Acute care- Neuro Flashcards
Suspected bacterial meningitis Mx
- IV access: take bloods + BCs
- LP
- Cefotaxime/ Ceftriaxone IV (+ Amoxicillin if >50y)
- Dexamethasone IV
Mx of patients with suspected bacterial meningitis + signs of raised ICP
Critical care input
Secure airway + high flow O2
IV access + Abx + Dex
Neuroimaging
Blood tests in suspected bacterial meningitis
FBC
Renal function
Glucose
Lactate
Clotting profile
CRP
CSF tests in suspected bacterial meningitis
Glucose, protein, MC+S
Lactate
Meningococcal + Pneumococcal PCR
enteroviral, herpes simplex + varicella-zoster PCR
Consider Ix for TB meningitis
PPx of bacterial meningitis in those who had contact in 7 days before onset
Ciprofloxacin PO once only
Mx of suspected bacterial meningitis in the community
Benzylpenicillin sodium IM
Mx of suspected viral meningitis
Ceftriaxone + Aciclovir IV whilst awaiting LP results (in case bacterial)
Generally self-limiting, with Sx improving over 7 - 14 days
Aciclovir if suspected secondary to HSV
Most common cause of viral meningitis
Enteroviruses e.g. Cocksackie
LP in viral meningitis
High cell count: Lymphocytes
Normal glucose
Normalish protein
Most common cause of viral encephalitis
HSV1
Lateral temporal lobe changes
Mx of encephalitis
Aciclovir IV
SAH Ix
Non contrast CT head, refer to neurosurgery
If within 6h + normal: consider ddx
If >6h + normal: LP for xanthochromia (at least 12h after)
CT intracranial angiogram: identifies vascular lesion
SAH Mx
A-E + connect to cardiac monitor
Paracetamol + Cyclizine
Neuro obs every 30 mins
NIMODIPINE: prevents vasospasm
Intervention within 24h: IR coil or craniotomy + clipping
DVT ppx: compression stockings
Stop + reverse anticoagulation
Most common cause of SAH
Head injury (traumatic SAH)
Intracranial “Berry” aneurysm (most common cause of spontaneous SAH)
List 3 conditions associated with berry aneurysms
HTN
PKD
EDS
5 complications of SAH
Rebleeding
Hydrocephalus
Vasospasm
Hyponatraemia (SIADH)
Seizures
Ix for extradural haemorrhage
Non contrast CT head: biconvex, limited by suture lines
Common site of extradural haemorrhage
Temporal region- thin skull at pterion which overlies the middle meningeal artery
Most common cause of extradural haemorrhage
Trauma, most typically ‘low-impact’ (e.g. a blow to the head or a fall)
Mx of extradural haemorrhage
No neurological deficit: cautious clinical + radiological observation
Definitive Tx: craniotomy + evacuation of haematoma.
Presentation of extradural haemorrhage
Initially loses, briefly regains + then loses consciousness again after a low-impact head injury.
Brief regain in consciousness = ‘lucid interval’ + is lost eventually due to the expanding haematoma + brain herniation.
As haematoma expands the uncus of the temporal lobe herniates around the tentorium cerebelli + patient develops a fixed + dilated pupil due to the compression of the parasympathetic fibers of CN 3
Cause of acute subdural haemorrhage
High impact trauma
Cause of chronic subdural haemorrhage
Rupture of bridging veins, slow bleed, seen in elderly + alcoholics
Ix for subdural haemorrhage
CT head
Acute: HYPERdense crescent
Chronic: HYPOdense crescent
Mx of acute subdural haemorrhage
Small/ incidental: Conservative
Monitor ICP
Definitive: Decompressive craniotomy
Mx of chronic subdural haemorrhage
Small/ incidental: conservative
Confusion/ neurological signs: BURR hole decompression
Ischaemic stroke Mx
- CT r/o haemorrhage
<4.5h from onset: Alteplase
>4.5h from onset: Aspirin - Rankin <3, NIHSS >5
Y + <6h + proximal anterior circulation: Thrombectomy
N: N/A - Aspirin 300mg 14 days
Secondary prevention after ischaemic stroke
No AF: Clopidogrel 75mg
AF: Apixaban
TIA Mx
Aspirin 300mg IMMEDIATELY unless CI
CI to Aspirin in TIA
Bleeding disorder
Already taking Aspirin
Taking an anticoagulant
Describe the time frame within which patients with TIA should be assessed
If >1 TIA/ suspected cardioembolic source/ severe carotid stenosis: discuss URGENT admission
If TIA in last 7 days: within 24h
If TIA >7 days previously: within 7 days
No driving until seen by specialist
Ix following suspected TIA
Diffusion weighted MRI: determine territory of ischaemia/ haemorrhage/ ddx
Urgent carotid doppler
Secondary prevention following TIA
Clopidogrel 75mg
Atorvastatin
Indication for carotid endarterectomy
If stroke/ TIA in carotid territory
+ NOT severely disabled
+ carotid stenosis >70%
Driving recommendations following TIA/ Stroke
Stroke/ TIA: 1 month off driving
Multiple TIAs over short period: 3 months off driving + inform DVLA
Raised ICP Mx
Head elevation to 30º
IV mannitol may be used as an osmotic diuretic
Controlled hyperventilation (to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP). Caution needed as may reduce blood flow to already ischaemic parts of the brain
Removal of CSF:
drain from intraventricular monitor
repeated LP (e.g. IIH)
ventriculoperitoneal shunt (for hydrocephalus)
Raised ICP Ix
Fundoscopy
CT/ MRI
Invasive ICP monitoring: catheter placed into lateral ventricles of brain to monitor pressure
5 Indications for CT head within 1h of head injury
GCS <13 on initial assessment or GCS <15 at 2h
Focal neurological deficit
Suspected open/ depressed skull fracture/ signs of basal skull fracture
Post-traumatic seizure
Vomiting more than one
Indications for CT head within 8h of head injury
Any loss of consciousness/ amnesia AND any of
>,65y
Coagulopathy
High impact injury e.g. fall >1m/ >5 stairs
Retrograde amnesia >30 mins
Indications for CT cervical spine within 1h
GCS <13 on initial assessment
Patient has been intubated
Definitive dx of C-spine injury is needed urgently e.g. before surgery
Patient is having other body areas scanned
Clinical suspicion of C-spine injury AND any of: >,65y, high impact injury, FND, paraesthesia in limbs
Myasthenic crisis Mx
Plasmapheresis, IVIG
GCA Mx
No visual loss: PREDNISOLONE PO 60mg
VIsual loss: METHYLPREDNISOLONE IV
GCA Ix
ESR + CRP
Temporal artery USS (if low probability)
Temporal artery biopsy
