Neuro Emergencies Flashcards
1
Q
When to think CNS infection
A
Fevere
h/a
neuro s/sx
2
Q
Bacterial meningitis: what is it?
A
NEURO EMERGENCY
inflammatory disease of leptomeninges
high morbidity/mortality
3
Q
Epidemiology of bacterial meningitis
A
- bacteria access CNA via bloodstream or contiguous spread
- inflammation damges BBB causing increased permeability (alterations in protein & glucose transpport)
- progressive cerebral edeam w/ increased ICP and decreased cerebral perfusion leads to neuro damage
4
Q
Exposure during delivery (babies) meningitis
A
E.coli, GBS
5
Q
Colonization from nasopharynx meningitis
A
sinusitis, OE, mastoiditis (Strep pneumo)
6
Q
crowded conditions (military, college)
A
N. meningitides
7
Q
Head trauma/Post-neuro procedures
A
Staph spp., gram (-)
8
Q
Most common causes of meningitis
A
N. meningitides, S. pneumo
9
Q
Risk factor of s. pneumo
A
Fractures of face/skull, cochlear implants
10
Q
Risk factors for L. monocytogenes (older and neonates)
A
Defects in cell mediated immunity, malignancy, pregnancy, chronic glucocorticoids, alcoholism
11
Q
Coag neg staph risk factors
A
Surgery, ventricular drains and foreign body
12
Q
S. aureus risk factors
A
Endocarditis, surgery, FB, ventricular drains, ulcers
13
Q
Who gets H. influenzae
A
unvaccinated children
adults
14
Q
Risk factors for H. influenzae
A
Diminished humoral immunity
15
Q
Gram neg. bacilli risk factors
A
neurosurgery w/wo drains
16
Q
Presentation of bacterial meningitis
A
progressive
Acute s/sx of sepsis (rapid progression and cerebral edema)
h/a
photopobia
N/V/Anorexia
focal neuro deficits (weak, cranial nerve palsies)
Seizures
AMS, Nuchal rigidity
Papilledema associated w/ ICP increase
PETECHIAL RASH AND PURPURA (N. meningitides)
Triad: fever, nuchal rigidity, AMS
17
Q
Triad for meningitis
A
fever
nuchal rigidity
AMS
18
Q
Tests for meningitis
A
Kernig
Brudzinski’s Sign
Jolt accentuation Test
19
Q
Kernig sign
A
Inability or reluctance to allow full extension of knee when hip is flexed at 90 degrees
20
Q
Burdzinski’s sign
A
Spontaneous flexion of hips during attempted passive flexion of neck
21
Q
Jolt accentuation test
A
Patient rotates his or her head horizontally at a frequency of two times per second; a positive test is the exacerbation of an existing headache
22
Q
Dx for bacterial meningitis
A
blood culture x2 (before abx) CT +/- LP Labs: CBC w/ diff, CMP, ESR, CRP, serum glucose compare to CSF glucose \+/- coag studies (if family hx)
23
Q
CSF findings for bacterial meningitis
A
↑ WBC (>1,000 with neutrophil predominance) ↓ glucose (<40) ↑ protein (100-500) (+) gram stain and culture***** ↑ opening pressure
CSF CULTURE IS GOLD STANDARD
24
Q
When to CT for bacterial meningitis
A
CT can before LP in patients w/ 1+ of the following: Immunocompromised state History of CNS disease New onset seizure Papilledema Abnormal level of consciousness Focal neurologic deficit
25
Risk of LP with increased ICP
cerebral herniation
26
gram + diplococci
pneumococcal
27
gram - diplococci
meningococcal
28
gram - coccobaccili
H. influenzae
29
Gram + rods and coccobacilli
L. monocytogenes
30
Tx of bacterial meningitis
Dexamethasone (glucocorticoid) + empiric IV abx IMMEDIATELY after blood culture and LP
31
Role of dexamethason
decreases long term neuro sequelae
32
Newborn tx
Ampicillin (listeria) + cefotaxine or gentamycin
33
1-23 mo tx
(s. pneumo, hib, e.coli, n. meningitides)
Vanco + cefriaxone or cefotaxine + dexamethsone
34
2- 20 yo tx
vanco + ceftriazone/cefotaxime + dexamethasone
35
50+ tx
ampicillin (listeria) + vanco + ceftriazone or cefotaxime + dexamethasone
36
Immunocompromised
Ampicillin + Vancomycin + cefepime or meropenem + Dexamethasone
37
Tx for PCN allergy
Vanco + moxifloxacin + Bactrim
38
Basilar skull fx tx
Ampicillin + cefotaxime or gentamycin
39
Penetrating trauma/post-neurosurgery tx
Vancomycin + ceftazidime or cefepime or meropenem
40
When does dexamethasone work
pneumococcal meningitis
41
Dosage for dexamethasone
0.15 mg/kg q 6 hrs x 4 d
42
Add on if continuing steroid
Rifampin (better CNS coverage)
43
Complications of meningitis
```
Septic shock
Disseminated intravascular coagulation
Acute respiratory distress syndrome
Possible neurologic long term complications:
- Impaired mental status or cognition
- Sensorineural hearing loss
```
44
Vaccinations for bacterial meningitis against
s. pneumo
n. meningitides
h. influenza
45
Post exposure prophylaxis options
Cipro
Rifampin
Ceftriaxone (pregnant pts)
46
What is aseptic meningitis?
evidence of meningeal inflammation but bacterial cultures are negative (often called viral meningitis -- but not always viral)
47
Tx for aseptic meningitis
Supportive
48
Most common cause of aseptic meningitis
Enterovirus (Coxsackie, echovirus) -- summer and autumn
Others: HSV-2, VZV, mumps, HIV, WNV, EBV, CMV
Others (uncommon):
mycobacteria, fungi, spironchetes
49
Causes of aseptic meningitis
Viral
Malignancy
Drug induced (NSAID, bactrim)
50
Drugs related to causing meningitis
NSAIDs
bactrim (abx)
chemo
phenazopyridine (pyridium)
51
Diffuse, maculopapular exanthema in mildly ill patient
enteroviral infection
primary HIV
syphilis
52
Thrush and cervical LAD
primary HIV
53
asymettric flaccid paralysis
WNV
54
vesicular genital lesions
HSV-2
55
Unvaccinated
parotitis suggests mumps
56
Dx for aseptic meningitis
Blood cultures X2 (before antibiotics)
CT? (same criteria as meningitis)
LP for CSF analysis
Gram stain, culture, glucose, protein, cell count
CBC with differential, CMP, ESR, CRP
Other laboratory tests, depending on clinical suspicion
57
CSF findings for aseptic meningitis
```
CSF Findings:
WBC <500 and >50% lymphocytes (if viral)
Normal glucose (40-80)
Normal or mildly ↑ protein (15-45 or 80-100)
(-) gram stain and culture
PCR
Cultures
May take 3-7 days for results
```
58
Tx for aseptic meningitis
empiric abs started and may be d/c
Viral: supportive; analgesic, antipyretics
Malignancy: involve oncology
Drug induced: d/c, sx will resolve
Uncommon infectious: treat accordingly, require ID and neuro involvement
59
When to give antiviral
immunocompromised or severe cases (Acyclovir)
60
Difference between meningitis and encephalitis
meningitis has normal brain function;
encephalitis: abnormalities in brain function are more common: AMS, seizures, motor or sensory deficits, personality changes, speech or movement disorders
can be blurred (meningoencephalitis)
61
Pathogenesis of encephalitis
viral infection of CNS resulting in inflammation of brain secondary to:
- Primary infection
- Post infectious encephalitis: acute disseminated encephalomyelitis (ADEM)
62
Primary infection
Due to direct viral invasion of CNS
Can be cultured from brain tissue
+Neuronal involvement
63
ADEM
No virus detected
Neurons are spared
Perivascular inflammation/demyelination
Typically occurs as initial infection is resolving
immune response -- attack on tissue
64
Epidemiology of encephalitis
Abrovirus (WNV - most common)
Influenza
Lyme disease, RMS, syphilis
Uncommon: VZV, EBV, HIV, mumps, measles, rubella, rabies
HSV-1!!!!!!! - most common cause of fatal
65
most common cause of encephalitis
WNV
66
Most common cause of fatal encephalitis
HSV-1
67
Presentation of encephalitis
h/a
fever
AMS
Confused, agitated, obtunded
Seizures
focal neuro deficit (hemiparesis, CN palsies, Increased DTRs)
Photophobia and nuchal rigidity (rare w/ encephaitis but seen w/ meningoencephalitis)
68
Meningoencephalitis sx
photophobia and nuchal rigidity
69
Clue for rabies
Hydrophobia, hyperactivity, pharyngeal spasms
70
St. louis virus clues
Tremors tongue, lips, eyelids
71
Flaccid paralysis and rash
WNV
72
Dx for encephalitis
Blood cultures x 2
CBC with diff, CMP
*CSF PCR for HSV, and enteroviruses, EBV
CSF: cell count, glucose, protein, gram stain, culture
- RBC in CSF can be indicative of HSV-1 infection Cultures (CSF)
- Viral, bacterial, fungal, mycobacterial
*Unless contraindicated (IDSA criteria), consult Neuro
MRI (CT if not available) - can take 3-4 d to be evident
EEG- normal
Serology (If pt not improving; IgM for WNV/mumps/EBV)
Brain bx (only if etiology unknown/last resort)
73
RBC in CSF
HSV-1 infection
74
temporal lobe changes on MRI
HSV
75
Hydrocephalus (ventricles huge) on MRI
bacterial/fungal/parasitic etiology
76
Tx for encephalitis
Acyclovir 10 mg/kg/ IV q8h (r/o HSV)
Seizure prophylaxis/control
Diuretic if increased ICP (mannitol, furosemide)
77
Worse prognosis for encephalitis
```
diffuse cerebral edema
intractable seizures
Increased initial ICP
(Serial ICP should be document for improvement)
HSV (high fatality)
```
78
Focal area of infection with a collection of pus, resulting from infection, trauma, or surgery
Cerebral abscess
79
Causes of direct spread of abscess
```
Typically single abscess
Otitis media, mastoiditis
Meningitis
Head/facial trauma
Sinusitis
Dental infection
S/P neurosurgical or spinal procedure
```
80
Inferior temporal lobe & cerebellum abscess etiology
subacute and chronic OM
| Mastoiditis
81
Frontal lobe abscess etiology
Frontal or ethmoid sinusitis
| Dental infection
82
Causes of hematogenous spread
```
Usually multiple abscesses
Associated with bacteremia
Chronic pulmonary infection
Skin infection
Pelvic infection
Intraabdominal infection
Bacterial endocarditis
Following esophageal dilatation
```
83
Main type of abscess (bacterial/viral/fungal)
bacterial
84
Abscess pathogen: paranasal
Strep spp.
| Haemophilus
85
Abscess pathogen: odontogenic
Strep
| Bacteroides
86
Abscess pathogen: otogenic
Strep
Enterobacter
Pseudomonas
87
Abscess pathogen: penetrating head trauma
staph aureus
| Enterobacter
88
Abscess pathogen: neurosurgery
Strep spp
Staph spp
Pseudomonas
89
Abscess pathogen: immigrant from mexico
Parasites (most common)
| Cysticercosis (taenia solium infection- pork tapeworm)
90
Pathogens in immunocompromised/HIV/AIDS
Toxoplasma gondii
Listeria monocytogenes
Nocardia asteroides
91
Fungal pathogens (multiple abscesses, poor outcome)
Cryptococcus
Coccidioides
Aspergillus
Candida spp
92
Presentation of cerebral abscess
```
Usually nonspecific, resulting in diagnostic delay
***Unilateral headache*** (69%) (unless multiple abscesses)
Sudden or gradual onset
Pain tends to be severe
Not relieved with OTC pain medications
Fever (45-50%)
Nuchal rigidity (15%)
- More common in occipital lobe abscess
Altered mental status
- Indicates severe cerebral edema
- Poor prognostic sign
Vomiting (if ↑ ICP)
Focal neurologic deficits (50%)
Seizures (25%)
Papilledema (25%)
- Late finding
```
93
Dx of cerebral abscess
```
blood Cx x 2
CBC w/ diff, CMP
MRI (study of choice) w/ contrast
CT-guided aspiration or surgical excision for culture
(CT w/ contrast)
```
94
MRI findings
ring-enhancing lesion
Early (1-2 weeks): lesion poorly demarcated, localized edema, acute inflammation, no tissue necrosis)
Late (>2 weeks): necrosis & liquefaction, lesion surrounded by fibrotic capsule
95
Tx for brain abscess
CT-guided aspiration/surgical excsion (neuro)
Abx empirically
Continue focused abx 4-8 weeks (must be IV)
Track regression/progression w/ MRI
96
oral source tx
Metro + Pen G
97
Otogenic/sinus source Tx
metro + ceftriaxone/cefotaxine
98
Hematogenous spread tx
Vanco + Metro
99
Postop neuro pts tx
vanco + ceftaxidime/cefepime/meropenem
100
Penetrating trauma tx
vanco + ceftriaxone/cefotaxime
101
Unknown source of abscess tx
Vanco + ceftriazone/cefotaxime + metro
102
IEA usually due to
complication of neurosurgery
(can spread from osteolyelitis of skull from fetal monitoring probes)
Less common: sinusitis, otitis, mastoiditis
103
Character of IEA
Localized lesion with central collection of pus
Surrounded by wall of inflammatory tissue which may calcify
Rarely spread caudally due to tight attachment of dura at foramen magnum
104
Presentation of IEA
Signs and symptoms from infection and expanding abscess
Common – fever, headache, lethargy, N/V
If secondary to sinusitis =
- =/- purulent drainage from nose or ear
Can compress the brain =
- Increased ICP
- Papilledema
- +/- focal neurologic changes
105
Dx of IEA
CBC with diff, ESR – can be variable
MRI w/contrast
CT with contrast if MRI not available
CT guided aspiration or open drainage for stains and cultures
106
Tx of IEA
drainage + empiric abx (start once sample of abscess obtained, by 1-2 d)
Neuro involvement (burr holes or craniotomy)
MRI repeated 4-6 weeks after tx
107
Drugs for contiguous spread
Metro + Ceftriaxone/cefotaxime
108
All other tx (post-neuro surgery/trauma) aka direct source
Vanco + Metro + Ceftriaxone/cefotaxime/ceftazidime
| covering for MRSA
109
Prognosis of IEA
very good
110
SEA
Spinal epidural abscess
| - in the spine, below foramen magnum
111
Pathophys of SEA
Bacteria gain access (hematogenous, direct extention (osteomyelitis), direct inoculation (epidural cath))
Longitudinal extension (acutely, may contain pus but often granulation tissue); more common in thoracolumbar area
Damage to spinal cord: compression, thrombosis of vessels, bacterial toxins/inflammation, arterial blood supply interruption
112
Most common area of SEA
thoracolumbar area
113
Microbes involved in SEA
s. aureus
Gram neg bacilli
strep
Coag neg staph (more common following spinal manipulation)
114
SEA risk factors
```
Diabetes mellitus
Alcoholism
HIV
Epidural catheter
Paraspinal injection
Trauma
Tattooing
Acupuncture
Bacteremia
IV drug abuse
Hemodialysis
```
115
Presentation of SEA: triad
fever
spinal pain
neuro deficit
116
Sx of SEA
fever
spinal pain
neuro deficit
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)
117
Dx of SEA
CBC with diff, ESR – may be elevated or normal
MRI w/contrast ASAP first line
- Positive early in course of infection
- Imaging of entire spine – “skip lesions”
- Differentiates epidural soft tissue edema from abscess
CT with contrast is 2nd line
CT guided extraction of pus from abscess for culture
118
Tx for SEA
blood cx x 2
Empiric abx ASAP (after cx)
Early surgical decompression and drainage
F/u MRI in 4-6 weeks
119
Abx for SEA
Vanco + (cefotaxime or ceftriazone or cefepime or ceftazidime)
120
Prognosis of SEA
```
death (5%)
irreversible paraplegia (22%)
related to duration of deficit
```
