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Phase 2a
Kaveesha RajapaksaRyad Chebbout
Neurology
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• Headache
• Weakness/Collapse
• Neurosurgical Emergencies
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Aims
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?
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Fred
Symptom Triad:• Headache• Nuchal Rigidity• Photophobia
Differential?
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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
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Meningism
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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
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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?
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Fred
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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)
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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
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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?
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Margaret
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Raised ICPCauses?
Other Sym/Sig?
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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?
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Patrick
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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
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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
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Tension Headache• Severe?• Gradual Onset• Band-Like• Every Day, Chronic• Bilateral
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Trigeminal Neuralgia• Recurrent, Sharp, Stabbing, Unilateral• Mandibular/Maxillary Distribution• Tic Doloureux
• Trigg: Eating, Washing, Shaving• Primary or Secondary (Aneurysm, Tumour, MS)• MRI• Carbamazepine/Lamotrigine
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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
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Headache Summary
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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
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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?
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Pathophysiology of Stroke2 Mechanisms: ischaemic & haemorrhagic
Ischaemic:
Thrombus (Atherosclerosis)Artery stenosisDissection (Major cause in under 40’s): Symptoms?EmbolicHypoperfusion (Anaemia, shock, watershed)
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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?
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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?
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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
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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
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TIADifference?
Example?
Classic DDx to TIA?
Stroke Risk prediction tool?
Investigations?
Management?
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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?
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Extradural HaematomaCause?
Pathophysiology of the disease?
Investigations?
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Treatment
Neurosurgery – Decompressive craniotomy
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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?
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Subdural Haematoma Pathophysiology?
Can you identify the risk factors in the history?
Why is the course different to EDH?
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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?
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Daphne
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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
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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?
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Managment• MRI• Spinal XR• Blood Cul., Bloods
• Dexamethasone IV• Neurosurgery