Ischaemic Stroke

Workup

  1. ECG
  2.  Bloods
    1. FBC, UEC + eGFR
    2. ESR
    3. Fasting lipids
    4. Fasting BSL +/- HbA1c
  3. Imaging
    1. CT head – rules out haemorrhage
    2. Carotid dopplers – indicated in anterior circulation strokes
    3. DWI MRI – more sensitive for inschaemic lesions
    4. CXR – aspiration

Thrombolysis

Balance of probability is that it works but the evidence is not great and should not be taken as dogma

  1. Within 3 hours of symptom onset
    1. No previous bleeding tendency / risks
    2. BP <185/110
    3. INR<1.7 if on warfarin
  2. Within 4.5 hours of symptom onset but has added exclusion criteria
    1. Patients >80
    2. Histoyry of stroke or DM
    3. >1/3 of MCA territory

Other stuff we do

  1. Load with 300mg of aspirin stat if haemorrhage excluded
  2. Lower BP only if >220/120; go slow and use a fast acting agent – balancing the risk between haemorrhagic transformation and underperfusing the brain
  3. Raised ICP
    1. Consider decompressive hemicraniectomy
    2. NO role for steroids in cerebral oedema
    3. Osmotic diuresis with hypertonic saline
  4. Aggresive normothermia
  5. Swallowing assesement
  6. Admission to stroke unit – good nursing!
  7. Don’t anticoagulate – risk of haemorrhagic transformation
  8. DVT prophylaxis with LMWH can be considered acutely – risk stratify please

Secondary prophylaxis

  1. SNAP
  2. Control HTN
  3. Control DM
  4. Aspirin + dipyrimidole; clopidogrel in those intolerant of aspirin
  5. Anticoagulate if in AF AFTER 2 weeks
  6. Statin
  7. Carotid enarterectomy if symptomatic and >50% stenosis or asymptomatic and >60% stenosis
  8. MDT rehab

Multiple Sclerosis

Definition + Pathology

  1. Inflammatory demyleninating disease with episodic neurological dysfunction in at least 2 areas of the CNS disseminated in time and space
  2. Multifocal areas of demyelination, loss of oligodendrocytes and astrogliosis
  3. Axon loss primarily in white matter

Classification

  1. Relapsing remitting –  majority of initial presentations – 50%+ move on to SPMS
  2. Secondary progressive – progressive worsening of symptoms with superimposed relapses
  3. Primary progressive – 20% –  lack of distinct attacks, but symptoms steadily worsen
  4. Relapsing progressive – gradual progression of disability from the onset of the disease and is accompanied by one of more relapses

Diagnosis

  1. Consider for first presentation of
    1. Transverse myelitis – weakness of both legs, sensory loss and incontinence
    2. Optic neuritis – acute, painful monocular loss of vision, colour loss may be prominent
  2. MS is a clinical diagnosis
  3. Evidence supporting a diagnosis
    1. MRI evidence of lesions disseminated in space – McDonald criteria
    2. Visual evoked potential studies showing dissemination in space
    3. MRI evidence of dissemination in time – McDonald criteria
  4. CSF may be tested for the presence of oligoclonal bands

Treatment of acute episodes

  1. High dose steroids – PO methyprednisolone 500mg-2g OD for 5 days
  2. Specialist neuro rehab service

Disease progression/modification

  1. Linoleic acid 20g OD may reduce progression of disability
  2. Consideration after discussion with specialist neurologist
    1. Azathioprine
    2. Mitoxantrone
    3. IVIG
    4. Plasma exchange
    5. 4-monthyl short course high-dose methyprednisolone
  3. No evidence for beenfit in
    1. Cyclophosphamide
    2. Anti-viral agents
    3. Long term conrticosteroids
    4. Hyperbaric oxygen
    5. Whole-body irradiation
    6. Myelin basic protein

Chronic management

  1. Vaccination
  2. Stress avoidance
  3. MDT involvement
    1. Social work
    2. Speech therapy
    3. OT
    4. Physio – splints, serial casting
    5. Rehab
    6. Silver chain / community nursing
  4. Fatigue – small benefit from amantadine 200mg OD
  5. Bladder
    1. Consider anticholinergics – oxybutynin
    2. Nocturia – 400mcg PO OD
  6. Spasticity
    1. Baclofen or gabapentin are first line
    2. Consider clonazepam, dantrolene, botulinum toxin if resistant
  7. Erectile dysfunction – sildenafil 25-100mg

Localising the lesion – cerebral syndromes

Lobes

Parietal lobe

  • Sensation
  • Gerstmann’s syndrome in dominant lobe (lobe dominance = left in most people)
    • Right-left disorientation (place left hand on right ear)
    • Acalculia (count backwards from 100 by 7s)
    • Agraphia (write)
    • Finger agnosia (name fingers)
  • Non-dominant parietal lobe
    • Dressing apraxia (turned-in PJs)
    • Spatial neglect (clock face test)

Frontal lobe

  • Motor cortex
  • Broca’s (expressive) aphasia – know what they want to say but can’t get it out
  • Prefrontal cortex – personality changes
  • Olfactory and optic nerves

Temporal lobe3

  • Olfactory cortex
  • Auditory cortex
  • Wernicke’s area
    • Receptive aphasia
    • Alexia
  • Antegrade and retrograde amnesia
  • Upper quadrant homonymous hemianopia

Occipital lobe

  • Visual cortex

 

Vascular supply

  • ACA
    • UMN LL>UL
    • Loss of sensation LL>UL
    • +/- dysphasia
    • +/- homonymous hemianopia
    • +/- higher function loss
  • MCA
    • UMN LL>UL
    • Loss of sensation LL>UL
    • +/- dysphasia
    • +/- homonymous hemianopia
    • +/- higher function loss
  • PCA
    • Cortical blindness
    • Visual agnosia