coma and brain death Flashcards
2 most common causes of comma
- cardiac or pulmonary failure >5min
- drug/alcohol overdose
other causes of coma
severe organ failure stroke or hemorrhage in CNS cranial trauma infections psychiatric pseudo-coma or catatonia (rare)
oculocephalic reflex
‘dolls eyes’
eyes go in opposite direction of head turn
oculovesticular reflex
cold water on ear drum- eye moves towards the stimulus with a nastagmus away
2 most important prognostic indicators of coma
-pupillary rxns to light
-spontaneous mvmts
if these are absent for 72 hours and no known reversible cause, pt has <5% chance of survival
requirements for brain death
no known reversible cause
no evidence of cerebral fnx
no evidence of brain stem fnx (loss of CN reflexes)
APNEA test
can do EEG or cerebral arteriography or radionuclide brain scans
persistent vegetative state
vegetative state >1month
still have brainstem fnx, but NO Cx fnx
alzheimers
most apparent in temporal and parietal lobes
drugs which lower amyloid do not help
risks fo alzheimers
almost all cases >65yrs W>M poorly educated, mentally inactive head trauma homozygous for e4 allele of ApoE
symptoms of alzheimers
almost always present w/loss of memory first
speech becomes restricted
visuspatial decline (get lost in familiar places)
depression
gait disorder
sundowning
CSF in alzheimers
soluble beta amyloid low
tau high
Tx of alzheimers
cholinesterase inhibitors
memantidine (blocks NMDAR)
anti-depressents
mentally and physically active
cholinesterase inhibitors for alzheimers
relief of memory impairment, agitated behavior, poor concentration do not work for very long -donepexil -rivastigmine -galantamine
mild cognitive impariment
pt who have limited problems w/memory or cognition
50% go on to develop alzheimers
lewy body dementia
fluctuating dementia w/agitated behavior decreased facial animation slowness and imbalance mild or no tremor visiual hallucinations BAD response to antipsychotic drugs live 5-7yrs like parkinsons except early onset of dementia and agitations
lewy bodies
contain alpha-synuclein
multi-infarct disease
dementia d/t known Hx of strokes
seizures more common then w/other dementias
often have concurrent vascular disease
fronto-temporal dementias
family of multiple disorders
increased Tau, TDP-43, Ubiquitin
typical onset 50-60
pick bodies
fronto-temporal dementia behavior dominant form
most common major personality changes obsessions overeating/overdrinking occasional weakness, ataxia, clumsiness no auditory/visual hallucinations
fronto-temporal dementia language predominante form
primary progressive expressive aphasia
CJD
transmissible spongiform encephalopathy prominent myoclonic jerks loss of balance and coordination EEG triphasic waves high 14-3-3 in CSF
normal pressure hydrocephalus symptoms
gait disturbances (wide)
incontinence (wet)
dementia (weird)
normal pressure hydrocephalus Dx
removal of 30cc of CSF provides symptom relief
normal pressure hydrocephalus Tx
ventriculo-peritoneal shunting
CV syncope
decreased CO cardiac arrhythmias aortic stenosis (elderly) idiopathic subaortic hypertrophic cardiomyopathy (HS kids) mitral valve prolapse (young women)
tonic phase of tonic-clonic seizure
clenching/tightening of mm in fixed position
arms flexed, legs extended
close mouth, open eyes
loss of urinary and sometimes bowel continence
clonic phase of tonic-clonic seizure
repetitive synchronous mvmts of arms and legs
physiologic changes during seizure
HR increases immediately O2 saturation drops BP increase pupils dilate and do not react to light metabolic acidosis
todds paralysis
rare
pt remains weak on one side for a day after seizure
Imaging for HA
recurrent migraine do not need image unless: recent change in HA pattern, focal neuro signs
MRI more likely to show cause
Dx of migraines
> = 5 attacks lasting 4-72hrs
= 2 of (u/l, pulsating, moderate/severe intensity, aggravation by physical activity)
=1 of (nausea, photophobia, phonophobia)
no evidence of secondary HA
idiopathic intracranial HTN
aka pseudotumor cerebri progressive diffuse HA w/intermittent loss of vision in 1 or both eyes obese young women papilledema often have extraoccular palsy
Tx of idiopathic intracranial HTN
weight loss
steroids
carbonic anhydrase inhibitors
defenestration of optic nn sheath or lumbar-periotoneal shunt
triptans
serotonin agonists
rizatriptan
eletriptan
CI in known coronary artery or cerebral vascular disease
ergotamines
DHE
causes significant vasoconstriction and can increase BP
given w/caffeine
great prophylaxis of migraine
amitriptyline
propanolol
topiramate
amitriptypline
tricyclic antidepressent low doses in evening may cause tachyarrythmias weight gain have to worry about suicide potential
propanolol
long acting once daily
relative CI in asthma, CHF, or bradycardia d/t heart block
topiramate
anticonvulsant
take at bedtime
may cause difficulties w/speech and cognition- nickname dopamax
weight loss, anorexia, loss of sensation in arms
good prophylaxis
gabapentin
zonaisamide
fair prophylaxis
valproic acid
verapamil
valproic acid
bad side effects weight gain lowering platelet count tremor hair loss
abortive Tx of cluster HA
sumatriptan injection or nasal spray
high dose O2
nasal lidocaine
preventative Tx of cluster HA
must use verapamil lithium prednisone deep brain stimulation
verapamil
CaCh blocker
may need high doses
ADR: hypotension and constipation
lithium
unclear effects on postsynpatic transmission
suicide potential
ADRs: renal and thyroid disease
prednisone
limited use d/t side effects
Tx of trigeminal neuraliga
carbamazepine
surgical
MS epidemiology
mean onset 29
rare 55
70% women, men worse prognosis
north of equator
pathology of MS
T-cell mediated do not know subtype of T cell do not know Ag do not know how T cells cross BBB macros, cytokines, and chemokines are involved
benign MS
have infrequent minor attacks and always return to normal basline
relapsing remitting MS
most common
intermittent attacks that progressively get worse and more frequent
baseline progressively gets worse after each attack
secondary chronic progressive MS
second most common
starts out like relapsing intermittent, but then just takes off as continuously degenerating disease
primary progressive MS
rare
never recover from ‘first attack
and just keep getting worse
kurtzke’s rule
90% of disabilities of MS occurs w/in first 10yrs
MS first attack symptoms
visual loss or double vision, most common, usually improves
weakness, usually improves
paresthesiaes, usually does not improve
depression can precede Dx by yrs
Dx of MS
multiple attacks in time and location
MRI
CSF
MRI of MS
9+ lesions
at least 1 gadolinium enhancing lesion
at least 1 lesion in cerebellum or brainstem
at least 3 periventricular lesions
CSF of MS
oligoclonal band in 90%
increased myelin basic protein or IgG index
increased WBC, but <100
optic neuritis
painful, sudden loss of vision usually u/l
pupillary light reflex usually lost -> marcus-gunn pupillary light reflex
50% develop MS
time to recovery shortened w/IV corticosteroids
internuclear opthalmoplegia (INO)
eyes cannot ADDuct, only ABduct
severe nystagmus
d/t damage of MLF
only two causes: MS or brainstem stoke
Tx of MS
beta interferons
glatiramer acetate
natalizumab
fingolimos
beta interferons
limit pathologic activity of MS
acenoz
beatseron
rebif
glatiramer acetate
only indicated for relapsing remitting MS
may micic meylin protein acting as decoy
natalizumab
possibly most effective
at risk for PML d/t JC virus
fingolimos
PO
limits circulation of lymphocytes fewer cross BBB
ADR: cardiac effects, coronary artery diseae
symptomatic Tx of MS
corticosteriods- during attack
antispasmoics
antidepressents
neuromyetlites optica/NMO
devics disease optic neuritis (usually b/l) and spinal cord demyelination w/o brain demyelination distinct from MS seldom have oligoclonal bands at risk for respiratory crisis infants-90s
NMO MRI
show spinal cord lesions at 3+ levels
usually severe w/cavitation and hemorrhage
pathology of NMO
Abs to aquaphorin 4 Chs
can follow infection
Miller fishcer variant of GBS
limited leg and arm weakness
opthalmoplegia and cerebellar deficits predominate
Dx of GBS
nerve conduction and electromyograms
LP abnormal, but takes a week significant elevated protein
chronic inflammatory demyelinating polyneuropathy (CIPD)
slower form of polyneuropathy developing over 3-6months
milder weakness, more sensory complains
responds to corticosteroids (GBS does not)
can also use plasma exchange or IVIG
Tx of GBS
plasma exchange
IVIG
benign paroxysmal postional vertigo (BPPV)
intermittent vertigo lasting <1min associated w/changes in head position walking impaired, but possible sometimes follows cold, URI, or trauma full relief by lying still lasts 1-2wks
pathology of BPPV
detachment of otolithic crystals
Dx of BPPV
clinical
no hearing loss
Dix-hallpike maneuver
Tx of BPPV
epley manuver meclizine scopolamine patch promethazine diazepam
Menieres disease
recurrent attacks over years/decades of vertigo, tinnitus, decline in hearing, pressure in ear
ultimately have hearing loss
completely immoblize pt
rare cochlear variatn w/prominent hearing loss and mild vertigo
pathology of menieres disease
increased volume of endolymphatic fluid -> bulges -> ruptures -> attack
mostly sporadic, rarely familial
Tx of menieres attack
meclizine
promethazine
scopolamine patch
prophylaxis of menieres attacks
low Na diet
K sparring diuretic
surgical repair
resolves in most pts eventually w/o surgery
cerebellar disease
ataxia
inability to walk/control direction
fall a lot
intention tremor
cerebellar stroke
sometimes few cerebellar symptoms seen ataxia, dysmetria, nystagmus, dysarthria vomiting walking may be impossible HA, diplopia if not detected infarct grows -> closes of ventricles -> hydrocephalus -> herniation
glasgow coma scale
9-13 minor
8-12 moderate
7 and below major
cushing reflex
after head injury or growth of tumor pts have HTN and bradycardia
SDH
venous
cresent
acute if 33mm
cohen prefers craniotomy
EDH
less common arterial middle menigeal a lucid interval surgical drainage always required
concussions
must do CT if LOC, persistent HA, or neuro signs
post concussive syndrome
persistent HA light headedness depression poor concentration irritability can last for wks-months resistent to Tx
chronic traumatic encephalopathy
Tau build up, especially in temporal and frontal lobes
brain atrophy
damaged septum pallicidum and corpus collosum
do not have amyloid plaques
four cardinal features of parkinsons
resting tremor
bradykinesia
disequillibrium
rigidity
other signs and symptoms of parkinsons
sleep disorders loss of sense of smell autonomic problems cramps/pains in back and shoulders depression, dementia smaller incomprehensible handwriting loss of power of voice
parkinsons epidemiology
55-59yrs, but anywhere from 40-70
smokers, caffeine consumers lower incidence
rural areas
M>W
drug induced parkinsonism
usually do not have resting tremor anti-cholinergics phenothiazines metoclopramide promethazine
progressive supranuclear palsy
usually no tremor, but severe disequillibrium
falls and choking seen early
progressive loss of extraoccular mvmts
dystonic extension of neck, furrowed brow, look scarred
blink frequently
usually die from aspiration pneumonia or fall
live 5-6yrs
essential tremor
most common mvmt disorder seen in practice
older onset worse prognosis
rue out huperthyroidism, medication cause, cerebellar disease
essential tremor Tx
propranolol
primidone
deep brain stimuation
tourettes
likely associated w/OCD, ADHD, depression
Tx w/haloperiodl or other D2 blockers
huntingtons
onset 40-50
chorea limited by dompamine blockers
resteless leg syndrome
AR inheritence Tx: -pramipexole -levodopa/carbidopa -Fe -benzodiazepines -gabapentin -opioids
MG
thymic tumors or hyperplasia common
nerve conduction studies shows decremental response
tensilon test
MG Tx
anticholinesterases
corticosteroids
plasmaphoreiss
IVIG
ALS
may present w/asymmetric weakness
no extraoccular eye mm involved
dysarthria most common early symptom
ALS presentatin
worsening weakness
frequent fasiculations
loss of speech, inability to move tongue, tongue atrophy
split hand w/ulnar sparing
cognitive decline in 105 (frontal lobe w/personality changes)
Dx ALS
EMG- denervation of 3+limbs
Tx of ALS
riluzole
