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Ok. Good. Ok, cool. Um, so, um, as it's with an echo. Ok, that's fine. I think it's just because I've, I've taken it off now. I've just joined, um, with my phone as well so I can just keep the chat up. Um, hopefully the echo has gone away now. Ok, great. Um Right. So we'll get started. Um, so I, like she was saying, I'm Nisha. Um I'm currently working as a clinical education fellow for this year. So this is basically my f three year. Um, but I've had a lot of experience with um acute medicine and some common presentations with neurology. So we're going to try and cover um, headaches a bit about um, bleeds, uh strokes and seizures and then if we have time at the end, um, I've included a kind of like five minute neurological exam um, that I, that we tend to use. Um, I think the lecture should be about around, um, just over an hour. Um, but it's quite a lot of content that we're gonna try and cover. Um, so I'll try and cut it down if possible. But um, we'll just keep an eye on the time and see how, how we get on. Um, so to begin with, we're gonna start with headaches. So if you guys can just put in the chart, um, what type of symptoms, um, you would usually ask a patient, um, about if they're presenting, um, with a headache, what type of things, common things, what they present with? Yeah. Yeah. Ok, cool. So, yeah, so all of these things are good things that we, that we need to ask about. So we've had onset dizziness, um vomiting, blurry vision, um aura. Um ok. I think someone's unable to see the screen can ever everyone else can see the screen, right? Oh, you can't see it. Ok. Let me have a look and see one second. Let me stop presenting and start presenting this again. Um What about now? Can you guys see it now? Ok, cool. All right. Sorry about that. Just some technical difficulty as uh as per usual. Um But as we were saying, so headaches. So as you guys said, um you should be asking so exploring the symptoms so further. So, um going usually we try to use Socrates to try to work through the history of the presenting complaint. So onset is good. But other things you should be asking about is um using things associated with pain, things that make the symptoms, make the headache better. Is there anything that makes the headache worse? Um, any associated symptoms? And then I've included quite a range of other symptoms. You, you should probably explore as well. So are there any um like you said, nausea and vomiting? But also are there any neurological features? So, motor or sensory, any photophobia, um neck stiffness and fever, recent trauma, weight loss, scalp tenderness, jaw claudication, um postural changes, facial changes. This kind of just shows you how broad um the headache differentials can be, but we'll try to go through um a little bit about common symptoms, um grouped with a, with a common presentation. Um On the next slide I have for you a question. So we've got a 90 year old lady who's presenting to Ed, she's got a right sided headache and on further questioning, um, the emergency doctors find out that she also gets pain on chewing on examination, there's no neurological deficit um and the visual fields are normal. However, there's right sided scalp tenderness. Um What is the most likely diagnosis out of these options if you guys can put it in the chat, please? What do you think it is? Yeah, exactly. Yeah. So we've kind of got a consensus that it is um temporal arthritis. Um, a secondary follow up question to this is out of the options that we have in the um, the uh from A to e um which ones of these are emergency presentations, which ones of these would you be really quite concerned about? Yeah. Yeah. Yeah, exactly. So, um we'll be really quite concerned about if it's a subarachnoid hemorrhage or if there's temporo um arteritis. So, on this side, I've put a summary of some emergency conditions that you might um encounter. So, on this list, like we said, we've got temporal arteritis, we've got arno hemorrhage. We've also got things like meningitis and encephalitis. Um symptoms are associated with bleeding. Um So subdural, extradural hemorrhage, they usually temper tend to present with some confusion, but they can also present with worsening headaches and we'll go into that a bit more um a bit later. Um And then we've kind of tried to, tried to group some of the symptoms together, which we'll go into a little bit further along. But so uh we were going through temporal arthritis. So things like the scalp tenderness, jaw claudication and also it can be associated with a um fox. So this is what we call um curtain downing. So they'll have a sudden loss of vision that feels like a curtain that goes down um across the um across their vision. And this is usually associated with um a uh a clot within the one of the um occipital arteries. Um So arteries supply in the occipital lobe. Um this is slightly different to migraines because what will happen with Ami Fugu is you've got that vertical cut and going down. Whereas with the migraines, sometimes they notice a vision that's coming horizontally. So from the left side of the eye to the right side of the eye or from the right to left. So they have this kind of horizontal change in vision rather than a vertical change. Um And then other things on here are subarachnoid hemorrhage. So that would have been with a worse or worst ever thunder clap type of headache, meningitis, encephalitis. So things like neck stiffness or um odd behavior. And then another one that's common as emergency presentation can be um acute um angle closure, glaucoma as well um with the non reactive um pupil um and eye pain. So um going to first of all, going into temporal arthritis. So obviously, this is a vasculitis of unknown cause usually presents in our of patients and it's usually unilateral and like I said, with the scalp tenderness on brushing, um usually associated with jaw claudication and um we on um investigation, we usually find how the patient has an urgent um has a raised esr. Um And then um the thing to highlight is in terms of management, it's important to have early recognition and treatment to reduce the risk of um permanent vision loss as a um number one kind of um most common complication that can happen. Um So, treatment usually involves high dose steroids and urgent ophthalmology review. Um Another type of headache that can present kind of similarly to this is trigeminal neuralgia, but this one, you tend to get more of a sudden shock type of pain on one side of the face and usually lasts a few minutes a second and it can also be triggered by chewing or speaking or touching. Um And usually we manage this with carBAMazepine, but you might also see in the acute side that we use things like amitriptyline or pregabalin as well. Um I have a couple of sides just summarizing um meningitis as well. So, um so with meningitis, like we said, the most common symptoms will be having that photophobia. Um usually having some sort of um headache going on as well. Um And usually having neck stiffness and a high fever. Um This is usually associated with bacterial meningitis, which we have the common organisms present for viral meningitis can be a bit more insidious. Your patient might present um a bit more well in themselves and, and with um nonspecific symptoms, um at the bottom, we have two common signs of meningitis. Can you guys write in the chart? What these, what these special investigation signs are or special examination signs are? Yeah. Yeah. So we have canning and Briski. So canning with the K for knee extension um on passive flexion and then Briski um which is where we have um passive um flex. So uh when we flex the passive flexion of the neck, then the patient does like that hip and um knee jerk. So those are usually the common presentation in the, in the middle. Um We check for blanching of the skin. So um with the with meningitis, sometimes it can present if it presents with this pyic type of rash that's non blanching, then it's where we have meningococcal septicemia. Um So, so we have more of the blood borne um type of infection. Um And this is obviously quite serious um and can also present with the meningeal type of symptoms. And usually we don't do a, we don't do a lumbar puncture if they have this um non blanching type of rash. Um This slide kind of summarizes CSF interpretation. Um I guess in your practice, um you probably see most commonly see bacterial and viral um differentiations of CSF interpretation. Um And usually the most, I think the most important features to keep an eye out for if you're doing, if you're taking a CSF sample will be, first of all, um you might have to measure the opening pressure. This is usually quite important with um headache presentations. Um And um that can be, for example, with patients that have um idiopathic raised intracranial hypertension as a differential for the headache, um appearances you should look at as well. So for example, bacterial can be t and viral can be clear. But in practice, um bacterial infections unless they're quite severe, don't always have those changes in the appearance. The main things you're going to be looking at is values. So we always remember that the bacteria uses up the glucose and then um releases the protein. But realistically, it's because the bacteria has more disruption with the blood brain barrier. So that's why you get a more significant rise in the protein. Um And like you said, they use up the glucose, whereas with viral, um the protein can be quite um quite normal or mildly elevated. And then the glucose is massively elevated. Um And for both bacterial and viral, they have a rise in the um white cell count, but the bacterial has a rise in neutrophils, whereas the viral will have a rise in um the uh lymphocytes. So, um monocyte um monocytes is an example. Um and then you'll probably, when you um get further, a further microbiology report, they'll probably comment on the type of um organism that's been seen. Um So, in terms of whether it's uh so what the morphology is of the um bacteria. Um If that's, if that's what's been seen on C sf this is just a summary slide that talks about the management protocol. So usually if you get a, a patient that's presenting um with um neck stiffness and photophobia um without signs of shock and no evidence of rash, then um this is usually indicates towards meningitis and usually start with doing a blood culture. And then the definitive um my a diagnostic tool would be doing a lumbar puncture. But you have to, first of all assess the risks of increased ICP. So for example, if they've got papilledema or if they've got focal neurological signs or uncontrolled seizures. These tend to be, these tend to be more signs of increased ICP, so, contraindication for doing a lumbar puncture. Um So, in this case, um we usually start treatment first and um get urgent senior support. Um If they don't have signs of these, we can perform a lumbar puncture. Um And we usually, you also, you should get senior support before doing that. Obviously, unless you're confident with doing that, um We usually start empiric antibiotic and usually viral um management. So usually it's IV cefotaxim or cefTRIAXone, but it depends on the trust that you're in and you should be able to start I va cyclovir until we get negative samples. Um but, but each trust has slightly different guidelines and usually you should speak with um microbiology first. Um And it's also important to note that um meningitis is a notifiable disease. So, usually expected to um inform public health, but usually the infectious disease team will advise you on this if on the other side, they show with signs of shock. Um Then in this case, you tend to start the sepsis six, get IV um blood, take blood cultures, get ICU input, um give the IV cefTRIAXone as it crosses the blood bone barrier and then consider inotropic support and because they're actively going to be in shock, um Usually we delay LP until they're um stable and that's what the contraindication is if they're presenting with that purpuric type of rash. Um I've just tried to include on this side a summary of the different types of headaches that you will um usually get present presentations with. Um I think quite commonly I've seen migraines, I've not really seen that many cluster headaches. Um There have been a couple of tension headaches, but usually you'll get migraines. Um in terms of presentations, I'm sure you guys are quite confident with this, but in terms of the symptomology, um there's a diagram at the top that kind of summarizes the um how it, how the each one presents. So with tension headaches, it's usually that type band type of pain. Um that's more like a dull um type of pain that's around the that's wraps around the whole of the head. Um Usually it's stress related and usually not associated with nausea and vomiting and treatment is usually just supportive. So using analgesia with migraines, it's usually that severe unilateral throbbing type of pain with nausea and vomiting um and photophobia and usually they have an aura and as part of that aura, they can have visual changes. So we usually notice that if they've got like a visual loss or they notice floaters, they tend to float horizontally across the eye and that more points towards migraine rather than like we said, that cut downing and that happens with, with a stroke. So with the ainu um food box, in this case, we tend to treat them with um paracetamol. And then, um, we usually try triptans here. It talks about oral triptans, but usually oral triptans. If they don't work well for the patient, there are other routes. So we offer them nasal sprays and subcutaneous triptans. And some of these work better than the oral. Um, at the same time, we give them um some sort of antiemetic and you might consider starting prophylactic doses, prophylaxis. So stuff like propranolol or topiramate. Um But it's important to know that these usually take quite a long time to um build up to a threshold um that works well for the patients. So the difficulty I face with migraine patients is that they feel that they're in a lot of pain and then they feel that, you know, um it's taking a long time to increase the prophylactic medication and nothing really works for them. Um But the best thing that we said is trying to make sure you've got all the basics covered. So they're on acute management prophylactic management and are referred to neurology or pain team for further advice and then cluster headaches um are, is that severe type of pain around one eye um associated with rhinitis, red eye. And um also um um their um leaky eye. So lacrimation and these usually tend to be recurrent episodes um lasting less than 90 minutes. And the treatment for this is usually 100% oxygen and again with sub um sub triptans and prophylaxis with um verapamil or calcium channel blockers. Um And then, like we said, um when you're exploring a history of presentation with migraines, try to explore the um triggers that can be present. And um with patients that have, that are of childbearing age, um using contraception, you should try to avoid using the combined oral contraceptive pill. Um especially if they have a migraine with aura as there's an increased risk of ischemic shock. OK. So using this knowledge that's on this slide, we have this question. So um you are working in a GP practice. Um A 22 year old female has visited the practice asking for a medication review. A consultant, neurologist has asked you to prescribe prophylactic therapy for a recently diagnosed migraine um for which she experiences an aura pro so she currently takes Yasmin um which is a combined oral contraceptive pill, um salut prn for asthma as well. So, out of these options, if you guys can put in the chart, what do you think is the most appropriate plan of um plan of action for her? Mhm. OK. I can see some of you guys have started to put responses in. So we'll give you about another minute or so if anyone else wants to, wants to put what they think it might be. Mhm OK. So we, it looks like most of you guys have gone for sea or you've gone for sea shirt slash D we've got a couple more coming in. So we've got, we've got another sea coming in as well. All right. So I am going to move on and give you guys the answer. So the answer is c so like we said, she's on a combined oral contraceptive pill. So, um we should switch this um to the progesterone only pill and then we said to prescribe prophylaxis. So this would either be propranolol or topiramate in her case. Um because she's got that history of asthma. We we have to use um topiramate um as propranolol is contraindicated in our patients with asthma. So, despite the topiramate being teratogenic, it should be prescribed um while stressing the importance of conception. Um So, in recent guidelines, so I think from June of this year, um there's been a change which says that topiramate should only be prescribed to women of childbearing potential with a pregnancy prevention plan. So that's something else that's probably going to have to be discussed as well. Um Because of that increased risk of um um neonatal diseases and things like that that can happen with um with topiramate. OK, let's move on. So another emergency presentation or common presentation um that I've just included here um is subarachnoid hemorrhoids. So just to recap the fact that it usually presents as the worst onset type of headache. Um usually with a 10 and 10 out of 10 pain, um can be associated with nausea and vomiting and gcs. And when you look at the um when you look at a subarachnoid hemorrhage on CT scan, you get that kind of hyper density um due to the bleed into the subarachnoid spaces um that eventually leads to um reduced oxygen to the tissues and um can lead to an increase in um ICP. Um This is just treatment. Uh This is the investigation algorithm that we tend to use. So the main thing that you guys need to remember is a six hour window. So usually, so if you've got a patient that presents with a query with a headache, that's, you know, they said it's the worst onset type of headache, thunderclap type of headache or you're not quite sure what the background is for the headache. We, if you're suspecting a subarachnoid hemorrhage, um usually you have to do a CT scan within six hours and it shows that hyper density. Um So, um if the CT scan is done within six hours and is positive subarachnoid hemorrhage, um then usually move on to do a CT angiogram to further assess what vessel is affected. Um If the CT scan um is uh done um within like you said six hours and is negative for a subarachnoid hemorrhage, then usually, then you rule out um you've ruled out subarachnoid hemorrhage if you're doing a CT scan and it's greater than six hours. Um then usually we have to consider doing a lumbar puncture. So the difference in the guideline is um that now you don't have to both do both a CT and a lumbar puncture to confirm having a subarachnoid hemorrhage if you've done a CT within the six hour window, um and that's confirmed subarachnoid, that's fine. Um If you've done a CT greater than six hours and you still think it's a subarachnoid, you then are you then should do a lumbar puncture um to confirm, um you know, confirm this. Um So that's, that's just the window that's there. And then if you do a lumbar puncture, it's just listed below that. The sign that you lose looking for is that acanthoma. Um So, uh that's why when you take the, it's important that you hide it from the sunlight. Um So, um you will have your sample bag, usually it's like a black bag and then you have four sample bottles. So you have to just be quite careful that you don't expose it to too much sunlight. You try to shut the bottle quite quickly and put it back in the bag. Um OK, moving on from that. So we're on, we're kind of in going into bleeds a little bit now. Um So we've got another question. So we've got a 59 year old male who's present who attends his GP he's got increased, increasing mild um confusion and this came on about two weeks ago and it has been progressively getting worse. Um His past medical history is significant for being in a road traffic condition about six weeks prior and he was discharged from the ed with no injuries but did suffer a head injury. And since then, he reports no headache, nausea, um, or changes in the vision on examination. There's no focal neurological deficit. Um, there's an ocular examination that's normal and a mental state exam which is unremarkable. Um I have included a CT scan, um, but I think I wanted to include a different one, but it's fine. We'll go through it in a minute. Um But which of these options is, um, the most likely cause for the man's presentation. Um Can you put what you think? Which one do you think in, in the chat, please? Yep. So we're starting to get some responses through. I'm gonna give you guys about another minute if anyone else wants to have a go. Um Let me know what they think the answer might be and then we'll go through it together. OK? All right. I feel like, OK, that's fine. So we'll go through it. Um So, um someone's asked, is it not a subdural hemorrhage rather than a hematoma? So I'm gonna throw that back to you and I'm gonna ask, um, you guys, anyone can put it in the chat. What do you guys understand? What's the difference between a hemorrhage and a hematoma? Yeah. So, so technically, um, so when you, so when you've got hemorrhage, that's technically where you've got where you've got active bleeding, but when we talk about brain bleeds um strictly. So, so like you said, it's more like a collection of blood. Um we can talk about it in sense of it being an old collection of blood and that's why it's important in this case. So that's why I said the CT scan might be a bit confusing and that's why I wanted to take it a whole, I thought I put different in. So when you, so what we're going to do is I'm going to move on to the next slide. So it's going to tell you that it's a subdural hematoma which is E and then I'm going to go through why I'm so sorry about that. I did tell him that I am in a lecture currently, apologies one second and get back on to, sorry, sorry about that. So, um why is it a subdural hematoma rather than um why we've written a sub subdural hemorrhage? So um let me move on to the next slide and then we'll try and make it a bit more clearer. So when we talk about su subdural bleeding, so subdural hemorrhage, so that's where we have bleeding or subdural hematoma. We've got where we've got a collection of blood. It's to do with the different times the time stamps. So if you talk about a subdural, um a subdural bleed, it tends to present so acutely um is can present within the 1st 48 hours, subacute can be days to weeks and then chronic bleeds can be to do with um weeks to months. So, in this case, that CT scan that was there that should have removed um is a presentation of an acute subdural um he hemorrhage. Um So, um in this case, that's why we've got the hyper density of blood. But because this gentleman is presenting two weeks later with these symptoms that are progressively getting worse. Strictly speaking, we should say this is a subdural hematoma because it's a collection, it's where the blood has been collecting and it's more of a chronic subdural um bleed that's going on. So in this case, that hyperdense area that we see um should be presenting as more of like a dark cresentic. So that's my error in terms of the image that's been presented on that. But that's why um the correct answer is saying a subdural hematoma. Um sometimes in some of the questions when you come across it, they will um like we said, strictly speaking, a hematoma should be an old collection of blood, but they, they sometimes um some physicians you'll come across won't have that differentiation. So they will say hemorrhages where you've got active bleeding hematoma is where you've got a collection of blood. And it doesn't necessarily um matter in terms of the time period. So that's the only differentiation there might be. Um But in this case, yeah, because it's a chronic presentation you can say the blood has been collecting. So that's why we say it's a hematoma. Um Right. So moving on from that, um when we talk about dural bleeds, we have subdural and extradural bleeds. So subdural bleeds um tend to be where we've got bleeding between the um dura and the arachnoid matter. And so that presents more like that cresentic um lemon type of shape that we get, that doesn't, that can cross um over the um suture lines. Um Then um I said it wrong, I apologize, the banana type of shape. So the cresentic type of shape that does um cross over suture lines. And then, like we said, it can be divided into acute subacute and chronic. Um They tend to have some sort of, it tends to be like an older patient that has some sort of traumatic um event and then they are lucid and then over time, they gradually um become more confused or gradually have a reduce in their GC S um management. If we're thinking it's a subdural bleed tends to be conservative if it's a small bleed. Um But if it's more of a large type of bleed, they might consider neurosurgery. So bare holes or craniotomy to reduce the pressure and then obviously trying to stop the anticoagulation to reduce the bleed. Um And then the extradural type of bleeds, this tends to be um where we've got bleeding between the dura mater. Um and this is usually due to um if there's some fracture of the bone that's um kind of caused a cut in the middle meningeal um artery. And this tends to be more with the, with our younger patients. So things like rugby players or um those that have trauma during sports, um they tend to feel ok, initially, um or they might have like a mild headache and then um they have a rapid deterioration in their GC S and a rapid worsening in their headache. In this case, like we said, this one, I apologize is the that lemon type of shape that we tend to get. So um this tends to be bound by suture lines. Uh and then we sometimes get a fracture line that's present in these cases. Um They usually require um urgent surgery to try to reduce the pressure. So, uh craniectomy to evacuate the um clot, they usually then also require mandator to try to reduce the edema and then um neuroprotective ventilation as well. So, subdural tends to be in our older patients that have a four that they might not really remember more of a progressive onset of the symptoms. And then um it's that banana shape that crosses suture lines. Whereas extradural tends to be our younger patients um that have a history of trauma and they tend to um have a reduction in their um neurological stability quite rapidly. And it's that lemon type of shape that's bound by suture lines So on this side, I've got a couple of different CT scans. So, um we're gonna work from the left hand side to the right hand side. Um And I'm gonna ask you what you think each one is. Um, if you guys don't know, it's fine, um, we can go through it. So looking at the first, the first one that's on the um, top left hand corner. Um What do you think this is present? This presentation is. So when we're looking at CT scans, um first of all to help you out, um if anyone wants to put it in the chart, so what appears hyperdense and what appears hypodense on a CT scan or? Yeah, CT head, noncontrast CT head. So when we say so hyperdense, so hyperdense is anything that's white. So these, so um some of the, so the first image um is, is what we say is hypodense. So that's where we have the darker areas. So hypodensities are darker, hyperdensities are um are lighter. So the white and that light white kind of color that tends to be like. Um Usually if you've got contrast material, if you've done a contrast scan, if it's a bleed. Um And also um if you've got like calcifications, these tend to show up as white matter. Um then the darker ones, these tend to be areas of ischemia, air and fat. If you've got an acute bleed, then this shows up white. So hyperdense and then if you've got an older, more chronic bleed, then this shows up older, this shows up not older, this shows up darker so hypodense areas. Um And this usually, I think after 24 to 48 hours after the bleed presents. So with that knowledge, on the first, on the first image that we can see on the top left hand side, um what do you think? So, he, he's, this one has a large area of hypodensity. Um What do you think this, this might represent? Yeah, exactly. Yeah. So he's, he's got a massive um ischemic stroke and we try to go over the um territories on the next one. Um or in the next coming slides then um looking at the second image that we've got. So from the left inside the second image um what's going on here? So she's, she's kind of got a collection of this hyperdense focus. Um Look at the, so first of all, what do you think it is? And then looking at the pattern of it, what do you think the pathology is that we're looking at? Mhm So it's a type of hemorrhagic stroke. What type of hemorrhagic stroke is? It keeps, yeah, sorry about that. That mean just et cetera. Um OK. So we've got, so yeah, got a couple of ones. So, yeah, so it's more of a intracerebral bleed, right? So if you look at the, so we've got this hyperdense focus, it's within it's more within the brain matter. Um on the, on the left hand side. So it's within the, it's within the cerebrum. Um rather than it being. Uh so if this one is intracerebral or, or, um and so that's why it's more like an intracerebral type of bleed if it was interventricular. Um it would, well in the middle, there's a, there's an area of intraventricular as well, um going on. So it, it's a bit of both really. Um So if that one is an intracerebral bleed, the next one along. So the third image along, what do you think this one is? Yeah. So starting at some months through. So that one is a subarachnoid bleed. So it's within the arachnoid matter and you get this kind of like five point type of um pattern that happens. Um And that's quite characteristic of a subarachnoid type of bleed, right? So we've got 22 more left. So moving on to the fourth picture um knowing what we know from the previous size. What do you think this one is? It's maybe not the clearest one of this, but I think it shows the features so it should be fine. So, well, if you guys fit in the chat, what do you think the fourth picture is? OK, I'll give you guys another minute if anyone else wants to answer as well. OK. So this one, yeah. So this one is actually an extradural um hemorrhage. So that's because if you look at it, um if you look at the inner margin, it's bound by the suture line. So it's causing a mass effect on the, on the brain. But it's the actual bleed itself is not crossing the suture line into the brain itself. It's not affect, affecting the rest of the um the matter basically of, of the brain, it's kind of bound and it's not the most clear like um lemon lentiform type of shape, but you get a bit of that round type of shape that's, that's present there. Um So if this one is, well, I mean, I shouldn't really say that but if this one is a, is an extra D or hemr, then um what do you think the last one is? And you're gonna tell me why, what, what you think the last one is so out put what you think it is and maybe say why, why you think it's that? Yeah. Yeah. So as some of you said, so um it's, it's a crescent shape and also it, it's go, it's kind of, it crosses over that suture line, right? You can see that it's involving the rest of the um brain mater. There's not that nice um kind of mass effect that you're seeing here where it's pressing on the brain matter. Instead it's more being incorporated within the brain matter. So this is why this one is the er, is a subdural um um hemorrhage or hematoma that we're seeing. Ok, cool. So what we're going to move into now? So we've spoken a bit about the hemorrhagic type of strokes that we see. So that usually tends to be subarachnoid hemorrhages or intracerebral hemorrhages. We are now going to move on. Yeah. So we're now going to move on to talk a bit more about strokes. Um, so generally speaking, when we speak about strokes, strokes can be divided into, um ischemic and hemorrhagic strokes. Um ischemic strokes tend to be more common than tragic ones. And then um usually presents with some sort of rapid onset of um of a focal neurological deficit depending on um where the vascular lesion lies. Um and usually lasts more than 24 hours if it lasts less than 24 hours. Um Then this is usually um due to a tia. Um and we'll talk about a bit about the ABCD um um two score as well. Um Then um uh usually because of the rapid onset, the most of the protocol talks about doing an urgent CT head and um considering doing um ivory thrombolysis, but I have a bit more, I have another side a bit more later that goes into this. So, on this next slide, what I wanted um you guys to understand is you when we talk about strokes, um when we try to group the symptoms, we tend to try to group the symptoms based on the Bamford classification, which I'll go on to on to the next slide. Um But the um the the important part of this side is to understand that there's usually three different types of um arteries, major arteries that are then divided into sub you know, arterial as well. But the major groups of the arteries supplies um that we have is going to be the anterior circulation, the middle circulation and then the the um posterior um cerebral arteries. So, with the anterior cerebral arteries, these tend to um the these sent to the anterior circulation along with the middle cerebral arteries. But particularly if the anterior cerebral arteries are are um affected, it usually causes um isolated lower limb deficits and um it often facial sparing if the middle cerebral artery is involved. Um then this is what causes that um hom hemianopia. So um that the visual defect that we have where you lose the um opposite side of the half of the visual field and it tends to be macular sparing if the the post Seror circulation tends to only be supplied by the postero cerebral arteries. Um Generally speaking, and this usually causes that homonymous hemianopia. But then also the macular region of the eye tends to be affected as well. So that's in terms of basic localization. On the next side, I've got the Bamford classification. So I'm gonna let you guys have a look at that, but at the same time, I'm going to explain it in a bit of a simpler way. Um So, like we said, when we talk about strokes there, if the, you can um generally speaking, um the anterior circulation, this involves the anterior cerebral arteries and the middle cerebral arteries. From these. Um you can have total arterial circulation, strokes, attacks, or you can have partial anterior circulation strokes. Um So packs um in these cases, the differentiating factor is that with tax, um you get all three of these symptoms. So you get a unilateral um hemiparesis, you get the homa hemianopia and then you get some sort of higher order dysfunction. So, dysphasia or neglect. So you're getting that unilateral hemiparesis because of the anterior um cerebral arteries being affected. You're getting that ho hemianopia because the middle cerebral artery is affected. And then um due to the dysfunction of usually of both of these, then you get end up with that high cerebral dysfunction. So, some sort of dysphasia or um neglect. And if you've got total anterior circulation um a stroke, then all three of these are present if it's a part partial anterior circulation stroke. So um a carotid artery or in the MC or AC A territories, then you tend to only end up with two of these deficits then um going on from this. So we've also got the um Lamina syndrome um syndromes. So usually these tend to involve it areas like the basal ganglia, internal capsule thalamus or the pons. And if you've got a lacuna type of stroke. Um This usually tends to present with 11 type one of these symptoms. So usually you get like a pure um sensory stroke or a poor pure motor stroke, or you get a sensorial motor stroke or you can get this ataxic hemiparesis as well. And then in terms of the posterior circulation being affected. Um so usually this is a vertebral, this is in the vertebral basilar territory um and it usually presents with one of the following symptoms. So, um like I said, if you've got um a posterior, if the postero cerebral artery is affected, then this usually causes that homonomous hemianopia, other reasons that can also be affected. So, for example, if you've got the basilar artery um being affected, then this can lead to like locked in syndrome and other things can be certain cranial um cranial nerve palsies that can be present. Um They can have um cerebellar dysfunctions as well um that tend to happen. Um And they need to basically have one of these types of symptoms for it to be a posterior circulation syndrome. I think in terms of remembering um what region is affected and what symptoms present. It can be quite difficult. I think with strokes, I think this is the Bamford classification is probably something that you're gonna have to refer to. Um you know, over a, over a time period and get used to it. But I think the remembering what um areas supply. Like we said, the anterior circulation, posterior circulation can kind of help to differentiate um what stroke you're presenting with depending on the symptoms. So, like you said, if you've got more lower limb symptoms, that's probably anterior circulation. If they've got that homonymous hemianopia with macular sparing, it's very middle cerebral artery. If they've got a pure motor or pure sensory type of symptom, it's usually lacunar syndromes or if they're presenting, like we said with the hos hemianopia, with macular sparing, um this might be a posterior circulation type of syndrome going on. Um or they might have things like cerebellar type of symptoms. If the posterior circulation is affected or if they've got locked in syndrome, then um this will be with the basilar artery um moving on from this side. I've just got a quick summary side about stroke management. So usually we try to do an urgent ct head. Um And then based on this, we'll get an idea of whether it's an ischemic or hemorrhagic stroke. If it's a hemorrhagic stroke, then usually we have to um have an urgent neurosurgical review. Um And I, and um it kind of review, if it's an ischemic type of stroke, then we usually tend to do um an urgency he gram. Um And then based on this, um we can consider um whether or not to do um a thrombolysis. So usually the guideline says that if it's with the um if it's a, um, if there's no large artery um occlusion, we do a IV hemolysis within 4.5 hours and then we uh 4.5 hours and then we ct at 24 hours. If there's a large artery occlusion, then the, we should ideally do the IV thrombolysis thrombolysis within 4.5 hours. But there's also ability to do a thrombectomy and this, this has to be done within six hours um with, um and usually has to be done in a, in a specialist center. Um Overall, I think the most important things is it before doing any of these things, if you're suspecting do a stroke being present, make sure that you've done your A two E assessment and then um spoken to a senior and then got your CT head. Um and then further down from this. So deciding on management in terms of doing a CT Angio or, you know, deciding on doing thrombolysis, this needs to be done um by your med. So by a senior that's um that's present. Um Right. So moving on from that one, I've got another question for you. So we've got a 72 year old woman that's presented with a past medical history of treated hypertension and she presents for review. She's had a two hour episode um where she couldn't find the right words when speaking yesterday. And now these symptoms are fully resolved. This has never happened before and there's no associated, um, features, neurological exam is unremarkable and her BP is about 100 and 50 systolic. Um, and her, and, um, her only, um, current medication is amLODIPine. What, what do you think, um, is the appropriate management? What do you guys think is going on? Um, if you guys can put in the chat, what do you think the appropriate management is? Or if you don't know what the appropriate management is? If you guys just put in the chart, what you think is going on? Mhm Yeah. All right. So I can see some of you guys have put some responses in the chat. Um So it looks like there's a bit of variation going on. So for this lady, um I think the most important parts of the history to keep an eye uh keep a note of is like we said, she's got, she's had this two hour episode. Um It's happened, um and the symptoms have, have completely resolved in less than 24 hours. Um This um happened like we said yesterday in this case, but like we said, she's had the symp they resolved in um less than 24 hours. Um She said that it's never happened before. The only thing she's got is high BP. So, um for this lady, she's actually had a tia and so we'll move on to the next one. So the appropriate management, usually if you've got a patient presenting with a tia type of symptom will be having um aspirin stat and then a specialist review within 24 hours and that's to do with her risk score. So, on this slide, um we've kind of got a bit of a summary about tias. So we said tias when you've got a neurological deficit that's lasting less than 24 hours, but most resolve within within an hour. Um So usually we, like we said, we treat with aspirin and then the, the actual review, um the timing of the review is to do with their risk score. So um we have to usually calculate this um ABCD. Um So DD score um for our lady, she's had um she had an age um greater than 60. Um her BP um was greater than 140. And then in her case, the duration was more than two, more than an hour, it was present for two hours. So in that case, she added up to more than four points and then that's why um she warranted having a 24 hour review um in addition to the aspirin. Um and then on the other case, if they, if, if the score is less than four, then usually we give them the 300 mgs of aspirin and then um we give them a one week review. Um other managements um would be um try would be to consider um urgently admitting if they've had multiple episodes of TIA um or if there's a query about it being embolic. Um then um usually we try to start them, we should give them um 300 mgs of aspirin acutely and then we start them on um clopidogrel 75 mgs um after two weeks uh long term. Um and then um um consider using uh and then also consider using Warfarin. If they, if they've got a history of a fibrillation, the general guidance is um to avoid driving um for about one for one month. And then, like we said, risk factor control. So statins, BP, diet and exercise. But I think for you guys, like you said, the important parts will be recognizing that it's a new liquid deficit lasts less than for 24 hours. Um reviewing in the history. Is this their first presentation or if they've had more than one presentation and then calculating their ABCD D score? Um And then, um I would say if you're seeing them on the acute tape, then um then getting a senior opinion or um getting just speaking to the stroke nurse, they're usually on call and then they can probably guide you as to whether or not the patient needs to be admitted in and what the long term management for the should be for your patient. Um But like we said, um make sure that they avoid driving until they've had that specialist review done. Ok. Um So moving on from this one, so like we said, we've, we've got a six, we've now got a six year old lady. She's had three episodes of transient, right? Monuc monocular blindness. So, um three episodes of um neurological deficit type of symptoms lasting less than 24 hours. Um, her rate is 88 BPM and she's in sinus rhythm. Um What is the single most um, appropriate investigation that we need to do um, to diagnose this condition. Um If you guys can put in the chat, what you think needs to be done. This one is a little, I think a little bit of a difficult question, but we'll go through why the why the option is in, in a minute. I'll give you guys about another minute. If anyone else wants to put in the chart, what they think, what the answer is. OK? All right. I am gonna give you guys the answer. So the actual answer is doing a carotid duplex. Um So doing, doing a carotid Doppler. So, yeah, so someone got it. So it's c so you're gonna do a, you're gonna do a carotid Doppler. Um The reason why you're gonna do a carotid Doppler is if you guys have ever gone to like neurology clinic or stroke clinic, they're always doing, um they're always quite well versed with doing um carotid ultrasounds and the key factor in this one is the fact that she's got that feature. So that risk that's there. Um And also, she's got transient, right monocular blindness. So, um what happens is if you've got um carotid stenosis or plaque build up within the carotid artery, this can um this can then lead to reduced blood flow to the eyes. And um this is one of the um single most common um complications of like carotid stenosis that can happen. And there's like I said, a quite a significant link between the risk of carotid artery stenosis and also stroke as well. So that's why in this case, we needed to do a carotid artery um ultrasound. So, um in terms of stroke, outpatient management, like we said, if you've got a patient that presents with a stroke or a, the important scan that you need to order is doing a carotid ultrasound. And this is to check if there's any stenosis of the carotid of the carotid arteries. And then for consideration of doing a prophylactic carotid end arterectomy, if there's ipsilateral stenosis of greater than 70% um also doing risk factor control. So, smoking diabetes, BP control. Um and then um we will talk about the chad vs in a minute, but then we also need to, so that's all involved in primary prevention. Um You need to also consider doing a chad vas score to um consider whether they need to be anticoagulated as well. Um Then secondary prevention usually involves some sort of antiplatelet therapy. Um usually involves statin as well and also long term clopidogrel and then rehabilitation, so involving other teams. So things like um salt reviews, physiotherapy ot um as well. Um I think the difficulty comes in is um you need to basically ensure that whatever patients you're starting on these primary secondary prevention, obviously with um guidance from the stroke team um that they have appropriate follow up um listed and that they're not just lost in the system. Um because a lot of, for a lot of our older patients, um, they have some episode of, um, stroke or stroke, like type of symptoms, they'll get started on all these types of medications, but then it increases the risks of other things like falls and brain bleeds, um, and, um, post jaw drops and things like this. Um, and so they require regular medication reviews, um, to ensure that, you know, what they're being given is actually helpful for them at that stage of life. So I think it's more in a geriatric type of review. So the main measures is just make sure that you're, that if you're in a stroke clinic and you're starting these things, um, that the patient that you're starting them for has an appropriate, um, follow up, um, listed and they're not, well, it's difficult but try to make sure that they're not too lost in the system. Um. Right. So we're moving on to the last part of this lecture. So I'm gonna try and summarize a little bit to do um with seizures, which is also probably quite a common presentation that you guys will come across. Um So, usually, um so when we say what we have epilepsy like, yes, no, this is a tendency to have seizures through episodes of um sudden abnormal um electric uh discharges. Um And then um this um and this usually then presents with um convulsion. So um where we've got that electric discharge and can present with um a proderm type of symptom. So, like mood or behavioral changes um and with or without an aura. So a feeling of um sensation, hallucination, limbs, changes in limb sensation, um emotional feelings um as well. And then they tend to have a post phase, which can happen from 15 minutes to hours after the episode, which usually involves like headaches, fatigue, myalgia, and weakness. Um When talking about um epilepsy generally, um we can group it into focal and generalized. So focal where they're localized to one lobe um uh with or without a usual aura. Um And generalize that usually involves both of the hemispheres um and simple. So they've maintained their conscious consciousness or complex without uh with um with loss of their consciousness. Um The commonest type of like generalized seizures that we usually tend to see will be tonic chronic seizures or absent seizures. Um And other ones could be like febrile seizures. We commonly see alcohol withdrawal seizures. And actually, I see I've seen a lot of pseudo seizures. Um It's usually obviously with our psychiatric patients in terms of localizing the um focal seizures. Um This is just a table that kind of tries to summarize um the symptoms that you might uh that you might see. Um I think um it's us, it's listed out quite nicely in the um clinical in the Oxford Clinical handbook, the Green, the Green book. Um So someone's asked how do you know if it's a pseudo seizure? Uh To be honest, it's quite difficult to differentiate whether it's a pseudo seizure or whether um whether it's a, a general type of seizure. Um I think it usually comes in in the observation of the, of the event. So um usually when you, when you get seizure seizures, um they tend to have, they sometimes tend to have a more of a gradual launch there and the consciousness tends to be um present. Um They, they still have like some response to pain. Whereas in it, an epileptic seizure, they have no response to pain and other movements um can also be present. So they tend to be, they tend to control their um like uh they tend to have like closed eyes. Um they tend to have um asynchronous movements and a it tends to be like quite a fluctuating type. Of course, they tend to, it's, it's not really very um very clear cut, but i it's usually when you observe the, the event and the frequency of the event. Um when you see a patient with pseudo seizures, they tend to um they uh they tend to be aware that the event has happened. Whereas if a patient is presenting with a seizure with a, with a more organic, you know, type of seizure, they tend to lose complete awareness of the event as well. Um Yeah, exactly. Yeah. So as Hannah said, you see it, you tend to see it with um patients with mental health issues, they tend to be really quite aware of the of the event and they tend to lower themselves to the like you said to the floor. Um It, you can kind of just, I don't know how to say it, but you kind of can just tell through observing them. So it's important that these events are observed by another healthcare professional or by one of the nurses. Um But the main thing is like we said, they've got that greater conscious awareness of the event. Um I hope that kind of helps it. It's I think it's through practice when you see a pseudo seizure. Um you'll know basically that it is a pseudo seizure and it usually comes with it with experience differentiating pseudo and um and um no, and, and you know, like a normal seizure, but if you're unsure, obviously treat like a seizure and then get a senior opinion as to whether or not it's a seo or a more organic type of seizure. Um So I'm just gonna go back to focal seizures. So what I was gonna say is um usually based on the, this is quite a nice summary table. Yeah, so we can say it's fabricated basically. So it is it it, so there are other factors that kind of play into the reason why our patients have um have pseudo seizures. But overall, yeah, it is, it is to do with, it's usually to do with other psychiatric conditions. And there's a lot more kind of other components that cause the patient to participate in, in, in and take in having a pseudo seizure. But it's kind of like that awareness of what they do of of the event is the main thing. Um So, um and like I said, they, they respond to pain and things like this as well. Um OK, so for focal seizures, in terms of I understanding the symptomology that we have, you can usually group it by which lobe um is present. So this table is quite nice with summarizing this. Um in terms of understanding the reason why you get certain symptoms coming from the different lobes. Um It's probably out of the scope of this lecture, it takes a bit more going back and going through um good Neurology and Neuroanatomy a bit more deeper. Um I think the Oxford Clinical Book Clinical handbook has quite a nice little section um about seizures and it did explain it quite nicely as to why you get the the certain symptoms. But overall understanding that from your temporal lobe, um it tends to present with autism, hallucinations, especially auditory hallucinations and emotional symptoms from your frontal lobe. Um you tend to get more of those motor type of symptoms. Um from the parietal lobe, it tends to present the sensory of motor symptoms and then occipital lobe um due to the supply to the eyes, we tend to get more of a visual type of symptoms or temporary visual field deficits. Um going into a bit more about generalized type of seizures. Um Like we said, these are widespread and these can be divided into tonic chronic myoclonic, a tonic and absent seizures. Um When we talk about tonic clonic, this is where you get that stiffness and then um and then twitching between my tonic is where we get those muscle jerks. A tonic is where they get a sudden loss of um muscle tone and then absent seizures usually seen in kids and usually last less than 10 seconds and they have multiple episodes a day or during the day where they're unable to concentrate on the task at hand. Um This um little uh kind of uh box that we've got here, the hips c um that's important. So you need to consider what the cause is of your seizure. So many times the seizures tend to be idiopathic. Um but there are some causes that we that present quite commonly, which is, which is in the pneumonic of the hips overall. Um if they're not idiopathic, other things can be like genetic factors, trauma, um metabolic. So, hypoglycemia commonly um electrolyte um abnormalities and um alcohol, especially with withdrawal, um other things in the hips. So we've got hyperglycemia, we've got infections. So, HSV encephalitis psychogenic um so space occupying lesions. So, cns tumors or abscesses, mets, um epileptic epileptiform disorder and then alcohol. So with withdrawal, um this table kind of summarizes the seizure type and first line management, but it's not always so clear cut. Um Overall, um if you're starting an antiepileptic, um we usually start the patients on monotherapy and then titrate that up until the maximum level before then switching to a different um type of monotherapy. But it's, I think it involves a close discussion with neurology. Um because for some patients, when you up titrate 11 kind of um anti epileptic, it can increase the frequency of their seizures. Um So it can take a lot or a couple of months of um or so of um careful kind of uh managing and um trying to up titrate down, titrate certain um whatever medication they're on. But usually, like we said monotherapy up titrate that to maximum and then try a different monotherapy. Um like it says for folk pro seizures, we tend, we tend to use carBAMazepine or lamoTRIgine for generalized seizures, we tend to use um the lamoTRIgine or levoris tmso Capra um or valproate, which is um contraindicated in childbearing age. Um and an absence seizure tend to tends to be sodium valproate or um eoux suximal. Um So, moving on from that one. we have the last case I think. Um So we have a 36 year old male who's brought into A&E after being found in the street, smells of alcohol appears disheveled and you are urgently. Um You are called urgently to his bedside by the charge nurse as he's become, as he's begun seizing. Um What do you guys think is the appropriate initial management take? Um If you guys can put it in the chart, it does require knowledge of the seizure management kind of pathway but have a go anyway and let me know what you think it is. Mhm Yeah. Yeah. Yeah. So sorry. It's kind of switched from ABC to 123. I'm not quite sure why, but the the he has just begun seizing. So the most important thing is to start the clock. So um we have to start the clock because Benzodiazepines will be started after five minutes of sei seizing. Um though, like I says, in reality, we ask our nurses to prepare it to be ready. So this slide just kind of summarizes status epilepticus. So um usually what will happen is you've got a patient that's seizing um And in the 0 to 5 minutes um that's not on here. You will start you with your A two B assessment and get your first dose of LORazepam ready then after the five minutes, um you can then, so uh so you wait another five minutes. So you're gonna be at 10 minutes now, you can give a second dose of LORazepam. Um Wait a further five minutes. So you're gonna be about 15 to 15 to 20 minutes at this time. Um If the patient is still seizing, then you consider giving like IV Phenytoin. And then if you reach the 30 minute mark and they're still seizing, then at this point, then, and they've not regained consciousness between, between seizures, basically. Um We then say that they're in a state of um status epilepticus and they require general anesthesia. The differentiating point is the se it can either be that one seizure that's lasting more than 30 minutes or they're having current seizures without retaining consciousness over that 30 minute period. So you might notice some, notice some seizing, stop seizing and there. So that tonic clonic jerking, it might stop and then continue. But the main thing is have they regained consciousness or not between the episodes? If they, if they regain consciousness between the episodes, usually we have to rear the clock again. Um But if they've not regained consciousness, then continue along the algorithm and treat like um ss epilepticus. The other thing to be to have to keep a note of is usually we give them IV, LORazepam. But if the IV route is unable to be, is unavailable, um which is, which it commonly is because if you imagine if they're having tonic jerking of their arms, it's probably not safe to get a cannula in. Um We usually more commonly tend to use Bal Midazolam or Rectal diazePAM um in practice. So that is basically the end of my presentation. I have kind of got this summary that I'm gonna go through, try and go through really quickly about um a five minute neurological examination. Um So generally speaking, like we said, the neurological examination is really quite um quite long. Um And uh but uh depending on what part of the um of the neurology you are examining basically, but for most patients that you see on the acute take, um you need to do a focus, a kind of general neurological exam so that we said a five minute neuro exam. And then based on this, if any, if there's anything from the history or any features that you're concerned about, then you might and rather do a more focused and more thorough examination. But overall the main factors or the main components of a five minute neurological exam that you need to assess will be mental status, um cranial nerves, which I'll go through how you can do it overall um motor um reflexes and sensory. So there's five components. So the mental status, you can usually just um examine this um through attention or orientation. And it usually is assessed through the history taking. So how much they're remembering of what you've told them, how much they're paying attention and then also their orientation to time um place and person. So I tend to assess mental status, like I said, through my history taking. And then I also just tend to ask them, um are you oriented to time place or person? Um If you entered my previous section?