Day 1 - Neuro Part 1 Infx & HA

Question 1

Common etiologies in empiric IV antibiotics choices for bacterial meningitis based on age; Important adjunct tx

Answer 1

(1) Less than one month - 1. E. Coli, 2. GBS, 3. Listeria = Ampicillin (Listeria); Cefotaxime/Gentamycin; (2) 1 month - 60 yr. - 1. S. pneumo, 2. N. meningitidis = Cefotaxime/Ceftriaxone (Vancomycin may be used empirically to cover S. aureus); (3) 60+ year - S. pneumo, Listeria, N. meningitidis, & Gram (-) bacilli = Ampicillin (Listeria), Cefotaxime/Ceftriaxone (N. meningitidis), Vancomycin (in case of S. aureus) (discontinue based on dx) ; Dexamethasone IV q 6 h for 4 days if > 6 months of age prior to or along with first dose of antibx (CHILDREN - reduces risk of neurologic sequalae such as hearing loss, especially in cases of HiB or Tb meningitis; ADULTS - reduces morbidity and mortality, especially in cases of pneumococcal meningitis )

Question 2

Tx approach for suspected viral meningitis

Answer 2

Tx symptomatically: Acetaminophen for pain, IV fluids PRN, Empiric antibx until bacterial meningitis excluded; Excluding bacterial meningitis: (1) If younger than 3 years, severely ill, or immunocompromised - continue antibx until culture results confirm (2) if outside above criteria - CSF profile negative & positive viral antigen; Acyclovir - if suspect HSV or signs of encephalitis, such as focal neurologic findings; discontinue if HSV PCR and cultures negative or if alternative dx made

Question 3

Tx Reye

Answer 3

Discontinue ASA/Salicylate; Hospitalization - ~ ICU for cardiorespiratory monitor & possible ventilation, supportive care, fluid/electrolyte management, maintain isovolemia, reduce brain swelling, avoid hypo-osmotic fluids (e.g., free water induce swelling) - give iso-osmotic fluids (e.g., LR, NS), elevate head of bed; Possibly corticosteroids, intracranial pressure monitor; If seizures, given phenytoin (not prophylactically)

Question 4

Differences in acute tx for tension, migraine, & cluster HA

Answer 4

(1) Tension: Oral NSAIDs, Ketorlac, Ergotamines, Triptans (2) Cluster: 100% O2, Ergots (vasoconstrictor), Triptans (3) NSAIDs, Ergots, Sumatriptan, Anti-emetics (e.g., chlorpromazine, perchlorpromazine, metoclopramide) ; Do NOT combine vasoconstrictors, but may combine vasoconstrictors with anti-emetics; Contraindications to vasoconstriction - CAD, Prinzmetal angina, Pregnant

Question 5

Ppx migraine HA

Answer 5

(1) CCB - verapamil first line (2) Beta blockers - propanolol, metoprolol (especially if comorbid HTN/Thyroid disease) (3) Antidepressants - TCAs like amitriptyline (Elevil?), nortriptyline (especially comorbid depression, insomnia, or pain syndrome); Note: Nortriptyline has less anticholinergic effects (more dementia) (4) NSAIDs - not first line due to complication of NSAID-induced (comorbid menstrual migraine or osteoarthritis) (5) Anticonvulsants - Valproic acid (especially comorbid bipolar disorder), Topiramate, Gabapentin

Question 6

HA: Made worse w/ foods containing tyramine

Answer 6

Migraine HA

Question 7

HA: besity now w/ papilledema

Answer 7

Pseudotumor cerebri

Question 8

HA: Jaw muscle pain when chewing

Answer 8

Temporal arteritis

Question 9

HA: Periorbital pain with miosis and ptosis

Answer 9

Cluster HA

Question 10

HA: phonophobia &/or photobia

Answer 10

Migraine HA

Question 11

HA: bilateral occipital/frontal pressure

Answer 11

Tension HA

Question 12

HA: Lacrimation &/or Rhinorrhea

Answer 12

Cluster HA

Question 13

HA: Elevated ESR

Answer 13

Temporal Arteritis

Question 14

HA: Worse headache of life

Answer 14

SAH (e.g. 2/2 berry aneurysm rupture)

Question 15

HA: Extraocular muscle palsies

Answer 15

Cavernous sinus thrombosis

Question 16

HA: Scintilating scotomas prior

Answer 16

Migraine HA

Question 17

HA: before or after orgasm

Answer 17

Post coital cephalgia

Question 18

HA: responsive to 100% O2 supplementation

Answer 18

Cluster HA

Question 19

HA: Head trauma, HA begins days after event, persists over a week, does not go ahead

Answer 19

Subdural Hematoma

Question 20

HA: 10 Sx suggesting brain tumor

Answer 20

(1) Mild HA progressively worsens over days to weeks (2) New onset HA after age 50 (3) Papilledema (elevated ICP) (4) Worsened by lifting, bending, cough, or valsava (due to elevated ICP) (5) Associated seizures, confusion, AMS (6) Abnormal neuro s/sx (7) Disturb sleep (8) Upon awakening (9) Vomiting preceding (10) Known systemic illnesses (e.g., collagen vascular diseases, HIV)

Question 21

Pseudotumor cerebri p/w

Answer 21

Young, obese female ; HA daily, worse in AM, pulsatile, possible n/v/EOM pain, papilledema

Question 22

Pseudotumor cerebri most worrisome complication

Answer 22

Vision loss

Question 23

Pseudotumor cerebri CT scan result

Answer 23

Absence of ventricular dilation = Normal CT

Question 24

Dx Pseudotumor cerebri

Answer 24

CSF pressure elevated > 200 mmHg in non-obese or > 250 mmHg in obese; (Check CSF pressure w/ patient lying down to equalize pressure)

Question 25

Tx approach Pseudotumor cerebri

Answer 25

(1) Confirm/Rule out other pathologies w/ CT or MRI (central venous thrombosis, brain tumors) (2) Discontinue offending agents - Vitamin A excess, Tetracycline, Withdrawal from corticosteroids (3) Weight loss (4) Acetazolamide (carbonic anhydrase inhibitor, diuretic - also tx altitude sickness, glaucoma) (5) Serial LPs (6) Optic nerve sheath decompression (7) Lumboperitoneal CSF shunting