Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Neurology > headaches/infection > Flashcards

headaches/infection Flashcards

1
Q

acute primary headache disorders

A

-migraine with or without aura- MC dx in primary care
-tension type headache- MC headache
-trigeminal autonomic cephalgias (Cluster headache) - rare and often presents to ER

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

tension headache (TTH)

A

-MC headache
-Neurovascular dilation of blood vessels innervated by trigeminal nerve (CN V)
-Bilateral, tight, band-like or pressure type pain
-Mild-Moderate intensity
-Self-limited
-± Pericranial and nuchal muscular tenderness
-Never incapacitating
-NO nausea, vomiting or neuro symptoms
-Rarely photophobia/phonophobia
-Lasts 30 min – 7 days
-Frequency: Rarely to daily
-aggravated by stress
-goes away with distraction
-major cause of work loss productivity
-75% of people will have at some point
-females > males

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

tension headache

A

-NOT TRIGGERED BY ACTIVITY
-Stress
-Mental/emotional tension
-Bright light
-Loud noises
-Smells
-Hunger
-Ambient temperature extremes
-Caps/headbands/ponytails
-Suboptimal/improper vision correction
-Pericranial muscle tension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

3 subtypes of tension headaches

A

-infrequent episodic tension HA: < 1 HA per month (MC)!!!
-frequent episodic tension HA: 1-14 HA per month
-chronic tension HA: >= 15 HA episodes per month

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

tension headache tx

A

-often self dx and self tx
-acute- NSAIDs
-chronic- amitriptyline (prophylaxis), massage, Cognitive behavioral therapy, HA clinic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

migraines epidemiology

A

-2nd most leading cause of disability
-as disabling as dementia, quadriplegia, and psychosis
-COMMON, DISABLING, UNPREDICTABLE
-15% women of childbearing age -> affects childcare and jobs
-Women > Men, MC: 30-39, can be familial

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

migraines

A

-Episodic and severe headaches associated with N/V and/or light/sound sensitivity

-Types:
-Migraine w/o aura (“Common” migraine) (70%)
-Migraine w/ aura (”Classic” migraine)
-Status Migrainosus: debilitating migraine lasting >72 hours
-Menstrual Migraine: occurs closely to onset of menstruation (2d before or 3 d after onset of bleeding)

-Precipitated or exacerbated by:
-Emotional stress (80%), menstruation or estrogen (65%), fasting (57%), weather changes (53%), alcohol (38%), food (27%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

4 phases of migraine headache

A

-know the timeline
-migraine can last a week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

prodrome/premonitory phase

A

-Symptoms that occur 3 hours – several days BEFORE migraine headache (NOT aura symptoms)
-60% of patients
-Mood changes: Depression, euphoria, irritability, drowsiness, restlessness, difficulty concentrating
-GI changes: !Food cravings! (chocolate, cheese, alcohol), anorexia, diarrhea or constipation
-Increased thirst or more frequent need to use the bathroom
-!Muscle stiffness (esp neck)
Fatigue: !Yawning (dopaminergic phenomenon), fatigue, insomnia
Photophobia/phonophobia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

aura symptoms

A

-a group of sensory, motor and speech symptoms
-warning signs for migraine (although sometimes can occur during or even after headache)
-Commonly misinterpreted as a seizure or stroke -> you can have unilateral weakness
-An aura can last from !5 to 60 minutes!
-15-30% of people who experience migraines have auras
-Aura symptoms are reversible
-Types of auras by frequency are : VISUAL > SENSORY > LANGUAGE
-Seeing bright flashing dots, sparkles, or lights.
-Seeing wavy or jagged lines.
-Blind spots in your vision.
-Temporary vision loss
-Numbness or tingling skin, pins and needles
-Ringing in your ears (tinnitus).
-Changes in smell or taste.
-Vertigo, dizziness
-Aphasia, dysarthria- least common

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

scintillating scotoma

A

-AKA visual migraine
-MC visual aura preceding migraine
-positive and negative symptoms mixed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

auras: visual, auditory, somatosensory, motor

A

-strokes are ONLY negative symptoms
-migraines can have positive and neg

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

migraine with aura or TIA

A

-Migraine:
-No CVS risk factors
-GRADUAL ONSET, slow, spreading,
-If more than one type of aura, its often sequential (one after another)
-Often positive THEN negative sxs!!!
-“tingling THEN numbness”
-“shimmering lights and zigzag vision THEN loss of vision”
-scintillating scotomas- both
-Long duration 15-60 minutes in 75%

-STROKE/TIA:
-CVS risk factors
-older people
-Acute/abrupt onset, simultaneous
-Negative symptoms only “loss of function”
-Shorter duration <10 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

POUND

A

-Pulsatile
-One day duration (4-72h)*
-unilateral- less important
-nausea*
-!debilitating- photophobia, phonophobia

-92% if 4 POUND
-64% if 3 POUND
-17% if <3 POUND

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Billy Baker is a 30-year-old man with a history of migraine who presents for his annual physical examination. He reports that he has had about three migraine attacks in the past month, and he is able to treat them effectively with sumatriptan. He does note, however, that the day before he gets an attack, he is unusually tired and irritable and has difficulty focusing at work. What phase of migraine is Mr. Baker describing?

A

Aura
Headache
Ictal
Postdrome
Prodrome******* -> you can take meds during the prodromal phase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

migraine PE

A

-Although a thorough neurological examination is essential,most exams will be NORMAL
-Normal vitals
-Normal neurologic exam
-Cranial nerves
-Motor
-Sense
-Gait and coordination
-Mental status

-Eye exam
-Check: Funduscopic, Visual Acuity, Visual Fields, EOM
-May have cranial or cervical tenderness , conjunctival injection, Horner’s syndrome

-Head and neck- ± Temporal tenderness, Muscle tenderness

-ENT (Nose for mucus sometimes, teeth for tenderness)

-complicated migraines can have-
-Hemisensory or hemiparetic neurologic deficits
-Aphasia, syncope, balance problems (Basilar type migraines)
-CN3 palsy (Ophthalmoplegic migraine)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

migraine tx

A

-assess disability
-Educate … incurable
-acute episodes -> abortive therapy!!
-Medicate
-1. Non-specific treatments
-2. Migraine specific
-Consider non-PO routes for N/V
-Avoid rebound headaches
-Nonpharmacologic measures
-Cognitive-behavioral therapy

-once pts are taking meds everyday for migraines -> can cause medication overuse headaches -> start prophylaxis therapy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

lifestyle modifications

A

-Prevention of triggers
-Avoid irregular lifestyle
-Eat and sleep regularly
-↓ Alcohol / caffeine intake
-Hydration
-Regular moderate exercise
-Try and reduce stress

-PEARL: Start a HEADACHE diary (frequency, intensity, triggers, medications used, success rates)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Select the factor that greatly increase risk of ischemic stroke in females with migraines with visual aura

A

Diabetes mellitus
Oral contraceptives*** -> progestin only BC or IUD
Hyperlipidemia
Hypertension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

migraine flow chart

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

acute migraine specific: triptans

A

-for severe
-Serotonin agonists - Bind to 5HT-1b/d receptors, reduce levels of CGRP
-induce vasoconstriction of extracerebral, cranial blood vessels -> dont give to stroke pts
-Suma-, Riza-, Ele-, Almo-, Zolmi-, Nara-, Frova- triptans- None proven to be superior to another -> trial them all if not working
-Forms: PO, IN, SQ, ODT -> If giving intranasal, give opposite rhinorrhea/congestion

-Clarify limits: 1 tab PRN, may repeat in 2 hours, limit 2 tabs/24 hours, and no more than 8d/mo -> too much can cause sensitization
-Eliminate pain within 2 hours for ~30% of patients

-Triptans are generally VERY WELL TOLERATED
-Common side effects - !Nausea, dizziness, dry mouth, headache, sleepiness, !fatigue, hot/cold sensations, !flushing, chest pain
-Less common side effects- Head, jaw, !chest tightness (from vasoconstriction), arm discomfort/tightening/tingling; throat discomfort!, cramps, flushing

-Contraindications: !Ischemic CVD/CVA, Prinzmetal angina!, uncontrolled HTN, pregnancy! (relative, new evidence might be safe)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

triptans: constrict blood vessels
-DONT NEED TO KNOW

A

-Contraindications for triptan use are due to its ability to constrict blood vessels (~10%)
-Known or suspected ischemic coronary artery disease (e.g. angina pectoris, documented silent ischemia, myocardial infarction, vasospastic “Prinzmetal” angina)
-History of stroke or transient ischemic attack
-Uncontrolled hypertension
-Peripheral vascular disease
-Ischemic bowel disease
-Wolff-Parkinson-White or other cardiac accessory conduction pathway-associated dysrhythmias
-Use of ergot agents (e.g., dihydroergotamine [DHE]) or triptans in the previous 24 hours
-Use of monoamine oxidase inhibitors in the previous 2 weeks
-Severe hepatic impairment
-In addition, triptans are usually avoided in hemiplegic migraine or migraine with brainstem aura.
-Currently available evidence does not support limiting the use of triptans with serotonin-specific reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors (SNRIs), or the use of triptan monotherapy, due to concerns for serotonin syndrome.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

medications chart

A

-ALWAYS check pregnancy and lactation status
-start with NSAID, if not working do triptans, then do gepants and antiemetics
-can take 6 meds for one migraine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

gepants, antiemetics

A

-abortive and prophylactic
-ergots too

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

a pt with hx of stomach ulcers may NOT be a good candidate for

A

NSAIDS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

The following are common side effects of triptans EXCEPT

A

Akathisia- cant hold still*****
Jaw, throat, or chest tightness
Palpitations
Tingling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

hx of cardiovascular ds or uncontrolled HTN may not be a good candidate for

A

triptans

28
Q

clinical PEARLS

A

-in an acute setting, response to analgesia is NOT a diagnostic test. Dangerous headaches can respond well to tylenol.
-Most women (50-80%) experience a REDUCTION in migraine headaches during pregnancy
-Women diagnosed with aura migraines should NOT be on combined oral contraceptives.
(Synergistic stroke risk increase with estrogens)

29
Q

migraine prophylaxis

A

-indicated if ≥4 headaches per month, debilitating attacks despite therapy, or if there is overuse of acute medication
-Start low go slow, often takes 6-8 weeks for improvement… 6 months for full effect
-Reduces the use of abortive medications (which can prevent MOH)
-Set realistic goals: Successful treatment is defined as ~40% reduction in number of headache attacks / days, a decreased in the duration of attacks, or an improvement in response to acute therapy
-Re-evaluate: May require dose titrations if partial improvement, or change of therapy if no response after 2 months
-Discontinue therapy: Consider tapering off if headaches controlled for 12 months

30
Q

prophylaxis chart

A

-WEAK EVIDENCE FOR CCBs -> IGNORE THAT

31
Q

migraine prevention therapy: beta blockers

A

-Propanolol 160mg daily (1st line)
-Most used drug class for migraine prevention
-Good for patients with: HTN, angina, ischemic heart disease
-Avoid in: Asthma/COPD, Bradycardia/AV conduction disorders

32
Q

migraine prevention: amitriptyline

A

-Highest risk of adverse events
-Good for patients with: Depression or insomnia
-Adverse effects are often sedation and dose-related anticholinergic effects (blurry vision, constipation, dry mouth, palpitations, urinary retention), orthostatic hypotension, QT prolongation
-Thus, avoid in: elderly, BPH, glaucoma, seizure disorder

33
Q

migraine prevention: anticonvulsants

A

-Divalproex (Depakote) or Topiramate (Topamax)
-Good for patients with seizure disorders
-Avoid in: Pregnancy and liver disease
-Adverse effects of DEPAKOTE: GI distress, nausea, vomiting, somnolence. Risk of liver failure, pancreatitis, thrombocytopenia. Labs including valproic levels needed.
-Adverse effects of TOPAMAX:
-Paresthesia’s most common. Abdominal pain, fatigue, impaired memory and concentration, kidney stones, nausea/vomiting, weight loss. Rarely, acute angle glaucoma. Risk for hepatotoxicity and metabolic acidosis. Warrant laboratory monitoring.

34
Q

A 28 year old make presents for evaluation of headaches. He has had several episodes of unilateral throbbing headaches that last 8-12 hours. When they occur he gets nauseated and wants to go to bed. Usually they are relieved after he lies down in a dark quiet room for the remainder of the day. He is missing significant amounts of work because of the headaches. He has a normal neurological exam today. Which of the following is true regarding his situation?

A

-He needs a CT scan to evaluate the cause of his headache
-When he gets his next headache, he should breathe in 100% oxygen and use triptan medications
-If he hasn’t already done so, he should use ASA 81mg orally every 4 hours as needed and take a stress management class
-An injectable or nasal spray triptan is most appropriate

35
Q

Which of the following is true about females with migraine with aura?

A

-They have increased risk of ischemic stroke
-They have the same risk of MI as females with migraine without aura
-They have the same risk of stroke and MI as controls
-They have decreased risk of coronary artery disease

36
Q

cluster headache

A

-Unilateral, excruciating headache attacks that are periorbital/temporal with autonomic symptoms
-Sharp or lancinating, More painful than childbirth, Frequently pace during attack
-Frequent (0.5-8/day) for 6-8 weeks
-Between 15 minutes and 2 hours, self resolving
-Predominantly middle aged males!
-Very rare
-Pathogenesis is unclear, considered a subtype of the trigeminal autonomic cephalgias
-Triggers: ETOH (vasodilator), nighttime, stress
-Physical exam:
-HORNERS syndrome (ptosis, miosis, anhidrosis)
-Nasal congestion, rhinorrhea
-Conjunctival lacrimation

37
Q

cluster headache criteria

A

-At least 5 attacks fulfilling the following criteria
-Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes (untreated)
-Headache associated with at least one of the following signs on the pain side:
-Conjunctival injection
-Lacrimation (84-91%)
-Nasal congestion (48-75%)
-Rhinorrhea
-Forehead and facial sweating (26%)
-Miosis
-Ptosis
-Eyelid edema

-Frequency of attacks: At least 1 every other day – up to 8 per day!

38
Q

cluster headache tx

A

-Abortive / symptomatic:
-OXYGEN is first line (6-10L of 100% by mask)
-!SQ Triptans is first line pharmacotherapy (if not in hospital)
-Ergot alkaloids
-Anesthetics

-Preventative / prophylactic:
-!Verapamil [CCB] (most effective)
-Steroids
-Mood stabilizers (Lithium)
-Anticonvulsants (Topiramate)

39
Q

medication overuse headache (MOH)
-DONT NEED TO KNOW

A

-Special note: Overuse of acute pain relievers can lead to MOH

-Diagnostic criteria include:
-HA occurring on ≥15 days/month in a patient with a pre-existing headache disorder
-!Regular overuse for >3 months of one or more acute/symptomatic treatment drugs:
-Ergotamine, triptans, opioids, or combination analgesics on ≥10 days/month
-Simple analgesics on ≥15 days/month
-Any combination of ergotamine, triptans, simple analgesics, NSAIDs, and/or opioids on ≥10 days/month without overuse of any single drug class alone
-Not better accounted for by another ICHD-3 diagnosis

-There is evidence of tolerance to analgesic over time
-MOH usually, but not invariably, resolves after the overuse is stopped

40
Q

Most likely diagnosis: Migraine without aura
Imaging: None needed at this time, there are no red flags
Most appropriate therapy: Triptans (subq, intranasal, sublingual)
Imitrex (Sumatriptan)
Oral: 25mg, 50mg, or 100mg orally once. If sxs recur the dose can be repeated 2 hours after initial dose. Max daily dose is 200mg orally.
Nasal spray: Initial dose is 5mg, 10mg, or 20mg into one nostril, once. If sxs recur, can be repeated 2 hours after initial dose. Max daily dose: 40mg intranasally
Subcutaneous injection: 1-6mg subcutaneously once. If sxs recur can repeat one hour after last dose. Max daily dose: 12mg subcutaneously

A
41
Q

areas of pain photo

A
42
Q

serious causes of secondary headaches

A

-Mass lesions (brain tumors and metastases)
-Hemorrhage (subarachnoid, intracranial, intracerebral)
-Infections (Meningitis or Encephalitis, Brain Abscess)
-Idiopathic intracranial hypertension [IIH]
-Ischemic strokes and TIAs
-Cerebral sinus thrombosis
-Giant cell arteritis
-Carotid or vertebral artery dissections
-Acute angle glaucoma, iritis, optic neuritis
-Carbon monoxide poisoning
-Hypertensive encephalopathy
-Pre-eclampsia
-Pheochromocytoma

43
Q

red flag symptoms chart

A

-sudden- max pain within few minutes, by the time you see them its resolving

44
Q

gluacoma

A

-steamy cornea
-fixed pupil
-injected eye
-check intraocular pressure of eye -> >30 is abnormal
-unilateral eye pain + headache
-rule out

45
Q

worrisome headache red flags SNOOP4

A

-fever, weight loss, malignancy, uncontrolled or new HIV
-confusion, impaired alertness, consciousness
-sudden, abrupt or split second thunderclap
-precipitated by exercise or valsalva
-new onset and progressive headaches, especially >50 years old
-first headache OR different from normal (change in attack frequency, severity, clinical features)

46
Q

JR is a 46 year old left handed man presented with headache among other symptoms
CURRENT HEADACHE
5 month history of approximately 3 episodes a week of metallic taste in his mouth for 20 minutes followed by visual disturbance for 5-15 minutes, followed by numbness in his leg, followed by a headache, which all self resolves in 30 minutes.
Visual disturbance: “Looking through water”
Tingling in left hand and left side of the tongue
Duration 5-15 minutes
Followed by numbness in his left leg
Headache is bitemporal, throbbing, lasts for a few minutes to ½ hour
Denies: photophobia, phonophobia, nausea or vomiting, positional worsening
PREVIOUS HEADACHES
15 year history of headaches, a couple episodes per year, triggered by alcohol or coffee
Family history of migraines
Rest of ROS is negative

A

-unexpected for migraine
-pattern of headache has changed
-older in age
-CT head
-MR
-lab studies
-CT shows right sphenoid ridge meningioma

-short term course:
-Surgical removal of tumor
Had residual numbness of the maxillary division of CN V on the right (V2 portion)
Some double vision
Episodes of numbness in tongue/cheek that continued into left hand
Occasional twitching of his left hand, lasted minutes in duration and he did not lose consciousness
Treated with medication for SEIZURES
6 month follow up: Normal neurologic exam

-12 month follow up:
-Severe headaches (9/10 intensity)
Throbbing, nausea
Worsened with movement
Sensitivity to light and sound
Reduction sensation to pinprick over V2 right cheek
Normal neuro exam otherwise
Aura sxs: prior to severe headache and transient
Blurry vision (10-20 min)
Transient numbness in left hand (5 min)

-> migraine with aura now with 12 month follow up

47
Q

Sally is a 31-year-old female with headache and mild visual changes
BP 140/88, HR 88, RR 16, T 98.6F
PE: Papilledema and peripheral vision loss
RX: OCPs

A

-idiopathic intracranial hypertension
-Diagnosis: Ophtho eval, LP, Neuroimaging (MRI, MRV)
Goals of treatment:
Treat the underlying disease, protect vision, control headache
Treatment:
Weight loss, low Na diet= most effective way to manage IIH, aim for ≥15% weight loss
Carbonic anhydrase inhibitors (ACETAZOLAMIDE) or Loop diuretics (FUROSEMIDE)
Headache: First line is Tylenol and NSAIDs, avoid opioids
What if the vision is currently threatened?
Surgical treatment: Optic nerve sheath fenestration (ONSF) with CSF shunt
Indications: Worsening visual field deficits despite treatment, LOSS of visual acuity, intratable headaches, hypotension frommedical treatment, non-compliance
Follow up: Monthly visits until stable

48
Q

idiopathic intracranial hypertension

A

-Formerly known as pseudotumor cerebrii!
-Idiopathic increased ICP with normal CSF indices, and no !apparent cause on imaging
-Rare (2-9/100,000)
-Increasing incidence in US due to !rising obesity (avg age 31, 94% overweight)
-MC: Overweight females of reproductive age (20-40yo)
-Missed dx can cause permanent vision loss in 6-24% or chronic debilitating headaches

Symptoms:
-!Headache is the main symptom – present in 92% of cases
-Usually non-specific (can be throbbing, pulsatile)
-“Classic” symptoms of high intracranial pressure: !HA worse with wakening/Valsalva/coughing/bending over!
-Intracranial noise (60%): Pulsatile tinnitus, ”rushing water or wind”
-!!!!!!!!!!Transient visual sxs (26-32%) : Blurry vision, flashes of light, diplopia- not an aura
-Neck stiffness or back pain (53%), retrobulbar pain (44%)

PE:
-± 6th nerve palsy! resulting in a horizontal diplopia
-Visual field loss! before visual acuity changes
-Optic disc papilledema!!! (hallmark)– refer if can’t see it yourself

49
Q

idiopathic intracranial hypertension: dx criteria

A

-Papilledema*
-Normal neurologic exam (except maybe sixth cranial nerve palsy)
-Normal neuroimaging (including exclusion of CVT with MRV)
-Normal CSF analysis
-Elevated LP opening pressure (there is some debate about the exact cutoff, but generally anything over 25 cm is considered abnormal)

-* Some patients will still be diagnosed with IIH if they have all of the other criteria, but not papilledema.

50
Q

bottom line

A

-If vision is impaired, stat referral to neurosurgery
-Treat headache with your usual medications
-Urgent referral to both Opththalmology and Neurology
-R/O life-threatening causes of papilloedema / ↑ ICP

51
Q

temporal arteritis (giant cell arteritis)

A

-Medium - Large vessel vasculitis that causes inflammation and thickening of the artery leading to ischemia
-!Risk factors:age>50,F>M

-Sx:
-New unilateral temporal headache
-Jawclaudication
-Blurred or transient monocular visual loss (Amaurosis fugax)
-System inflammation: Fatigue, fever, weight loss

-PE: !Tender temporal artery and/or weak temporal pulse

-Labs:!ESR> 50mm/h,CRP>20mg/L
-Definitive Dx: Temporal arterybiopsy
-Treatment ishigh-dosesteroids
-Do not wait for biopsy if strong suspicion
-Associated withpolymyalgiarheumatica (PMR) - shoulder and pelvic girdle stiffness and pain
-Complications: Blindness, stroke, aortic aneurysm

52
Q

Mr. Jones is a 29-year-old male who presents to your Emergency Department with chief complaints of fever, headache, and neck stiffness. His initial recorded temperature is 103º F and on examination he is somnolent and difficult to arouse, he is unable to answer your questions, and he has a positive Brudzinski’s sign.

A

On your initial evaluation of Mr. Jones, you are immediately concerned about a high likelihood of a central nervous system infection. You begin empiric treatment that includes antibiotics for possible bacterial meningitis with intravenous ceftriaxone, vancomycin, and adjunctive dexamethasone after drawing blood cultures. A broad workup is undertaken to identify a suspected source of infection. You order a CT scan of the brain because of his profound altered mental status, but the images identify no contraindications to lumbar puncture. Initial CSF results from the LP show a WBC of 659 with 85% neutrophils, no RBCs, normal glucose levels, elevated protein levels, and a negative Gram’s stain. You add on an HSV PCR that comes back negative, and therefore do not begin any empiric treatment with acyclovir. You contact the intensive care unit to admit the patient for close monitoring and continued treatment of suspected bacterial meningitis.

53
Q

meningitis

A

-Life-threatening infection/inflammation of the central nervous system (CNS), specifically the membranes that surround the brain and spinal cord
-Pathophysiology: Seeding from an adjacent URI (sinusitis, OM), bacteremia, or inoculation after trauma/surgery
-Risk factors:
-Pregnancy, farm workers (listeria), communal living, HIV, asplenia, headache, VP shunts, mastoiditis, immunosuppression, neurosurgery

54
Q

meningitis types

A

-Bacterial
-Acute, purulent:
-Streptococcus pneumoniae is the MC cause of bacterial meningitis, overall -> can spread from pneumonia or sinusitis
-Neisseria meningitis is the MC cause in teens and the second MC in adults
-Group B strep is the MC in newborns , also consider Listeria and Ecoli in newborns
-Abscess/Empyema: polymicrobial (bacteria + fungi)
-Chronic Bacterial Meningitis: (eg, tuberculosis (aseptic))

-Viral “aseptic”
-Acute, aseptic: (eg, enteroviruses)
-Encephalitis: (eg, HSV-1 encephalitis (herpes simplex encephalitis, type 1), HIV, CMV)
-Arthropod-borne: (eg, West Nile virus)

-Fungal- aseptic
-Chronic: (eg, histoplasmosis)
-Vasculitis: (eg, mucormycosis)
-Granulomatous: (eg, cryptococcus)

-Miscellaneous
-Protozoa: (eg, toxoplamosis)
-Metazoa: (eg, cysticercosis (tape-worm))
-Prion disease: creutzfeldt-jakob disease (CJD)

55
Q

meningitis by age

A

know this chart
-ampicillin treats the listeria -> really given to neonates and elderly

56
Q

meningitis symptoms

A

-Most patients will present within 24 hours of symptom onset
-triad- nuchal rigidity, fever, headache
-Symptoms:
-Fevers/chills (95%)
-Meningeal symptoms:
-Headache (84%) / nuchal rigidity (74%)
-Photosensitivity
-Nausea (62%) / vomiting
-AMS! (71%), seizures -> suspect meningeal encephalitis

-Physical exam findings
-+Kernig’s sign = after hip flexion, cannot straighten the knee
-+Brudzinski’s sign = neck flexion produces knee/hip bending
-Petechiae or palpable purpura often seen in n. meningococcal -> non blanching

-Infants: Resp distress, jaundice, poor feeding, restlessness, irritability, bulging fontanelles, hypothermia or hyperthermia

57
Q

meningitis dx

A

-LP: CSF analysis gives definitive dx
-Cell count w/ diff!
-Glucose and protein
-Gram stain and bacterial culture!
-PCR (for viral meningitis)

-Serum tests- bc many of these pts are bacteremia
-CBC w/ diff and platelet count
-Blood cultures x 2
-Complete metabolic panel
-Coags (PT/PTT/INR) if petechiae or purpura
-HIV, RPR, Lyme, Fungal cultures based on clinical suspicion

58
Q

lumbar puncture

A

-Left lateral recumbent, prone, or upright position
-Needle inserted into subarachnoid space at the L3-4 or L4-5 interspace
-8-15 mL CSF in each tube x 3
-AE: backache, headache, radicular pain, paresthesia’s, paraparesis (1.5%)

-Contraindications:
-Adults: No absolute contraindications
-Peds: Cardiopulmonary compromise, increased ICP, papilledema, focal neuro deficits, skin infection over the LP site

-Precautions:
-Thrombocytopenia (<50k-80k) or anticoagulation (INR>1.4)
-Spinal epidural abscess
-Increased ICP

-Complications:
-Spinal hematoma (back pain, weakness, decreased sensation, incontinence)
-Post dural headache (headache worse when vertical, improved when supine)
-Infection
-Bleeding
-Most serious: Cerebral herniation

59
Q

post dural (LP) headache

A

-Why does it happen?
-CSF “leak” through “hole” -> decrease fluid around brain
-Direct activation of adenosine receptors -> vasodilation

-What causes a post LP headache?
-Size of needle = likelihood of headache
-Parallel needle bevel = ↓ post LP headache
-Stylet replacement = ↓ post LP headache

-Symptoms can last hours to weeks
-Headache within 5 days LP
-Neck stiffness
-Tinnitus
-Photophobia
-Nausea

-Treatment
-Mild = supportive, lay supine few hours
-Moderate to severe = Epidural blood patch

60
Q

meningitis: CT or LP?

A

-When is a CT head needed prior to LP?
-CTH may be done to r/o possibility to mass lesion/increased ICP which can lead to devasating brain herniation if LP is performed
-Perform CT prior to LP if the following risk factors are present:
-Immunocompromised state (HIV, immunosuppressive therapy, solid organ or hematopoietic cell transplant)
-Hx of CNS disease (mass lesion, stroke, focal infection)
-New onset seizure (within 1 week)
-Papilledema
-Altered level of consciousness (AMS)
-Focal neurologic deficit(s)

-Indications for an LP
-Meningitis (all patients unless contraindications), SAH, CNS malignancies, demyelinating diseases, Guillain Barre
-Children/infants: Coma, CSF shunt, hx of hydrocephalus, recent hx of CNS trauma or NSGY, papilledema, focal deficits

61
Q

meningitis CSF findings

A
62
Q

meningitis tx

A

-Post-exposure prophylaxis:
-Ceftruaxone 250mg once IM (125 if <15yo)
-Alternative: Rifampin 600mg PO q12h x 2 days, or, ceftriaxone

-Adults primary empiric therapy:
-!!!Ceftriaxone 2g IV + Vancomycin 20mg/kg IV
-Add !!!Ampicillin 2g IV if >50yo to cover for listeria

-Neonates empiric therapy:
-!!!!Ampicillin 100mg/kg q8h IV + Cefotaxime 100mg/kg IV (if <90d)
-Ampicillin 100mg/kg q8h IV + Gentamicin 4mg/kg q24h IV

-Special considerations:
-Acyclovir 10mg/kg IV q8h if HSV cause
-Amphotericin B or fluconazole for HIV/AIDs

-!!!!Steroids (dexamethasone 10mg IV, or, 0.6mg/kg in peds) have been shown to reduce CSF inflammation -> rude mortality, allows do this

-Droplet precautions- PPE

63
Q

A 46-year-old male is brought to the emergency department by his wife due to a seizure event. She reports that prior to the event, he complained of headache, fever, and nausea. She also reports her husband appeared confused. On exam, the patient cannot clearly answer questions. A CT of the head shows no evidence of a hemorrhage, or a space-occupying lesion. MRI of the brain is shown. A lumbar puncture is performed, and cerebral spinal fluid analysis shows a normal opening pressure, a lymphocytic pleocytosis, normal glucose, and elevated protein. PCR is positive for herpes simplex virus-1.

A

-may have started as meningitis
-now its encephalitis
-tx- acyclovir

64
Q

encephalitis

A

-Infection of the brain parenchyma causing inflammation within the CNS
-Most often due to viral infection (HSV-1 MC)
-!!!!Headache, fever, and abnormal cerebral function*:
-Motor or sensory deficits, cranial nerve deficits
-AMS, Altered behavior or personality changes
-Speech or movement disorders
-Seizures

-CSF findings similar to viral meningitis
-CSF PCR for HSV1 and HSV2 and enteroviruses
-Treatment: IV acyclovir (if caused by HSV), supportive care (IV fluids, antiemetics, seizure prophyalxis if needed, control edema)
-HSV encephalitis ~70% mortality if untreated

65
Q

brain abscess

A

-Often follows surgery or trauma
-Common causes: !Toxoplasmosis, !fungal infections (cryptococcus, histoplasmosis, candidiasis, Coccidioides etc) and !bacterial causes (strep, staph)
Brain abscesses often appear as “ring enhancing lesions”
Note there are a wide number of non-infectious causes of ring enhancing lesions such as brain metastases
-LP contraindicated
-Management: Surgical drainage, antibiotics

66
Q

cerebral ring enhancing lesion

A

dont memorize this

67
Q

HA flow chart

A

didnt cover this

Neurology (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions