phase 2 jenny brocklebank and sarah hurst the peer teaching society is not liable for false or...

Phase 2

Jenny Brocklebank and Sarah Hurst

The Peer Teaching Society is not liable for false or misleading information…

• Causes of stroke• Stroke syndromes• Stroke classification• Investigations for stroke• Management of stroke• TIA• Differentiating between the types of headache• Management of headaches


Aims

• Rapid onset • neurological deficit • result of a vascular lesion • infarction of central nervous tissue


Stroke

• Ischaemic 80%– Thrombosis– Emboli

• Haemorrhagic 20% – Hypertension– Berry aneurysm rupture (SAH)– Arterio-venous malformation– Trauma


Stroke

• Risk Factors– Thrombosis: HTN, diabetes, smoking, obesity– Emboli: AF– Cocaine use can cause vasoconstriction– Hypercoagulability: oral contraceptive pill, alcohol,

thrombophilas– Previous TIA/ stroke


Stroke


Stroke

Anterior Cerebral Artery:•Lower limb•Confusion

Middle Cerebral Artery:•Face•Whole body except lower limb•Dysphasia

Posterior Cerebral Artery:•Hemianopia


StrokeOSCP Classification

•TAC: Total Anterior Circulation•PAC: Partial Anterior Circulation•LAC: Lacunar•POC: Posterior Circulation

Then add:•I for ischaemic•H for haemorrhage•S for syndrome (used prior to imaging)

•Higher cortical dysfunction•Hemianopia•Hemiplegia or sensory loss

•TAC: have all 3 •PAC: have 2

POC: cerebellar, cranial nerves, eye


Stroke•Lacunar: deep perforating arteries

•Internal capsule: pure motor or sensory. Small, localised.•Vascular dementia: multiple lacunar infarcts

•Posterior cerebellar artery: •Vertigo•Horner’s •Ataxia•Facial sensory loss

•Basilar:•Locked in syndrome


StrokeInvestigations• Imaging:

– CT. Quick, shows haemorrhage– MRI. Differentiate between old and new infarcts. Shows

other pathology

• Bloods:– FBC: polycythaemia– Clotting: thrombophilia

• ECG: AF• Carotid doppler: arterial disease, stenosis


StrokeManagement:CT TO EXCLUDE HAEMORRHAGE. Thrombolysis if within 4.5hrs of event: IV alteplase (TPA)Aspirin (2wks), Clopidogrel (long term)Supportive Care:Swallowing assessment, stockings, hydration, turningRehab:Physio, OT, home adaptationsSecondary prevention:Control HTN, statins, stop smoking


TIA• <24hrs (average 5-15 mins)• Transient episode of neurological dysfunction• Ischaemia without infarction• Amaurosis Fugax: painless, transient, monocular

blindness: emboli in retinal artery• Treatment: aspirin and dipyridamole to prevent

future stroke


TIA: risk of future strokeABCD2 A Age>60 1B BP>140/90 1C Clinical features:

Unilateral weakness 2Speech disturbance without weakness 1

D Duration of TIA>60 mins 210-59mins 1

D Diabetes 1


HeadacheBeyonce has been experiencing headaches about every other day for the last 4 months. She describes them as feeling like a tight band around her head. Upon further questioning she revealed that she has been feeling very stressed since the release of the video of her husband and sister fighting in a lift.


Tension HeadacheCOMMON THINGS ARE COMMON• “tight band around head”• Life stresses• Bilateral• No nausea or vomiting• Possible photophobiaTreatment• REASSURANCE• Analgesic withdrawal• TCAs: amitriptyline


HeadachePruders is a 27 year old man who is complaining of episodic,

severe headaches. The headaches are normally preceded by the sensation of “flashing lights” before his eyes. The headaches are severe and associated with nausea and occasionally vomiting. The only thing that alleviates them is lying down in a dark room.


MigraineCharacteristics:• Periodic attacks• Unilateral• Complete resolution between attacks• Severe pain, pulsatileAssociated Symptoms:• Photophobia• Nausea and vomitingAura:• Visual : scotoma, fortification spectra• Sensory: tingling• Motor: aphasia, hemiplegia


MigraineTriggers:• Food and drink: coffee, cheese, chocolate, red wine• Lack of sleep, too much sleep• Noise, lights• StressManagement:• Stop contraceptive pill• Resolution: dark, sleep• Mild: paracetamol, anti-emetics• Severe: triptans (serotonin agonists)• Prophylaxis: beta blockers, amitriptyline


HeadacheSeverus is a 47 year old man who is complaining of headaches

which are ‘the worst pain’ he has ever felt, worse than the pain of losing Lily. The pain is behind one eye and is a sharp pain. His eyes also water and his nose runs. They have been occurring every day for the last 4 weeks.


Cluster Headache• Excruciatingly painful• Unilateral: temple, forehead or behind eye• Comes on rapidly• Autonomic: ipsilateral lacrimation, rinorrhoea, facial

sweating, miosis • Depression, exhaustion, anxiety (suicide headache)• Lasts 45-90 mins• Occur once or twice a day, often at same times (alarm clock

headache)• Clusters of a few weeks, followed by attack free periods


Cluster HeadacheManagement:• Acute: triptans, 100% O2• Verapamil (CCB)• Topiramate (anti-epileptic)

20s – 50s. Affects men more.


HeadacheDamien is a 7 year old boy who’s parents bring him to A&E with

a 6 hour history of irritability, lethargy, fever, headache, photophobia and neck stiffness. He is also beginning to develop a purple non-blanching rash before your eyes.


MeningitisInflammation of the meninges Examination: Kernig’s and Brudzinski’s signs Septicaemia: a systemic infection in circulating blood.

Meningococcal disease can cause septicaemia with or without meningitis. Symptoms: petechial rash, fever, rigors, cold peripheries, tachcardia

Viral meningitis: less severe, benign, self limitingOrganisms: N neisseria meningitidisH haemophilus influenzae bS streptococcus pneumoniae


MeningitisManagement:IV benzylpenicillin Then do blood cultures, LPIf bacterial: cefotaximeSupportive

Notifiable Disease

Contact Tracing:Rifampicin If serotype C: immunisation if not already immunised


HeadacheVladimir is a 41 year old man who presents to A&E describing

the “worst headache he has ever had, it feels like I have been hit on the back of the head”. He is also nauseous and is asking for the lights in his bay to be turned off as he is finding them so uncomfortable to look at.


Subarachnoid HaemorrhageThunderclap headacheVery sudden, severeLocalises to back of head / neckMeningisms (photophobia, n+v, neck stiffness)Sentinel HeadachesCollapse and coma

Commonest cause: rupture berry aneurysmHigh mortality. 50% die suddenly, 10-20% die in hospital from rebleed.

Diagnosis: CT, LP (xanthochromia)Management: resus, surgical clipping, nimodipine


Subarachnoid Haemorrhage


HeadacheTom, 46, presents with a 4 week history of gradually worsening

nausea and a vague headache that is worse in the morning and when coughing or straining.


Raised intracranial pressurePain: Worse when lying down, bending, coughing, straining. Worse on

waking up. Gets progressively worse.PapilloedemaVomitingDecreased consciousnessBlurred visionFocal neurological deficits

Causes: mass in cranial cavity (tumour or abscess), increased CSF, venous sinus thrombosis, cerebral oedema (head injury or meningitis)


HeadacheGuillaume is a 74 year old gentleman who has experienced

excruciating superficial pain over the left side of his scalp. This pain is exacerbated by touch e.g. combing his hair or putting on his hat.


Giant cell arteritisGranulomatous inflammatory disease of blood vessels

(carotid/temporal)Disease of elderly, women>menSymptoms: • Extreme tenderness over scalp• Fever• Anorexia and weight loss (due to jaw claudication) • Linked to polymyalgia rheumatica• Visual disturbance (amaurosis fugax)• Risk sudden irreversible blindness


Giant cell arteritisInvestigations:• Bloods: raised ESR• Temporal artery biopsy: granulomatous changes

Management:• Acute: oral prednisolone • Aspirin (reduce risk of visual loss)


Questions?

phase 2 jenny brocklebank and sarah hurst the peer teaching society is not liable for false or...

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