Infectious Disorders and Neoplasms of CNS

Question 1

Describe meningitis

Answer 1

• Inflammation of the meninges of brain & spinal cord secondary to infection
• Needs to be treated quickly
• Inflammation can extend to 1st & 2nd layers of cortex & spinal cord
• Increased chance of tissue infarction, scar tissue formation, which can restrict CSF flow, resulting in hydrocephalus
• Stretch & pressure on meninges can cause the cardinal sign: headache

Question 2

Pathogenesis of meninges

Answer 2

• Bacterial & viral infections: Pneumonia, Influenza, Meningococcus, Tuberculosis, Enterviruses, Herpes virus
• Pathogens invade host mucosal epithelium, multiply in blood stream & cross BBB into CSF
• CSF offer much less immunity from pathogens due to lack of immune cells
• Besides inflammation of meninges, neuronal cell death can occur through apoptosis & necrosis
• White matter injury also occurs secondary to small vessel vasculitis, venous thrombosis & focal ischemia

Question 3

Clinical manifestations of meningitis

Answer 3

• Primary signs: headache, sudden high fever, stiff neck
• Other signs: altered mental status, vomiting, focal deficits, loss of appetite, sensitivity to light
• Positive meningeal signs: Nuchal rigidity, Kernig’s sign, Brudzinski’s sign
• In severe cases: opisthotonus, seizures, reduced level of consciousness

Question 4

How to diagnose meningitis

Answer 4

• Lumbar puncture for culture to determine the type of organism involved
• CT or MRI
• Time course of onset indicates type of organism
• Viral meningitis can develop in hrs and bacterial can take 1-2 days
• Gram staining of bacterial cells for. faster diagnosis of. bacterial meningitis

Question 5

Treatment of meningitis

Answer 5

• Treated promptly with antibiotics that can cross BBB
• Steroids like dexamethasone to reduce inflammation
• Viral meningitis is symptomatic
• Prognosis of. viral meningitis is excellent, most individuals recover in 1-2 wks

Question 6

Describe encephalitis

Answer 6

• Acute inflammatory disease of the brain parenchyma caused. by direct viral/bacterial invasion or by hypersensitivity initiated by virus
• Inflammation primarily in gray matter of CNS
• Viruses. carried by mosquitoes & ticks are responsible

Question 7

Causative viruses of encephalitis

Answer 7

• West nile virus
• Herpes simplex
• Mycoplasma
• Protozoa
• Complication from bacterial meningitis

Question 8

Clinical manifestations of encephalitis

Answer 8

• Sx depend on etiologic agent & brain area involved
• Fever, headache, n/v followed by altered mental status (lethargy, confusion, memory disturbances), seizures
• May be focal signs, hemiparesis, aphasia, sensory deficits, ataxia, chorea, athetosis
• Infants: irritability, poor appetite
• Meningeal irritation can cause stiff back, neck

Question 9

Clinical manifestations of encephalitis from west nile virus

Answer 9

• Fever
• Headache
• Stiff neck
• Photophobia
• Lesion of anterior horn cells cause paralysis & diminished reflexes

Question 10

Clinical manifestations of encephalitis from herpes simplex

Answer 10

• Seizures
• Hallucinations
• Memory disturbances

Question 11

Diagnosis and treatment of encephalitis

Answer 11

• Dx depends on detection of IgM antibody in serum or CSF, EEG
• MRI better than CT
• Tx depends on infectious agent: Acyclovir improves outcomes from herpes simplex
• Close supervision of Sx is critical
• Prognosis depends on infectious agent, recovery from paralysis is variable, depending on degree of motor neuron involvement

Question 12

Describe primary versus secondary CNS neoplasms

Answer 12

• Primary: develop in brain, spinal cord, or surrounding structures; benign or malignant
• Secondary: metastatic; spread to CNS from another site such as lung or breast

Question 13

Describe paraneoplastic syndromes versus leptomeningeal carcinoma

Answer 13

• Paraneoplastic: may. occur bc of remote effects or indirect effects on CNS from cancer elsewhere in body
• Leptomeningeal Carcinoma: when cancer metastasizes to pia &. arachnoid with multiple lesions in meninges & CSF pathways

Question 14

Diagnosis and treatment of CNS neoplasms

Answer 14

• Dx is devastating to patient & family
• Difficult decisions about treatment options & QOL issues add stress
• Caregiving & financial struggles are. frequently encountered
• Situation is improving with dramatic new advances in radiologic imaging, neurosurgery, adjuvant therapy
• At present ~50% of patients with CNS tumors can be successfully treated & have excellent long term prognosis

Question 15

Effects of CNS neoplasms

Answer 15

• Most primary malignant tumors are locally invasive & cause significant morbidity & mortality
• Early effects: displacement of Brian or spinal cord tissue or blockage of CSF circulation causing increased ICP
• Tumor grows -> compression increases -> specific neurologic deficits
• As tumor progresses symptoms of brain tumors may range from minimal (lethargy) to marked (paralysis)
• Primary CNS tumors do not usually metastasize outside CSN due to lack of CNS lymphatic system to transport cancer cells

Question 16

Initial signs of a CNS neoplasms

Answer 16

• Headache: tension type and migraine most common
• Changes in mental status
• Behavioral changes
• Papilledema, swelling in optic disc
• ~20-50% adults develop seizure activity: may be the first sign of tumor in them

Question 17

Clinical manifestations of CNS neoplasms

Answer 17

• Headache
• Visual changes
• Nausea
• Vomiting
• Cognitive changes
• Lethargy
• Behavioral changes
• Seizures
• Syncope
• Weakness
• Hemiparesis, hemiplegia
• Apraxia
• Cortical sensory deficits
• Sensory impairments
• Cranial nerve palsies
• Aphasia
• Facial numbness
• Hearing disturbances
• Anosmia
• Swallowing difficulties
• Paralysis of outward gaze
• Papilledema
• Incoordination
• Ataxia
• In children: diastases of cranial sutures & enlarging head size

Question 18

How to diagnose of CNS neoplasms

Answer 18

• Clinical examination & imaging
• MRI more informative than CT

Question 19

Medical treatment of CNS neoplasms

Answer 19

• Surgical removal of tumor
• Radiation therapy
• Chemotherapy
• Hormonal therapy
• Immunotherapy

Question 20

CNS neoplasms implications for PT

Answer 20

• Cluster of symptoms indicating. possible tumor: headache, N/V, lethargy, etc, and progression of symptoms despite physical therapy interventions
• Will require immediate referral to physician

Question 21

CNS neoplasms implications for PT in acute post-op rehab

Answer 21

• Knowledge of different tumors for treatment planning, goal setting, pt/family education
• Knowledge of complications from surgery, radiation, chemotherapy and be able to adjust interventions
• Management of increases ICP: shunt, elevation of head to 20-30º, neck in neutral, avoid extreme hip/knee flexion
• Patient education to observe status of drainage in shunt, precautions to avoid coughing, sneezing, or blowing nose, check body temp. is normal
• ROM may be started is medically stable to minimize risk of DVT

Question 22

CNS neoplasms implications for PT in subacute & ambulatory rehab

Answer 22

• Continue monitoring required vital signs, neurologic changes, and adverse effects
• No heat or cold to irradiated. areas for several wks after Tx until skin has healed
• Strength & endurance training, functional mobility, balance, gait training, AD requirements. depending on impairments
• Good outcomes with interval training
• Avoid exercises that increase ICP like vigorous resistive exercises or isometrics
• Outcome measure: Karnofsky scale

Question 23

CPG for cancer patients

Answer 23

• Goal of 150 min of mod-intensity aerobic exercise over 3-5 days & resistance training at least 2 days per wk
• Resistance sessions involve 8-10 muscle groups, 8-10 reps. 2 sets for 2-3 days/wk
• Pre-exercise assessment recommended
• When possible it’s recommended cancer patients exercise in a group