Neuro: Emergencies Flashcards
Why is spinal cord compression an emergency?
Neurones in the spinal cord have a limited ability to regenerate so delays in management can result in irreversable cord damage and potential life long loss of function
Aetiology of spinal cord compression?
Trauma
Prolapsed intravertical disc
Atlantoaxial subluxation (RA)
Infection (discitis in IVDU)
Boney mets
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
What is Cauda Equina and how might it present?
Cauda equina syndrome is compression of the nerve roots caudal to termination of the cord (cornus medullas, usually at level of L2/3 in most adults) resulting in characteristic symptoms:
Saddle anaesthesia (loss of sensation in the perineum – around the genitals and anus)
Loss of sensation in the bladder and rectum (not knowing when they are full)
Urinary retention (compression sufficient to cause UR overflow incontinence) or incontinence (due to loss of sensation)
Faecal incontinence
Bilateral sciatica
Bilateral or severe motor weakness in the legs
Reduced anal tone on PR examination
Sexual dysfunction
Less consistent: loss of lower limb reflexes, loss of anal tone, lower limb weaknes and sensory deficit (often symetrical)
Cord compression above what level can lead to tetrapegia/quadraplegia?
T1
What type of paralysis can an impingement below T1 cause?
Paraplegia
Red flag symptoms of spinal cord compression?
Weakness
Paraesthesia
Ataxia
Urinary retention
UMN signs (clonus, hyperreflexia)
What do the nerves of the cauda equina supply?
Sensation to the lower limbs, perineum, bladder and rectum
Motor innervation to the lower limbs and the anal and urethral sphincters
Parasympathetic innervation of the bladder and rectum
CES complications
Even with early surgery, patients can be left with bladder, bowel or sexual dysfunction. Leg weakness and sensory impairment
CES management
Immediate hospital admission
Emergency MRI scan to confirm or exclude cauda equina syndrome (CT myelogram if contraindicated)
Neurosurgical input to consider lumbar decompression surgery WITHIN 48 HOURS
What tumours commonly metastisie to bone?
Breast
Thryoid
Kidney
Prostate
Lung
What is MSCC and how does it present?
When a metastatic lesion compresses the spinal cord (before the end of the spinal cord and the start of the cauda equina), this is called metastatic spinal cord compression (MSCC). This is different to cauda equina, which specifically refers to compression of the cauda equina.
MSCC presents similarly to cauda equina, with back pain and motor and sensory signs and symptoms. A key feature is back pain that is worse on coughing or straining.
MSCC is an oncological emergency and requires rapid imaging and management. There are specialist MSCC coordinators who should be involved early to coordinate the imaging and treatment of patients with MSCC.
MSCC management?
Treatments will depend on individual factors. They may include:
High dose dexamethasone (to reduce swelling in the tumour and relieve compression)
Analgesia
Surgery
Radiotherapy
Chemotherapy
Which intravertabrsal discs most commonly cause CES?
L4/5 L5/S1
What type of motor neurone picture will CES cause?
Lower motor neruone signs
What type of motor neurone picture will cord compression at the cervical spine cause?
UMN
Over what timeframe should surgical decompression be performed in CES?
Within 48 hours of onset of symptoms
How does hyperventilating play a role in management of raised ICP?
Aims to keep CO2 within its normal limits as hypercapnea will cause vasodilation of cerebral vessels and further increase ICP
What is cushings triad
Bradycardia
Hyperventilation
Hypertension
Sign of raised ICP
Extradural haemorrhage
This is a haemorrhage between the skull and dura mater of the meninges. Commonly caused by trauma to the pterion, with subsequent tearing of the middle meningeal artery, patients present with:
acute severe headache,
contralateral hemiplegia,
and a rapid deterioration in GCS following a lucid period. On CT, a
biconvex hematoma is diagnostic. This occurs as the haemorrhage stops expanding at the sutures of the
skull, where the dura meets the skull, causing the haemorrhage to expand towards the brain. Neurosurgical
intervention is usually needed.
DSM 5 classification of delerium?
- Due to another medical condition
- Substance intoxication
- Substance withdrawal
- Delirium due to multiple eiteologies
- Medication related
Further specifiers:
Time: Acute - hours/days Persistent: weeks/months
Level of activity:
Hyperactive (increased psychomotor activity - e.g. myocolonus)
Hypoactive (psychomotor retardation)
Mixed (fluctuations between both0
What might delerium be otherwise called?
Acute confusional state
Encephalopathy
Acute brain failure
ITU psychosis
Acute reversible psychosis
Acute mental status change
Organic brain syndrome
Highest prevalence of delirium?
In increasing order:
Post repair of fractured hip
Post CABG
Nursing homes
ICU elderly
Terminally ill patients
What should always be considered when there is an acute or subacute deterioration in behavior, cognition or function?
Delerium
Consequences of missed delerium?
Increased mortality
Increased morbiditiy: poor functional recovery, possible future cognitive decline, increased institutionalisation, depresssion, PTSD
Risk factors for delerium?
Elderly: imapaired Ach neurotransmission, vascular changes, pharmacokenitic changes
CNS disorders: major neurocognitive disorders represents one of the greatest risk factors
New medications (including starting more than 3-5 new meds)
Burns patients
Low serum albumin
Drug and alcohol abuse
Clinical course of delerium?
Abrupt of acute onset - within days
FLuctuation in symptom severity:
Waxinag and waning, worse at night, may result in diagnostic uncertainty