Cerebellar stroke

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Cerebellar stroke by Mind Map: Cerebellar stroke

1. Differential diagnosis 'Audio podcast'

1.1. Peripheral vertigo

1.1.1. Most common differentials of peripheral vertigo

1.1.1.1. 1. Vestibular neuritis

1.1.1.2. 2. Menieries disease

1.1.1.3. 3. Trauma/post op

1.1.1.4. 4. Schwannoma

1.1.2. Helpful HINTS

1.1.2.1. Head impulse

1.1.2.2. Skew deviation

1.1.2.3. Nystagmus

1.2. Cerebellar syndrome

1.2.1. PASTRIES

1.2.1.1. P: Posterior fossa tumour A: Alcohol S: Multiple sclerosis T: Trauma R: Rare I: Inherited (e.g. Friedreich's ataxia) E: Epilepsy medication (carbamazepine, phenytoin toxicity) S: Stroke

2. Pathophysiology 'Pure Text'

2.1. Introduction

2.1.1. Significant morbidity and mortality

2.1.2. Overall accounts for 2%

2.2. Anatomy

2.2.1. Lobes

2.2.2. Zones

2.2.3. Functional divisions

2.3. Aetiology

2.3.1. Ischaemic

2.3.1.1. Cardiac emboli

2.3.1.1.1. Disproprionately high - post cardiac catherisation

2.3.1.2. Dissection

2.3.1.3. Atherosclerosis

2.3.1.4. Hypercoagulable states

2.3.1.5. Recreational drug use

2.3.2. Haemorrhagic

2.3.2.1. Primary

2.3.2.1.1. Blood pressure

2.3.2.2. Secondary

2.3.2.2.1. Structural cause

2.3.2.2.2. CAA

3. Management 'flowchart'

3.1. Treated as per any standard ischaemic stroke

3.1.1. RCP guidelines

3.1.1.1. Summary of cerebellar management

4. Complications 'Video'

4.1. Malignant cerebellar syndrome

4.1.1. Blowing up a ballon inside a bottle - example

4.1.1.1. Tight posterior fossa

4.1.1.2. Brainstem compression or compression of 4th ventricule

4.1.1.3. Transtentorial or transforaminal herniation

5. Investigations 'Case study'

5.1. MRI

5.1.1. Gold standard

5.1.2. Diffusion weighted imaging

5.2. CT head

5.2.1. Occipital and temporal bones reduce ability to detect infarction

5.2.1.1. Not first line

5.2.2. Useful to rule out mimics in acute phase

5.3. Posterior artery vascular imaging

5.3.1. CT angiogram

5.3.1.1. Often first line as quickly obtained

5.3.1.2. However risks involved with contrast

5.3.2. MRA

5.3.2.1. Best modality for images and non invasive

5.3.2.2. Able to obtain acutely

5.3.3. Dopplers

5.3.3.1. Not useful in assessment

5.3.3.2. Unable to visualise due to bony anatomy

5.4. Blood tests

5.4.1. Lipids

5.4.2. HbA1c

5.5. Echocardiogram

5.5.1. If structural ECG changes or abnormal rhythm

5.5.2. Look for left atrial appendage thrombus

5.5.3. Often V scan used on ward

5.6. ECG

5.6.1. Atrial fibrillation

6. Presentation 'Multimedia on iPhone'

6.1. Symptoms

6.1.1. Often presents with generalised symptoms

6.1.1.1. Nausea and vomiting

6.1.1.2. A form of generalised dizziness - not true vertigo

6.1.1.3. Unsteadiness

6.1.1.4. Double vision

6.1.2. Transcript of patients presenting complaint

6.2. Signs

6.2.1. 'DANISH'

6.2.1.1. D: Dysmetria & dysdiadochokinesis A: Ataxia N: Nystagmus I: Intention tremor S: Slurred/staccato speech H: Hypotonia

7. References

7.1. Many thanks to the patients on ward 3E RLH

7.2. Ioannides K, Tadi P, Naqvi IA. Cerebellar Infarct. [Updated 2019 Mar 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470416/

7.3. Jensen MB, St. Louis EK. Management of Acute Cerebellar Stroke. Arch Neurol. 2005;62(4):537–544. doi:10.1001/archneur.62.4.537

7.4. Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction.Lancet Neurol. 2008; 7:951–964.

7.5. Kattah, J., Talkad, A., Wang, D., Hsieh, Y. and Newman-Toker, D. (2009). HINTS to Diagnose Stroke in the Acute Vestibular Syndrome. Stroke, 40(11), pp.3504-3510.

7.6. National guidelines for stroke - Prepared by the intercollegiate stroke working party - Fifth Edition 2016