Exam 3 - Neurology Emergencies Flashcards by Kelsey Peiser

What is the most likely pathogen for bacterial meningitis exposure during delivery?

E. Coli, Group B strep

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What is the most likely pathogen for bacterial meningitis from the nasopharynx?

S. pneumoniae

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What is the most likely pathogen causing bacterial meningitis from crowded conditions?

N. meningitides

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What is the most likely pathogen causing bacterial meningitis from post-neurosurgical procedures?

Staph, gram (-)

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What organism is most likely to infect elderly and neonates with bacterial meningitis?

L. monocytogenes, gram (-) bacilli

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What organism is most likely to unvaccinated individuals with bacterial meningitis?

H. influenzae

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What is the classic triad associated with bacterial meningitis?

Fever
Nuchal rigidity
Altered mental status

***headache is also very common

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What specialized tests may indicate bacterial meningitis?

Kernig’s sign
Brudzinski’s sign
Jolt accentuation test

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What is a hallmark finding of N. meningitides?

Meningococcal rash

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What is the gold standard diagnostic test for bacterial meningitis?

CSF Culture

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What will the CSF analysis look like in bacterial meningitis?
(WBC, glucose, protein, cells)

WBC: Elevated; > 1,000
Glucose: Decreased; < 40
Protein: Elevated; 200-500
Cells: Elevated; Neutrophils

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When would you obtain a CT before LP in a patient with possible bacterial meningitis?

If patient has 1 or more of the following risk factors:

Immunocompromised
History of CNS disease
New onset seizure
Papilledema
Abnormal level of consciousness
Focal neuro deficit

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What type of bacterial infection does a gram-positive diplococci suggests?

Pneumococcal (S. pneumo)

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What type of bacterial infection does a gram-negative diplococci suggests?

Meningococcal (N. meningitides)

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What type of bacterial infection does a gram-negative coccobacilli suggests?

H. influenzae infection

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What type of bacterial infection does a gram-positive rods and coccobacilli suggest?

L. monocytogenes infection

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What is the initial management in a patient with possible bacterial meningitis?

Initial dexamethasone + empiric IV antibiotics immediately after blood cultures and LP

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Which bacteria does Dexamathasone have significant benefit in?

Pneumococcal meningitis

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What is the treatment for a newborn with bacterial meningitis infected with group B strep, E. coli, or L. monocytogenes?

Ampicillin + cefotaxime or gentamycin

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What is the treatment for a 1 month to 50 year old with bacterial meningitis infected with S. pneumoniae, N. meningitides, H. influenza, or E. coli?

Vancomycin + ceftriaxone or cefotaxime + Dexamethasone (Dexamethasone only for S. pneumo)

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What is the treatment for > 50 year old with bacterial meningitis infected with S. pneumoniae, N. meningitides, L. monocytogenes, gram neg bacilli?

Ampicillin + Vancomycin + ceftriaxone or cefotaxime + Dexamethasone

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What is the treatment for immunocompromised with bacterial meningitis infected with S. pneumoniae, N. meningitides, L. monocytogenes, gram neg bacilli?

Ampicillin + Vancomycin + ceftriaxone or cefotaxime + Dexamethasone

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What should be prescribed for post-exposure prophylaxis of N. meningitides?

Cipro 500 mg PO x 1
Rifampin 600 mg Q12 hours x 2 days
Ceftriaxone (pregnant clinician or family member) 250 mg IM x 1

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What is aseptic meningitis?

Clinical evidence of meningeal inflammation but bacterial cultures are negative

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What is the most common viral cause of aseptic meningitis?

Enterovirus

What are some historical clues of aspectic meningitis?

- Travel and exposure history (ticks, TB) | - Sexual activity (HSV-2, syphilis, HIV)

What will the CSF analysis look like in aseptic meningitis? | WBC, glucose, protein, cells

WBC: Decreased; < 500 Glucose: Normal; 40-80 Protein: Normal to mildly elevated; 15-45 or 80-100 Cells: Elevated; Lymphocytes (if viral)

What is the management of aseptic meningitis?

Empiric antibiotics are started at presentation and may be discontinued once gram stain is negative and bacterial meningitis is ruled out. Treatment is supportive. Can give antiviral in severe cases or in immunocompromised

What is more common in encephalitis versus meningitis and helps to distinguish the two from each other?

Abnormalities in brain function are more common in encephalitis (AMS, seizures, sensory deficits, speech or movement disorders)

What is the most common cause of fatal encephalitis?

Herpes simplex virus (HSV-1 usually)

What is the most common cause of viral encephalitis in the US?

West Nile Virus

What are some common etiologies of encephalitis?

- West Nile Virus - HSV-1 - CMV - Influenza

What are some common etiologies of meningitis?

- Coxsackie - HSV-2 - HIV - Mumps - Measles

What are some focal neuro deficits that can be seen with encephalitis?

Hemiparesis, CN palsies, increased DTRs

What is a common clinical manifestation of encephalitis?

Seizures

What CSF finding can be indicative of a HSV-1 infection which could be causing encephalitis?

RBC in CSF

What will the CSF analysis look like in viral encephalitis? | WBC, glucose, protein, cells

``` WBC: Decreased; < 250 Glucose: Normal; 40-80, but decreased if HSV infection Protein: Elevated; < 150 Gram stain: Negative Cells: Elevated; Lymphocytes ```

What is the diagnostic study of choice for encephalitis?

MRI with contrast

On MRI, what are temporal lobe changes suggestive of?

HSV

On MRI, what can hydrocephalus suggest?

Bacterial/fungal/parasitic etiology of encephalitis

What is the management of encephalitis?

- Acyclovir - Seizure prophylaxis/control - Diuretics if increased ICP

If an abscess is localized to the inferior temporal lobe or cerebellum, what is the possible etiology?

- Subacute and chronic otitis media | - Mastoiditis

If an abscess is localized to the frontal lobes, what is the possible etiology?

- Frontal or ethmoid sinusitis | - Dental infection

In which population are parasites the most common etiology of a cerebral abscess?

Immigrants from Mexico

What is the most common parasitic brain infection in immigrants from Mexico?

Cysticerosis due to Taenia solium infection

What is the most common clinical manifestation of a cerebral abscess?

Unilateral headache that is severe and not relieved with OTC pain medications

What are some general clinical manifestations of a cerebral abscess?

- Unilateral headache - Fever - Focal neuro deficits - Seizures - Papilledema (late finding)

What is the imaging study of choice for a suspected cerebral abscess? What will this study show?

MRI with contrast which will show a ring-enhancing lesion

What is the management of a cerebral abscess?

- CT-guided aspiration or surgical excision - IV antibiotics empirically - Dexamethasone if substantial mass effect

What is the antibiotic regimen of choice if cerebral abscess was due to oral source?

Metronidazole + penicillin G

What is the antibiotic regimen of choice if cerebral abscess was due to otogenic or sinus source?

Metronidazole + ceftriazone OR cefotaxime

What is the antibiotic regimen of choice if cerebral abscess was due to hematogenous spread?

Vancomycin + Metronidazole

What is the antibiotic regimen of choice if cerebral abscess is in a postop neurosurgical patient?

Vancomycin + either ceftazidime OR cefepime OR meropenem

What is the antibiotic regimen of choice if cerebral abscess was due to penetrating trauma?

Vancomycin + either ceftriaxone OR cefotaxime

What is the antibiotic regimen of choice if cerebral abscess was due to unknown source?

Vancomycin + either ceftriaxone OR cefotaxime + Metronidazole

What are common clinical manifestations associated with an intracranial epidural abscess?

Fever, headache, lethargy, nausea, vomiting

What is the imaging study of choice if suspicious for an intracranial epidural abscess?

MRI with contrast

What antibiotic regimen is recommended for intracranial epidural abscess due to continguous spread?

Metronidazole + ceftriaxone OR cefotaxime

What antibiotic regimen is recommended for intracranial epidural abscess due other cause such as trauma or post-neurosurgery?

Vancomycin + Metronidazole + (ceftriaxone OR cefotaxime OR ceftazidime)

What must be performed to obtain stains and cultures of an intracranial epidural abscess?

CT-guided aspiration or open drainage

Where is a spinal epidural abscess most commonly located?

Thoracolumbar area

What pathogen is the most common cause of a spinal epidural abscess?

S. aureus

What are the three major risk factors for a spinal epidural abscess?

- Immunocompromised - Direct inoculation - Hematogenous

What classic diagnostic triad is associated with a spinal epidural abscess?

Fever, spinal pain, neurologic deficits

What symptoms can be observed in the progression of a spinal epidural abscess?

- Back pain - Nerve root pain (shooting "electrial" pain) - Motor weakness, sensory changes, bowel/bladder dysfunction - Paralysis which quickly becomes irreversible (24-36 hours)

What is the first line imaging study to obtain in a patient with suspected spinal epidural abscess?

MRI with contrast

What is the management of a spinal epidural abscess?

- Blood cultures x 2 - Vancomycin + (cefotaxime OR ceftriaxone OR cefepime OR ceftazidime) - Early surgical decompression and drainage - Follow up MRI in 4-6 weeks