1. Phase 2 Jenny Brocklebank and Sarah Hurst The Peer Teaching Society is not liable for false or misleading information…

2. Causes of stroke Stroke syndromes Stroke classification Investigations for stroke Management of stroke TIA Differentiating between the types of headache Management of headaches The Peer Teaching Society is not liable for false or misleading information… Aims

3. Rapid onset neurological deficit result of a vascular lesion infarction of central nervous tissue The Peer Teaching Society is not liable for false or misleading information… Stroke

4. Ischaemic 80% – Thrombosis – Emboli Haemorrhagic 20% – Hypertension – Berry aneurysm rupture (SAH) – Arterio-venous malformation – Trauma The Peer Teaching Society is not liable for false or misleading information… Stroke

5. Risk Factors – Thrombosis: HTN, diabetes, smoking, obesity – Emboli: AF – Cocaine use can cause vasoconstriction – Hypercoagulability: oral contraceptive pill, alcohol, thrombophilas – Previous TIA/ stroke The Peer Teaching Society is not liable for false or misleading information… Stroke

6. The Peer Teaching Society is not liable for false or misleading information… Stroke Anterior Cerebral Artery: Lower limb Confusion Middle Cerebral Artery: Face Whole body except lower limb Dysphasia Posterior Cerebral Artery: Hemianopia

7. The Peer Teaching Society is not liable for false or misleading information… Stroke OSCP Classification TAC: Total Anterior Circulation PAC: Partial Anterior Circulation LAC: Lacunar POC: Posterior Circulation Then add: I for ischaemic H for haemorrhage S for syndrome (used prior to imaging) Higher cortical dysfunction Hemianopia Hemiplegia or sensory loss TAC: have all 3 PAC: have 2 POC: cerebellar, cranial nerves, eye

8. The Peer Teaching Society is not liable for false or misleading information… Stroke Lacunar: deep perforating arteries Internal capsule: pure motor or sensory. Small, localised. Vascular dementia: multiple lacunar infarcts Posterior cerebellar artery: Vertigo Horner’s Ataxia Facial sensory loss Basilar: Locked in syndrome

9. The Peer Teaching Society is not liable for false or misleading information… Stroke Investigations Imaging: – CT. Quick, shows haemorrhage – MRI. Differentiate between old and new infarcts. Shows other pathology Bloods: – FBC: polycythaemia – Clotting: thrombophilia ECG: AF Carotid doppler: arterial disease, stenosis

10. The Peer Teaching Society is not liable for false or misleading information… Stroke Management: CT TO EXCLUDE HAEMORRHAGE. Thrombolysis if within 4.5hrs of event: IV alteplase (TPA) Aspirin (2wks), Clopidogrel (long term) Supportive Care: Swallowing assessment, stockings, hydration, turning Rehab: Physio, OT, home adaptations Secondary prevention: Control HTN, statins, stop smoking

11. The Peer Teaching Society is not liable for false or misleading information… TIA <24hrs (average 5-15 mins) Transient episode of neurological dysfunction Ischaemia without infarction Amaurosis Fugax: painless, transient, monocular blindness: emboli in retinal artery Treatment: aspirin and dipyridamole to prevent future stroke

12. The Peer Teaching Society is not liable for false or misleading information… TIA: risk of future stroke ABCD2 A Age>60 1 B BP>140/90 1 C Clinical features: Unilateral weakness 2 Speech disturbance without weakness 1 D Duration of TIA >60 mins 2 10-59mins 1 D Diabetes 1

13. The Peer Teaching Society is not liable for false or misleading information… Headache Beyonce has been experiencing headaches about every other day for the last 4 months. She describes them as feeling like a tight band around her head. Upon further questioning she revealed that she has been feeling very stressed since the release of the video of her husband and sister fighting in a lift.

14. The Peer Teaching Society is not liable for false or misleading information… Tension Headache COMMON THINGS ARE COMMON “tight band around head” Life stresses Bilateral No nausea or vomiting Possible photophobia Treatment REASSURANCE Analgesic withdrawal TCAs: amitriptyline

15. The Peer Teaching Society is not liable for false or misleading information… Headache Pruders is a 27 year old man who is complaining of episodic, severe headaches. The headaches are normally preceded by the sensation of “flashing lights” before his eyes. The headaches are severe and associated with nausea and occasionally vomiting. The only thing that alleviates them is lying down in a dark room.

16. The Peer Teaching Society is not liable for false or misleading information… Migraine Characteristics: Periodic attacks Unilateral Complete resolution between attacks Severe pain, pulsatile Associated Symptoms: Photophobia Nausea and vomiting Aura: Visual : scotoma, fortification spectra Sensory: tingling Motor: aphasia, hemiplegia

17. The Peer Teaching Society is not liable for false or misleading information… Migraine Triggers: Food and drink: coffee, cheese, chocolate, red wine Lack of sleep, too much sleep Noise, lights Stress Management: Stop contraceptive pill Resolution: dark, sleep Mild: paracetamol, anti-emetics Severe: triptans (serotonin agonists) Prophylaxis: beta blockers, amitriptyline

18. The Peer Teaching Society is not liable for false or misleading information… Headache Severus is a 47 year old man who is complaining of headaches which are ‘the worst pain’ he has ever felt, worse than the pain of losing Lily. The pain is behind one eye and is a sharp pain. His eyes also water and his nose runs. They have been occurring every day for the last 4 weeks.

19. The Peer Teaching Society is not liable for false or misleading information… Cluster Headache Excruciatingly painful Unilateral: temple, forehead or behind eye Comes on rapidly Autonomic: ipsilateral lacrimation, rinorrhoea, facial sweating, miosis Depression, exhaustion, anxiety (suicide headache) Lasts 45-90 mins Occur once or twice a day, often at same times (alarm clock headache) Clusters of a few weeks, followed by attack free periods

20. The Peer Teaching Society is not liable for false or misleading information… Cluster Headache Management: Acute: triptans, 100% O2 Verapamil (CCB) Topiramate (anti-epileptic) 20s – 50s. Affects men more.

21. The Peer Teaching Society is not liable for false or misleading information… Headache Damien is a 7 year old boy who’s parents bring him to A&E with a 6 hour history of irritability, lethargy, fever, headache, photophobia and neck stiffness. He is also beginning to develop a purple non-blanching rash before your eyes.

22. The Peer Teaching Society is not liable for false or misleading information… Meningitis Inflammation of the meninges Examination: Kernig’s and Brudzinski’s signs Septicaemia: a systemic infection in circulating blood. Meningococcal disease can cause septicaemia with or without meningitis. Symptoms: petechial rash, fever, rigors, cold peripheries, tachcardia Viral meningitis: less severe, benign, self limiting Organisms: N neisseria meningitidis H haemophilus influenzae b S streptococcus pneumoniae

23. The Peer Teaching Society is not liable for false or misleading information… Meningitis Management: IV benzylpenicillin Then do blood cultures, LP If bacterial: cefotaxime Supportive Notifiable Disease Contact Tracing: Rifampicin If serotype C: immunisation if not already immunised

24. The Peer Teaching Society is not liable for false or misleading information… Headache Vladimir is a 41 year old man who presents to A&E describing the “worst headache he has ever had, it feels like I have been hit on the back of the head”. He is also nauseous and is asking for the lights in his bay to be turned off as he is finding them so uncomfortable to look at.

25. The Peer Teaching Society is not liable for false or misleading information… Subarachnoid Haemorrhage Thunderclap headache Very sudden, severe Localises to back of head / neck Meningisms (photophobia, n+v, neck stiffness) Sentinel Headaches Collapse and coma Commonest cause: rupture berry aneurysm High mortality. 50% die suddenly, 10-20% die in hospital from rebleed. Diagnosis: CT, LP (xanthochromia) Management: resus, surgical clipping, nimodipine

26. The Peer Teaching Society is not liable for false or misleading information… Subarachnoid Haemorrhage

27. The Peer Teaching Society is not liable for false or misleading information… Headache Tom, 46, presents with a 4 week history of gradually worsening nausea and a vague headache that is worse in the morning and when coughing or straining.

28. The Peer Teaching Society is not liable for false or misleading information… Raised intracranial pressure Pain: Worse when lying down, bending, coughing, straining. Worse on waking up. Gets progressively worse. Papilloedema Vomiting Decreased consciousness Blurred vision Focal neurological deficits Causes: mass in cranial cavity (tumour or abscess), increased CSF, venous sinus thrombosis, cerebral oedema (head injury or meningitis)

29. The Peer Teaching Society is not liable for false or misleading information… Headache Guillaume is a 74 year old gentleman who has experienced excruciating superficial pain over the left side of his scalp. This pain is exacerbated by touch e.g. combing his hair or putting on his hat.

30. The Peer Teaching Society is not liable for false or misleading information… Giant cell arteritis Granulomatous inflammatory disease of blood vessels (carotid/temporal) Disease of elderly, women>men Symptoms: Extreme tenderness over scalp Fever Anorexia and weight loss (due to jaw claudication) Linked to polymyalgia rheumatica Visual disturbance (amaurosis fugax) Risk sudden irreversible blindness

31. The Peer Teaching Society is not liable for false or misleading information… Giant cell arteritis Investigations: Bloods: raised ESR Temporal artery biopsy: granulomatous changes Management: Acute: oral prednisolone Aspirin (reduce risk of visual loss)

32. The Peer Teaching Society is not liable for false or misleading information… Questions?