phase 2a kaveesha rajapaksa ryad chebbout the peer teaching society is not liable for false or...

Phase 2a

Kaveesha RajapaksaRyad Chebbout

Neurology

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

• Headache

• Weakness/Collapse

• Neurosurgical Emergencies


Aims


GCS

27 year old gentleman, mechanic, lives with parents, smoker, T1DM.1 day hx headache, feeling hot and sweaty.

What else do we need to know?

Differential?


Fred

Symptom Triad:• Headache• Nuchal Rigidity• Photophobia

Differential?


Meningism

Signs Triad:• Kernigs – hip flexion and knee extension = pain• Brudzinski – lift head off couch = involuntary lifting of

legs• Nuchal Rigidity – inability to flex neck forward


Meningism


Meningitis• Meningococcus, Pneumococcus (Listeria, CMV, H.influenzae)• IV/IM Benzylpenicillin• FBC, U&E, LFT, Coag, Glu• Blood Culture• LP +/- CT• Dexamethasone IV + Cefotaxime IV +/- Ampcillin IV +/-

Acyclovir IV• Rifampicin Prophylaxis

• Sepsis, DIC, Seizures, Coma


Meningococcal Septicaemia• Petechial Rash + Sepsis (cold peripheries, Decreased

CRT, Hypotensive, Tachycardic• No LP• Cefotaxime IV• ICU

Further questioning revealed that Fred had been forgetting things recently, wandering off, acting inappropriately and been drowsy.

Cause?


Fred


Encephalitis• Infectious Prodrome = Fever +/- Rash +/-

Lymphadenopathy +/- Cold Sores +/- Conjunctivitis • Bizarre Behaviour, Decreased GCS, Headache, Seizure

• Viral (HSV-1/2, Bacterial Meningitis, TB, Malaria)• Immediate Acyclovir IV• Bloods, Blood Cul., Viral PCR, CT Head, LP (viral PCR)


Subarachnoid Haemorrhage• Berry Aneurysm, Arterio-Venous Malformations• RF: Smoking, HTN, Bleeding Disorders• Causes of Berry Aneurysm?

• Occipital ‘thunderclap’ Headache• Decreased GCS (drowsiness, coma)• Focal Neurology (PCOM = CNIII)• CT - not always seen• LP – xanthochromia > 12hr after onset


Subarachnoid Haemorrhage• Neurosurgery- Nimodipine- Ct Angio- Coiling/ Clipping/ Stent/ Balloon Remodeling

54 year old lady, 1/52 hx headache, worse in morning and coughing, vomited this morning.Retired, lives alone.On examination find hard, fixed, 5x5cm lump in rt breast, and right axillary lymphadenopathy.

What has happened?


Margaret


Raised ICPCauses?

Other Sym/Sig?


Raised ICP• Papilloedema• Decreased GCS, Pupillary Changes, Seizures, Focal

Neurology, VI Nerve• CT +/- LP• LP = Opening Pressure (normal < 15mmHg)

• Neurosurgical• Dexamethasone (tumour)• Mannitol

52 yr old gentleman, banker, non-smoker, lives with wife and child.1/52 hx headache, severe. No neck stiffness, no photophobia, no fever, worse towards end of day, no vomiting, no focal neurology.

What else do you want to know?

Differential?


Patrick


Migraine• Unilateral, throbbing, 4-72hr• Nausea/Vomiting, Photophobia, Phonophobia• Preceded by aura (visual, somatosensory, motor)

• Triggers: Choc, Cheese, Alcohol, Exercise• Acute: NSAID/Triptan• Prev: Propanolol


Cluster Headache• Rapid onset, severe, around one eye• Miosis, Lacrimation, Injection, Rhinorrhoea, Ptosis• 15-160min, 1/2 x Day, 4-12wks, pain-free

months/years

• RF: Male, Smoker• Acute: O2, Triptan


Tension Headache• Severe?• Gradual Onset• Band-Like• Every Day, Chronic• Bilateral


Trigeminal Neuralgia• Recurrent, Sharp, Stabbing, Unilateral• Mandibular/Maxillary Distribution• Tic Doloureux

• Trigg: Eating, Washing, Shaving• Primary or Secondary (Aneurysm, Tumour, MS)• MRI• Carbamazepine/Lamotrigine


Giant Cell Arteritis• >50yrs, Subacute onset (~2wk)• Headache, Scalp Tenderness, Jaw Claudication (pain in

jaw whilst eating), Amaurosis Fugax• ESR• Prednisolone PO• Temporal Artery Biopsy• Polymyalgia Rheumatica- Aching/Tenderness/Stiffness- Bilateral- Shoulders/Proximal Limb

• Meningitis• SAH• Encephalitis• SOL/Raised ICP• Migraine• Cluster• Tension• Trigeminal Neuralgia• GCA

Others:- Medication Overuse- Glaucoma- Dental Abscess- Sinusitis- Chronic Subdural

Haematoma- Trauma


Headache Summary


James77 year old retired miner, Hx of drooping right face while making breakfast; awake but not responsive to wife, followed by slumping to his right and falling of his chair.

PMH: AF, angina, MI 5 years ago, High BP and cholesterol

DH: Aspirin, Simvastatin, Ramipril, Bendroflumethiazide, etc etc.

Smoker: 20 a day for 61 years. Drinks 3 pints of beer every week


JamesAny more you would like to know?

Why was he unresponsive?

Why did he fall down?

What is the DDx (and the difference)?

How many risk factors can you identify? Whats missing?


Pathophysiology of Stroke2 Mechanisms: ischaemic & haemorrhagic

Ischaemic:

Thrombus (Atherosclerosis)Artery stenosisDissection (Major cause in under 40’s): Symptoms?EmbolicHypoperfusion (Anaemia, shock, watershed)


Anatomy Recap


Classification of StrokeTACS (Total) – Motor and Sensory +Hemianopia + Higher cortical dysfunction

PACS (Partial) – 2/3 of the above or Higher cortical dysfunction alone

LACS (Lacunar) – Usually pure motor or pure sensory

POCS (Posterior) – Hemianopia, cerebellar, nystagmus, cranial nerve with contralateral motor or sensory problem

What is Higher Cortical dysfunction?


JamesOn examination – Weakness of right arm and leg is 3/5, brisk reflexes, extensor plantars, cranial nerves grossly intact, has receptive dysphasia

What stroke syndrome does he have?

What is the initial investigation? (Specific)

Further investigations?


TreatmentABCDE

Oxygen if Sats below 95%

Alteplase if Ischaemic and TPA not contraindicated. If TPA contraindicated, then Aspirin

Contraindications – Stroke or MI in the past 3 monthsAny major bleeds or Surgery recentlyLow platelets or been on warfarin for long (INR >1.7)Pregnancy


Post Stroke ManagementInvestigations such as carotid doppler or MR angiography

Long term medical therapy – Aspirin and Clopidogrel, Antihypertensive, Heparin/Warfarin if AF

Rehab – Physio, OT, SALT


TIADifference?

Example?

Classic DDx to TIA?

Stroke Risk prediction tool?

Investigations?

Management?


NatashaA 15 year old was hit on the left temple with a baseball and he became unconscious. After about ten minutes, he regained consciousness, but he soon became lethargic, and over the next two hours, he was stuporous.

His left pupil was fixed and dilated an was becoming increasingly SOB.

DDx?


Extradural HaematomaCause?

Pathophysiology of the disease?

Investigations?


Treatment

Neurosurgery – Decompressive craniotomy


Derek72 year old presents with gradually increasing confusion over 3/7, headache which is worse on lying down, and right sided weakness

PMH: Fall 2 weeks ago, Previous TIA 7 years ago

DH: Aspirin

SH: Non-Smoker, Drinks 15 pints over the weekend

Diagnosis?


Subdural Haematoma Pathophysiology?

Can you identify the risk factors in the history?

Why is the course different to EDH?


Treatment

Watchful waiting

Neurosurgery if required

83 yr old lady, known colon cancer, chemotherapy.Complains of sudden onset back pain and inability to walk.Examination reveals:- Weak Legs- Flaccid Legs with reduced reflexes- Sensation Loss below L1- Loss of Anal Tone

What’s going on?Causes?


Daphne


Spinal Cord Compression• Malignancy, Infection (abscess), Trauma• Back Pain• Bilateral Radicular Pain, LMN Signs at Level of

Compression, UMN Signs and Sensory Loss Below, Sphincter Disturbance

• Acute: Tone and Reflexes Reduced


Cauda Equina Syndrome• Lesions at or below L1• Lumbosacral Pain (early)• Flaccid, Areflexic, Often Asymmetric Paraparesis• Saddle Anaethesia• Bladder/Bowel Dysfunction (late)

Is it UMN or LMN?


Managment• MRI• Spinal XR• Blood Cul., Bloods

• Dexamethasone IV• Neurosurgery

phase 2a kaveesha rajapaksa ryad chebbout the peer teaching society is not liable for false or...

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misleading information

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coma slide

onset slide

lp viral pcr slide

lp cefotaxime iv icu

ct head

decreased gcs