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Yr 5 - Neuro > Revision - TIA, Stroke & SAH > Flashcards

Revision - TIA, Stroke & SAH Flashcards

1
Q

What are 3 exceptions to giving 300mg aspirin immediately in TIA?

A

1) Pt taking anticoagulant or has a bleeding disorder –> needs immediate assessment/imaging for haemorrhage

2) Pt already taking low dose aspirin –> continue this dose until specialist assessment

3) Aspirin contraindicated

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2
Q

Referral for patients who have had a suspected TIA in the last 7 days?

A

Urgent assessment by specialist (within 24h)

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3
Q

Referral for patients who have had a suspected TIA which occurred more than 7 days ago?

A

Assessment by specialist within 1 week

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4
Q

What imaging is indicated in a TIA?

A

MRI

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5
Q

When is a carotid doppler not indicated in TIA?

A

If they are not a candidate for carotid endarterectomy

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6
Q

2ary prevention following TIA? (2)

A

1) antiplatelet therapy to follow on from initial aspirin therapy: clopidogrel

2) atorvastatin (20-80mg daily)

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7
Q

What is 1st line antiplatelet in 2ary prevention of TIA?

A

Clopidogrel 75mg OD

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8
Q

What can be given during 2ary prevention of TIA in patients who cannot tolerate clopidogrel?

A

Aspirin + dipyridamole

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9
Q

What is the aim of statin therapy in 2ary prevention of TIA?

A

Reduce non-HDL cholesterol by 40%

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10
Q

What is a carotid artery endarterectomy?

A

a surgical procedure to remove a build-up of fatty deposits (plaque), which cause narrowing of a carotid artery.

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11
Q

When is a carotid artery endarterectomy recommended?

A

Recommend if the patient has suffered stroke or TIA in the carotid territory and is not severely disabled.

ONLY if carotid artery stenosis >70%

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12
Q

What is the most important risk factor of a haemorrhagic stroke?

A

HTN

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13
Q

What are the 2 types of haemorrhagic stroke?

A

1) Intracerebral

2) Subarachnoid

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14
Q

What are the 2 main subtypes of ischaemic strokes?

A

1) Thrombotic

2) Embolic (AF is an important cause)

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15
Q

What classification is used in stroke?

A

Oxford Stroke Classification (also known as the Bamford Classification).

This classifies stroke based on initial symptoms.

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16
Q

What criteria is assessed in the Oxford Stroke Classification?

A

1) Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg

2) Homonymous hemianopia

3) Higher cognitive dysfunction e.g. dysphasia

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17
Q

What arteries are involved in a total anterior circulation infarct?

A

Middle and anterior cerebral arteries

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18
Q

What criteria from the Oxford Stroke Classification are present in a total anterior circulation infarct?

A

All 3 criteria

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19
Q

What criteria from the Oxford Stroke Classification are present in a partial anterior circulation infarct?

A

2/3 criteria

OR

higher cerebral dysfunction alone

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20
Q

What arteries are involved in a lacunar infarct?

A

Perforating arteries around the internal capsule, thalamus and basal ganglia.

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21
Q

How does a lacunar infarct present?

A

With 1 of the following:

1) Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all 3

2) Pure sensory stroke

3) Ataxic hemiparesis

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22
Q

What arteries are involved in a posterior circulation infarct?

A

Vertebrobasilar arteries

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23
Q

Presentation of a posterior circulation infarct?

A

Presents with 1 of the following:

1) Cerebellar or brainstem syndromes

2) LOC

3) Isolated homonymous hemianopia

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24
Q

Initial mx of an ischaemic stroke?

A

1) Neuroimaging - to exclude haemorrhagic

2) Aspirin 300mg (for 2 weeks)

3) Exclude hypoglycaemia

4) Admission to a specialist stroke centre

5) Thrombolysis with alteplase (if criteria met)

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25
Q

When is aspirin 300mg given in stroke?

A

AFTER haemorrhagic stroke excluded by CT

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26
Q

What is the criteria for thrombolysis in ischaemic stroke?

A

1) Symptom onset <4.5 hours

2) Patient has not had a previous intracranial haemorrhage, uncontrolled HTN, pregnant etc

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27
Q

What should ALWAYS be excluded in a suspected stroke?

A

Hypoglycaemia

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28
Q

Symptoms of a posterior stroke?

A
  • nystagmus
  • vertigo or dizziness
  • N&V
  • head motion intolerance
  • new gait unsteadiness
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29
Q

If patients with stroke are unable to swallow 300mg aspirin orally, what is next option?

A

600mg PR

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30
Q

Once a patient who has had an ischaemic stroke has been moved to stroke unit, further investigations & management plans can be carried out for risk factors.

What 2 investigations can be considered?

A

1) Carotid artery doppler

2) ECG

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31
Q

Mx of AF causing ischaemic stroke?

A

Consider anticoagulation 14 days post stroke

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32
Q

Are lower or upper extremeties affected more in an anterior cerebral infarct?

A

Lower > upper

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33
Q

Are lower or upper extremeties affected more in a middle cerebral infarct?

A

Upper > lower

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34
Q

Associated effects of posterior cerberal artery infarct?

A
  • Visual agnosia
  • Contralateral homonymous hemianopia with macular sparing
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35
Q

Associated effects of a basilar artery infarct?

A

Locked in syndrome

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36
Q

What do lacunar strokes have a strong association with?

A

HTN

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37
Q

Give some absolute contraindications to thrombolysis?

A

1) Previous intracranial haemorrhage

2) Seizure at onset of stroke

3) Intracranial neoplasm

4) Suspected SAH

5) Stroke or traumatic brain injury in preceding 3 months

6) LP in preceding 7 days

7) GI haemorrhage in preceding 3 weeks

8) Pregnancy

9) Oesophageal varices

10) Uncontrolled hypertension >200/120mmHg

11) Active bleeding

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38
Q

Who is thrombectomy considered in?

A

Considered in patients with a confirmed blockage of the proximal ANTERIOR circulation or proximal POSTERIOR circulation.

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39
Q

What is thrombectomy done alongside?

A

IV thrombolysis

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40
Q

What is thromboylsis done with in stroke?

A

Alteplase

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41
Q

What is alteplase?

A

a tissue plasminogen activator

Plasminogen is activated to plasmin –> degrades fibrin clots

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42
Q

Site of lesion: anterior cerebral artery

What are the associated effects?

A

Contralateral hemiparesis & sensory loss.

Lower extremity > upper.

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43
Q

Site of lesion: middle cerebral artery

What are the associated effects?

A

1) Contralateral hemiparesis and sensory loss: Upper extremity > lower.

2) Contralateral homonymous hemianopia

3) Aphasia

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44
Q

Site of lesion: posterior cerebral artery

What are the associated effects?

A

1) Contralateral homonymous hemianopia with macular sparing

2) Visual agnosia: impairment in recognising visually presented objects

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45
Q

What is Weber’s syndrome?

A

A type of midbrain stroke

Infarct is in branches of the posterior cerebral artery that supply the midbrain.

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46
Q

Associated effects of Weber’s syndrome?

A

1) Ipsilateral CN III palsy –> down and out eye

2) Contralateral weakness of upper and lower extremity

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47
Q

What arteries are affected in lateral medullary syndrome?

A

Posterior inferior cerebellar artery (PICA)

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48
Q

What is lateral medullary syndrome also known as?

A

Wallenburg syndrome

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49
Q

Site of lesion: posterior infererior cerebellar artery

What are the associated effects?

A

1) Ipsilateral: facial pain & temp loss

2) Contralateral: limb/torso pain and temperature loss

3) Ataxia, nystagmus

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50
Q

What artery is affected in lateral pontine syndrome?

A

Anterior inferior cerebellar artery

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51
Q

Site of lesion: anterior infererior cerebellar artery

What are the associated effects?

A

1) Ipsilateral: facial pain & temp loss

2) Ipsilateral: facial paralysis and deafness

3) Contralateral: limb/torso pain and temperature loss

3) Ataxia, nystagmus

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52
Q

A stroke affecting which artery presents with contralateral homonymous hemianopia with macular sparing and visual agnosia?

A

Posterior cerebral artery lesion

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53
Q

A stroke affecting which artery presents with oculomotor nerve palsy (‘down and out’)?

A

Weber’s syndrome - midbrain stroke (branches of posterior cerebral artery)

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54
Q

Give some causes of a spontaneous SAH

A

1) Intracranial aneurysm e.g. saccular ‘berry’ aneurysm –> most common

2) AV malformation

3) Pituitary apoplexy

4) Mycotic (infective) aneurysms

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55
Q

What are some conditions associated with berry aneurysms?

A

1) HTN

2) APKD

3) Ehlers-Danlos

4) Coarctation of the aorta

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56
Q

1st line investigation in SAH?

A

Non-contrast head CT

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57
Q

Next investigation in SAH if:

a) if CT head is done within 6 hours of symptom onset and is normal

b) if CT head is done more than 6 hours after symptom onset and is normal

A

a) rule out SAH

b) wait until 12h after symptom onset and do LP

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58
Q

When should lumbar puncture be done in SAH?

A

12h after symptom onset

59
Q

When must a non-contrast head CT be done in suspected SAH for it to be diagnostic?

A

Within 6 hours

60
Q

Lumbar puncture results in SAH?

A

1) Presence of xanthochromia in the CSF, making the CSF appear yellow rather than clear.

2) Normal or raised opening pressure

61
Q

What is xanthochromia?

A

RBC breakdown

62
Q

Give some complications of SAH

A

1) re-bleeding

2) hydrocephalus

3) hyponatraemia

4) vasospasm

5) seizures

63
Q

Cause of hyponatraemia post-SAH?

A

SIADH

64
Q

What scoring system is used to assess functional independence and was developed for use in patients AFTER a stroke?

A

Barthel index

65
Q

What is an epidural haemorrhage often the result of?

A

Head trauma - particularly trauma to the pterion, leading to tearing of the middle meningeal artery.

66
Q

Clinical features of epidural haemorrhage?

A

1) Acute severe headache

2) Contralateral hemiplegia

3) Rapid deterioration in GCS following lucid period

67
Q

Risk factors for subdural haemorrhage?

A

Age, alcohol misuse, anticoagulation, history of head trauma

68
Q

Cause of a subdural haemorrhage?

A

Tearing of bridging veins between cortex and dura mater.

This can occur due to minor trauma in those with risk factors.

69
Q

What are 4 posterior stroke syndromes?

A

1) Basilar artery occlusion

2) Anterior inferior cerebellar artery infarct

3) Posterior inferior cerebellar artery infarct i.e. Wallenburg’s syndrome, lateral medullary syndrome

4) Weber’s syndrome/medial midbrain syndrome

70
Q

Presentation of Wallenberg syndrome (lateral medullary syndrome)?

A

Dysphagia, ipsilateral Ataxia, ipsilateral Nystagmus, Vertigo, Anaesthesia (Ipsilateral facial numbness and contralateral pain loss on the body) and ipsilateral Horner’s syndrome

71
Q

After thrombolysis in stroke management, when should aspirin be taken?

A

Aspirin 300mg after 24h from alteplase

72
Q

What can rapid correction of severe hyponatraemia cause?

A

Osmotic demyelination syndrome i.e. central pontine myelinolysis

73
Q

What can untreated, severe hyponatraemia cause?

A

Cerebral oedema (and then brain herniation)

74
Q

Features of osmotic demyelination syndrome?

A
  • dysarthria, dysphagia, paraparesis or quadriparesis, seizures, confusion, and coma
  • locked in syndrome
75
Q

What is thrombectomy?

A

An exciting new treatment option for patients with an acute ischaemic stroke.

76
Q

When is thrombectomy indicated in an ischaemic stroke?

A

Within 6h of symptom onset

in people with confirmed occlusion of the PROXIMAL ANTERIOR circulation

77
Q

When can an extended target time of 6-24 hours be considered for thrombectomy?

A

Who have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (that is, basilar or posterior cerebral artery)

IF

if there is the potential to salvage brain tissue

78
Q

What is a headache, fever & focal neurology suggestive of?

A

Brain abscess

79
Q

What arrhythmia can SAH cause?

A

Torsades de pointes (can deteriorate into ventricular fibrillation).

80
Q

How can SAH cause torsades de pointes?

A

Due to a sudden catecholamine release in response to the acute hemorrhage

81
Q

What is BNP?

A

A hormone produced mainly by the left ventricular myocardium in response to strain.

82
Q

Give some causes of a raised BNP

A

1) HF

2) Any cause of LV dysfunction e.g. myocardial ischaemia or valvular disease

3) Reduced excretion e.g. CKD

83
Q

What does a NNT of 20 mean in a prevention study?

A

20 patients would need to be treated to prevent 1 event.

E.g. for 1000 patients treated, there would be 50 fewer events.

84
Q

Mx of TIA due to AF

A

Following a TIA, anticoagulation for AF should start IMMEDIATELY once imaging has excluded haemorrhage

i.e. lifelong apixaban

85
Q

Mx of ischaemic stroke due to AF?

A

Aspirin for 2 weeks

Anticoagulation after this

86
Q

What artery is affected in amaurosis fugax?

A

Retinal/opthalmic artery

87
Q

What is the central retinal artery a branch of?

A

Ophthalmic artery (this is a branch of the internal carotid)

88
Q

What is a broad complex following an MI almost always due to?

A

VT

89
Q

What is the first line radiological investigation for suspected stroke?

A

Non-contrast head CT

90
Q

What BP is an absolute contraindication to thrombolysis in an acute ischaemic stroke?

A

≥185/110

Lower BP first

91
Q

What can be seen on an ECG in acute pericarditis?

A

Widespread ST elevation

92
Q

What artery is affected:

  • Contralateral hemiparesis and sensory loss with the upper extremity being more affected than the lower
  • Contralateral homonymous hemianopia
  • & aphasia
A

Middle cerebral artery

93
Q

How does pontine haemorrhage commonly present?

A
  • reduced GCS
  • paralysis
  • bilateral pinpoint pupils
94
Q

What is the preferred antiplatelet for secondary prevention following stroke?

A

Clopidogrel

95
Q

What 2 classes of drugs are at most risk of causing medication overuse headache?

A

Triptans & opioids

96
Q

What is Chagas’ disease?

A

caused by the protozoan Trypanosoma cruzi.

97
Q

What is the most frequent and most severe manifestation of chronic Chagas’ disease?

A

Cardiomyopathy

98
Q

A seizure causing post-ictal dysphasia is associated with what lobe?

A

Temporal

99
Q

What type of seizure is a ‘complex’ febrile convulsion?

A

Focal seizure

100
Q

Give 2 contraindications for bupropion (smoking cessation medication)

A

1) Epilepsy - lowers seizure threshold

2) Pregnancy & breastfeeding

101
Q

What score categorises patients into levels of frailty according to their function?

A

Rockwood frailty scale

102
Q

What is the preferred imaging modality in patients with suspected TIA?

A

MRI brain with diffusion-weighted imaging

103
Q

What is autonomic dysreflexia?

A

Clinical syndrome that occurs in patients who have had a spinal cord injury at, or above T6

  • extreme HTN (can lead to haemorrhagic stroke) W
  • flushing
  • sweating above level of cord lesion
  • agitation
104
Q

What is the best assessment tool for differentiating between stroke and stroke mimics?

A

The Recognition of Stroke in the Emergency Room (ROSIER) scale

105
Q

What type of dopamine receptor agonists are most associated with pulmonary, retroperitoneal & cardiac fibrosis?

A

ergot-derived dopamine receptor agonists (bromocriptine, cabergoline)

106
Q

What type of dementia is MND most associated with?

A

Frontotemporal dementia

107
Q

What 2 types of dementia is parkinsonism associated with?

A

1) parkinson’s dementia
2) LBD

108
Q

Cause of bilateral vs unilateral foot drop?

A

Bilateral –> peripheral neuroapthy

Unilateral –> common peroneal nerve lesion

109
Q

Does domperidone exacerbate Parkinson’s symptoms?

A

No - doesn’t cross BBB

110
Q

What is the preferred antiemetic in parkinson’s disease?

A

Domperidone

111
Q

What drug has the strongest evidence base for reducing relapse in multiple sclerosis?

A

Monoclonal antibodies such as natalizumab

112
Q

What branches does the basilar artery give off?

A

Pontine arteries

113
Q

When should statins be started after stroke?

A

48h after stroke onest in those not already taking a statin

114
Q

Does the absence of oligoclonal bands in the CSF exclude a diagnosis of MS?

A

No

115
Q

What type of nerve fibres transmit signals slowly and produce dull and diffuse pain sensations?

A

C fibres

116
Q

What surgical procedure may be used to treat myasthenia gravis?

A

Thymectomy

117
Q

What medication may be used to slow the progression of the disease and extend survival by several months in amyotrophic lateral sclerosis (ALS)?

A

Riluzole

118
Q

What is the usual first-line prophylactic treatment for chronic or frequent tension headaches?

A

Amitriptyline

119
Q

What cholinesterase inhibitor prolongs the action of acetylcholine and improves symptoms in myasthenia gravis?

A

Pyridostigmine

120
Q

What type of receptor do triptans stimulate?

A

5-HT receptors (serotonin receptors)

121
Q

What type of nerve fibres transmit signals fast and produce sharp and localised sensations?

A

A delta fibres

122
Q

What medication may be used to prevent vasospasm in subarachnoid haemorrhage?

What is the mechanism of action of this drug?

A

Nimodipine

CCB

123
Q

What threshold is used for defining chronic versus acute pain?

A

> 3m duration

124
Q

What dose of oxycodone is approximately equivalent to 10mg of oral morphine?

A

6.6mg

125
Q

What term refers to when pain is experienced with sensory inputs that do not normally cause pain (e.g., light touch)?

A

Allodynia

126
Q

What dose of tramadol is approximately equivalent to 10mg of oral morphine?

A

100mg

127
Q

What type of medication is taken alongside levodopa and slows the breakdown of the levodopa in the brain, extending the effective duration of the levodopa?

A

COMT inhibitors (e.g. entacapone)

128
Q

What medication is used first-line to treat relapses of multiple sclerosis?

A

Methylprednisolone

129
Q

What are the most common antibodies found in patients with myasthenia gravis?

A

Acetylcholine receptor (AChR) antibodies

130
Q

What type of benign tumour is associated with neurofibromatosis type 2?

A

Schwannoma

131
Q

Which TB med can cause peripheral neuropathy?

A

Isoniazid

132
Q

What gait disturbance may be seen in Charcot-Marie-Tooth disease? (1)

A

High stepping gait (due to foot drop)

133
Q

Which medication is used to treat the symptoms of Lambert-Eaton myasthenic syndrome?

A

Amifampridine

134
Q

What vitamin may be beneficial in treating migraines?

Who should avoid supplementing with this?

A

Vitamin B2 (riboflavin)

Patients who are pregnant or planning pregnancy

135
Q

What type of benign tissue growth is associated with tuberous sclerosis? (1)

A

Hamartomas

136
Q

What is the mechanism of action of amantadine used to treat Parkinson’s disease? (1)

A

Glutamate antagonist

137
Q

What special test is used to support a diagnosis of myasthenia gravis?

A

Edrophonium test

138
Q

What is the first-line medical treatment for Guillain-Barré syndrome?

A

IV immunoglobulins

139
Q

What is the main side effect of long-term use of levodopa?

A

Dyskinesia

140
Q

What is the first-line imaging investigation in patients with a suspected brain tumour?

A

MRI

141
Q

What condition can cause features of Parkinsonism associated with autonomic dysfunction and cerebellar ataxia?

A

Multiple system atrophy

142
Q

What are the mechanisms of action of tramadol? (2)

A

Serotonin and norepinephrine reuptake inhibitor (SNRI)

Opioid receptor antagonist

143
Q

What investigation is done at the same time as a LP in meningitis?

Why?

A

Blood glucose for comparison to the CSF glucose

144
Q
A

Yr 5 - Neuro (13 decks)

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