Acute neurological issues

Question 1

What are the five different acute neurological issues?

Answer 1

Infection - meningitis and encephalitis
Status epilepticus
Headaches of sudden onset such as subarachnoid haemorrhage
Gaint cell arteritis
Acute cord compression

Question 2

What antibiotics are given when menigitis is suspected? How?

Answer 2

Benzylpenicillin intravenously or intramuscularly

Question 3

When in a suspected menigitis case might a CT or head scan be ordered before a lumbar puncture?

Answer 3

When concerned there may be other things causing an increased intracranial pressure
- focal neurological signs
- Papilloedema = swelling of the optic nerve
- uncontrolled seizures
-GCS12 or less

Question 4

How does the wbc vary in the CSF based on the type of pathogen causing meningitis?

Answer 4

wbc count is elevated in both compared to normal
bacterial wbc count is higher, greater proportion of neutrophils
viral - greater proportion of lymphocytes

Question 5

What method of pathogen identification should be used if patient it treated with antibiotics before lumbar puncture?

Answer 5

Sensitivity in results decreases by 20%
PCR is more accurate and more likely to give results and be positive compared to gram stain

Question 6

What are some risk factors for acute bacterial meningitis?

Answer 6

Infants, elderly, pregnant or immunosuppressed
Smoker, alcholism, or drug use
Foreign travel
CSF shunt or other foreign object in the meningeal layers
Splenectomy
Crowding, such as student halls of residence

Question 7

How does the survival rate from meningitis vary based on the type of pathogen?

Answer 7

Meningococcal sepsis has the highest mortality rate
Pneumococcal meningitis has a greater morbidity and mortality than menigococcal menigitis
Tuberculosis has a significant risk of death even with treatment
viral menigitis has a better prognosis than bacterial

Question 8

What pathogen often causes encephalitis?

Answer 8

Herpes simplex virus
HSV1

Question 9

What are some common symptoms of encephalitis?

Answer 9

Fever and a headache
Seizures
Weakness or loss of movement in muscles
Changes in personality
Difficulty speaking
Loss of consciousness

Question 10

What are the treatments for encephalitis?

Answer 10

Commonly give aciclovir - inhibits DNA polymerases

Question 11

What are the complications and prognosis of encephalitis?

Answer 11

Complications include, permanent memory loss, personality changes, seizures, problems with planning, concentration and problem solving
Encephalitis due to HSV1 is fatal in 20% of patients and causes complication in 50%.

Question 12

What is status epilepticus?

Answer 12

A life threatening neurological condition five minutes of continued or repetitive seizure
Convulsive - with involuntary movement, stiff limbs and lack of consciousness, may have incontinence and tongue biting, often a focal onset seizure.
Non-convulsvie - mainly shows as altered mental status, loose consciousness, no involuntary movement of limbs

Question 13

What is the posictal stage in a seizure?

Answer 13

When the seizure ends and the person begins to return to normal. Often confused, nauseus, headaches and hypertension

Question 14

What are some of the causes of epilepsy?

Answer 14

Repetitive alcohol induced or alcohol withdrawl seizures.
Metabolic problems - low Na+
Infection
Recreation drugs or overdose
low blood sugar
Underlying tumour
Stroke
Trauma.

Question 15

What are the guidelines for the management of emergency convulsive status epilepticus?

Answer 15

Emergency hospital admission
Try to stop the seizure - identify cause and prevent further seizure
Benzodiazepines in hospitals and community - these are GABA agonists, that increase the inhibitory effects of GABA, reduce the likelihood of an action potential being generated.
May need ventilation and ICU care

Question 16

What does epilepsy north recommend as the pharmacological methods of treating status epilepticus?

Answer 16

Lorazepam - in first 5-10mins, can be repeated once
Levetiracetam (calcium channel blocker)- is seizure lasts more than ten minutes (may give valproate or phenytoin instead - sodium channel blockers)
Is seziure continues critical care is contacted
In ICCU anaesthesia often propofol is given once the seizure has lasted for thirty minutes or more.

Question 17

What investigations and treatment should be happening in statis epilepsis alongside trying to stop the seizure?

Answer 17

Resuscitation and support
ECG
Pregnancy test
Oxygen
ABCDE
Consider causes
Start to contact neurology.

Question 18

What is a thunderclap headache?

Answer 18

A headache with a sudden onset reaching maximum severity within 1 minute
Patients often describe it as being hit on the back of the head.

Question 19

What can cause a thunderclap headache?

Answer 19

A pituitary bleed
Subarachnoid/intracerebral haemorrhage
Infection - meningitis
Tumour
Arterial disection
CSF leak
Cerebral venous thrombosis
Phaeochromocytoma
RCVS

Question 20

What is the difference between a primary and a secondary headache?

Answer 20

Primary headache has no underlying cause
Secondary headache is a symptom of something else
18% of headaches are due to a secondary cause.

Question 21

What can indicate an emergency in a headache history?

Answer 21

Sudden onset
Severe enough to wake up at night
Associated vomiting
Worse in the morning, on coughing, when stooping (valsalva maneouvers)
Visual obscurations
Alongside an abnormal neurological exam.

Question 22

What is giant cell arteritis?

Answer 22

Systemic inflammatory granulomatous large vessels
Inflammation of the inner lining of the large vessels, commonly in the head, neck and arms, this narrows the vessels and can restrict blood flow.
Granulmas are clumps of immune cells that block blood vessels.
Most common in the elderly and women, has no known cause.

Question 23

What is the clinical presentation of giant cell arteritis?

Answer 23

Headache in temporal area
Proximal pain
Jaw claudication (ache)
Blurred vision then sudden visual loss
Swelling of the artery often visible
co-existent polymayalgia rheumatica
NON specific : aching, malaise, weight loss, fever, loss of apetite.

Question 24

What physical exam might the doctor do for giant cell arteritis?

Answer 24

Check all the pulses, occlusion in one of the large vessels might mean the pulse is different.
Check optic nerve and vision for retinal vessel occlusion, look for a pale or section of paleness on the retinal disk - can indicate chane of permanent vision loss

Question 25

What investigations are done in a giant cell arteritis diagnosis?

Answer 25

ESR - over 500mm/h
CRP test
Temporal artery biospy
Colour duplex ultrasonography.

Question 26

What are the risks of untreated giant cell arteritis if not treated correctly?

Answer 26

Irreversible blindness
Stroke if large vessels are involved
multi infarct dementia

Question 27

What do you treat giant cell arteritis?

Answer 27

High dose steroids
Monitor ESR
Adjust dose as appropriate
Watch for relapses
AIms to prevent vision loss and ischemia of brain tissue
May also be given low dose aspirin, methotrexate and tocilzumab.
Usually make a full recovery if treated early

Question 28

What is acute spinal cord compression?

Answer 28

Pressure on the spinal cord, this stops the nerves from working correctly, nerves may swell or it blocks their blood supply.
Is a surgical emergency
Patients may struggle to move or have pain/unusual senstations in the limbs or bladder dysfunction

Question 29

What are some causes of acute spinal cord compression?

Answer 29

Trauma such as a fracture or dislocation
Tumout
Epidural abscess or infection
Disk or spinal stenosis
Arthropathy

Question 30

What examinations can help find the location of a spinal cord lesion?

Answer 30

Looking for UMN or LMN pattern weakness
If acute spinal shock - loss of reflexes and sensation below the site on injury
Sensory level
Reflex sensitivity increases
muscle spasms
Spincheter loss? urinary retention
Clonus at the ankle
Plantars upgoing (hallucis extends rather than flexes)

Question 31

How do you manage an acute spinal cord compression?

Answer 31

Urgent MRI
Contact neursurgery or spinal team
Treatment depends on cause: steroids, surgery, radiotherapy
Risk of permanent damage increases is treatment is delayed.