response
63
Sleep
Normal physiological state of rest where level of consciousness and reaction to stimuli is reduced, but which is rapidly reversed.
64
Stages of sleep
Non-REM N1- lightest, easy to rouse N2 - 50% normal sleep N3 - slow wave sleep - difficult to rouse REM - 20% sleep, rapid eye movement and minimal muscle tone
65
Physiological effects of sleep
Resp - partial airway obstruction due to reduced tone and increased resistance - reduced TV, reduced MV, increased CO2 - decreased response to hypoxia and hypercapnia CVS - bradycardia, reduced SVR, reduced BP - redistribution of blood to splanchnic organs - reduced CBF (inc during REM) Others - increased pituitary outflow - reduced oesophageal motility
66
EEG in sleep
N1 - loss of alpha, presence of theta N2 - spindles and k complexes, theta N3 - delta waves REM - sawtooth, theta, flattening
67
Sedation and sleep
sleep - effect of hypothalamic GABA-ergic inhibition of arousal pathways sedation - reduced GABA neurotransmission critically ill sedated patient - N1 sleep, microarousal every 10 seconds
68
Normal EEG waveforms
- ISO - infra slow oscillations 0 preterm neonates - delta - 0.5-4Hz - deep sleep, may be pathological in encephalopathy, dysfunction - theta 4-7hz - drowsiness and early N1/N2 sleep. focal activity may be focal cerebral dysfunction - alpha 8-12hz - normal awake EEG in occipital region sigma waves - sleep spindles - beta - beta rhythm in health

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