1
Q
what are the 2 types of stroke
A
ischaemic- blocked artery - more common
haemorrhagagic- artery the breaks
Haemorrhagic can be further divided into Intracerberal haemorrhage- stays within the cerebrum and a SAH- occurs between the PIA mater and the Arachnoid mater
2
Q
if symptoms resolved in 24 hours what I sit called
A
TIA
3
Q
2 ways an ischeamic stroke can happen
A
endothelial cell damage
and embolism
4
Q
describe endothelial cell damage
A
irritants damage endothelium, now a site of atherosclerosis- plaque forms.
5
Q
describe embolism
A
when a blood clot breaks from one location and travels and becomes lodged in a vessel with a small diameter
6
Q
what does lacunar stroke
A
damage to the middle cerebral artery and affects legs
7
Q
what can shock lead to?
A
reduction in blood throughout the body
8
Q
risk factors for stroke?
A
smoking
dm
heart disease
alcohol
9
Q
is there recovery with embolic stroke?
A
no
10
Q
is there recovery from a haemorrhage stroke or embolic?
A
haemorrhagic
11
Q
What do we use to estimate the risk factor of strokes?
A
CHA2DS2-VASc ) Congestive heart failure - HTN - Age >75 (2 points) - DM - Stroke prior, TIA (2 points) - Vascular disease - Age 65-74 - Female
12
Q
Stroke tests:
A
) HTN
- ECG - AF
- Echo
- Carotid doppler US - for stenosis
- MRI/CT
13
Q
how do we prevent strokes:
A
- Stop smoking
- Control BP
- Move around/exercise
- Hyperlipidaemia
14
Q
What is TIA?
A
An ischaemic (usually embolic) neurological event with symptoms lasting <24hours MAY LEAD TO STROKE
15
Q
Cause of TIA?
A
Atherothromboembolism from carotid
- Cardioembolism
- Hyperviscosity
- Vasculitis
16
Q
Tests for TIA
A
FBC, ESR, U&ES, glucose, lipids
- CXR
- ECG
- Carotid doppler +/- angiography
- CT/diffusion weighted MRI
- Echocardiogram
17
Q
treatment for TIA?
A
) Control CV risk factors
- Antiplatelet drugs (aspirin, then clopidogrel)
- Anticoagulation indications (if cardiac source of emboli)
- Carotid endarterectomy is >70% stenosis
18
Q
what is ABCD2 risk score
A
risk of stroke following suspected tia
- Age >60
- BP high
- Clinical features (unilateral weakness 2, speech 1)
- Dyration of symptoms (>1hr 2, <1hr 1)
- DM
19
Q
what makes up the ABCD2 Score?
A
- Age >60
- BP high
- Clinical features (unilateral weakness 2, speech 1)
- Dyration of symptoms (>1hr 2, <1hr 1)
- DM
20
Q
what is a subarachnoid haemorrhage?
A
Spontaneous bleeding into the subarachnoid space, often catastrophic
21
Q
symptoms of SAH
A
- Sudden onset excruciating headache (thunderclap)
- neck pain as a result of irritation to meninges
- Vomiting
- Collapse
- Seizures
- Coma
- Possible preceding sentinel headache
22
Q
signs of SAH
A
Neck stiffness
- Kernig’s sign (leg extension)
- Retinal, subhyaloidand vitreous bleeds
- Focal neurology at presentation may suggest site of aneurysm
23
Q
cause if SAH
A
) Berry aneurysm rupture
- trauma
- Arteriovenous malformations - get tangled up
- Encephalitis, vasculitis, tumour, idiopathic
24
Q
Risk factors for SAH?
A
) Previous aneyrysmal SAH
- Smoking
- Alcohol misuse
- High BP
- Bleeding disorders
- SBE
- Family history
25
Places where berry aneurysms can occur?
- Posterior communicating with internal carotid
- Anterior communicating with anterior cerebral artery
- Bifurcation of middle cerebral artery
26
tets for sah?
- Urgent CT/MRI can show blood pool
| - Consider Lumbar Puncture >12hr after headache (yellow due to Hb breakdown)
27
Treatment for SAH?
) Fluids and maintaining cerebral perfusion
- Nimodipine- CCB stops vasospasms
- Endovascular coiling or surgical clipping
- Catheter or CT angiography before intervention
28
complications of SAH?
) Fluids and maintaining cerebral perfusion
- Nimodipine
- Endovascular coiling or surgical clipping
- Catheter or CT angiography before intervention
29
What is a haemtoma?
The accumulation of leaked blood inside the body within tissue planes. collection of blood
30
what is a haemorrhage?
The leakage of blood from a blood vessel due to lack of integrity in the vessel wall or clotting mechanism. ACTIVE BLEEDING
31
What does a SAH make
a pool of blood which applies pressure on skull, brain tissue and blood vessels
- blood irritates the meninges
- leads to inflammation and scarring
- obstruction of csf outflow
- leads to hydrocephalus
32
Talk about the meninges
protective layer of the brain
Dura
Arachnoid- contains subarachnoid space contains csf
Pia
33
what is a subdural haemorrhage
bleeding below the dura mater
34
what happens in subdural space?
venous drainage
35
what causes a subdural haematoma
rupture of bridging veins that can happen due to brain atrophy, alcohol abuse and head trauma
36
what does a subdural haematoma cause?
1) Gradual rise in ICP
2) Shift in midline structures away from side of clot
3) Eventual tentorial herniation and coning
37
risk factors for a subdural haematoma?
- Elderly (atrophy makes bridging veins more vulnerable)
- Falls (epilepsy, alcoholics)
- Anticoagulation
38
symptoms of a subdural haematoma?
```
- Fluctuating level of consciousness
+/-
- Insidious physical/intellectual slowing
- Sleepiness
- Headache
- Personality change
- Unsteadiness
```
39
what does a ct/mri shhow about a subdural haematoma?
Clot +/- midline shift, crescent shaped collection of blood over 1 hemisphere
40
Treatment of a subdural haematoma?
- Reverse clotting abnormalities
| - Craniotomy/burr hole washout on >10mm or with midline shift >5mm
41
What is Extra dural?
above the dura closest to the skull
42
what is a common symptom that should make you think extradural haematoma
Lucid interval - deteriorating consciousness after any head injury that initially produced no loss of consciousness/drowsiness
43
what causes extradural haematoma?
- Fractured temporal/parietal bone causing laceration of middle meningeal artery after trauma to temple just lateral to eye
- Any tear in a dural venous sinus
44
name some more clinical features of extradural haematoma
```
lucid interval
increase headache
vomitin g
confusion
seizure
```
45
if an extradural haematoma happens what is the main cause of death?
respiratory arrest
46
differential diagnosis of extradural haematoma
epilepsy
| co poisoning
47
what is the tests for extradural haematoma
lp
ct-biconvex lens
XR- fracture lines crossing middle meningeal vessels
48
management fo extradural haematoma?
Clot evaluation +/- ligation of the bleeding vessel
49
What is epilepsy?
spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures
50
what are convulsions?
The motor signs of electrical discharges
51
what are the elements of a seizure?
Prodrome-Change in mood or behaviour hours or days before
Aura- Implies a focal seizures often from the temporal lobe - flashing lights and smells
Post-ictal- Dysphasia following a focal seizure in the temporal lobe, headache confusion
--
52
structural cause of epilepsy?
Cortical scarring
Stroke
Hippocampal sclerosis
53
non-structural cause of epilepsy?
Tuberous sclerosis
sarcoidosis
SLE
54
What is a focal seizure?
Originating within networks linked to one hemisphere and often seen without underlying structural disease
55
What is a generalised seizure?
Simultaneous onset of widespread electrical discharge throughout bilaterally distributed networks with no localising features
--
(abnormal electrical activity causing a seizure begins in both halves (hemispheres) of the brain at the same time)
56
Give 3 provoking causes for seizures
- Trauma
- Stroke
- Haemorrhage
- Increased ICP
- Alcohol/benzodiazepine withdrawal
- Metabolic disturbance
- Infection
- High temp
- Drugs
57
Give 2 tests for epilepsy
- EEG
- MRI
- Drugs screen, LP
58
What are the non-pharmacological treatment options for epilepsy?
) Relaxation, CBT
- Surgical resection
- Vagal nerve/deep brain stimulation
59
when should we start a person on anti-epileptic drugs?
After 2 or more seizures/high risk of recurrence
60
Pharmacological treatment for focal seizures?
1) Carbamazepine or lamotrigine
| 2) Levetiracetam, oxcarbazepine, or sodium valproate
61
Pharmacological treatment for generalised tonic-clonic seizures? (1st/2nd line)
1) Sodium valproate or lamotrigine
2) Carbamazepine, clobazam, levetiracetam or topiramate
- -
62
what is dementia?
A neurodegenerative syndrome with progressive declines several cognitive domains
usual presentation: Memory loss over months/years
63
How do we diagnose dementia?
- History
- Cognitive testing (AMTS)
- Examination for physical cause
- Medication review
64
What tests do we do in dementia?
- Bloods for reversible/organic causes
- MRI can identify reversible pathologies or underlying vascular damage
- PET functional imaging - shows how organs and tissues are working
- EEG
- HIV, syphilis, autoantibodies
65
give 3 subtypes of dementia?
1) Alzheimer's disease -The cumulative effect of many small strokes.
CLINICALLY PRESENTS:
Sudden onset and stepwise deterioration, we look for:
- High BP
- Past strokes
- Focal CNS signs
2) Vascular dementia
3) Lewy body dementia- presents as:
- Fluctuating cognitive impairment
- Detailed visual hallucinations
- Parkinsonism
66
When should we suspect Alzheimers disease?
->40
- Persistent, progressive, global cognitive impairment
however if you have downs syndrome you'll have it earlier
67
Symptoms of Alzheimers?
- Visuo-spatial skill affected
- Memory loss
- Verbal abilities affected
- Executive function (planning) effected
- Anosognosia - impairs a person's ability to understand and perceive his or her illness
- Irritability later
68
what accumulates in Alzheimers disease?
beta-amyloid peptide- a degradation product of amyloid precursor protein, this leads to a loss of neurotransmitter ACh
69
What parts of the brain are most vulnerable to neuronal loss in AD?
(HATS)
- Hippocampus
- Amygdala
- Temporal neocortex
- Subcortical nuclei
70
How do we manage Alzheimers disease?
- Acetylcholinesterase inhibitors
- Antiglutamatergic treatment
- Antipsychotics (severe non-cognitive only)
- BP control
71
What is the extrapyramidal triad of Parkinson's?
- Tremor- worse at rest often involves pill rolling
- Hypertonia
- Bradykinesia
72
2 cause of Parkinson's
- Parkinson's disease
| - Drugs, trauma, encelophathy, toxicity, HIV
73
Pathogenesis of parkinsons disease?
- Loss of dopaminergic neurons in the substantial nigra
| - Associated with Lewy bodies in the basal ganglia, brainstem, cortex
74
how do we treat parkinsons disease?
- Symptom control
- Deep brain stimulation (dopamine responsive)
- Surgical ablation of overactive basal ganglia circuits
- Postural exercises and weightlifting
75
medications we can give in Parkinsons disease
- Levodopa
- Dopamine agonists
- Apomorphine
- Anticholinergics
- MAO-B inhibitors
- COMT inhibitors
76
give 4 things we need to know in a headache history?
) Types/number
- Time
- Pain
- Associations
- Triggers
77
what is the most common type of headache?
tension
78
give 2 symptoms of a tension headache?
bilateral
| non pulsatile
79
how do we treat tension headache?
message
| antidepressants
80
what are the symptoms of cluster headache and who are they more common in?
```
men and smokers
) Rapid onset excruciating pain around one eye that may become watery ad bloodshot with lid swelling
- Lacrimation
- Facial flushing
- Rhinorrhoea - runny nose
```
81
how do we treat an acute cluster headache?
- 100% O2
| - Sumatriptan
82
preventative treatments of a cluster headache?
- Avoid alcohol
- Corticosteroids short term
- Verapamil
83
what is the classical presentation of a migraine?
Visual or other aura lasting 15-30 mins followed within 1hr by unilateral, throbbing headache
- Isolated aura with no headache
- Episodic severe headaches without aura, often premenstrual, usually unilateral with N&V +/- photophobia/phonophobia
84
what is a prodome?
Precedes headache by hours/days
- Yawning
- Cravings
- Mood/sleep change
85
what are the three types of aura?
- Visual - chaotic distorting, jumbling, dots, zigzags, lines
- Somatosensory - paraesthesiae spreading from fingers to face
- Motor - dysarthria and ataxia, ophthalmoplegia, hemiparesis
- Speech - dysphasia, paraphasia
86
triggers for a migraine
CHOCOLATE
- Chocolate
- Hangovers
- Orgasms
- Cheese/caffeine
- Oral contraceptives
- Lie-ins
- Alcohol
- Travel
- Exercise
87
diagnostic criteria of a migraine if no aura?
- 5 or more attacks
- Lasting 4-72 hours
- N&V
- Or P/P
- Any 2 of unilateral, pulsating, impairs/aggravated by routine activity
88
2 preventative treatments for migraines?
- Avoid triggers
- Ensure analgesic rebound headache not there
- Propranolol or topiramate
89
treatment for an acute migraine attack?
Oral triptan and NSAID/paracetamol
| Anti-emetics
90
2 non pharmacological treatments for migraines?
- Hot/cold packs
- Rebreathing into bag
- Acupuncture
91
What is a multiple sclerosis
Inflammatory plaques of demyelination in the CNS disseminated in space and time (multiple sites, >30d between attacks)
poorly myelinated leads to axonal loss
occurs more in females
MS is an autoimmune disease- T cell mediated
92
how does MS present?
- Usually monosymptomatic
- Unilateral optic neuritis
- Numbness/tingling in limbs, leg weakness
- Brainstem/cerebellar symptoms (diplopia, ataxia)
a hot bath and exercise makes it worse
93
how do we diagnose ms?
- 2 or more attacks/relapses
- 2 or more clinical lesions
- Exclusion of other conditions
94
what does csf show in ms?
Oligoclonal bands of IgG on electrophoresis that are not present in the serum (CNS inflammation)
95
what does mri show in ms?
plaque detection
96
how do we manage MS?
- Lifestyle advice (avoid stress)
- Disease modifying drugs
- Treat relapses
- Symptom control
97
what disease modifying drugs duo we give in ms?
- Dimethyl fumarate
- Alemtuzumab (monoclonal antibody against T cells)
- Natalizumab (monoclonal antibody against VLA-4 receptors that allow immune cells to cross the BBB)
98
What is motor neurone disease?
A cluster of neurodegenerative diseases characterised by a selective loss of neurons
99
where is the selective loss of neurones in motor neurone disease
- motor cortex
- cranial nerve nuclei
- anterior horn cells
100
how do we distinguish mnd from myasthenia grevis
MND never affects eye movements
101
what are 4 clinical patterns of MND?
- ALS/amyotrophic lateral sclerosis
- Progressive bulbar palsy
- Progressive muscular atrophy
- Primary lateral sclerosis
102
name 4 presentations of MND?
- stumbling spastic gait
- foot drop
- weak grip
- umn and lmn signs
103
diagnostic test for mnd?
LMN and UMN signs in 3 regions
104
what treatments do we give in MND?
- Antiglutamatergic drugs
- symptoms control
- pallative care
105
what is meningitis
inflammation of the meninges
106
3 causes of meningitis
) Meningococcus
- Pneumococcus
- Haemophilus influenzae
- Listeria monocytogenes
107
features of meningitis
```
headache
leg pain
cold hands and feet
later=
neck stiffness
photophobia
```
108
tests for meningitis?
- ) U&E, FBC, glucose, coagulation
- ) Blood culture, throat swabs, serology
- ) LP usually after CT
- ) CSF for MC&S, gram stain, protein, glucose, virology/PCR, lactate
- ) CXR for TB
109
treatment for meningitis?
- ) IV fluids and resus
- ) <55 cefotaxime IV (or ceftriaxone)
- ) >55 cefotaxime and ampicillin IV
- ) Aciclovir if viral suspected
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