Management of bacterial meningitis - in primary setting - secondary setting - >3months age - <3months age - prophylaxis

GP + non-blanching rash: IM Benzylpenicillin Hospital: IV 2g Ceftriaxone or IV Cefotaxime + amoxicillin/ampicillin if 3months with bacteria) Prophylaxis: Ciprofloxacin or Rifampicin Strep-resistant -Vancomycin

Neuro Flashcards by Aniyra J Chan

When do we prescribe Gabapentin?

Epilepsy. For seizures/ neuropathic pain.

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What drug should you prescribe for aggression/ chorea?

Dopamine receptor Antagonist

eg Risperidone

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Bacterial Meningitis causes

1 Streptococcus pneumoniae - most common overall

Listeria monocytogenes - pregnant

Neisseria meningitidis

Streptococcus agalactiae - neonates

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Migraine Mx:

Prophylactic: Topiramate/ propanolol

1L: NSAID, paracetamol, TRIPTAN

2L:

3L: Amitriptyline

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Viral Meningitis causes

= more common than bacterial

Enteroviruses

Echovirus
Coxsackievirus
Poliovirus

Herpes Simplex Virus

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Management of viral meningitis

Nowt specific

Supportive.

Acyclovir for HSV

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How to tell the difference between bacterial and viral meningitis?

Lumbar puncture:

Viral: lymphocytosis, normal protein/ glucose
Bacterial: low glucose, raised protein

Also bacterial: Kernig’s + Brudzinski’s signs

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Management of bacterial meningitis

in primary setting
secondary setting
- > 3months age
- <3months age
prophylaxis

GP + non-blanching rash: IM Benzylpenicillin

Hospital:
IV 2g Ceftriaxone

or IV Cefotaxime + amoxicillin/ampicillin if <3months (listeria)
+
IV Dexamethasone if purulent CSF/ >3months with bacteria)

Prophylaxis: Ciprofloxacin or Rifampicin

Strep-resistant -Vancomycin

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Define haemorrhagic stroke

Rupture of cerebrospinal artery

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Management of an Ischaemic Stroke

ABCDE

IV Alteplase WITHIN 4.5hr onset - Thrombolysis

CT Head - new stroke?

Aspirin 24hr after tx

(Do not lower BP acutely UNLESS malignant; may impair cerebral perfusion)

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Contraindications to Thrombolysis for Stroke

> 4.5 hr since onset

Recent head trauma, GI/ intracranial haemorrhage, recent surgery. acceptable BP, platelet count/ INR/BP

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When can a Mechanical Thrombectomy be formed in Ischaemic Stroke patients?

Anterior: within 6hr onset

Posterior: within 12hr onset

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Stroke prevention/ Chronic stroke management?

HALTSS

Hypertension 2wk AFTER stroke
Antiplatelet: Clopidogrel/ Warfarin (AF)/ rivaroxaban
Lipid-lowering: Atorvastatin
Tobacco: stop smoking
Sugar: Diabetes screening
Surgery: Carotid endarterectomy IF carotid stenosis >50%

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How are anterior strokes classified?

a) Contralateral hemiplegia/paresis AND
b) Contralateral homonymous hemianopia AND
c) Higher cerebral dysfunction (aphasia, neglect)

TACI = ACA + MCA
PACI = a+b OR c = ACA or MCA

LACI = pure motor/ pure sensory/ sensorimotor/ ataxic hemiparesis. NO higher dysfunction.

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How are posterior strokes classified?

Posterior:

a) Cerebellar dysfunction OR
b) Conjugate eye movement disorder OR
c) Bilateral motor/sensory deficit OR
d) Ipsilateral cranial nerve palsy with contralateral motor/sensory deficit OR
e) cortical blindness/ isolated hemianopia

= POCI

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Which arteries do POCIs involve?

Vertebrobasilar arteries + associated branches

> cerebellum, brainstem, occipital lobe

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Define haemorrhagic stroke

Weakened cerebral vessels lead to rupture and haematoma formation.

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What are the two types of haemorrhagic stroke?

Intracerebral haemorrhage - 75%

Subarachnoid haemorrhage - 25%

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Strong risk factors for haemorrhagic stroke

Age, male, FHx, haemophilia, anticoagulation therapy, hypertension, vascular malformations.

Cocaine, amphetamines

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Acute management of haemorrhagic stroke

Decompressive hemicraniectomy

BP Control <140/80

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Pt presents with Lower back pain, saddle parasthesia and are incontinent.

Investigation? Other presentations Cause? Likely diagnosis? Mx?

Cauda Equina Syndrome

sudden loss of sphincter control

Urgent MRI + Surgical decompression < 48hr

Cause: lumbar disc herniation L4-S1

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Young pt presents with sudden severe back pain following a gymnastics competition.

Likely diagnosis?

Vertebral disc degeneration

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Pt presents with severe pain and stiffness of their shoulder and neck.

Likely diagnosis? Where else could they be stiff?

Polymyalgia rheumatica

Affected areas: neck, shoulders, hips, lumbar spine

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Management of Acute Cord Compression

Steroids - dexamethasone (if malignancy)

Surgical decompression

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Cord compression presentations

Acute UMN signs + sensory disturbance below the lesion Bladder/ bowel incontinence "weak, hyperreflexive legs + paraesthesia "

Management of all seizures

Lamotrigine, Levetiracetam, Valproate

Mx of Focal Seizures

Carbamazepine, Gabapentin, Phenytoin

Mx of Absence seizures

Ethosuximide

Mx of epilepsy + heart problems

Digoxin (inhibits Na/K/ATPase)

Which epilepsy drug is CI in pregnancy

Valproate = teratogenic

Pt presents with rigidity, bradykinesia and postural instability. Tremor is worse at rest. Likely diagnosis? Management? Associations?

Parkinson's LEVODOPA + Co-careldopa (SE n, hallucinations) DA agonist - ropinirole MAO-Bi - Selegline COMTi - Entacaopone Assoc with Lewy-Body dementia

Pt presents with sudden painless vision loss and a stiff neck/shoulders. Likely diagnosis? Management?

Giant Cell Arteritis (jaw claudication, tender scalp) Prednisolone + protective bisphosphonate (lansoprazole, alenronate)

Causes of peripheral neuropathy

Diabetes HIV B12 deficiency

MND is associated with which dementia?

Fronto-temporal (Pick's) Dementia

Most common cause of meningitis

VIRAL - enteroviruses - echovirus - Coxsackie

Viral causes of meningitis

Enteroviruses (echo, coxsackie) Herpes Simplex Virus Varicella zoster

What are the main causes of Bacterial Meningitis?

Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenza b Listeria monocytogenes (bimodal age)

Immunocompetent Patient under 60 presents in the hospital with bacterial meningitis. Treatment?

1L IV Ceftriaxone + Dexamethasone 2L Chloramphenicol + Dexamethasone If suspected penicillin-resistant pathogen use 3rd-gen Vancomycin cover

Immunocompetent Patient under 60 presents in the hospital with bacterial meningitis. After empirical tx, they are found to have Listeria monocytogenes. Tx?

IV amoxicillin or IV Trimethoprim

Immunocompetent Patient under 60 presents in the hospital with bacterial meningitis. After empirical tx, they are found to have Staphylococcus aureus. Tx?

IV Flucloxacillin + Rifampicin 2L IV Vancomycin + Rifampicin

Immunocompetent Patient under 60 presents in the COMMUNITY with bacterial meningitis. Tx IF they have a rash?

IV Benzylpenicillin/ chloramphenicol Urgent referral

Baby presents in the hospital with bacterial meningitis. Empirical treatment?

2g IV Ceftriaxone + IV Ampicillin

Most common cause of encephalitis?

HSV-1

Inflammation of brain parenchyma

Encephalitis

Pt presents with fever, headache and altered mental status. CSF shows normal plasma:glucose ration. Likely diagnosis? Tx?

Encephalitis IV Aciclovir IV Benzylpenicillin

Pt presents with a red, painful rash across her cervical dermatome. The rash is fluid-filled blisters and is "burning". She is febrile and fatigued. Likely diagnosis? Investigations? Tx?

Herpez zoster - Shingles (reactivated varicella zoster) Inv: PCR, CSF, Blood culture Tx: - Acyclovir - analgesia - antipyretics

Pt presents with parasthesia of the peripheries and describe a tingling shooting pain in the feet. They show distal weakness and fasciculations on the legs. They display a + Romberg test (sensory ataxia). Likely diagnosis? Possible causes? Treament?

Peripheral neuropathy Diabetes, medicine, alcohol, CKD, injury infection, connective-tissue disorder, inflammation, malnourishment Tx: - underlying - Pregabalin/ gabapentin (pain) - supportive

Pt presents with temporal headache and temporary vision loss. Her jaw hurts intermittently and she has double vision. Likely diagnosis? Investigations? Treatment?

Giant Cell Arteritis American College of Rheumatology: - ESR>50 - abnormal temporal artery biopsy - age >50 - New headache - temporal artery abnormality minimum 3/5 Tx: - prednisolone - aspirin - Tocilizumab

What is Tocilizumab used for? Outline pharmacology

Giant cell arteritis maintenance Monoclonal Ab against IL-6 receptor. Helps with GCA remission.

Pt presents with muscle weakness of her hands worse on exertion, and eased with rest. She describes double vision. On examination her eyes are drooping (ptosis). Likely diagnosis? Investigations? Treatment? Complications

Myasthenia Gravis 1L AChR Ab (85%) MuSK Ab (10%) Ice pack - ptosis improves EMG-Single fibre EMG CT Chest - thymoma? Tx: Acute: Prednisolone Long-term: Acetylcholinesterase inhibitor - Pyridostigmine + methotrexate Complications: Myasthenia Crisis (resp failure), Thymoma

A patient is diagnosed with Myasthenia gravis, What investigation will you also consider?

CT Chest - Thymoma?

37 yr woman from Sweden presents with a 2 day history of blurry vision and pain the right eye. Her visual acuity is 1/60 and there is some loss of colour vision. Neuro exam is normal, so no CNS involvement Fundoscopy reveals a swollen right optic disc. Likely diagnosis? Investigations? Treatment?

Multiple Sclerosis (optic neuritis) Investigations: MRI head + SC - gadolinium-enhanced lesions of ventricles - myelitis Lumbar Puncture - Oligoclonal banding (IgG) Treatment: Empirical Methylprednisolone If relapse-remitting: injectable beta-interferon (long-term)

Lorazepam use

Acute management of seizures

Pt presents with meningism, fever and nausea, as well as confusion and papilledema. Likely diagnosis? Investigations?

Suspected Meningitis with raised ICP. 1L CT Head (quicker than MRI) Then Lumbar Puncture

22yr old M presents to A&E with worsening bilateral headache. He is febrile but otherwise fit and well. CT Head shows subtle sulcal effacement. LP exudes Frank purulent fluid and a raised opening pressure. Most likely underlying pathogen?

Neisseria meningitidis

22yr old M presents to A&E with worsening bilateral headache. His PHx shows he is immunocompromised CT Head shows subtle sulcal effacement. LP exudes Frank purulent fluid and a raised opening pressure. Most likely underlying pathogen? Tests? Treatment?

Cryptococcus neoformans Ag-test + India-Ink stain Treatment - 2wk IV Amphotericin B + Flucystosine - 8wk fluconazole

Describe the LP of a pt with acute bacterial meningitis

Macroscopically purulent, neutrophilic leukocytosis, low glucose, high protein

Describe the LP of a pt with acute viral meningitis

Lymphocytes, slightly raised protein, normal glucose

Pt is suspected to have viral meningitis. There is no signs of encephalitis. Likely cause? Treatment?

Enterovirus (Coxsackie/ Echovirus) Self-limiting. Give analgesia, antipyretics, nutrition, fluid.

Pt is suspected to have viral meningitis. She is irritable, febrile and confused. Likely cause? Treatment?

HSV1/2 IV Acyclovir

1 month old Baby presents with 12hr vomiting, crying, irritability. He is pyrexial and cries when his head is moved. Treatment?

Probably bacterial meningitis. IV Cefotaxime (>1month old) AND Ampicillin (listeria cover)

Anti-GD1a

Guillain Barre syndrome