Stroke and acute neurological complaints Flashcards
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).
PMH: History of migraine.
Examination: in A&E still has headache 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
Suggest CT, if normal send home.
Thunderclap? could be subarachnoid haemorrhage, need to rule out.
Where are the pain receptors that cause headaches as a symptom?
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.
What is the purpose of headache assessment?
Diagnose headache subtype.
Determine cause (exclude secondary cause).
To explain diagnosis and rationale for treatment.
Optimise treatment.
What is part of the headache assesment
History:
Onset, frequency, duration, quality, intensity, location, triggeres, easers
Associated symptoms:
PMHx,
DHx: over/ counter drugs
SHx: ETOH, smoking, illicit drugs
Examination:
Full neuro
Fundoscopy
Menigism
Systemic exam
Temp
Blood pressure
IMagine and tests
CT, MRI
ESR bloods
LP
How are headaches classified?
What comes under those cathegories
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.
What are the headache red flags?
Age of onset: 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.
How do patients present with subarachnoid haemorrhage?
- 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.
What does this show?
subarachnoid hemorrhage
How does the sensitivity of a CT head change with time for a SAH
first 12h 98%
3 days 80%
1 week 50%
after 3 weeks 0%
WHat investigations do you do on a patient, which you think might have a subarachnoid haemorrhage
- CT headhead
- if negative after 12h do an LP and then check for xanthochromia using a spectrophotometer (can not do it by eye)
What are the causes of thunderclap headache?
Intracranial infection:
- meningitis.
CSF pressure related:
- 3rd ventricle colloid;
- cyst
- spontaneous intracranial hypotension (SIH).
Vascular:
- i_schaemic 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.
underlined he said are really important to know
List secondary headache conditions which may have normal CT head scans.
- Meningitis.
- SAH.
- Ischaemic stroke.
- Cerebral venous thrombosis.
- Cervical arterial dissection.
- Reversible cerebral vasoconstriction syndrome.
- Cerebral vasculitis and temporal arteritis.
- Pituitary apoplexy.
- Malignant hypertension.
If someone present with vertigo, how do you broadly classify vertigo? What are the main structures involved anatomically?
Peripheral:
Semicircular canals.
Vestibular nerve.
Central
cerebellum
brainstem
What are conditions cause vertigo in the peripheral and in the cental vestibular system
Peripheral:
BPPV
meniere’s
Vestibular neurits
Central
- Isolated vertigo.
- 4% of isolated nystagmus is caused by stroke. Other CNS deficits.
What are the main feature of BPPV
short burst of vertigo
aggravated by head movement
What test is used to identify BPPV
Hallpike maneouvre
What conditions cause dizziness in the peripheral vestibular system?
BPPV. Meniere’s. Vestibular neuritis.
What conditions cause dizziness in the central vestibular system?
Isolated vertigo. 4% of isolated nystagmus is caused by stroke. Other CNS deficits.
How do you identify in a patient with vertigo whether it is central of peripheral
central will present with other CNS deficits
How do classify the different types of pathologies in someone with diplopia
Low motor neurone lesion
- Neuromuscular junction Muscle
- lower motor neurone
Upper motor neurone lesion
- Brain
- Brain stem
- Spinal
Lady can not abduct right eye
What does she have?
abducens nerve palsy
guy can not adduct right eye
and has nystamus like movement on the left eye when trying to look to the right
What does he have?
internuclear ophtalmoplegia
What is fatigability and what condition might it be seen in?
Ptosis develops, eye alignment changes vertically, causes diplopia as eyes are disconjugated.
Myasthenia gravis.
Lady with ptosis, pupil dilation and inability to adduct her right eye
What does she have
3rd nerve palsy
In a 3rd nerve palsy, what is the level of lesion in the nervous system?
Neuromuscular junction.
patient
weakness on right side of face with sparing of the forehead
Where is the lesion?
UMN lesion
- Frontalis muscle is innervate by both cerebral cortexes and therefore you still get some innervation by the ipsylateral side
If LMN lesion then there would be no innervation and therefore it would not be forehead sparing
What does this patient have?
bell’s palsy
LMN
left facial nucleus
left facial nerve problem
What does this show
haemorrhage- bright white
person has facial palsy (UMN)
Calcium in choroid plexus- variation - not the abnormality here
what does this ECG show
AF
guy who presents with right homonomys hemianopia
Where is the lesion?
left occipital lobe lesion
figure 1 - first came in 2-8 hours
figure 2: 7-14 days (brain is liquifying on the left occipital lobe)
What is Multi modal brain imaging?
imaging tool that visualises the areas of the brain that are still salvagable
allows us to do endovascular thrombectomy and thrombolysis much later on (even 24 hours later as oposed to 4.5 hours )
