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Unit 2 Emerg/Surg > L7: Neuro emergencies pt 1 > Flashcards

L7: Neuro emergencies pt 1 Flashcards

1
Q

Inflammatory disease of leptomeninges

A

bacterial meningitis

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2
Q

Bacteria access the CNS by…

A
  1. Bloodstream
  2. Contiguous spread
    → Inflammation damages the blood-brain barrier causing ↑ permeability→ alterations in protein and glucose transport→ Progressive cerebral edema with ↑ ICP and ↓ cerebral perfusion→ neurologic damage
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3
Q

Possible complications of bacterial meningitis

A

septic shock
DIC
acute respiratory distress syndrome

long term neuro: AMS
impaired cognition
sensorineural hearing loss

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4
Q

Labs for Bacterial meningitis

A 
Positive Blood cultures X2 (before antibiotics)
CBC with differential
CMP, ESR, CRP
Serum glucose→ compare to CSF glucose
\+/- coag studie
LP
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5
Q

Gold standard for diagnosing bacterial meningitis

A

LP with CSF analysis

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6
Q

G+ diplococci on gram stain is

A

pneumococcal

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7
Q

G- diplococci on gram stain is

A

meningococcal

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8
Q

G+ rods and coccobacilli on gram stain is

A

L monocytogenes

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9
Q

G- cooccobacilli on gram stain is

A

H influenzae

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10
Q

Bacterial meningitis presentation

A

Progressively→ days or following a febrile illness

Acutely→ signs and symptoms of sepsis, rapid over several hours, cerebral edema

HA (severe and generalized), Photophobia, N/V/A
Focal neurologic deficits
Weakness, cranial nerve palsies. Seizures
Altered mental status, Nuchal rigidity
Papilledema associated with ↑ ICP→ grade 1 to 4

Classic triad → Fever + nuchal rigidity + Altered mental status

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11
Q

N meningitis bacterial meningitis appears

A

Petechial rash and palpable purpura
(+) Kernig’s sign, Brudzinski’s sign
(+) Jolt accentuation test

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12
Q

Kernig’s sign

A

Inability/reluctance to allow full extension of knee when hop is flexed at 90 degrees

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13
Q

Brudzinksi’s sign

A

Spontaneous flexion of hops during attempted passive flexion of neck

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14
Q

Jolt accentuation test

A

Patient rotates head horizontally at a frequency of two times per second

(+) → exacerbation of an existing headache

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15
Q

Predictive of adverse outcomes in bacterial meningitis

A

altered mental status, seizures, and/or hypotension

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16
Q

Mainstay of treatment for bacterial meningitis

A

Dexamethasone .15mg/kg q 6 hours x 4 days
+
empiric IV antibiotics

immediately after blood cultures and LP

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17
Q

Dexamethasone helps bacterial meningitis by and if….

A

Decrease rate of hearing loss. neurologic sequelae ,morbidity and mortality

Benefit only in pneumococcal meningitis

Only continue if gram stain or blood cultures (+) for S. pneumoniae

+/- add Rifampin if steroid continued

Initiated shortly before/same time as antibiotic therapy (or it does not improve outcome)

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18
Q

2 types of injury most likely to have bacterial meningitis contiguous strep

A

Basilar skull fracture

Penetrating trauma/post-neurosurgery

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19
Q

Who gets blood cultures (without LP) stat instead of blood cultures + LP STAT when there’s suspicion for bacterial meningitis

A 
Immunocompromised
History of CNS disease
New onset seizure
Papilledema
Altered consciousness
Focal neuro deficit

These ppl get a CT next, then an LP if no CI

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20
Q

Bacterial meningitis types that we vaccinate against

A

S. pneumoniae
N. meningitidis
H. influenza

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21
Q

Post-Exposure prophylaxis for bacterial meningitis

A

Cipro
Rifampin
Ceftriaxone* (pregnant patients)

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22
Q

Your patient has pneumococcal meningitis as shown by gram stain/blood cultures

A

Continue the dexamethasone
Add rifampin
Targeted abx

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23
Q

Your patient has non-pneumococcal meningitis as shown by gram stain/blood cultures

A

Discontinue dexamethasone

Targeted abx

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24
Q

The gram stain or culture cam back negative but other CSF findings consistent with bacterial meningitis

A

Continue empiric antibiotic therapy + dexamethasone

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25
Q

Aseptic meningitis aka

A

“Viral meningitis” but it isn’t always viral

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26
Q

Clinical evidence of meningeal inflammation but bacterial cultures are negative

A

Aseptic meningitis

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27
Q

Aseptic meningitis presentation

A 
Similar presentation to bacterial meningitis
Symptoms less severe→ supportive care 
Complete recovery with no sequela
Generally non-specific
Headache, Fever, N/V
\+/-Photophobia
\+/- Nuchal rigidity
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28
Q

Labs for aseptic meningitis

A 
Follow same diagnostic approach as bacterial meningitis
Blood cultures X2 (before antibiotics)
\+/-CT? (same criteria as bacterial)
CBC with differential, CMP, ESR, CRP
\+/-Other (clinical suspicion)
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29
Q

Most common cause of viral aseptic meningitis

A

Enterovirus

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30
Q

Viral causes of aseptic meningitis

A

Enterovirus (most common)→ Coxsackie, echovirus
(summer and autumn)
HSV-2, VZV, mumps,
HIV, West Nile virus,, EBV, CMV

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31
Q

Causes of infectious non-viral meningitis

A

Rare
Mycobacteria
Fungi→ Cryptococcus, coccidioidomycosis
Spirochetes→ Treponema pallidum, Borrelia burgdorferi

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32
Q

Malignancy as a cause of aseptic meningitis

A

Direct invasion of the meninges (uncommon)

Leukemia, lymphoma, melanoma, breast, lung, GI cancers

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33
Q

Drug induced aseptic meningitis can be caused by

A

Rare
Delayed hypersensitivity reaction vs. direct meningeal irritation
NSAIDs, TMP-SMX, chemotherapy,
phenazopyridine (pyridium)

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34
Q

Aseptic meningitis + travel

A

TB

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35
Q

Aseptic meningitis + ticks exposure

A

Borrelia burgdorferia

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36
Q

Aseptic meningitis + sexual activity

A

HSV-2
syphilis
HIV

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37
Q

Aseptic meningitis or encephalitis + unvaccinated + parotitis

A

Mumps

38
Q

Aseptic meningitis + diffuse, maculopapular exanthema in mildly ill patient

A

Enteroviral infection
Primary HIV
Syphilis

39
Q

Aseptic meningitis + oropharyngeal thrush + cervical LAD

A

Primary HIV

40
Q

Aseptic meningitis or encephalitis + Asymmetric flaccid paralysis

A

West nile virus

41
Q

If you’ve got aseptic meningitis and bacterial meningitis has been ruled out (aka CSF)

A

Discontinue empiric antibiotics

42
Q

Viral Aseptic meningitis treatment

A 
self limiting
supportive
analgesia
antipyretics
severe/immunocompromised  get acyclovir
43
Q

Drug induced Aseptic meningitis treatment

A

Discontinue meds and it’ll resolve in a few days

44
Q

Meningitis vs encephalitis

A

Meningitis→ preservation of cerebral function. Fever,headache, and meningismus more common.

Encephalitis→ abnormalities in brain function more common: AMS, seizures, motor or sensory deficits personality changes, speech or movement disorders

Meningoencephalitis→ unclear which→ +/- photophobia, nuchal rigidity

45
Q

Arboviruses (2)

A

Can cause encephalitis

West Nile Virus
St. Louis encephalitis

Transmitted by mosquitos so more common in summer

46
Q

Most common cause of fatal encephalitis

A

HSV-1

causes epilepsy

47
Q

Other causes of encephalitis

A 
Influenza
Lyme disease
Rocky Mountain spotted fever
syphilis
Uncommon→ VZV, EBV, HIV, mumps, measles, rubella, rabies
48
Q

West nile virus is found in

A

Africa
Asia
Europe
US

49
Q

St. Louis virus is found in

A

Midwest/Southwest US

50
Q

Lyme disease is found in

A

Wooded areas and Colorado

51
Q

Primary infection in encephalitis

A

Due to direct viral invasion of CNS
Cultured from brain tissue
Neuronal involvement

52
Q

Post-infectious encephalitis

A

Acute disseminated encephalomyelitis (ADEM)

No virus detected
Neurons are spared
Perivascular inflammation/demyelination
Typically occurs as initial infection is resolving

53
Q

Encephalitis presentation

A

Headache, Fever
Altered mental status (subtle to unresponsive)
Confused, agitated, obtunded
Seizures (common)
Focal neurologic deficits
Hemiparesis, CN palsies, ↑ DTRs
Photophobia and nuchal rigidity (rare, may be seen in meningoencephalitis)

54
Q

Encephalitis + tongue/lip/eye tremors

A

St. Louis virus

55
Q

Encephalitis + hydrophobia, hyperactivity, pharyngeal spasms

A

Rabies

56
Q

CSF findings indicative of HSV-1 as a cause of encephalitis

A

RBC
Decreased CSF/blood glucose

(also: temporal lobe changes on MRI)

57
Q

MRI with contrast of encephalitis will show

A

+/- abnormalities acutely
3-4 days for changes:
Hydrocephalus→ bacterial, fungal, parasitic etiology
Temporal lobe changes (MRI) → HSV

58
Q

Do serology for encephalitis if…

A

not improving or no pathogen identified→ IgM antibody serum and CSF testing for West Nile, mumps, EBV

59
Q

Do a brain biopsy of encephalitis if…

A

Last resort

etiology still unknown

60
Q

Encephalitis prognosis

A

Initial diffuse cerebral edema or intractable seizures→ poor neurologic recovery, increased mortality

Elevated initial ICP → prognostic for bad outcome

Serial ICP→ document to show improvement

HSV most important to identify and treat→ fatal, causes epilepsy

61
Q

Encephalitis management

A

Empiric→ Acyclovir 10 mg/kg IV q8 hours

Seizure prophylaxis/control

Increased ICP→ diuretics→ mannitol, furosemide

62
Q

Encephalitis management

A

Empiric→ Acyclovir 10 mg/kg IV q8 hours

Seizure prophylaxis/control

Increased ICP→ diuretics→ mannitol, furosemide

63
Q

Common viral causes of meningitis

A 
Coxsackie
HSV-2
HIV
Mumps
Measles

but all can still cause encephalitis

64
Q

Common viral causes of encephalitis

A

West Nile Virus
HSV-1
CMV
Influenza

but can still cause meningitis

65
Q

Focal area of infection with a collection of pus resulting from infection, trauma, or surgery in the brain

A

Cerebral abscess

66
Q

3 ways you could get a cerebral abscess

A
  1. Direct spread→ typically a single abscess. Otitis media, mastoiditis, meningitis, head/facial trauma, sinusitis, dental infection, post neurosurgical or spinal procedure.
  2. Hematogenous spread→ multiple abscesses and bacteremia. Infections: chronic pulmonary, skin, pelvic, intraabdominal, bacterial endocarditis. Following esophageal dilatation.
  3. No site/underlying condition→ 20-40%
67
Q

Cerebral abscess in inferior temporal lobe and cerebellum from direct spread is caused by

A

subacute or chronic otitis media, mastoiditis

68
Q

Cerebral abscess in frontal lobes from direct spread is caused by

A

frontal or ethmoid sinuses, dental infection

69
Q

Hematogenous spread causes abscesses in the _____

A

MULTIPLE ABSCESSES

so everywhere

70
Q

Cerebral abscess presentation

A

Nonspecific→ diagnostic delay

Unilateral headache
(unless multiple abscesses)
→ Sudden or gradual onset
→ Severe pain, not relieved with OTC pain medications

Fever (45-50%)

Nuchal rigidity (15%) → More common in occipital lobe abscess

Altered mental status→ severe cerebral edema→ bad sign

Increased intracranial pressure→ Vomiting

Focal neurologic deficits (50%)

Seizures (25%)

Papilledema (25%) → Late finding

71
Q

An immigrant from Mexico might have a cerebral abscess caused by

A

Cysticercosis→ Taenia solium, pork tapeworm larvae→ Common in immigrants from Mexico

72
Q

An immunocompromised patient could get a cerebral abscess caused by

A

Toxoplasma gondii
Listeria monocytogenes
Nocardia asteroides

73
Q

Fungal cerebral abscesses…

A

Multiple abscesses
Poor outcomes

Cryptococcus
Coccidioides
Aspergillus
Candida

74
Q

Diagnostic workup for cerebral abscess

A

Blood cultures X2 (before antibiotics)

CBC with diff, CMP

MRI without contrast→ 1st choice

CT-guided aspiration or surgical excision for cultures

CT with contrast

75
Q

What does a cerebral abscess look like on MRI without contrast?

A

Ring-enhancing lesion

Early (1-2 weeks) → lesion poorly demarcated, localized edema, acute inflammation, no tissue necrosis

Late (>2 weeks) → necrosis and liquefaction, lesion surrounded by fibrotic capsule

76
Q

Managing a cerebral abscess

A

CT-guided aspiration or surgical excision
Neurosurgery involvement
IV Antibiotics empirically→ based on suspected origin, gram stain→ culture results→ 4-8 weeks
oral don’t penetrate

MRI→ Track regression/progression

77
Q

With a cerebral abscess, it’s necessary to use _____ because _____

A

IV Antibiotics empirically

Oral abx don’t penetrate

78
Q

What’s an intracranial abscess? How do you get one?

A

1/10 of epidural abscess

Localized lesion with central collection of pus surrounded by wall of inflammatory tissue +/- calcified
Tight attachment of dura at foramen magnum→ Rapidly spreads caudally

Complication of neurosurgery
Fetal monitoring probes→ osteomyelitis of skull→ spread
Less common: sinusitis, otitis, mastoiditis

79
Q

Intracranial abscess presentation

A

Signs and symptoms from infection and expanding abscess
Fever, headache, lethargy, N/V
Secondary to sinusitis→ +/- purulent drainage from nose or ear
Can compress the brain→ Increased ICP, papilledema, +/- focal neurologic changes

Can mimic intracranial mass lesions: metastatic tumors, hematomas, brain abscess, meningioma

80
Q

Intracranial abscess diagnostics

A

CBC with diff, ESR – can be variable
MRI w/contrast (1st choice), CT with contrast
CT guided aspiration or open drainage→ stains and cultures

81
Q

Intracranial abscess management

A

Neurosurgery→ burr holes, craniotomy
Empiric antibiotics once abscess sample obtained (1-2 days max), sooner if immunocompromised or concerning
→ Contiguous spread→ Metronidazole + ceftriaxone/cefotaxime
→ Other→ Vancomycin + Metronidazole + Ceftriaxone/Cefotaxime/Ceftazidime
Repeat MRI 4-6 weeks→ monitor. Good prognosis with tx

82
Q

Spinal epidural abscess presentation and progression

A

Initial manifestations may be non-specific
Classic triad→ fever, spinal pain, neurologic deficits
+/- Fever absent→ delay in diagnosis

Progression of symptoms:
Back pain, focal and severe
Nerve root pain (shooting, “electrical” pain)
Motor weakness, sensory changes, bowel/bladder dysfunction
Paralysis→ quickly becomes irreversible (24-36 hrs)

83
Q 
fever
\+
spinal pain
\+
neurologic deficits
A

Spinal epidural abscess “classic triad”

84
Q

Diagnostics for spinal epidural abscess

A

CBC with diff
ESR →elevated or normal
MRI w/contrast entire spine ASAP→ first line
→ Positive early in course of infection
→ “skip lesions” down spine
→ Differentiates epidural soft tissue edema from abscess
CT with contrast→ 2nd line
CT guided extraction of pus from abscess for culture

85
Q

Skip lesions on MRI with contrast of entire spine

A

Epidural abscess

86
Q

Epidural abscess prognosis

A

Death due to sepsis or complications – 5%
Irreversible paraplegia – up to 22%
Some degree of neurologic damage related to duration of deficit

87
Q

Epidural abscess treatment

A

Blood cultures x2
Empiric antibiotics ASAP once diagnosis is suspected (after blood cultures!)
→ Vancomycin + cefotaxime/ceftriaxone/cefepime/ceftazidime
x 4-8 weeks
Early surgical decompression and drainage
MRI in 4-6 weeks→ follow up

88
Q

At risk of spinal epidural abscess

A

Immunocompromised→ HIV, DM, alcoholism
Direct Inoculation→ Epidural catheter, paraspinal injection, trauma
Hematogenous→ tattooing, acupuncture, bacteremia, IVDU, hemodialysis

89
Q

Spinal epidural abscess pathophysiology

A

Bacteria gain access→ Hematogenous spread, Direct extension (osteomyelitis), Direct inoculation into spinal canal (epidural catheter)

Longitudinal extension
Acutely, granulation tissue +/- pus
More common in thoracolumbar area

Damages spinal cord→ direct compression, thrombosis of vessels, bacterial toxins/inflammation, interrupt arterial blood supply

90
Q

Most common cause of spinal epidural abscess

A

S aureus

91
Q

Other causes of spinal epidural abscess

A

G- bacilli > Streptococci > Coag neg staph (more common after spinal manipulation)

Unit 2 Emerg/Surg (8 decks)

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