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Case 16 Flashcards

1
Q

What are the general routes of bloodbourne infection ? (4)

A

Peripheral nerves, local from ears/sinuses, local injury (face/skull/spine), congenital

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2
Q

How do blood Bourne infections differ depending on their path of transfer ?

A

Across the blood brain barrier -> Encephalitis

Across the blood CSF barrier -> Meningitis

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3
Q

How do the BBB and blood CSF barrier differ in terms of structure ?

A

BBB - astrocyte footplates, thick BM, endothelium (no fenestrations)
Blood CSF barrier - choroid plexus, thin BM, endothelium (with fenestrations)

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4
Q

How can microbes traverse the barriers into the CNS?

A

Grow across (infect cells that comprise the bacteria) , Passive transport across in intracellular vacuoles, carried in via infected WBCs, invasion via peripheral nerves

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5
Q

How does Rabies track to the CNS ?

A

Bite site -> muscle -> peripheral nerves -> CNS glial cells/nerves where it multiplies

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6
Q

What are the common bacterial causes of meningitis ?

A

Streptococcus pneumoniae, Neisseria Meningitidis, Listeria monocytogenes

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7
Q

Which form of meningitis is more serious and why ?

A

Bacterial because it can develop into invasive sepsis -> multiple organ failure -> cognitive/limb dysfunction -> death

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8
Q

How do bacterial causes of meningitis vary with age ?

A

Listeria monocytogenes occurs in the extremes of age.

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9
Q

What are the risk fx for bacterial meningitis ? (3)

A

Newborn (weak immune system, passed on at birth), community setting (large groups ^spread), travel (sub Sahara, Mecca)

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10
Q

What are the common signs and sx for meningitis in a kid ?

A

Tense bulging fontanelle (soft spot), fever, cold, extremities , stiff neck, abnormal behaviour, blotchy skin/rash

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11
Q

What are the 3 key signs of meningitis for an adult ?

A

Fever, stiff neck, severe headache

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12
Q

When is CT indicated for meningitis ? (5)

A

GCS drops, new focal neurology, ^ICP, papilloedema, immunocompromised (^susceptible to infection)

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13
Q

LP is normally performed if meningitis is suspected. When is it CI? (4)

A

^ICP (GCS down) , extensive/spreading purpua, shock/convulsion/coag abnormalities, superficial infection at LP site.

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14
Q

How is bacterial meningitis indicated in LP results ?

A

Yellow/turgid, ^P, ^polymorphs, ^protein, glucose drops

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15
Q

How is viral meningitis indicated in LP ?

A

Clear fluid, ^lymphocytes, normal everything else

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16
Q

How are TB and fungal results similar and different on LP ?

A

Same; yellow/viscous fluid, ^/normal P, normal polymorphs, ^lymphocytes
Different; TB has ^protein , Glucose decrease in TB whereas normal/low in Fungal

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17
Q

How would you manage bacterial meningitis ?

A

abx and steroids ->Cefotaxine, Ceftriaxone +/- Vancomycin if in area of drug resistance.

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18
Q

When does mx of bacterial meningitis change ?

A

With newborns give Ampicillin/amoxicillin as it covers listeria
Can’t give Ceftriaxone with a Ca containing infusion.

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19
Q

What is significant about Meningitis ?

A

It’s a notifiable disease, consultant in communicable disease control needs to be alerted.

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20
Q

What medication is given close contacts of those infected with meningitis ?

A

Ciprofloxacin and rifampicin (chemoprophylaxis)

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21
Q

Viral meningitis is ^common but milder form. What are the main causes ? (4)

A

HSV, mumps (paramyxovirus), enteroviruses (Coxsackie, polio), HIV

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22
Q

What is encephalitis and what is major UK cause ?

A

Acute inflam/swelling of brain from infection/immune response. V rare, most common is HSV1.

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23
Q

How would you dx and tx Encephalitis ?

A

CSF for viral PCR + microscopy, culture/sensitivies, blood culture.
Tx; Aciclovir (antiviral)

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24
Q

What is cerebral abscess ?

A

Infection of brain ^mass of pus in or around skull (sinuses, otitis media, dental abscess)

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25
What are the sx of expanding intracranial mass ?
4 F's; fever, fits, focal, fatal
26
What happens when infections spread intracranially from the 'danger triangle of the face'?
Septic cavernous sinus thrombosis
27
What is furious rabies ?
80% of infections. dysfunction/invasion of limbic system decreases inhibition so aggression ^. ^saliva and aversion to H2O
28
Where does rabies go once px bitten ?
replicated in skeletal muscle, binds to Ach receptors at neuromuscular junction travels within axons in peripheral nerves via retrograde fast ch. Replictes in motor neurone of spinal cord and DRG ^to brain.
29
What are the common CNS infections in immunocompromised px ?
CMV, mycobacterium TB, crytococcus neoformans (fungal meningitis)
30
How is the cortex differentiated?
Rim of grey matter (cell bodies) that surround white (connections)
31
What are the signs of an UMN lesion ?
No wasting. Spastic tone , pyramidal decrease power, brisk reflexes, planter response, fasciculations.
32
What is the classical presentation of extradural haemorrhage ?
Brief LOC -> Lucid interval -> sudden drop of headache, vomit, LOC, pupil problems
33
What is the cause of subdural haemotomas ?
Ruptured bridging veins, common in OAPs and alcoholics. Venous blood, worse outcome
34
Why would you give Nimodipine for subarachnoid haemorrhage ?
CCB so reduces vessel spasm risk. refer to neuro to clip aneurysm
35
What is the flow of CSF ?
Ependymal cells in choroid plexus -> lat ventricle -> foramen of monro -> 3rd -> aqueduct of slyvius -> 4th -> foramen of Lushcka (2 lat) and Forman of magendie (midline) -> midbrain -> sup sagittal sinus.
36
What are the causes of obstructive hydrocephalus ? (4)
tumour, abscess, cyst, congenital aquaduct stenosis
37
What are the causes of non obstructive/communication hydrocephalus ? (4).
intracranial haemorrhage (SAH, IVH), infection, meningitis, post trauma
38
What is the tx for communicating hydrocephalus ?
Ventroperitoneal shunt, tube in lat ventricle down skin into peritoneum that absorbs CSF, goes past the obstruction.
39
What are the causes of cauda equina syndrome ?
herniated lumbar disc, generative spinal stenosis, tumour, trauma
40
What is the RAS ?
Reticular activating system, network processes info of brainstem hypothalamus cerebral cortex before cerebrum
41
What are the indicators of GCS and how many is each category out of ?
14/15 - mild, 9-13 - moderate, <8 severe/coma | E/4 , V/5, M/6
42
How is the verbal score broken down for GCS ?
``` 5 = normal response 4 = confused/incorrect 3 = random words 2 = random noises 1 = no response ```
43
How is the motor score broken down on GCS ?
``` 6 = obeys commands 5 = localise to pain 4 = withdraw from pain 3 = Abnormal flex response 2 = Abnormal ext response 1 = No response ```
44
What are the common non-neuro causes of coma
hypoglycaemia, hyponatremia, drugs, alcohol. (generalised brain tissue failure)
45
What is the normal ICP and what are the contents of the cranial vault ?
5-15 mmHg | Vol = tissue (1400ml) , CSF (150ml), blood (150ml)
46
What is the compensation mechanism as ICP ^ ?
blood and CSF move into spinal canal and extra cranial vasculature.
47
What is Cushing's triad and what does it indicate ?
Hypertension, bradycardia, irreg (normally decrease RR) | Indicates brainstem compression
48
Why does the pupil become fixed and dilated in intracranial hypertension ?
Descending P on CN3 (autonomic constrictor) so paralysis -> dilation.
49
What is indicated by P1, P2, P3 on the ICP waveform ?
P1, heart contraction P2, tidal wave through brain tissue P3, aortic valve closes small lift in pressure
50
What is the indication if P2>P1 ?
Suggests high pressure/non compliant brain
51
How would you open the airway in an unconscious px ?
Jaw thrust, thumbs behind jaw angle bring forward. Lifts tongue out of post pharynx
52
What type of O2 would you give to a px to help with breathing ?
Mask with reservoir bag delivers high conc O2 and 15L/min. Target PO2 >94.
53
What type of fracture is indicated by CSF leakage from the ear and nose ?
Basal skull fracture, compromising MMA
54
When is Mannitol used ?
When bleeding has stopped assuming bbb is intact to decrease ICP. Draws out fluid from nerve tissue.
55
What medication would be used to decrease ICP in a non trauma setting ?
Dexamathasone. Tissue swelling or inflammation.
56
What is the MOA of Midazolam ?
Benzodiazepine ^GABA suppression of nerve activity. ^Cl ions in neurons which hyper polarises them to decrease AP.
57
What is the name of an oral drug that is indicated for long term decrease in epileptic seizures ?
Carbamazepine. Inhibits aberrant CNS Na ch as GABA agonist.
58
Px has 2 seizures in the space of 5 mins with no return to normal, what drug is first line ?
Midazolam (a benzodiazapine) | Life threatening status epileptics.
59
What changes would be seen in a parietal lobe lesion ?
Attention deficits eg. contralat hemispatial neglect syndrome -> px doesn't pay attention to side of body opposite lesion.
60
What is the difference between agnosia and prosopagnosia and which area of the brain is affected ?
Agnosia - auditory px can't recognise basic sounds Prosopagnosia - can't recognise faces Temporal lobe
61
What is the function of the angular gyrus ?
Relates language info. Located in the parietal lobe near the other brain areas.
62
What area connects Broca's and Wernicke's and what action will the px be unable to perform if damage occurs ?
Arcuate fasciculus. Px can't repeat auditory info.
63
What are the 3 canals in the cochlea and what ions do they contain ?
Scala tympani and vestibuli contain ^Na 'perilymph' | Scala media ^K 'endolymph'
64
Nerves cause organ of court and tectorial membrane to bounce disturbing the stercocilia (inner hair cells). what next ?
Mechanically gated K ch open on stercocilia, K from endolymph ^ membrane potential. Ca ch open , Ca -> release NT -> activates auditory nerves -> signal to brain.
65
What is the difference between the medial and anterior temporal lobes ?
Medial creates LTM, role in episodic declarative involves hippocampus Lateral creates semantic memory
66
What is the action of the cerebellum and basal ganglia. How do they relate to temporal/limbic lesions ?
Non declarative (procedural) memory. Lesions to temporal preserve px ability to perform motor skill but they'll lack the ability to remember having performed said skill
67
What are the parts of the basal ganglia ? (4)
``` Caudate nucleus (eye move) Putamen (proceed/anticipate movement) Globus pallidus (reg muscle tone for action) Substantia nigra (reg sub conc activity in muscles) ```
68
Why do the different presentations of Lewy body dementia and Parkinsons arise ?
LDB , cortex then basal ganglia so cognitive goes before movement Parkinsons, mostly basal ganglia so cognitive 2nd
69
What is the function of the ant cingulate cortex ?
Frontal section of cingulate gyrus for attention and distraction. activated in pain, modulated in chronic pain to decrease suffering .
70
What is delirium ?
Mental confusion from being medically unwell eg. surgery, meds. acute onset, self aware, daily live varies, STM impaired, disturbed sleep.
71
Which inflammatory markers are produced during delirium ?
CRP, IL-1, IL-6, TNF-a
72
How can stress cause delirium?
^sympa tone and decreases para -> impairs cholinergic function -> delirium.
73
Which artery is occluded in lateral medullary syndrome ?
Post inferior Cerebellar artery
74
What signs are shown during lateral medullary syndrome ? (6)
Spinothalamic (contra loss pain and temp body) , trigeminal tract (ipsilat loss of pain and temp face), dysphagia (nucleus ambiguous), ispilat Horner's (DLF), vertigo (vestibular nuclei), ipsilat ataxia (spinocerebellar tract)
75
What cells do brain tumours contain ?
Glial cells (gliomas) which can divide throughout life. Or meningeal coverings of brain (meningiomas)
76
What is a neuroma ?
Peripheral nerve damage -> sprouting of axons that can't find location -> lump on nerve V sensitive.
77
How are Glial cells different in the CNS and PNS ?
CNS - oligodendrocytes (block regrowth) form myelin sheath. | PNS - Schwann cells (allow axonal regrowth)
78
What structure controls extracellular K conc, removes and deactivates some NTs (particularly glutamate)
Astrocytes
79
What are microglia ?
small glial cells, 'WBCs' of the brain. attack diseased organisms and phagocytose damaged cells
80
What is the trigger of Apoptosis ?
Loss of trophic fx needed for cell to survive (BDNF), NGF or triggered by extracellular fluids (TNF)
81
Apoptosis is orchestrated by proteolytic enzymes (capsases) and DNAses. What happens to the resulting apoptotic bodies ?
Phagocytose in CNS by microglia. No inflam response.
82
How does necrosis occur ?
cell injury reduces integrity -> contents break down -> necrosis. Cell ruptures inflammation in tissue. Cells aren't replaced so damage to bbb -> infiltration of peripheral phagocytic cells
83
What factor to invading macrophages secrete to encourage axonal regrowth ?
Galectin 1. ^schwann cell migration and axon growth.
84
Which cytokines are involved in the formation of a glial scar ?
IL-6, TGF-b, FGF-2. Released from microglia, neurons and astrocytes.
85
Which inhibitory molecules block the growth of adult axons -> embryonic axons ?
NogoA (produced by oligodendrocytes), Tenascin, Versican
86
What is the cause of LOC in concussion ?
functional disturbance of RAS of brainstem , high twisting force during sagittal rotation
87
Which haemorrhage is most likely after a contrecoup injury?
Subdural, rebound hits opposite side of skull and bridging veins rupture between brain surface and dural sinuses.
88
What are petechial haemorrhages ?
small source of blood leakage at interface of grey and white matter -> severe brain injury +/- midline shift
89
Which NT is involved in excitotoxicty ? what are it's normal and patho levels ?
Glutamate, toxic at 2-5 umol/L (normally 0.6). Stroke can ^>10.
90
How can levels of Glutamate be decreased to avoid excitotoxicity ?
Converted to glutamine using glutaminase enzyme. This isn't an NT so conc drops.
91
What are the action of Ca dependant enzymes in necrosis ? (4)
Caplains degrade neuronal cytoskeleton Proteases digest structural proteins Phospholipases digest cell membranes Endonucleases cause DNA fragmentation

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