1. Stroke, Head Trauma and conciousness Amy Wood, Haddy Cosh, Vishal Chauhan, Asfand Baig, Stewart O’Conner

2. Definition

3.  a syndrome of rapid onset of cerebral deficit (usually focal)  Lasting > 24 hours or leading to death and no cause apparent other than a vascular one

4. Stroke Risk Factors  Non Modifiable   Modifiable 

5. Stroke Risk Factors  Non Modifiable  Age  Male  FHx  Race – black/ hispanic  Modifiable  HT  IHD  AF  DM  Hypercholesterolaemi a  Smoking  Alcohol

6. Types    

7.  Ischaemia/ embolism causing cerebral infarct – 80%  Intracebral Haemorrhagic – 15%

8. Causes -Haemorrhagic      

9.  Ruptured aneurysm  Trauma (subarachnoid/intracerebral)  Dissection (carotid/vertebral)

10. Causes - Ischaemic      

11.  Cerebral Thrombosis  Cerebral Emboli  Give examples  Lacunar

12. Symptoms - General

13.  Weakness/Paralysis or numbness on contralateral side  Vertigo/dizziness  Headache  Visual loss/blurred vision  Faintness  Confusion  Speech problems  Difficulty swallowing  Cognitive problems  Memory problems  Consciousness alterations  BUT…DEPENDS ON SITE

14. Stroke Syndromes        

15.  TACS - Total Anterior Circulation Syndrome  PACS - Partial Anterior Circulation Syndrome  LACS - Lacunar Syndrome  POCS - Posterior Circulation Syndrome

16.  What are the differences between them?

17. SyndromeSymptomsArtery TACS Higher Dysfunctions Dysphasias Visuospatial problems Homonymous Hemianopia Motor/Sensory Deficits ICA, MCA, (ACA) PACS 2/3 Similar to TACI Partial motor/sensory deficits Higher dysfunction alone MCA, (ACA) LACS Pure Motor or Sensory or Sensorimotor loss Ataxic Hemiparesis Small vessels (Perforating arteries) POCS Cranial nerve palsy & contralateral motor/sensory deficit Bilateral motor or sensory deficit Cerebellar signs Eye Movement deficits/isolated homonymous hemianopia Vertebral PCA

18. Extras - watersheds SyndromeSymptomsArtery Watershed ACA- MCA "Man-in-a-Barrel" Syndrome Aphasia Internal Carotid Artery occlusion Watershed MCA- PCA Visual ProcessingICA Susceptibility to ischaemia: Systemic BP drop ACA-MCA occlusion of carotid

19. TIA

20.  Sudden focal deficit – usually only a few seconds  Presentation very similar to stroke  Amaurosis fugax??  <24 hours with complete recovery  Issue: after 1 hour ischaemic damage has already occurred  High risk of recurrence and full stroke

21. Causes- TIA

22. Carotid artery insufficiency – 80% Veterbrobasilar Insufficiency – 20% Circle of Willis – collateral supplies

23. Management 1. Assessment/ diagnosis  Location  Subtype  Cause 2. Acute intervention 3. Secondary prevention  Reduce risk factors

24. Assessment and Diagnosis

25. Assessment: Diagnosis  Clinically usually  FAST  Imaging - <3hrs  CT  Available  Exclude haemorrhage  MRI  If brainstem or cerebellar symptoms

26. Urgent CT required

27. Acute intervention

28.  Admit to Acute Stroke Unit for assessment  Iscahaemic – Thrombolysis rTPA within 3 hrs of symptoms  Haemorragic – emergency surgery

29.  Antiplatelet drugs (Aspirin 150-300mg) if infarct  Contraindicated if haemorrhage!!  Monitor/prevent complications  Physiological monitoring for first 72 hours to maintain CO and supply to brain  HR, Temperature, BP, O2 sats, Blood sugar, ECG Acute intervention

30. Complications

31.  Post-stroke pain/thalamic pain  1 week- 6 months after stroke  Anywhere in spinothalamic system  Contralateral side referral of pain  Burning + sharp  Hyperalgesia & Allodynia  Treat as for neuropathic pain  TCAs

33. Layers of the brain a) Pia mater b) Arachnoid mater c) Dura mater d) Superior sagittal venous sinus e) Skull f) Falx celebri g) Subarachnoid space

34.  Pia  Arachnoid  Dura Subarachnoid – arteries Subdural – Bridging veins Epidural – Meningeal arteries

35. Normal CT  Usually going to be symmetrical  Ventricles symmetrical and equally full

36. Midline Shift  Coup injury – injury on same side of force  Contra coup– injury on the opposite side on injury  If you see midline shift, you have a high pressure situation

37. Case 1  Young lady hit on the side of head by a glass at a gig, seemed to recover, Found slumped 50 minutes later  Ix?  CT/MRI, x-ray if fracture  Where may she have been hit?  Pterion  What bones converge here?  frontal, parietal, sphenoid, temporal  What does this area cover?  Middle meningeal artery  Type of intracranial haemorrhage?  extradural (epi)  Type of blood characterises this?  Arterial  Why passed out?  raised ICP  Rx  surgical

38. Extradural haematoma:  Midline shift  Lenticular shape  This can be middle meningeal artery – pterion bone breaks  Cerebral perfusion pressure = mean arterial pressure – ICP  Extradural haematoma you give Mannitol – 100mL at 20%  Diuretic

39. Case 2  Old alcoholic man had a fall in the park now noticed to be very drowsy with low consciousness  Ix:  CT/MRI  Likely haematoma?  Subdural  Other symptoms?  Headache, confusion, N/V, tinnitus, speech and visual problems, dizziness, weakness  Where is the bleed likely to be?  bridging veins  Type of blood?  venous  Rx depends on size + growth rate: often conservative (body reabsorbs), sometimes burr-hole drainage  Acute or Chronic

40. Subdural Haematoma:  Runs along the surface of the brain, underneath the dura  Depending on the GCS score of the patient you may need to remove it  Midline shift

42. Subarachnoid Haemorrhage  Sudden onset severe headache, often at the back of the head, Neck stiffness, Impaired consciousness (drowsiness / coma), Cranial nerve signs, Hemiplegia  The bleeding occurs as the result of rupture of aneurysm (80%) and AV malformations (15%) or trauma

43. Contusion (bruise)  Intra- axial  As bruise swells, pressure goes up – all features of raised ICP (coma)  If you remove them you need to do a craniotomy

44. Diffuse Axonal Injury RTAs / shaken baby syndrome  If a rotational force is applied, the axons are damaged and you can have damage very far away from the original injury – diffuse axonal injury  Small contusions all over the brain  The worse it looks on the CT scan, the worse the injury in the patient – especially if you see an injury in the brainstem  DAI doesn’t look as bad on CT as some of the other ones, but can be much worse

45. Le fort Fractures

46. Blow-Out Fractures

47. With a mass lesion why do you not get an immediate loss of consciousness?

48.  Due to an ability to Compensate!  Intra cranial vol = vol CSF + vol Brain + vol blood + vol Mass lesion  Skull can’t expand  Compensation – 10-20 ml CSF in to lumbar cisterns  Compensation exceeded  Increase in ICP  herniation

49. What are the 3 key symptoms of raised ICP?  Papilloedema  Headache  Nausea and Vomiting

50. Label diagram

51. Name two areas of the brain that can be damaged, leading to loss of consciousness?  Compression of reticular formation from herniation  Large damage to cortical regions

52. How unconscious are they?  What is the main tool that we use to measure this?

53. Glasgow Coma scale

54. “Patient has Glasgow coma score of 9” What’s wrong with this?

55. It’s more useful to say:  GCS = V1 E3 M5 V3 E3 M3 etc.  They are different situations that may need managing differently

56. Three indicators of change of brain function in the unconscious patient?  Reaction to painful stimulus – (part of Glasgow Coma scale)  Vestibulo-ocular reflex  E.g Caloric test, doll’s head test  Size and reaction of pupils

57. What are the three components of consciousness?  Alertness - upper brainstem reticular formation - wakefulness  Awareness - cerebral cortex state of awareness and interaction with environment  Attention - limbic system and frontoparietal association areas - affect, mood, attention, motivation pay attention to