RFs for stroke
age, afib, htn, dm2, smoking, dlp, valvular replacement, recent MI
RFs SAH
alcohol, PKD, family hx of SAH, Marfans/Ehlers Danlos, drug use, chiropractic manipulation, activities associated with BP elevation
SAH management
BP management with labetalol/nicardipine to prehemorrhage BP or MAP <140. ICU. Nimodipine 60mg po q4 hours (decreases vasospasm), discuss seizure prophylaxis with specialist. Reverse coagulopathy
Scoring system to predict stroke risk in TIA patients, treatment
Age >60, BP >140/90, Clinical features - speech impairment/unilateral weakness, Duration, Diabetes. ASA 75-325, clopidogrel 75
Treatment ischemic stroke (no thrombolysis)
permissive hypertension up to SBP 220, ASA 325
emergency headaches that are not routinely identified on plain CT
Cervical artery dissection (carotid and vertebral)
Cerebral venous thrombosis (CVT)
CO poisoning
Giant cell arteritis
Headache physical exam?
Carotid artery dissection management
Consider anti-platelet/anti-coagulant if extracranial. If intracranial, anticoagulants are CI because of risk of SAH
Why can carotid artery dissections cause partial Horners?
due to local expansion (secondary to thrombus stretching the vessel) affecting the sympathetic fibres travelling along the internal carotid. Ptosis, miosis, but no anhidrosis (as fibres for sweat travel along the external carotid).
What can you see with vertebral artery dissection?
Wallenberg Syndrome (dysmetria, ataxia, ipsilateral hemiplegia and contralateral loss of pain and temperature sensation) and other posterior circulation stroke syndromes – i.e. vertigo, diplopia, visual field deficits. CNS deficits may be contralateral or bilateral.
Clinical features of CVT
risk factors associated with thromboembolic disease, as well as papilledema, younger patients (<40yo), orbital chemosis and proptosis in cavernous CVT, dilated scalp veins and scalp edema in sagital CVT, and CNS or ENT infections such as sinusitis
Clinical features and management of IIH
presents as refractory headache with blurry vision and visual field defects in young, obese women on oral contraceptive pills; signs include papilledema and VERY high opening LP pressure in the face of normal CT scan; it is treated with diuretics, not anticoagulation
Red flag headaches
Lesion on CT scan (blood, pus or tumor):
Blood ‐ Subarachnoid hemorrhage, subdural hemorrhage, or stroke – hemorrhagic or not
Pus ‐ meningitis or encephalitis
Tumor ‐ tumor – 1ry or 2ry, benign or malignant
Other diagnoses in the head:
Cervical artery dissection – carotid or vertebral
Hypertensive encephalopathy
Pre‐eclampsia (or eclampsia)
Cerebral venous thrombosis or idiopathic intracranial hypertension
Glaucoma
Temporal arteritis
Thinking ‘outside the box’: Carbon monoxide (CO) poisoning
