NeuroSurg
-
Stroke
Doctor Instruction:
Your patient is Charlie, a 63-year-old man presenting with problems with speech. Please take a history and carry out a relevant examination.
Patient History:
Charlie, 63y/o M, Engineer.
Your partner noticed a few hours ago that you were difficult to understand while speaking during dinner. Your speech has been slurred, according to your partner, and it happened very suddenly. Your partner was really worried about this and therefore called an ambulance.
You have noticed you cannot see things on your left which is “kinda weird” – you have never experienced this before in the past – you have to constantly rotate your neck to the side to see more. You also feel tired and not “really yourself”. You noticed you could not pick up your fork with your left hand or lift your left leg up when you tried to walk. These symptoms have not settled since then.
You are unsure whether you have swallowing difficulties, but you ate fine before slurred speech kicked in. No dizziness/ unsteadiness/ numbness/ headache/ confusion/ loss of consciousness/fever.
Ideas, Concerns, Expectations:
You think this might be another "ministroke". You had this last year which quickly resolved. You think you are likely to get better because of this. You have no concerns – you don't know why your partner was so concerned about this. You just want to go home and don't want to miss out on watching your favourite TV show.
Past Medical History:
Hypertension, atrial fibrillation, obesity, hypercholesteremia, previous “ministroke” x1 last year. Had a hernia operation in 2014.
Drug History:
Atorvastatin, aspirin, amlodipine, ramipril, apixaban.
NDKA
Family History:
Father had a heart attack when he was 50
Social History:
You live with your partner in a semi-detached house.
You work as an engineer.
You smoke 10 cigarettes a day since when you were a teenager (can't remember for how long exactly).
you drink a pint of beer every weekend.
Examination Findings:
Slurred speech
Left-sided weakness for arm and leg
Left homonymous hemianopia
No higher cerebral dysfunction (dysphasia, visuospatial disorder)
Differentials:
Stroke – likely ischaemic PACS ( Ischaemic stroke (87%) vs Haemorrhagic stroke (13%) )
Stroke – other forms
TIA
Investigations:
Observations + neuro observations
ECG / Echo – to rule out cardiac cause
Bloods: glucose (exclude hypoglycaemia), U&Es (neurological signs + exclude renal failure), FBC (r/o anaemia or infection), coagulation screen with INR
USS doppler carotids – rule out aortic stenosis
Non-contrast CT Scan (immediate) – to determine management: ischaemia vs haemorrhage
For further investigations: MRI Scan/CTA/MRA
Management:
Conservative:
Smoking cessation
Dietary changes
Lose weight
Exercise
Alcohol Control
Manage risk factors/co-morbidities: hypertension, hypercholesteremia, diabetes, AF, obesity, high cholesterol level…etc.
Rehabilitation (MDT: PT + OT + SALT + Nurses+ Dietician + social services + Optometry/Opthalmology + psychology + Orthotics)
Neuro observations + monitor with supportive care.
Maintain target oxygen saturation
Medical:
Referral to hyperacute/acute stroke unit.
Ischaemia:
Thrombolysis (<4.5 hours from onset) – alteplase if ischaemic and intracranial haemorrhage has been excluded (repeat CT scan needed post-thrombolysis to rule out haemorrhage complication).
Alternative: mechanical thrombectomy (6-24 hours of onset)
Antiplatelet therapy with PPI (e.g. STAT aspirin 300mg after CT and continued for 2 weeks – to be switched to clopidogrel 75mg lifelong for secondary prevention of stroke)
Statin e.g. atorvastatin 80mg life-long for secondary prevention
Haemorrhagic:
Withhold blood thinners
Urgent referral for neurosurgical assessment
Control blood pressure.
Consider reversal of anticoagulation.
Viva Questions:
What are the risk factors for stroke?
High blood pressure (hypertension)
Smoking
Diabetes
High cholesterol levels
Heart disease
Obesity and lack of physical activity
Poor diet
Excessive alcohol consumption
Age and gender (risk increases with age and is higher in men)
Family history and genetics
Previous stroke or transient ischemic attack (TIA)
Certain medical conditions (e.g., sickle cell disease)
Sleep apnea
Certain medications (e.g., hormone-based contraceptives)
What is the ROSIER scale?
The ROSIER (Recognition of Stroke in the Emergency Room) scale is a clinical tool used to aid in the early recognition and diagnosis of stroke, particularly within the emergency room setting. It's designed to help healthcare professionals quickly assess the possibility of a patient experiencing a stroke and facilitate prompt intervention. The scale evaluates specific signs and symptoms commonly associated with stroke.
The ROSIER scale typically considers various criteria, including facial weakness, arm weakness, speech disturbance, and age, to determine the likelihood of a patient having a stroke.
What are the indications for immediate CT Head?
Acute Head Trauma: Significant head injury.
Stroke or TIA: Focal neurological deficits or suspected stroke.
Subarachnoid Hemorrhage: Sudden severe headache.
Intracerebral Hemorrhage: Sudden severe neurological symptoms.
Mass Lesion or Tumor: New-onset or worsening neurological symptoms.
Infections or Abscesses: Suspected intracranial infections.
Hydrocephalus: Symptoms of increased intracranial pressure.
Vascular Abnormalities: Suspected aneurysms or AVMs.
Altered Mental Status: Sudden mental status changes.
Seizures: Prolonged or atypical seizures.
Severe Headaches: Sudden severe or atypical headaches.
Ophthalmologic Symptoms: Acute visual disturbances.
Post-Operative Patients: Recent neurosurgery with acute symptoms.
What are the key cerebellum defect signs?
Ataxia: Uncoordinated movements and balance issues.
Dysmetria: Difficulty judging distances accurately.
Intention Tremor: Shaking during purposeful movements.
Speech Disturbances: Slurred or abnormal speech rhythm.
Nystagmus: Involuntary rhythmic eye movements.
Vertigo or Dizziness: Sensation of spinning or unsteadiness.
Wide-Based Gait: Feet spaced apart for stability.
Incoordination of Movements: Difficulty with precise motions.
Tremor: Rhythmic shaking or quivering movements.
Reflex Abnormalities: Altered reflex responses (reduced or increased).
Tell me about the Bamford classification of ischaemic stroke.
The Bamford classification categorizes ischemic strokes into four types based on their clinical presentation:
Total Anterior Circulation Infarct (TACI): Severe deficits involving at least two areas (leg, arm, face, higher cortical functions).
Partial Anterior Circulation Infarct (PACI): Moderate deficits that don't meet TACI criteria.
Posterior Circulation Infarct (POCI): Involves brainstem and/or cerebellum, causing specific symptoms.
Lacunar Infarct (LACI): Small, deep infarcts causing motor or sensory deficits.
-
Spinal Stenosis
Doctor Instruction:
Your next patient is a 51-year-old woman called Rebecca, presenting with lower back pain. Please take a history and perform an appropriate examination.
Patient History:
Rebecca, a 51-year-old female, nurse
You have always been having lower back pain for the past few years, but this has been getting gradually worse. The pain is dull and intermittent. Very often, the pain can diffuse and radiate towards the buttocks, back of the thighs, and feet - when this happens, the pain feels like a burning or cramping sensation. It can be associated with weakness in both legs. The symptoms can be triggered or worsened by sitting down, standing straight and walking downhill. It goes away after a few minutes after being at rest. Bending forward improves symptoms. You tried paracetamol, which only helped a little with pain.
If you walk for more than 50 yards, you will start noticing numbness and weakness in your legs.
No previous injury/trauma. Waterworks normal. The bowels are working normally. No other abnormal sensations or weaknesses. No incontinence. No stiffness. No fever. No weight loss. No night sweats.
Ideas, Concerns, Expectations:
You think because you often have to bend your back due to work, the pain may be caused by poor posture. You are concerned because it is starting to affect your ability to work in the hospital as a nurse. You would like to see if you can get stronger painkillers and possibly have a scan of your back.
Past Medical History:
Obesity, hypercholesterolemia, acromegaly, T2DM.
No past relevant surgical history.
Drug History:
Atorvastatin, metformin NKDA.
Family History:
Father has ankylosing spondylitis.
Social History:
You work as a senior nurse in a local hospital.
You smoke around ten cigarettes daily for over ten years but don't drink alcohol.
Live with husband in a semi-detached house.
Independent.
Examination Findings:
Lower spinal tenderness on palpation at L4-5 region.
Complete motor and sensory neurological examinations are normal.
Features of acromegaly e.g. enlarged hands, feet and facial features.
Lower limb vascular examination is normal.
No cervical tenderness or restricted movement. Gait normal.
No cauda equina syndrome features.
Peripheral pulses and ABPI normal.
Differentials:
Lumbar spinal stenosis - likely to be due to degenerative changes
Osteoarthritis of the spine
To rule out cauda equina syndrome
Ankylosing spondylitis/spondylolisthesis
Rule out peripheral arterial diseases
Other causes of back pain: spinal tumour, disc herniation, trauma, fracture, and epidural abscess.
Investigations:
Imaging:
XR Lumbar spine (may show degenerative changes/spondylolisthesis)
MRI Spine. Alternatively, CT myelography/spine when MRI is not available or unsuitable.
Consider ABPI / CT angiogram to exclude peripheral arterial disease where intermittent claudications are present.
Special tests:
Consider electromyographic (EMG) walking test - increased F latency values in lumbar spinal stenosis
Consider electromyographic paraspinal mapping
Management:
Conservative:
Exercise
Weight loss if overweight
Physiotherapy e.g. exercises that minimally stress the back, such as walking, swimming, or bicycling. Exercise may also strengthen the paraspinal muscles.
NSAIDSs e.g. naproxen, celecoxib +/- PPI cover / antacids
Paracetamol
Medication for neuropathic pain e.g. amitriptyline, gabapentin, pregabalin.
Consider oral steroids for acute exacerbation of painful symptoms.
Activity modification e.g. limit heavy lifting/prolonged sitting/repetitive bending/twisting of the back.
Consider deep heat therapy with massage to relieve spasms associated with back pain
Surgical:
Consider decompression surgery +/- fusion e.g. laminectomy ( removal of the lamina from affected vertebra) followed by physiotherapy
Consider interspinous distraction procedure to reduce backward movement of the spine.
Consider epidural injections with local anaesthetic and corticosteroids under specialist guidance for short/long-term pain relief.
Viva Questions:
Explain the pathophysiology of spinal stenosis.
Spinal stenosis is the narrowing of the spinal canal, which holds the spinal cord and nerves. It's often due to age-related disc degeneration, arthritis, and thickened ligaments. This narrowing can compress the spinal cord and nerves, leading to pain, numbness, and weakness. Factors like herniated discs and inflammation worsen the compression. Treatment involves pain management, physical therapy, and sometimes surgery to relieve pressure on the nerves and spinal cord.
At what level of the spine does spinal stenosis occur most commonly?
Spinal stenosis most commonly occurs in the lumbar (lower back) region of the spine. This is because the lumbar spine bears the most weight and undergoes significant movement, which can contribute to degenerative changes over time. Lumbar spinal stenosis can result in compression of the spinal cord and nerve roots, leading to symptoms such as lower back pain, leg pain, numbness, and weakness. However, spinal stenosis can also occur in the cervical (neck) and thoracic (mid-back) regions of the spine, albeit less frequently.
What are the causes of spinal stenosis?
Degeneration of spinal structures due to aging.
Disc degeneration and herniation.
Osteoarthritis and bone spurs.
Thickened ligaments.
Congenital factors and genetics.
Injuries and trauma.
Tumors or abnormal growths.
These factors narrow the spinal canal, compressing nerves and causing stenosis symptoms.
What are the risk factors of spinal stenosis?
Age: Risk increases with aging.
Genetics: Family history matters.
Congenital: Narrow canal from birth.
Injuries: Past spine trauma or surgery.
Lifestyle: Heavy lifting, certain jobs.
Obesity: Excess weight strains spine.
Diseases: Arthritis, diabetes, etc.
Scoliosis: Abnormal spine curvature.
What are the red flag symptoms/signs of back pain?
Neurological Issues: Weakness, numbness, or tingling.
Bladder/Bowel Problems: Loss of control.
Severe Pain: Unbearable or unrelenting.
Fever: Along with back pain.
Unexplained Weight Loss: Rapid and unintended.
Cancer History: Especially if pain is new.
Night Pain: Worse at night.
Trauma: After injury or accident.
Age Over 50: New-onset pain.
Steroid Use: Especially long-term.