Day 1 - Neuro Part 1 Infx & HA Flashcards
Common etiologies in empiric IV antibiotics choices for bacterial meningitis based on age; Important adjunct tx
(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 )
Tx approach for suspected viral meningitis
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
Tx Reye
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)
Differences in acute tx for tension, migraine, & cluster HA
(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
Ppx migraine HA
(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
HA: Made worse w/ foods containing tyramine
Migraine HA
HA: besity now w/ papilledema
Pseudotumor cerebri
HA: Jaw muscle pain when chewing
Temporal arteritis
HA: Periorbital pain with miosis and ptosis
Cluster HA
HA: phonophobia &/or photobia
Migraine HA
HA: bilateral occipital/frontal pressure
Tension HA
HA: Lacrimation &/or Rhinorrhea
Cluster HA
HA: Elevated ESR
Temporal Arteritis
HA: Worse headache of life
SAH (e.g. 2/2 berry aneurysm rupture)
HA: Extraocular muscle palsies
Cavernous sinus thrombosis
HA: Scintilating scotomas prior
Migraine HA
HA: before or after orgasm
Post coital cephalgia
HA: responsive to 100% O2 supplementation
Cluster HA
HA: Head trauma, HA begins days after event, persists over a week, does not go ahead
Subdural Hematoma
HA: 10 Sx suggesting brain tumor
(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)
Pseudotumor cerebri p/w
Young, obese female ; HA daily, worse in AM, pulsatile, possible n/v/EOM pain, papilledema
Pseudotumor cerebri most worrisome complication
Vision loss
Pseudotumor cerebri CT scan result
Absence of ventricular dilation = Normal CT
Dx Pseudotumor cerebri
CSF pressure elevated > 200 mmHg in non-obese or > 250 mmHg in obese; (Check CSF pressure w/ patient lying down to equalize pressure)
Tx approach Pseudotumor cerebri
(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
