Emergencias neurológicas

Question 1

Quais os fatores de risco para AVE?

Answer 1

Risk factors: Age, hypertension, hyperlipidemia, smoking, diabetes, hypercoagulable states, cardiac arrhythmias such as atrial fi brillation, cardiomyopathy, & presence of a car diac thrombus, among many others.

Question 2

Qual a definição de síndrome neurovascular aguda?

Answer 2

An acute neurologic event, secondary to ischemia or hemorrhage

Question 3

Quais os exames iniciais frente a uma síndrome neurovascular aguda?

Answer 3

• Avaliação neurológica (<10 minutos): Obtain NIH stroke scale (NIHSS) & document vitals & time
• Exames complementares (<25 minutos, interpretados em < 45 minutos): EKG, cardiac monitor, vital signs, accucheck, keep O2 sat > 92%, CBC, ESR, T & S, PT-INR, PTT, Chem 7, LFTS, cardiac markers, STAT CT/CTA head & neck, & CT perfusion. If ordering MRI, make sure pt doesn’t have pacer or metal in body.
• Decidir sobre terapia de reperfusão: Determine if pt meets criteria for IV TPA or intravascular procedure

Question 4

Quais as indicações da trombólise?

Answer 4

Indications: Age ≥ 18 yr; signifi cant neurologic defi cit expected to result in long-term disability; CT Brain that does not show a hemorrhage or well-established new infarct; acute ischemic stroke sx with time of onset clearly defi ned as <3 h. For cases where onset is 3–4.5 h, IV TPA may be considered (NEJM 2008;359:1317).

Question 5

Quais as contraindicacoes a trombolise?

Answer 5

Contraindications to IV TPA: Hypodensity > 1/3 territory on head CT; blood on CT; recent stroke, head trauma, or intracranial procedure (<3 mo); h/o intracerebral hemorrhage (ICH), brain aneurysm, vascular malformation, brain tumor (may consider w/ CNS lesions w/ very low likelihood to bleed, such as small unruptured aneurysms or benign tumors w/ low vascularity); resolving or minimal defi cit; suspicion of SAH; recent trauma or surgery (<15 days); active internal bleeding; h/o GI/GU bleeding (<22 days); recent LP or noncompressible arterial puncture (<7 days); bleeding diathesis (INR > 1.7; PT > 15; PTT > 40; platelets < 100, or known bleeding diathesis); uncontrollable HTN: SBP > 185, DBP > 110 despite medications to lower it; seizure at onset if defi cits are believed to be due to postictal state. If dx of vascular occlusion made, then Rx may be given; for the 3–4.5 h window, other contraindications include: NIHSS > 25, h/o oral anticoagulant use, combination of previous stroke & DM.

Question 6

Como administrar a alteplase?

Answer 6

# Cuirados antes: Initial workup &amp; labs as above. Check list of contraindications. Double check time window (<4.5 h). Obtain consent from pt or family.
# TPA dose: 0.9 mg/kg w/ a max dose of 90 mg. Give 10% as bolus IV over 1 min &amp; the remainder over 60 min. 
# Cuidados durante e após: Maintain goal SBP < 180, DBP < 105. If BP needs to be lowered, use labetalol 5–20 mg IV q10–20min or nicardipine infusion 5–15 mg/h. Monitor pt in an intensive care unit for at least 24 h observation. Avoid arterial sticks, anticoagulation, antiplatelet agents for 24 h. During the fi rst 24 h after TPA is given, check BP q15min × 2 h, then q30min × 6 h, then q1h for 24 h after starting Rx. F/u CT brain at 24 h. STAT CT if change in neurologic exam. When pt is stabilized, complete routine stroke workup. (See chapter on  Stroke and Cerebrovascular Neurology.) (NEJM 1995;333:1581; MGH Acute Stroke IV/IA Thrombolysis Protocol 2005)

Question 7

Quais as indicações de tratamento endovascular?

Answer 7

Indications for IA procedures: Signifi cant neurologic defi cit causing long-term
disability; defi cits attributable to large vessel occlusion (basilar, vertebral, internal carotid, or middle cerebral artery M1 or M2 branches); noncontrast CT scan w/o hemorrhage or well-established infarct; time of onset of ischemic stroke clearly defi ned. For anterior circulation, window is 6–8 h of nonfl uctuating defi cits. For posterior circulation, window less well defi ned & can be many hours or days of fl uctuating, reversible sx.

Question 8

Quais as contraindicações ao tratamento endovascular?

Answer 8

Contraindications for IA procedures: ICH; well-established acute infarct on CT or MRI; major infarct > 1/3 cerebral hemisphere; CNS lesions w/ high likelihood of hemorrhage (brain tumors, abscess, vascular malformation); seizure at onset if defi cits are believed to be due to postictal state (if dx of vascular occlusion made, then Rx may be given); suspicion of SAH.

Question 9

Como preparar paciente para trombectomia?

Answer 9

Preparing pt for IA TPA/mechanical thrombolysis: If pt is a candidate for IA TPA or mechanical clot retrieval, contact a neurointerventionalist or a facility with a neurointerventional service. Maintain O2 sat > 92%. Treat fever w/ Tylenol. Keep pt NPO. Avoid placing Foley, NGT, femoral catheters, a-line, or central venous line unless necessary. Do not give heparin. Do not lower BP unless MI or BP >220/120. If BP needs to be lowered, use labetalol 5–20 mg IV q10–20min or nicardipine IV 5–15 mg/h. Monitor BP q15min or continuously. Pt will need to be admitted to an intensive care unit for 24 h observation

Question 10

Quais os cuidados pós-trombectomia?

Answer 10

After IA TPA/mechanical thrombolysis: Pt will need STAT CT head right after procedure to evaluate for hemorrhage & admission to an ICU for post-TPA/intervention monitoring. F/u CT head at 24 h. When pt is stabilized, complete routine stroke workup; see chapter on Stroke and Cerebrovascular Neurology ( JAMA 1999;282:2003).

Question 11

Quais os fatores de risco para hemorragia intraparenquimatosa?

Answer 11

Risk factors or potential underlying causes: Hypertension, amyloid angiopathy, aneurysm, vascular malformation, trauma, neoplasm, venous sinus thrombosis, hemorrhagic conversion of a stroke, vasculitis, coagulopathy, cocaine, amphetamines, alcohol, a variety of infections among many others.

Question 12

Qual o manejo da hemorragia intraparenquimatosa?

Answer 12

• Classificar pela imagem: To calculate volume of hemorrhage = ( a × b × c)/2, where a = length, b = width, & c = number of cuts on CT brain (assuming cuts are 0.5 mm each). If signifi cant mass effect, consider osmotic agents & hypertonic saline as needed. (See below for management of acute elevation in intracranial pressure.) Calculate ICH score.
• ABCs, intubation if depressed level of consciousness & inability to protect airway.
• Controle da PA e invasões vasculares: A-line, goal SBP 100–160. Central line, if anticipated will need 23% saline or become hypotensive
• Correção do coagulograma e demais laboratoriais: CBC, Chem 7, PT-INR, PTT, blood bank sample, d-dimer, fi brinogen, LFTs. If INR > 1.3, correct coagulopathy STAT. Give Vitamin K 10 mg IV × 1 & FFP 2–4 Units STAT for a goal INR of <1.3. Consider profi lnine if available. Check coags q4h × 24 h & repeat FFP & Vitamin K if needed for goal INR < 1.3.
• Avaliar neurocirurgia: Avoid corticosteroids. Surgical evacuation may be considered in select cases of cerebellar hemorrhages. No evidence of benefi t from surgical evacuation of basal ganglia, thalamic, & pontine hemorrhages (Stroke 1997;82:2126).
• Enviar a UTI: Consider admission to an intensive care unit for close monitoring. F/u CT brain in 6 h. STAT CT if change in neurologic exam (NEJM 2001;344:1450; Lancet 2009;373:1632; MGH Adult ICH Protocol 2008)

Question 13

Qual o quadro clinico da hipertensao intracraniana?

Answer 13

Late findings: anisocoria, decerebrate or decorticate posturing, apnea, coma, Cushing triad (hypertension, bradycardia, & irregular respirations), papilledema.

Question 14

Como fazer o manejo da hipertesao intracraniana?

Answer 14

# Estabilização inicial: ABCs, consider intubation if depressed mental status or inability to protect airway, vital, signs, cardiac monitoring, HOB elevated 30 degrees. 
# Decidir sobre monitorização invasiva: Goal ICP is <20 mm Hg &amp; cerebral perfusion pressure > 60–70. Consult neurosurgery for possible EVD or ICP monitor or hemicraniectomy posterior fossa decompression if lesion with significant mass effect. 
# Tratar herniação (ex. anisocoria + rebaixamento do NC): 
1. OSMOTERAPIA: STAT mannitol 100 g IV bolus, followed by 0.5–1 g/kg (No HC, manitol 20% 250mL EV). Contraindications: low BP, anuria secondary to renal disease, serum osm > 340. Hold dose for Na > 160, serum osm > 340, or osm gap > 10. Osm gap = measured − calculated serum osms. Calculated serum osms = 2Na + BUN/2.8 + Glu/18. Check Chem 7, serum osmolarity q6h. OR Hypertonic saline: Goal sodium 145–155. For 20% saline, give 40 cc × 1 via central line over 20 min, followed by 15–30 cc q6h via central line if needed. For 3% saline, 40–50 cc/h can go through peripheral IV for up to 12 h, then needs a central line. Contraindications: Na > 160. 
2. Hyperventilation: For goal pCO2 ∼ 30 
3. Avaliar benefício do corticoide: If ICP due to tumor or infection, then dexamethasone 10 mg IV × 1, then 4 mg q6h.
4. Cuidado com sódio: For any pt w/ a mass lesion, stroke, tumor, hemorrhage, keep goal sodium 145–155. Avoid free water in IVF, such as D5W, 1/2 NS, D5 1/2 NS, LR. This is especially important to monitor, since these are frequently used as maintenance fl uids ( J Emerg Med 1999;17:711–719).

Question 15

Qual a manifestacao clinica da meningite bacteriana aguda?

Answer 15

Clinical presentation: Si/sx: Fever, nuchal rigidity, n/v, headache, photophobia, seizure, altered or depressed mental status, papilledema, neurologic defi cits, rash in meningococcus. Uncomplicated viral meningitis does not typically p/w neurologic defi cits. Classic triad of fever, neck stiffness, & altered mental status w/ low sensitivity (∼44%). Almost all pts p/w at least two of following sx: headache, neck stiffness, altered mental status (GCS < 14), fever

Question 16

Quais os exames complementares na meningite bacteriana?

Answer 16

# Sangue: Labs: Chem 10, CBC, UA, CXR, blood cx × 2, coags. Consider PPD, HIV, ESR, CRP, further w/u for system infection depending on clinical history. 
# TC antes do LCR: When CT brain recommended before LP: altered mental status, seizures, immunocompromised state, abnormal neurologic exam, papilledema. If obtaining CT prior to LP, draw stat blood cultures & start empiric antibiotic coverage immediately (i.e., do not wait for LP to start antibiotics). (NEJM 2001;345:1727). 
# LCR: Lumbar puncture: should obtain opening  pressure, cell count & differential, protein, glucose, Gram stain, & culture. Consider wet mount for fungal stain, AFB, India ink, VDRL, Lyme PCR, HSV PCR, PCR of other viruses, latex agglutination for specific bacterial infections depending on clinical history.

Question 17

Como é um LCR sugestivo de meningite bacteriana?

Answer 17

# Celularidade: High (10– 10,000) PMN predom
# Proteinorraquia: High (>50)
# Glicorraquia: Low (<40)
# Testes específicos: GS, cx, latex agglutination positive

Question 18

Qual a conduta frente a uma meningite bacteriana?

Answer 18

Antibiotico: Empiric coverage: Antimicrobial choice depends on age of pt, allergies, & clinical setting. Modify antimicrobial choice based on organism identifi cation & sensitivities.
Age 16–50 yr Vancomycin + third gen. cephalosporin N. meningitides, S. pneumoniae, H. infl uenzae
Age > 50 yr Vancomycin + third gen. cephalosporin + ampicillin N. meningitides, S. pneumoniae, L. monocytogenes, GNR
Immunocompromised Vancomycin + ampicillin + third gen. cephalosporin covering pseudomonas
N. meningitides, S. pneumoniae, L. monocytogenes, H. infl uenzae, GNR
# Corticoterapia: Consider dexamethasone for bacterial meningitis: dexamethasone 10 mg × 1 before or w/ fi rst dose of antibiotics, then 10 mg q6h × 4 days. Avoid empiric dexamethasone if allergy/sensitivity, antibiotic therapy, head trauma, CSF shunt, or infection is not bacterial (NEJM 2002;347:1549).
# Medidas de saude coletiva: recommended for close contacts of pts w/ meningococcal meningitis w/ either rifampin, ceftriaxone, ciprofl oxacin, or azithromycin. Respiratory isolation for 24 h in cases w/ meningococcal meningitis. Notify.

Question 19

Quais são os tumores mais associados a metastase epidural com compressão medular? Qual o exame em doentes com lombalgia e antecedente de cancer?

Answer 19

# Malignancies that commonly metastasize to the cord: breast, lung, prostate, renal cell, & thyroid ca.
# Imagem: Dx: Clinical history & MRI spine w/ gadolinium; in pt w/ h/o malignancy, obtain imaging of entire spine.

Question 20

Qual a manejo da compressão medular maligna?

Answer 20

# Corticoide: If paraparesis & evidence of cord compression on imaging, give Dexamethasone 100 mg IV × 1, then 24 mg po qid × 3 days, followed by a taper over 10 days or when definitive Rx (surgery or XRT) is underway. For minor neurologic sx & no paraparesis & mild cord compression on imaging, administer dexamethasone 10 mg IV × 1, followed by 4 mg q6h, tapered over 10 days or when definitive Rx (surgery or XRT) is underway. 
# Descompressão: Consult  neurosurgery for possible surgical decompression, radiation oncology for XRT, & neuro-oncology for long-term follow-up/ monitoring (Lancet 2005;366:643; Neurology 1989;39:1255; Curr Oncol Rep 2008;10:78).

Question 21

Qual a apresentação clínica do status epilepticus?

Answer 21

Clinical presentation: Status epilepticus (SE): >5 min of persistent, generalized convulsive seizure activity or ≥2 discrete seizures where there is incomplete recovery of consciousness in between. Diverse causes & clinical sx, including unresponsiveness, obtundation, repetitive rhythmic movements. May be convulsive or nonconvulsive. Approximately 7% generalized tonic-clonic seizures will progress to SE ( J Intensive Care Med 2007;22:319).

Question 22

Qual o manejo dos primeiros cinco minutos de crise?

Answer 22

0–5 min: ABCs, O2 sat, coma exam, ECG, IV access & draw labs for Chem 10, CBC, LFTs, PT-INR, PTT, AED levels, ABG, cardiac markers, urine & serum toxicology. Place pt on cardiac monitor
Não USAR DROGA!

Question 23

Como administra BDZ no status epilepticus?

Answer 23

Lorazepam: 4 mg IV over 2 min (may give as 1–2 mg boluses); if still having seizures, may repeat × 1 in 5 min. OR diazepam 5 mg IV q3min × 4, while starting dilantin load. If no IV access, give diazepam 20 mg pr OR midazolam 10 mg intranasally, buccally, or IM.

Question 24

Como administrar AED no status epilepticus?

Answer 24

Fosphenytoin: Load 20 mg/kg PE IV at 150 mg/min. Keep on cardiac monitoring. May give an additional 500 PE IV if no response. Dilantin 1,000 mg IV at <50 mg/min. May give an additional 500 mg IV if no response after 20 min. (Note: Do not give w/ glucose or dextrose due to precipitation.) Valproate 1 g over 15–20 min (20–40 mg/kg). Therapeutic level is 50–100. May give an additional 500 mg after 20 min.

Question 25

Como fazer os anestésicos no status epilepticus?

Answer 25

Anesthesics: IV midazolam: Load 0.2 mg/kg; repeat 0.2–0.4 mg/kg boluses every 5 min until seizures stop, up to a maximum loading dose of 2.9 mg/kg. Initial IV rate 0.1 mg/kg/h w/ a maintenance range from 0.05 to 2.9 mg/kg/h. If still having seizure, switch to or add propofol or pentobarbital. IV propofol: Load 1–2 mg/kg; repeat 1–2 mg/kg boluses every 3–5 min until seizures stop, up to a maximum total loading dose of 10 mg/kg. Initial IV rate: 2 mg/kg/h. IV dose range: 1–15 mg/kg/h. If still having seizures, give an additional 20 mg/kg over ∼5 min. If still having seizures, add or switch to IV midazolam or propofol. IV phenobarbital: 20 mg/kg at 50–100 mg/min. If still having seizures, add or switch to IV midazolam, propofol, or pentobarbital. 
IV pentobarbital: Load 5 mg/kg at up to 50 mg/min; repeat 5 mg/kg boluses until seizures stop. Initial IV rate: 1 mg/kg/h. IV dose range: 0.5–10 mg/kg/h; 
# Titulação: traditionally titrated to burst suppression on EEG but titrating to seizure suppression is reasonable as well. Pt will need to be admitted to an intensive care unit. Begin EEG monitoring as soon as possible if patient does not rapidly awaken or if any continuous IV Rx is used. Consider CT brain or MRI brain. Evaluate for & correct underlying causes. Intubation is necessary.

Question 26

Quais as variantes da sindrome de Guillain-Barre?

Answer 26

Variants: AIDP, Miller Fisher syndrome, acute motor sensory axonal neuropathy (AMSAN), acute motor axonal neuropathy (AMAN), acute pandysautonomia, sensory GBS. (See chapter on Peripheral Neuropathy for workup & differential dx.)

Question 27

Quais as medidas de suporte para SGB?

Answer 27

Place on monitor & watch for autonomic instability; NIFs & FVCs TID. Remember: O2 sat is not sensitive & pt will become hypercarbic before becoming hypoxic. Intubate if FVC < 15 cc/kg or 1 L & NIF < 20 or rapid decline. If intubation >2 wk, consider tracheostomy. Plasma exchange or IVIg: benefi t if given w/in 2 wk of symptom onset; see below for dosing (Lancet 1997;349:225). Narcotics for back pain; protect eyes from drying out; DVT prophylaxis; watch for SIADH.

Question 28

Como fazer a plasmaferese na SGB?

Answer 28

Plasmapheresis: Five exchanges (40–50 mL/kg) qod w/ saline & albumin replacement fl uid. Risks: Bleeding, infection, hematoma formation, pneumothorax w/ venous access. Contraindications: sepsis, active bleeding, cardiovascular instability.

Question 29

Como fazer a IVIG na SGB?

Answer 29

IVIg: 0.4 g/kg/day daily × 5 days. Check IgA level prior to administering IVIg. Pretreat w/ acetaminophen & diphenhydramine before each infusion & repeat the dose 6 h later if necessary. Risks: headaches, myalgias, arthralgias, fl u-like sx, fever, & vasomotor reactions. Rare but serious complications: anaphylaxis in IgA defi cient pts, aseptic meningitis, CHF, stroke, MI, renal failure. Contraindications: hyperviscosity, CHF, CRF, congenital IgA defi ciency.

Question 30

Como informar o prognóstico na sindrome de Guillain Barre aos pacientes?

Answer 30

Prognosis: Fatal in <5%, 20% disabled, & 20% have permanent defi cits; 3% recurrence; maximum defi cit w/in 4 wk of onset. Poorer outcome w/ axonal variants, age > 60, bedbound, intubated, rapid onset w/ max < 7 days, prior diarrheal illness, motor amplitude < 250 ( J Clin Neurosci 2009;16:733).

Question 31

Qual a definição da crise miastenica e quais os gatilhos?

Answer 31

# Definição:  Pts in myasthenic crisis may p/w worsening weakness with the risk of respiratory failure or death. 
# Gatilhos: nfection, medications (see below), stress/surgery/trauma, botox administration. 
# Drugs to avoid: Beta-blockers, procainamide, lidocaine, quinidine, aminoglycosides, tetracycline, ciprofl oxacin, clindamycin, phenytoin, lithium, trimethadione, chloroquine, D-penicillamine, & magnesium

Question 32

Como fazer as medidas de suporte para a crise miastenica?

Answer 32

Management: Place on cardiac monitor; consider monitoring in the intensive care unit. FVC & NIFs tid. Intubate for FVC < 15 mL/kg & NIF < −20 or rapid respiratory decline. O2 sat is not sensitive & pt will become hypercarbic before b ecoming hypoxic.

Question 33

Como prescrever drogas colinergicas na crise miastenica?

Answer 33

Cholinergics: Neostigmine 0.5 mg IV push, followed by pyridostigmine 24 mg in 500 mL D5 1/2 NS.

Question 34

Como prescrever corticoterapia na crise miastenica?

Answer 34

Steroids: Consider methylprednisolone 60 mg IV daily. Steroids may acutely worsen weakness; so monitor closely.

Question 35

Como fazer terapia imunomoduladora na crise miastenica?

Answer 35

Plasma exchange/IVIg: Plasma exchange: remove 2–3 L 3×/wk until improvement, usually fi ve to six exchanges. (See section on GBS for side effects.) IVIg: 2 g/kg infused in divided doses over 2–5 days. Check IgA before giving. Pretreat w/ Tylenol & Benadryl before each infusion & repeat the dose 6 h later if necessary. (See section on GBS for side effects.)