A 10 - Emergency in Neurology Flashcards

1
Q

what does neurological emergency associated with?

A

disorders of consciousness:
- respiratory
- circulatory failure
- epileptic activity

These three groups of symps interact with each other, i.e. any of them may lead to the other two or augment their effects within a short period of time.

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2
Q

in which situations Neurological emergencies arise in?

A
  1. A nervous system lesion causes central or peripheral respiratory failure
  2. A nervous system disease leads to life threatening complications (infections, thrombotic events)
  3. Nervous system dysfunction is caused by diseases and abnormal states originating outside the nervous system (metabolic disturbances, global cerebral ischemia, hypoxia, intoxication)
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3
Q

what can cause resp. failure in neurological emergency?

A

caused by damage to:
○ The CNS → Raised ICP
○ The PNS → Myasthenia, Guillan-Barré syndrome
○ Neural structures, including the muscles

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4
Q

what can be the complications of resp. failure?

A

Respiratory failure from any cause may also lead to secondary damage of parts of the CNS, which are sensitive to hypoxia (cortex, basal ganglia)

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5
Q

examples of circulatory failure due to neuronal causes?

A
  • rare *

● Neurogenic pulmonary edema
● spinal shock

● CNS complications of circulatory failure however, are common and serious (e.g. in global cerebral
ischemia, complete destruction of the brain occurs in five minutes in normal ambient temp.)

● Global cerebral functional disturbance occurs in case of impairment of parenchymal organs (e.g.
renal or hepatic failure)

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6
Q

what are the 2 main groups of Disorders of consciousness?

A

Disorders of arousal (sleep-like state)

Disorder of awareness (inadequate thinking and behaviour)

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7
Q

what is arousal?

A

the ability to wake up from sleep when stimuli are applied

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8
Q

what is the Anatomical basis of arousal

A

intact functioning of the ascending reticular activating system (ARAS)

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9
Q

what is reduced arousla?

A
  • mildest to severe forms *

○ Somnolence
○ Stupor
○ Coma

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10
Q

what is somnolence?

A

verbal stimuli enough to generate awakening reaction

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11
Q

what is stupor?

A

verbal stimuli hardly effective, may open eyes to painful stimuli

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12
Q

what is coma?

A

cannot be awakened and posture is usually abnormal (decorticate/decerebrate)
■ Coma I: Brainstem reflexes are preserved
■ Coma II: Brainstem reflex

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13
Q

Disorder of awareness?

A

inadequate thinking and behaviour

● The CNSs global function is impaired
● Signs of focal cognitive deficit (e.g. alexia, acalculia) are not part of this condition
● Arousal is normal, but the content of memory is disturbed, inaccessible or their use is
inappropriate

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14
Q

Clinical form in awareness disorder?

A

○ Persistent vegetative state (decorticate state/apallic syndrome)

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15
Q

what could be the causes of disorders of awareness?

A

Damage to the cerebral cortex:

○ Global cerebral ischemia caused by circulatory arrest, severe metabolic conditions like hypoglycemia, renal- and hepatic failure, postconvulsive state, Wernicke’s encephalopathy, final stages of cortical dementias

○ Extensive white matter damage (diffuse axonal injury after head trauma)

○ Bilateral damage to the thalamus

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16
Q

what is considered as permanent disorder of awareness?

A

when lasting longer than 30 days

17
Q

what remains intact in disorder of awareness?

A

Rostral brainstem remains intact:
- thermoreg.
- sleep-wake cycle
- cardiorespiratory
- other visceral functions + endocrine syst. is working

18
Q

how does the patient with disorder of awareness seems to be?

A

awake → eyes open and vestibuloocular reflex can be elicited, but attention cannot be aroused

19
Q

what are the characteristics of disorder of awareness if it lasts days - week but not more than 30 days?

A
  • characteristic decorticate posture
  • signs of corticospinal tract lesion (Babinski, suction reflex, Bulldog reflex) can be elicited
20
Q

what can Painful stimulus cause in disorders of awareness?

A

excessive sweating
tachycardia
hyperventilation

21
Q

what is Akinetic mutism?

A
  • Patient is awake, but mute and lies without moving
  • Mutism is not caused by aphasia (comprehension usually preserved)
  • Paralysis excluded by normal withdrawal reaction to painful stimuli
22
Q

what could be the causes of Akinetic mutism?

A

● Jet bleeding (rupture of an ant. comm. artery aneurysm)
● Frontobasal contusion
● Bilateral ischemia in the territory of the ant. cerebral a.
● Subfalcial herniation
● Occlusive hydrocephalus
● Butterfly tumors growing across the corpus callosum into the prefrontal lobes
● Tumors of 3rd ventricle

23
Q

what can you say about Confusion?

A

■ Attention and thinking is impaired
■ Typical example is seen after an epileptic seizure

24
Q

what can you say about Delirium?

A

The disorder of attention and awareness is the core symptom (also abnormal preception - illusions and hallucinations)

25
Q

How quickly delirium evolves?

A

Usually evolves quickly (few hours - 24h)

26
Q

main causes of delirium?

A
  • metabolic disorders
  • drug
  • alcohol
  • may be a complication of right hemispheric lesions (at the parieto-occipito-temporal junction)
27
Q

Management of patients with disorders of consciousness
(see E-learning III/12.3)

A

(see E-learning III/12.3)

● history

● ABC, GCS

● Define the type and severity of the disorder of consciousness

● Signs of recent injuries? Immediate neuroimaging

● Neck stiffness/positive meningeal signs (meningitis, subarachnoid hemorrhage, imminent tonsillar herniation

● Brainstem reflexes and examination of the motor system

28
Q

How can you use the hostroy in Management of patients with disorders of consciousness ?

A

history is available → can point to a cause

○ Sudden onset + presence of focal signs → structural brain lesion

○ Gradual onset in pt. with known chronic renal/hepatic diseases or known psychiatric disorder → suggests other causes than structural brain lesions

29
Q

how to examine Brainstem reflexes and the motor system?

A
  • Pupillary light reflex
  • corneal reflex
  • trigemino-facial pain reaction
  • vestibuloocular reflex
  • cough reflex
  • apnoe test
30
Q

what causes Increased ICP?

A

○ Focal space occupying lesions (tumor, abscess, hemorrhage)

○ Disorders of CSF circulation (occlusive hydrocephalus)

○ Cerebral edema (vasogenic, cytotoxic, interstitial)

31
Q

what are the consiquences of Increased ICP?

A

Can cause herniations