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Sub-dural haematoma
fluid in sub-dural space - heterogenous (old and new blood) - crescent outline
esp in elderly, alcohol, ?minor trauma
 
extra-dural - hyperdense, convex shape ? with fracture
 
Multiple TIA think
focal seizures - brain pathology or hypoglyc
fixed critical stenosis - internal carotid (low BP)
 
In TIA - usually know what they want to say even if they can't say it
 
Beware of persisting Sx in TIA/stroke - esp sensory Sx, while motor ones clear
 
Acute mild cerebral infarct - use antiHT
 
LVH with HT - end organ damage - risk of failure, AF and sudden death
start with ACE-ARB but prob need 2-3 drugs
 
Look at British HT society website - guidelines
 
Migraine
basilar artery distribution
 
 Anticoagulate - 5/7 post mild TIA, 2/52 post stroke
balance - risk of bleeding into new infarct vs risk of embolism
 
degenerative spine - nerve root compression - pain
monoparesis (only one limb) usually not TIA/stroke
 
''TIA Mx''
Clopidogrel, statin, ACE
 
90% of risk of MI and CVA (population level)
Current smoker
Unhealthy diet
Physical inactivity
Diabetes
Psycho-social stress
HT
High Lipoprotein apoA/apoB ratio
Abdo obesity
 
Pathology TIA/CVA
Embolism - thrombus / atheroma - carotid bifurcation or aortic arch
thromboembolism (or tumour) left atrium or ventricle (AF)
thrombosis circle of willis (small vessel disease in brain)
ICA dissection - trauma or spontaneous
venous thromboembolism through patent Foramen Ovale
 
Dysdiadochokinesia ???
 
Labyrinthitis
beware stroke or SOL
TIA's seldom involve posterior circulation of brain (cerebellar signs)

Amaurosis fugax - painless transient monocular visual loss
embolic, hemodynamic, ocular, neuro, idiopathic
 
Repeated identical transient neuro events - not usually TIA .... ?seizures, ?hypo-perfusion, ?functional
 
Vascular Sx - pain and coldness
 
Migraine
No need to image
often thought to be TIA
 
Nerve compression injury
 
Anxiety / functional disorder
lots of attacks in short space with no impairment
no red flags
background of stressors
need good explanation to pt

Carpal tunnel - weakness with reduced co-ordination, numbness with pins and needles - thumb to ring finger
associated with hypothyroid and acromegaly
 
Ulnar nerve compression - elbow Sx, sensory change little finger, weakened grip
 
Radial nerve damage -  in mid arm, dorsum sensation and wrist extension affected
 
Cortical hand (pre-central gyrus) - motor Sx - abduction and extension of index middle and ring fingers
 
Subclavian steal - limb Sx (pallor, cold, blue, pain) with syncope when arm is used (blood reaches arm via circle of willis ....!!)
 
Carotid disease
starts with intimal thickening, then thick fibrous cap atheroma, in time the cap thins due to inflammation and may rupture / erode and then calcify
ruptured / eroded - more likely to get thrombus and then embolism
smoking, antiHT, antiplatelets, statins, may alter process
plaque less stable in men cf women
 
''TIA mimics''
low BP, hypothermic, hypoglcaemic

Demyelination - limb weakness, amaurosis fugax
MRI - white matter lesions - blob - vascular lesion, linear - demyelination
 
TIA - blood thinner, statin, antihypertensive
remember driving
 
Alexia - loss of reading ability, dominant lobe lesion often occipital
Acalculia - loss of simple sums ability - lesion in parietal lobe (angular gyrus)
Dysgraphia - difficulty writing - encode thoughts (parietal lobe (AG)) then transcribe words (frontal lobe (Exner's writing centre))
 
Migraine - may have deep hyperintense white matter changes on MRI
Migraine with aura - increase risk of stroke esp if COCP (post circulation territory stroke)
 
MRI may show changes with TIA - esp with higher ABCD2 score
 
Carotid dissection - with Horners syndrome
exposes subendothelial layer of artery and clot develops and lumen is narrowed
 
Horners - eyelid drooping (ptosis) with pupil constriction (meiosis) ? dec sweating (anhydrosis), conjunctival redness, enophthalmos
problem with sympathetic (autonomic) nerves
 
Transient global amnesia - inability to store new info so repeated questioning, normal ADL, recognition of family, seldom recurs (think seizure) and last 2-4 hrs
 
Bitemporal inferior quadrantanopia - superior optic chiasm
Inferior homonymous quadrantanopia - parietal lobe
 
Posterior circulation TIA
vertigo ?? hearing loss
 
Inter-arm differences in BP - caused by atherosclerosis causing obstructive arterial disease
HT (use higher BP to guide treatment), DM, renal failure
 
Carotid endarterectomy (mostly done under LA)
higher degree of stenosis - more strokes saved
unable to operate if completely occluded
 
bells palsy
LMN lesion of 7th cranial nerve
eye rolls up and lateral when eyelid tries to close
frontalis muscle is involved (unlike in UMN lesion when its spared)
weakness persists whether voluntary (motor cortex) or involuntary (from emotion - ant cingulate cortex) while with UMN it is only on voluntary
ear pain, tinnitus, headache, dizziness, impaired speech, loss of taste, numbness (trigeminal - not affected but weakness makes it feel odd)
if some function recovered by 3/52 - likely to fully recover
Mx - prednisolone, corneal lubrication
if other CN lesions remember cerebellar-pontine angle tumour