1
Q
Prevalence of shoulder pain after stroke
A
one study said Hemiplegic shoulder pain is the most common complication after stroke (~55%)
24–64% (usually moderate to severe)
unclear aetiology, but often assx with subluxation of joint
2
Q
TIA management
A
Lifestyle, DAPT, statin & anti-BP (+/- PPI)
- Clopi & Aspirin 300mg stat then 75mg for 21d - then clopi
- Consider PPI
- Refer to specialist within 24h of symp
- If bleeding disorder/anticoag then CT
- if >7 days since symps then refer to be seen within 7 days
altenative DAPT:
Ticag 180mg stat then 90mg BD + Aspirin 300 stat then 75mg for 30 days, followed by ticag 90 BD OR clopi 75
NCGS 2023
3
Q
ABCD2 score
A
CKS says
“Do NOT use scoring systems, such as ABCD2, to assess risk of subsequent stroke or to inform urgency of referral for people who have had a suspected or confirmed TIA. “
4
Q
Risk of stroke after a TIA in 2 days
A
2 days: 2.0 - 4.1%
(( 7 days: 3.9 - 6.5% ))
~33% will eventually have a stroke ( 50% of those occurring within a year)
Emergency treatment in specialized stroke services lowers the risk of a completed stroke from 11.0% to 0.9% , compared to non-urgent settings
5
Q
criteria for decompressive hemicraniectomy in an acute stroke :
A
- Clinical deficits suggestive of infarction of middle cerebral artery , with a score on the NIHSS of >15
- Decrease in level of consciousness - score of ≥1 on item 1a of the NIHSS.
- CT showing infarct ≥50% of MCA territory, with or without additional infarction in the territory of the A or PCA on the same side, OR infarct volume ≥ 145 cm3 on diffusion-weighted MRI.
assess < 24h
Treated < 48h
6
Q
Thrombectomy after stroke
A
- If modified Rankin scale <3 (slight disability) and NIHSS > 5
- together with IV thrombolysis (if no contra)
- within 6hr if confirmed occlusion of the proximal anterior circulation (internal carotid or MCA )
- Or from 6-24hr confirmed occlusion of the proximal anterior circulation with salvageable tissue
- OR posterior circ <12h w NIHSS >10, intracranial vertebral or basilar occlusion
7
Q
Young female patient presents with signs of stroke. CT brain angio shows “STRING OF BEADS” appearance. Diagnosis?
A
Fibromuscular dysplasia (FMD)
- a non-atherosclerotic, non-inflammatory condition producing segmental stenoses in all vascular beds
- confirm with CT angio of kidneys
8
Q
Two TIAs in last week mx
A
Crescendo TIA
newest NCGS guidance:
Discharged with urgent 7 days FU
** cannot see this. I think it should be <24h still
9
Q
Restarting DOAC for AF post stroke
A
CKS:
people with disabling ischaemic stroke who are in AF are treated with aspirin 300 mg for first 2 weeks before anticoagulation treatment is considered
10
Q
Post stroke spasticity management
A
- physical factors , stretching, Mx pain constipation
- BoNT is effective in focal spasticity, must be used in parallel with other options (like splinting/casting)
- PO antispasmodic agents (baclofen) if generalised , but aware of SE
- Stretching can counter muscle shortening and prevent the development of contractures (limited research though)
11
Q
Stroke DVLA
A
- 1 month for stroke / TIA
- if multi, 1m after each episode
12
Q
patient found to be in AF post TIA
A
Commence 300mg aspirin…. And warfarin
In ischaemic stroke wait two weeks before warfarin in case haemorrhagic transformation
13
Q
Updated treatment windows for acute ischemic stroke
A
- Thrombolysis 4.5 hr
- Up to 9h if salvageable tissue on CT Perfusion / MRI with DWI-FLAIR mismatch (or 9h from midpoint of sleep)
If Proximal ant circulation:
* Thombolysis+Thrombectomy 6 hr
* or 6-24hr if salveagable tissue (thrombolysis “irrespective of when presenting if thrombectomy”)
If proximal posterior circulation:
* Thombolysis+Thrombectomy 24hr if salveagable tissue
14
Q
imaging for ?TIA
A
CKS:
Do not offer CT brain for ?TIA unless there is clinical suspicion of an alternative diagnosis that CT could detect
If bleeding disorder or anticoag then CT
After specialist TIA clinic, consider MRI to look for territory of ischaemia
Everyone who is candidate for carotid endarterectomy should have urgent carotid imaging
15
Q
When you refer for carotid endarterectomy
A
- TIA or acute non-disabling stroke with stable neurological symps
- symptomatic severe stenosis ≥50% NASCET , or ≥70% ECST
- to be performed within 7d of symps
- If not suitable for open surgery then carotid angio and stenting
- Under 70yr old can consider either stenting or endarterectomy appaz but CKS does not mention this
16
Q
Thrombolysis drugs for stroke
A
Tenecteplase or alteplase both recommended
Tenecteplase is cheaper as per CKS
As effective and similar adverse events
17
Q
Mx if stroke and symptomatic DVT/PE
A
anticoagulation treatment in preference to treatment with aspirin
(unless there are other contraindications to anticoagulation) CKS
18
Q
Mx haemorrhagic stroke and symptomatic DVT / PE
A
- either anticoagulation or a caval filter
- to prevent the development of further pulmonary emboli
19
Q
Statin post stroke
A
- Unless contra, high-intens statin at diagnosis
- aiming for HDL chol > 40 %
Not recommended: Fibrates, bile acid seq, nicotinic acid, omega-3.
Ezetimibe ONLY if also fam hyperchol
previously suggested that statin increase ICH but large pop-based cohort study found no evidence
20
Q
Decorticate vs decerebrate posturing in GCS
A
Decorticate
- M3
- flexion to chest (to “core”)
Decerebrate
- M2
- arms straight and extended out to the sides (dEcErEbrate for Extensor)
21
Q
Stroke Thrombolysis Absolute contraindications
A
Absolute:
- ICH
- cerebral vascular lesion or malignancy
- Ischaemic stroke within 3m
- Suspected aortic dissection
- Active bleeding or bleeding tendancy (excluding menses) or plt < 100
- Signif closed-head / facial trauma within 3m
22
Q
Stroke thrombolysis relative contraindications
A
Relative:
- Any previous ICH
- Hx of poorly controlled HTN
- Presenting with BP >180 or >110
- Ischaemic stroke > 3m
- CPR > 10min or major surgery in prev 3w
- internal bleeding within 2-4 w
- Noncompressible vascular punctures
- Recent invasive procedure
- Pregnancy
- Active peptic ulcer
- Pericarditis or pericardial fluid
- Anticoag in 48h
- Age >75 yr
- Diabetic retinopathy
- recent LP
- Seizure at onset
23
Q
What is best to use to scale patient outcomes post stroke?
A
Barthel Index (BI)
- Measures functioning/mobility for ADLs and indicates the need for assistance in care
- widely used scale to measure outcomes in stroke medicine / rehab outcomes
24
Q
Intensity of stroke rehabilitation / physiotherapy
A
NICE 2023 recommends:
- at least 3h per day 5x per week (more than studyPRN)
- Offer needs-based rehabilitation across MDT (focused on goals)
as long as able to participate + where functional goals can be achieved
More intense PT improved QoL and ADLs
25
How early do you screen for communication difficulties post stroke
within 72 hours of onset of stroke symptoms
26
How early do you assess swallow post stroke
- Assess on admission
- If this screen indicates problems, then SLT between 24-72h of admission
- NG within 24h (unless had thromolysis) +/- bridle / gastrostomy
- if thrombolysis then after 24h
27
Mx of post stroke shoulder pain
Consider:
- taping
- neuromuscular electrical stimulation (NMES)
- steroid inj
- nerve block
- all should be given advice on protecting limb from shoulder injury
28
Lacunar stroke symptoms
one of:
- unilat weakness and or sensory deficity of face & arms, arm & leg, or all 3
- pure sensory stroke
- ataxic hemiparesis
## Footnote
*subcortical stroke*
29
Partial Anterior Circulation Stroke
(majority MCA). Two of:
- Unilat weakness and/or sensory deficit of face, arm and leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
30
Total anterior circulation stroke features
(majority MCA).
All of:
- Unilat weakness and/or sensory deficit of face, arm and leg
- homonymous hemianopia
- higher cerebral dysfunction (dysphasia, visuospatial disorder)
31
Posterior circulation stroke
One of:
- Cerebellar / brainstem (crossed) signs
- LOC
- Isolated Homonymous hemianopia (with macular sparing, contralat)
32
Anterior cerebral artery stroke features
- Frontal & parietal lobes
- Contralat sensory loss
- Contralat leg weakness (Leg>arm)
- Dominant hemisphere -> mutism
- Non-dom hemisphere -> delirium
- Bilat infarcts -> incontinence, mutism
33
Middle Cerebral Artery stroke features
- Y **M** CA
- Frontal, parietal & sup temporal lobes
- Contralat sensory loss, hemiparesis
- Dominant hemisphere -> dysphasia, dyspraxia
- Non-dom hemisphere -> hemineglect
34
Superior MCA stroke features
- Brocca area = speech motor
- expressive dysphasia
- "broken articulation"
- inferior frontal gyrus
35
Inferior MCA stroke features
- Wernicke Area = speech association
- Receptive dysphasia
- "word salad"
- superior temporal gyrus
36
Gerstmann Syndrome
- Angular gyrus (inferior parietal lobule)
- dysgraphia
- dyscalculia
- dyspraxia
37
Anton Syndrome
- Bilat occipital infarcts
- Cortical blindness with denial of deficit
38
Pure motor or sensory stroke location
internal capsule
39
Dejerine-Roussy Syndrome
- Thalamic pain syndrome
- contralat sensory loss and hemi-body pain
40
Hemibalismus - location and features
- Subthalamic nucleus
- Sudden violent movements of contralateral side
- Stroke caused by non-ketotic hyperglycaemia (assx with relative ischaemia)
41
Weber syndrome
- Medial midbrain (Cerebral peduncle)
- Ipsilat 3rd nerve palsy (ptsosis diplopia)
- Contralat hemiparesis
42
Locked in syndrome
- Proximal & middle basilar artery segments (or Bilateral median pontine infarcts)
- Quadriplegia
- Bulbar (lower CN) weakness
43
Marie Foix syndrome
- AKA lateral pontine syndrome, *AICA syndrome (anterior inferior cerebellar artery)*
- ipsilat facial weakness, facial sensory loss, hearing loss, tinnitis
- Contralat weakness and loss of sensation to pain/temperature
- Ipsilateral ataxia (falls towards lesion)
- **f-AICA-l nerve**
44
Millard-Gubler Syndrome
Mid pons
Ipsilat facial weakness
Contralat limb weakness
45
Wallenberg syndrome
- AKA Lateral medullary syndrome
- posterior inferior cerebellar artery (PICA) (branch of vertebral artery) = **PICA = chewing**
- Ipsilat facial weakness, facial sensory loss
- Horner's syndrome (miosis ptosis anhydrosis), palatal weakness, dysphagia and ataxia
- Contralat body loss of pain and temp
- Most common Sx N&V, bilateral nystagmus
46
Posterior cerebral artery stroke features
- Vertigo
- Unilat limb weakness
- Alexia/dyslexia
- Homonymous hemianopia
- Visual agnosia / Prosopagnosia (difficulty recognizing familiar faces)
- Difficulty reading or perceiving colors
- diplopia
- Simultanagnosia (inability to perceive multiple objects at once)
47
Mx for intracranial atherosclerotic stenosis in acute stroke
if high risk of TIA or intracranial stenosis: **DAPT**
- 90d Aspirin Clopi
- or 30d Aspirin Ticag
- (followed by aspirin)
Found to be superior to intracranial arterial angioplasty and stenting in the SAAMPRIS trial (Chimowitz et al., 2011)
48
TIA and newly found to be in AF
OP TIA clinic , risk factor modification and anticoag
49
When do you need immediate CT imaging in suspected acute stroke
- indications for thombolysis /ectomy
- on Anticoag
- known bleeding tendancy
- GCS below 13
- unexplained progressive / fluctuating symptoms
- papilloedema, neck stiff, fever
- severe headache at onset of stroke symps
(immediately = next slot or at least within hr)
If not above then within 24h of symptoms
50
CT head for acute stroke Sensitivity and Specificity
~55% and >90%
51
Hyperacute and acute stroke : CT head features
- Loss of grey-white matter interface
- hypoattenuation of deep nuclei
- Effacement of cortical sulci (mass effect/swelling increasing over time)
52
Subacute stroke: CT head features
(between 24h and 5 days)
- **cortical petechial haemorrhages** (not haemorrhagic transformation) result in elevation of the attenuation of cortex AKA CT Fogging Phenomenon
- **vasogenic oedema** with greater mass effect
- subacute changes better detected by MRI (showing **restricted diffusion**) improving sensitivity from 50 to 90%
53
Chronic stroke: CT head features
- Loss of brain tissue (negative mass effect)
- Hypoattenuation (low density)
54
When do you refer for carotid stenting post TIA
symptomatic carotid stenosis that meets carotid intervention criteria but **not suitable for open surgery**
e.g.
- inaccessible carotid bifurcation
- re-stenosis following endartectomy
- Radiotherapy-assx carotid stenosis
55
Acute ischaemic stroke/TIA secondary to **cervical artery dissection** Mx
- needs CT or MR with angiography
- should still receive thrombolysis (if otherwise eligible)
- Tx w anticoag or antiplatelet for at least 3m
- or DAPT (asp / clopi) for 21d then monotherapy for 3m
(these patients usually younger with preceding neck trauma)
NCGS 2023
56
Basilar artery thrombosis presentation
- rapid onset of advanced **motor / bulbar symptoms w decrease level of consciousness**
- insidious or **'stuttering' symptoms** (fluctuating) over days, ending with bulbar / motor symptoms or LOC
- prodromal: headache, neck pain, loss vision, binocular diplopia, dysarthria, dizziness/vertigo, hemiparesis, paraesthesias, ataxic, tonic-clonic type movements
(do CT cerebral angiogram )
57
Basilar artery thrombosis prognosis
- Mortality rate > 85%
- but 40% with recanalisation (thrombolysis/thrombectomy)
(do CT cerebral angiogram )
58
head impulse-nystagmus-skew deviation (HINTS) test finding in stroke
- head impulse negative (normal VOR)
- bilateral and/or vertical nystagmus for LMS
- Skew deviation is present in LMS
IN - Impulse Normal
FA - Fast phase Alternating (The direction of the nystagmus changes with the direction of gaze)
RCT - Refixation on Cover Test (Skew Deviation)
total hearing loss also indicates stroke (only partial in labyrinthitis)
59
Risk factor for transient global amnesia
- Migraines (incidence rate ratio of 2.48)
- Cardiovascular risk factors (hyperlipidaemia, IHD)
60
Diagnostic features of transient global amnesia
- Witnessed
- Must be anterograde amnesia during
- Cog imp is limited to amnesia
- No clouding of consciousness or loss of identity
- No neuro or epileptic signs/symptoms
- Resolves <24h
- No recent head injury or active epilepsy
61
Transient global amnesia vs transient epileptic amnesia
TEA:
- usually be on waking
- <1h
- antero-retrograde or only retrograde amnesia
- temporal lobe features (olfactory/gustatory hallucinations, oral automatisms
62
How long is PE thrombolysis contraindicated after ischaemic stroke
6 months (some places say 3-6) absolute contra
(Stroke thrombolysis is relative contra 3m after stroke)
63
Pt had stroke then thrombolysis
Later that day has unsafe swallow
Mx
- SLT assessment if not done
- NG after 24h
64
Modified Rankin Scale (mRS)
- 0: Assymp
- 1: No signif disability, ADLs w "some symptoms"
- 2: Slight disability, independent but can't do all previous activities
- 3: Mod disability, some help but walk unassisted.
- 4: Mod-severe disability, Assistance for ADLs and walking
- 5: Severe disability, constant nursing care, is bedridden
- 6: Dead
## Footnote
degree of disability post stroke
65
National Institute of Health Stroke Scale Score (NIHSS) interpretation
- 0 : No stroke
- 1–4 : Minor
- 5–15 : Moderate
- 16–20 : Moderate/severe
- 21–42 : Severe
66
Annual incidence of stroke in uk?
0.5%
67
BP target for ICH
- Systolic 130-140
- within 1h and sustained for 7d
- (but max 60mmHg drop in first hr)
Consider it if they present >6h after symps
68
Commonest stroke mimic
Seizure (~21%)
followed by hypogly and sepsis
69
Predictors of a stroke mimic
- Low NIHSS score (<5) together with:
- BP <140 mmHg systolic
- diabetes
- Lack of arrhythmia hx
70
3 week hx of worsening involuntary movements on left side of body, writhing
CT head Mildly increased density in right basal ganglia
HbA1c 88, Ketones 0.5
Dx and Mx
- Non-ketotic hyperglycemic hemichorea-hemiballismus (NKH-HC/H)
- due to basal ganglia dysfunction from hypergly
- Typially elderly asian women
- Tx VRII
71
When do you mobilise patients after stroke?
- Assess ASAP
- if needing little/no assistance: within 24h
- if difficulting mobilising, then typically 24-48h
72
When do you give dual antiplatelets in stroke?
- Presenting <24h of TIA / minor stroke *(NIHSS ≤ 3)*
- high risk of TIA
- symptomatic intracranial stenosis *(Tx for 3m)*
*(aspirin & clopi 90d or aspirin ticag 30d)
(also guidance for TIA Mx)*
73
R sided weakness
L sided partial ptosis and diplopia
L midbrain
Weber's Syndrome
*mnemonic: Spider web in eye so eye droops = you move ipsilat arm i.e. cannot move contral arm*
74
nerve damage that spares forehead
UMN
75
Does Bell's Palsy involve forehead or not
LMN so involves forehead
*(frontalis muscle)*
76
horner's vs 3rd nerve palsy features
- Horner's = miosis (small pupil) and normal movement
- 3rd Palsy = big, blown pupil
77
What strokes cause horner's vs 3rd nerve palsy
- Horner's = Lat Medullary Syndrome (Wallenberg) = small pupil
- 3rd Palsy = Weber = midbrain = mydriasis - big, blown pupil
78
NIHSS scoring
- Age & month (2 if wrong or aphasic)
- 'Blink eyes' & 'squeeze hands' (2)
- Horizontal gaze (2)
- Limb ataxia (2)
- Sensation (2)
- Dysarthria (2)
- Extinction/inattention (2)
- Aphasia (3)
- Consciousness (3)
- Visual Fields (3)
- Facial palsy (3)
- motor drift (4 for each limb)
79
Risk of stroke after a TIA in 7 days
**7 days: 3.9 - 6.5%**
((2 days: 2.0 - 4.1%))
~33% will eventually have a stroke ( 50% of those occurring within a year)
Emergency treatment in specialized stroke services lowers the risk of a completed stroke from 11.0% to 0.9% , compared to non-urgent settings
80
What percentage of patients with TIA will eventually have a stroke
~33% will eventually have a stroke
( 50% of those occurring within a year)
81
Why do you get macular sparing in homonymous hemianopia
Macular area is supplied by both:
- posterior cerebral artery
- and middle cerebral artery
82
Stroke location: Homonymous hemianopia with macular sparing (contralat)
Posterior circulation stroke
83
Key feature of brainstem stroke
Crossed findings (i.e. contra and ipsi)
84
Three areas of brainstem and cranial nerves
- midbrain (C3-4)
- pons (C5-8)
- medulla (C9-12)
85
Features of medial medullary syndrome
- Contralat hemiparesis of body
- Ipsilateral tongue weakness
- Anterior spinal artery
- Think: M in Medial Medullary = Macdonalds sign = eating. and M arch at base of ant spinal artery
86
Median Pontine syndrome
- facial asymmetry
- horizontal gaze palsy
- internuclear ophthalmoplegia
(Basilar artery = branches off the base lead to problems of the face)
87
Lateral medullary syndrome vs Webers
LMS (Wallenberg's *PICA*):
* Ipsi facial numbness, loss taste, horner's (small pupil)
* Contralat **loss of pain/temp**, ataxia, vertigo, dysphagia
Webers: Cerebral peduncle (midbrain)
* Ipsilat 3rd nerve palsy (ptsosis diplopia)
* **Contralat hemiparesis**
88
Mx of anticoag for prosthetic heart valve with acute ischaemic stroke
Aspirin and stop anticoag 7 days
## Footnote
NICE CKS if "disabling ischaemic stroke and at significant risk of haemorrhagic transformation"
89
Modified Rankin Scale
global measure of disability, rating overall functional status post stroke / neuro disability
90
What area of CNS has role in micturition?
* Pre-frontal cortex
* Pontine micturition center (PMC) in brainstem
91
Updated thrombolysis windows for ischaemic stroke
* Thrombolysis 4.5 hr
* Up to 9h if salvageable tissue on CT Perfusion / MRI with DWI-FLAIR mismatch
* 9h from midpoint of sleep with salv tissue
* Pre-thrombectomy irrespective or when presenting (if not contraindicated)
92
Tx for Bell's Palsy
* Prednisolone 50mg OD for 10d **if < 72h**
* Eye lubrication
* Refer if not improved in 2w
93
scoring system to measure degree of disability post stroke
modified Rankin Scale
94
MCA infarct
24h later, severe headache and rapid deterioration
Mx
**Malignant MCA Syndrome**
CT head to confirm
Mx Decompressive hemicraniectomy
*Large infarct causing vasogenic edema and increased ICP.
? Surgery just for < 60yr*
95
Post-stroke hypercholesterolaemia target
non-HDL reduction of > 40% in 3months
96
30 day mortality post ischaemic stroke
12%
97
30 day mortality post haemorrhagic stroke
30%
98
Locked in syndrome - what is vascular site
- Usually **Proximal & middle basilar artery segments**
- (causing bilateral median pontine infarcts)
99
Mx SAH on Warfarin
* IV PCC priority
* IV Vit K (but works slower)
## Footnote
FFP if PCC unavailable
100
SAH - when to suspect re-bleeding
* Sudden drop in conscious levels
* Spike in BP
* Tonic/extensor posturing
* Pupillary changes
101
Mx of SAH
* Neuro surg input
* BP <180
* Consider enteral nimodipine (guided by neurosurg)
* Stop and reverse anticoagulation
102
Vertebral artery occlusion
* transient decreased consciousness
* vomiting
* vertigo
* Dysphagia/dysarthria posterior inferior cerebellar artery (PICA) (branch of vertebral artery) = **PICA = chewing**
103
Recurrence rate of transient global amnesia
Low - typically one-off
(3 - 20%)
104
fluctuating confusion and increasing falls
Alcohol ++ history
Cannot abduct left eye (otherwise normal neuro)
DDx
Most likely SDH
*Ddx could be Wernicke's but there would be cerebellar signs*
105
*where* is pathology to cause Internuclear ophthalmoplegia (INO)
medial longitudinal fasciculus (MLF)
106
Horner's syndrome: What effect with Atropine?
Constricted pupil that **does not immediately dilate in response to atropine**
107
Pt presents with stroke
Raised Hb and Plt
Key test to confirm diagnosis
BM biopsy & JAK2 V617F mutation
## Footnote
(Polycythemia Vera)
108
Creutzfeldt-Jakob Disease (CJD) MRI findings
* bilateral basal ganglia hyperintensities
* Bilateral medial thalamus and pulvinar hyperintensity
109
periodic sharp wave complexes (PSWCs) on EEG
Creutzfeldt-Jakob Disease (CJD)
110
Creutzfeldt-Jakob Disease (CJD) EEG findings
periodic sharp wave complexes (PSWCs)
111
Most sensitive test for Creutzfeldt-Jakob Disease (CJD)
- MRI with DWI or FLAIR sensitivity 98%
- CSF 14–3–3 protein : 90%
- EEG 60%
112
How quickly should patient with TIA be seen by specialist?
< 24h
## Footnote
Unless it occurred > a week ago, then it is < 7 days
113
Risk factors for **haemorrhagic transformation** of ischaemic stroke following reperfusion therapy?
* Severity of stroke *(NIHSS > 15, the risk of HT is > 50%)*
* Advanced age
* AF
* hyperglycaemia
* longer time from stroke onset to treatment
114
Cut off for idiopathic intracranial hypertension
opening pressure >25cm H2O
115
Medication that worsens idiopathic intracranial hypertension
* lithium
* cimetidine
* tetracycline
* tamoxifen
* vitamin A
* nitrofurantoin
116
Symetrical painless weakness of finger flexors and quadriceps
Muscle atrophy on MRI
Inclusion body myositis
## Footnote
autoimmune Idiopathic inflammatory myopathies
117
Polymyositis vs Inclusion body myositis
Poly: Rash and muscle pain with signif CK
IBM: No rash or pain. Modest CK
Both get weakness
## Footnote
Both autoimmune Idiopathic inflammatory myopathies
118
Inclusion body myositis
Tx
No Tx apart from PT
*other idiopatic inflam myopathies Tx with Steroids/DMARDs/IV immunoglob*
119
2yr progressive back pain
burning pain into buttocks / thighs
Norma SLR
Lumbar spinal stenosis
*Prolapsed lumbar disc has pain on SLR*
120
What neurotransmitter does Botulinum toxin act on
Prevents **acetylcholine** release from motor nerve terminals
121
subacute degeneration of spinal cord predominantly affects...
* dorsal culumn *(vibration / proprioception)*
* lateral column *(paraparesis/ataxia)*
## Footnote
Presents with:
* spastic paraparesis
* impaired Romberg sign
* loss of vibration sense
* proprioception
* 2-point discrimination
* ataxic gait
* reduced sensation
122
“Inverted V” sign or “Inverted rabbit ears” sign
MRI Spine
Dorsal columns in subacute degeneration of spinal cord
123
Isolated Homonymous hemianopia
Posterior circulation
124
jet sign on MRI / CT
Normal pressure hydrocephalus
125
expressive dysphasia stroke anatomy
inferior frontal gyrus
(Broca's)
126
receptive dysphasia stroke anatomy
superior temporal gyrus
(Wernicke's)
127
carotid endarterectomy stenosis cut offs
* ≥ 50% NASCET
* or ≥ 70% ECST
128
Stroke, NIHSS 14, on Apixaban
Thrombectomy
(assuming it is within time window & prox ant/post circulation stroke)
*Giving PCC etc is not recommended*
129
Importance of checking blood sugar before stroke thrombolysis
* Hypoglycaemia = stroke mimic
* Hypergly = assx with IC bleeding and worse outcomes
130
Mx of haemorrhagic stroke
Antihypertensives - target syst 130-140 < 1 h for 7 days
If:
* They present < 6 hours
* Their syst BP is 150-220
* Aren't going for neurosurg evac
* GCS > 6 and reasonable prog
## Footnote
*no specific recommendations out of that BP and time window*
Geris SCS
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