Stroke and acute neurological complaints

Question 1

Where are the pain receptors that cause headaches as a symptom?

Answer 1

Brain tissue is insensate.

Traction or dilatation of intracranial vessels.
Traction of large extra cranial veins.
Compression, traction or inflammation of cranial and spinal nerves.
Meningeal irritation and raised intracranial pressure.
Spasm or trauma to cranial or cervical muscles.
Disturbance of serotonergic projections.

Question 2

What is the purpose of headache assessment?

Answer 2

Diagnose headache subtype.
Determine cause (exclude secondary cause).
To explain diagnosis and rationale for treatment.
Optimise treatment.

Question 3

How are headaches classified?

Answer 3

Primary headache (no causative disorder): migraine, tension type, cluster headache, other primary headaches.
Secondary headache (causative disorder): head or neck trauma, vascular disorder, CNS infection, intracranial pressure disorder, metabolic disorders, drug withdrawal disorders, headache psychiatric disorder, dental, ENT or ocular problem.
Cranial neuralgias.

Question 4

Case 1:
27y/o man, right-handed, presents with sudden onset severe occipital headache while at work, sitting in from of computer for 2hrs, stressed with deadlines, drinking too much coffee.
No N or V or LOC. Stopped work, went home and rested (early bed).
History of migraine.
Examination: in A&E normal examination, no focal signs, apyrexial, obs stable.
What is your plan?
a) reassure and send home
b) present case and go home “I am year 3”
c) suggest CT, if normal send home
d) suggest CT head then LP
e) sumatriptan 50mg and await response

Answer 4

Suggest CT, if normal send home.

Thunderclap? could be subarachnoid haemorrhage, need to rule out.

Question 5

How do patients present with subarachnoid haemorrhage?

Answer 5

1/3 present with acute onset severe headache as the only symptom.
5-11% misdiagnosed, most commonly as migraine.
Headache onset: abrupt, sudden, acute, thunderclap over seconds or minutes.

Question 6

What are the headache red flags?

Answer 6

Age of onset: always consider secondary headache at any age with new headache or headache that differs from their normal; middle-aged to elderly (>50) GCA.
Type of onset: abrupt and severe (thunderclap).
Temporal: progressively severe or increasing frequency.
Pattern: significant change in headache pattern.
Neurological signs: meningioma (stiff neck), focal signs, confusion, altered LOC.
Systemic signs: abnormal examination, fever, weight loss.
Triggers: posture, valsalvar, coughing, exertion.
Secondary risk factors: systemic disease, cancer, HIV, 3rd trimester pregnancy/postpartum, recent head injury.

Question 7

What are the causes of thunderclap headache?

Answer 7

Intracranial infection: meningitis.
CSF pressure related: 3rd ventricle colloid; cyst; spontaneous intracranial hypotension (SIH).
Vascular: ischaemic and haemorrhagic stroke; SAH; cerebral venous thrombosis; cervical arterial dissection; reversible cerebral vasoconstriction syndrome (RCVS); cerebral vasculitis; pituitary apoplexy; posterior reversible encephalopathy syndrome.
Others: acute hypertensive crisis; idiopathic thunderclap headache.

Question 8

List secondary headache conditions which may have normal CT head scans.

Answer 8

Meningitis.
SAH.
Ischaemic stroke.
Cerebral venous thrombosis.
Cervical arterial dissection.
Reversible cerebral vasoconstriction syndrome.
Cerebral vasculitis and temporal arteritis.
Pituitary apoplexy.
Malignant hypertension.

Question 9

What are the peripheral parts of the vestibular system?

Answer 9

Semicircular canals.

Vestibular nerve.

Question 10

What are the central parts of the vestibular system?

Answer 10

Brainstem.

Cerebellum.

Question 11

What conditions cause dizziness in the peripheral vestibular system?

Answer 11

BPPV.
Meniere’s.
Vestibular neuritis.

Question 12

What conditions cause dizziness in the central vestibular system?

Answer 12

Isolated vertigo.
4% of isolated nystagmus is caused by stroke.
Other CNS deficits.

Question 13

Where might the level of the lesion be in the nervous system in an upper motor neurone lesion?

Answer 13

Brain
Brain stem
Spinal cord

Question 14

Where might the level of the lesion be in the nervous system in a lower motor neurone lesion?

Answer 14

Low motor neurone
Neuromuscular junction
Muscle

Question 15

What is fatigability and what condition might it be seen in?

Answer 15

Ptosis develops, eye alignment changes vertically, causes diplopia as eyes are disconjugated.
Myasthenia gravis.

Question 16

In a 3rd nerve palsy, what is the level of lesion in the nervous system?

Answer 16

Neuromuscular junction.

Question 17

What is Horner’s syndrome?

Answer 17

Ptosis, miosis, and anhydrosis.

Enophthalmos.

Question 18

What is the epidemiology of stroke?

Answer 18

A developing problem.
1 in 10 deaths is caused by a stroke.
3rd most common cause of death.
Worldwide 15m people suffer a stroke each year, 1/3 die and 1/3 disabled.

Question 19

What is a stroke?

Answer 19

The sudden death of brain cells due to blockage of blood flow or rupture of an artery to the brain parenchyma.
Ischaemic (85%) or haemorrhagic (12%) or SAH (3%).

Question 20

How does an intra-cerebral haemorrhage cause symptoms of stroke?

Answer 20

Pressure of increasing amounts of blood.
Blood itself (blood is irritating to the brain tissue, causing it to swell.

Question 21

What are some causes of haemorrhagic stroke?

Answer 21

Hypertension.
Rupture of an aneurysm or AVM.
Haemorrhagic necrosis (e.g. tumour, infection).
Venous outflow obstruction (CVT).
Trauma.
Altered haemostasis.

Question 22

What are the types of causes of ischaemic stroke?

Answer 22

Cryptogenic (30%).
Large vessel atherosclerosis (20%).
Small vessel disease (25%).
Cardio-embolic (20%).

Question 23

What causes ischaemic stroke?

Answer 23

Thrombus blocks artery to brain, prevents oxygen delivery.
Intracranial atherosclerosis.
Carotid plaque with emboli.
Aortic arch plaque.
Cardiogenic emboli.
Small artery disease.
Carotid stenosis.
Atrial fibrillation.
Valve disease.
Ventricular thrombi.

Question 24

What are the types of large artery atherosclerosis?

Answer 24

Intracranial stenosis.
Carotid stenosis (>50%).
Aortic arch plaque.

Question 25

What are the modifiable/ non-modifiable risk factors for large artery atherosclerosis leading to ischaemic stroke?

Answer 25

HT.
DM.
CAD.
Smoking.
Cholesterol.
BMI.
Age.
FMHx.

Question 26

What is the management plan for patients with large artery atherosclerosis or ischaemic stroke prevention?

Answer 26

Modify lifestyle factors.
Antiplatelet (e.g. aspirin, clopidogrel).
Duplex scan looking for stenosis.
Carotid endarterectomy is of additional benefit for symptomatic carotid disease.

Question 27

What are the cardioembolic causes of ischaemic stroke?

Answer 27

Atrial fibrillation and paroxysmal AF.
Valve disease.
Ventricular thrombi.

Question 28

What are the various complaints in acute stroke?

Answer 28

Alteration in consciousness: stupor or coma; confusion or agitation/memory loss; seizures; delirium.
Vision and eyes: monocular or binocular; visual field (hemianopia); vertigo, diplopia.
Ataxia: poor balance, clumsiness, or difficulty walking.
Speech and swallow: slurring of speech or difficulty understanding or expressing language; swallowing problems.
Headache: abrupt intense or unusually severe; associated with decreased level of consciousness/neurological deficit; unusual/severe neck or facial pain.
Facial weakness or asymmetry: paralysis of facial muscles (e.g. when patients speak or smile); may be on same side (ipsilateral) or opposite side (contralateral) to limb paralysis.
Weakness and paralysis.
Sensory loss.
Unilateral hearing loss, nausea, vomiting.

Question 29

What neuromuscular syndromes occur in left (dominant) hemisphere stroke?

Answer 29

Aphasia.
Right hemiparesis.
Right-sided sensory loss.
Right visual field defect.
Poor right conjugate gaze.
Dysarthria.
Difficulty reading, writing, or calculating.

Question 30

What neuromuscular syndromes occur in right (non-dominant) hemisphere stroke?

Answer 30

Neglect of left visual field.
Extinction of left-sided stimuli.
Left hemiparesis.
Left-sided sensory loss.
Left visual field defect.
Poor left conjugate gaze.
Dysarthria.
Spatial disorientation.

Question 31

What neuromuscular syndromes occur in brainstem/ cerebellum/ posterior hemisphere stroke?

Answer 31

Motor or sensory loss in all 4 limbs.
Crossed signs.
Limb or gait ataxia.
Dysarthria.
Disconjugate gaze (diplopia).
Nystagmus (vertigo).
Bilateral visual field defects.

Question 32

What neuromuscular syndromes occur in small subcortical hemisphere or brain stem stroke (lacunar syndromes)?

Answer 32

Pure motor.
Pure sensory.
Sensory motor.
Ataxic hemiparesis.
Dysarthria clumsy hand syndrome. 
(Without abnormalities of higher brain function, sensation, or vision).

Question 33

What is bright on a CT scan?

Answer 33

Blood
Contrast
Bone
Calcium
Metal

Question 34

What is dark on a CT scan?

Answer 34

Air
CSF/water
Oedema

Question 35

Case 1:
24y/o female from Somalia.
Gradual onset generalised headache with some nausea and lightheadedness eases with eating.
Has had 3-4 attacks in the last month.
PMHx: DM (insulin dependent); depression.
SHx: refugee, orphaned aged 6.
O/E: left homonymous hemianopia.
Metal artefact seen on CT.
What is the likely cause of the headache?

Answer 35

Hypoglycaemia.

Metal artefact caused hemianopia- bullet remained from genocide as a child.

Question 36

What is the ischaemic cascade?

Answer 36

When brain cells are deprived of sufficient oxygen, a biochemical cascade is initiated, involving several pathways known as the ischaemic cascade, leading towards cell death: necrosis, apoptosis and inflammation.

Question 37

What are the dynamic changes following ischaemic stroke?

Answer 37

Necrosis and apoptosis.
Inflammation.
Repair and remodelling (angiogenesis and neurogenesis).
Increased density (&darkness) on CT brain.

Question 38

What is the ischaemic penumbra window of opportunity?

Answer 38

Ischaemic zone surrounds a central core of infarction.
Viability of brain tissue is preserved if perfusion is restored within a critical time period.
Tissue surrounding the infarct that is salvageable, but at risk.

Question 39

Case 2:
History: sudden onset of diplopia and left-sided weakness of the face, arm and leg.
On examination: right eye failure of abduction on right lateral gaze, weakness of CN VII with forehead sparing on the left, tone and reflexes increased on the left, weakness of arm and leg on left side, up going plantar on left.
What is this syndrome?

Answer 39

Millard Gilbert syndrome.