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EMed Exam 2 > Neuro Emergencies > Flashcards

Neuro Emergencies Flashcards

1
Q

When to think CNS infection

A

Fevere
h/a
neuro s/sx

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2
Q

Bacterial meningitis: what is it?

A

NEURO EMERGENCY
inflammatory disease of leptomeninges
high morbidity/mortality

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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
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4
Q

Exposure during delivery (babies) meningitis

A

E.coli, GBS

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5
Q

Colonization from nasopharynx meningitis

A

sinusitis, OE, mastoiditis (Strep pneumo)

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6
Q

crowded conditions (military, college)

A

N. meningitides

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7
Q

Head trauma/Post-neuro procedures

A

Staph spp., gram (-)

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8
Q

Most common causes of meningitis

A

N. meningitides, S. pneumo

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9
Q

Risk factor of s. pneumo

A

Fractures of face/skull, cochlear implants

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10
Q

Risk factors for L. monocytogenes (older and neonates)

A

Defects in cell mediated immunity, malignancy, pregnancy, chronic glucocorticoids, alcoholism

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11
Q

Coag neg staph risk factors

A

Surgery, ventricular drains and foreign body

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12
Q

S. aureus risk factors

A

Endocarditis, surgery, FB, ventricular drains, ulcers

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13
Q

Who gets H. influenzae

A

unvaccinated children

adults

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14
Q

Risk factors for H. influenzae

A

Diminished humoral immunity

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15
Q

Gram neg. bacilli risk factors

A

neurosurgery w/wo drains

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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

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17
Q

Triad for meningitis

A

fever
nuchal rigidity
AMS

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18
Q

Tests for meningitis

A

Kernig
Brudzinski’s Sign
Jolt accentuation Test

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19
Q

Kernig sign

A

Inability or reluctance to allow full extension of knee when hip is flexed at 90 degrees

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20
Q

Burdzinski’s sign

A

Spontaneous flexion of hips during attempted passive flexion of neck

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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

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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)
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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

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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
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25
Q

Risk of LP with increased ICP

A

cerebral herniation

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26
Q

gram + diplococci

A

pneumococcal

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27
Q

gram - diplococci

A

meningococcal

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28
Q

gram - coccobaccili

A

H. influenzae

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29
Q

Gram + rods and coccobacilli

A

L. monocytogenes

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30
Q

Tx of bacterial meningitis

A

Dexamethasone (glucocorticoid) + empiric IV abx IMMEDIATELY after blood culture and LP

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31
Q

Role of dexamethason

A

decreases long term neuro sequelae

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32
Q

Newborn tx

A

Ampicillin (listeria) + cefotaxine or gentamycin

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33
Q

1-23 mo tx

A

(s. pneumo, hib, e.coli, n. meningitides)

Vanco + cefriaxone or cefotaxine + dexamethsone

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34
Q

2- 20 yo tx

A

vanco + ceftriazone/cefotaxime + dexamethasone

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35
Q

50+ tx

A

ampicillin (listeria) + vanco + ceftriazone or cefotaxime + dexamethasone

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36
Q

Immunocompromised

A

Ampicillin + Vancomycin + cefepime or meropenem + Dexamethasone

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37
Q

Tx for PCN allergy

A

Vanco + moxifloxacin + Bactrim

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38
Q

Basilar skull fx tx

A

Ampicillin + cefotaxime or gentamycin

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39
Q

Penetrating trauma/post-neurosurgery tx

A

Vancomycin + ceftazidime or cefepime or meropenem

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40
Q

When does dexamethasone work

A

pneumococcal meningitis

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41
Q

Dosage for dexamethasone

A

0.15 mg/kg q 6 hrs x 4 d

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42
Q

Add on if continuing steroid

A

Rifampin (better CNS coverage)

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43
Q

Complications of meningitis

A 
 Septic shock
 Disseminated intravascular coagulation
 Acute respiratory distress syndrome
 Possible neurologic long term complications:
- Impaired mental status or cognition 
- Sensorineural hearing loss
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44
Q

Vaccinations for bacterial meningitis against

A

s. pneumo
n. meningitides
h. influenza

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45
Q

Post exposure prophylaxis options

A

Cipro
Rifampin
Ceftriaxone (pregnant pts)

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46
Q

What is aseptic meningitis?

A

evidence of meningeal inflammation but bacterial cultures are negative (often called viral meningitis – but not always viral)

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47
Q

Tx for aseptic meningitis

A

Supportive

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48
Q

Most common cause of aseptic meningitis

A

Enterovirus (Coxsackie, echovirus) – summer and autumn

Others: HSV-2, VZV, mumps, HIV, WNV, EBV, CMV

Others (uncommon):
mycobacteria, fungi, spironchetes

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49
Q

Causes of aseptic meningitis

A

Viral
Malignancy
Drug induced (NSAID, bactrim)

50
Q

Drugs related to causing meningitis

A

NSAIDs
bactrim (abx)
chemo
phenazopyridine (pyridium)

51
Q

Diffuse, maculopapular exanthema in mildly ill patient

A

enteroviral infection
primary HIV
syphilis

52
Q

Thrush and cervical LAD

A

primary HIV

53
Q

asymettric flaccid paralysis

A

WNV

54
Q

vesicular genital lesions

A

HSV-2

55
Q

Unvaccinated

A

parotitis suggests mumps

56
Q

Dx for aseptic meningitis

A

 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
Q

CSF findings for aseptic meningitis

A 
 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
Q

Tx for aseptic meningitis

A

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
Q

When to give antiviral

A

immunocompromised or severe cases (Acyclovir)

60
Q

Difference between meningitis and encephalitis

A

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
Q

Pathogenesis of encephalitis

A

viral infection of CNS resulting in inflammation of brain secondary to:

  • Primary infection
  • Post infectious encephalitis: acute disseminated encephalomyelitis (ADEM)
62
Q

Primary infection

A

 Due to direct viral invasion of CNS
 Can be cultured from brain tissue
 +Neuronal involvement

63
Q

ADEM

A

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

immune response – attack on tissue

64
Q

Epidemiology of encephalitis

A

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
Q

most common cause of encephalitis

A

WNV

66
Q

Most common cause of fatal encephalitis

A

HSV-1

67
Q

Presentation of encephalitis

A

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
Q

Meningoencephalitis sx

A

photophobia and nuchal rigidity

69
Q

Clue for rabies

A

Hydrophobia, hyperactivity, pharyngeal spasms

70
Q

St. louis virus clues

A

Tremors tongue, lips, eyelids

71
Q

Flaccid paralysis and rash

A

WNV

72
Q

Dx for encephalitis

A

 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
Q

RBC in CSF

A

HSV-1 infection

74
Q

temporal lobe changes on MRI

A

HSV

75
Q

Hydrocephalus (ventricles huge) on MRI

A

bacterial/fungal/parasitic etiology

76
Q

Tx for encephalitis

A

Acyclovir 10 mg/kg/ IV q8h (r/o HSV)
Seizure prophylaxis/control
Diuretic if increased ICP (mannitol, furosemide)

77
Q

Worse prognosis for encephalitis

A 
diffuse cerebral edema
intractable seizures
Increased initial ICP 
(Serial ICP should be document for improvement)
HSV (high fatality)
78
Q

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

A

Cerebral abscess

79
Q

Causes of direct spread of abscess

A 
 Typically single abscess
 Otitis media, mastoiditis 
 Meningitis
 Head/facial trauma
 Sinusitis
 Dental infection
 S/P neurosurgical or spinal procedure
80
Q

Inferior temporal lobe & cerebellum abscess etiology

A

subacute and chronic OM

Mastoiditis

81
Q

Frontal lobe abscess etiology

A

Frontal or ethmoid sinusitis

Dental infection

82
Q

Causes of hematogenous spread

A 
 Usually multiple abscesses
 Associated with bacteremia
 Chronic pulmonary infection
 Skin infection
 Pelvic infection
 Intraabdominal infection
 Bacterial endocarditis
 Following esophageal dilatation
83
Q

Main type of abscess (bacterial/viral/fungal)

A

bacterial

84
Q

Abscess pathogen: paranasal

A

Strep spp.

Haemophilus

85
Q

Abscess pathogen: odontogenic

A

Strep

Bacteroides

86
Q

Abscess pathogen: otogenic

A

Strep
Enterobacter
Pseudomonas

87
Q

Abscess pathogen: penetrating head trauma

A

staph aureus

Enterobacter

88
Q

Abscess pathogen: neurosurgery

A

Strep spp
Staph spp
Pseudomonas

89
Q

Abscess pathogen: immigrant from mexico

A

Parasites (most common)

Cysticercosis (taenia solium infection- pork tapeworm)

90
Q

Pathogens in immunocompromised/HIV/AIDS

A

 Toxoplasma gondii
 Listeria monocytogenes
 Nocardia asteroides

91
Q

Fungal pathogens (multiple abscesses, poor outcome)

A

 Cryptococcus
 Coccidioides
 Aspergillus
 Candida spp

92
Q

Presentation of cerebral abscess

A 
 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
Q

Dx of cerebral abscess

A 
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
Q

MRI findings

A

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
Q

Tx for brain abscess

A

CT-guided aspiration/surgical excsion (neuro)
Abx empirically
Continue focused abx 4-8 weeks (must be IV)
Track regression/progression w/ MRI

96
Q

oral source tx

A

Metro + Pen G

97
Q

Otogenic/sinus source Tx

A

metro + ceftriaxone/cefotaxine

98
Q

Hematogenous spread tx

A

Vanco + Metro

99
Q

Postop neuro pts tx

A

vanco + ceftaxidime/cefepime/meropenem

100
Q

Penetrating trauma tx

A

vanco + ceftriaxone/cefotaxime

101
Q

Unknown source of abscess tx

A

Vanco + ceftriazone/cefotaxime + metro

102
Q

IEA usually due to

A

complication of neurosurgery
(can spread from osteolyelitis of skull from fetal monitoring probes)

Less common: sinusitis, otitis, mastoiditis

103
Q

Character of IEA

A

 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
Q

Presentation of IEA

A

 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
Q

Dx of IEA

A

 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
Q

Tx of IEA

A

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
Q

Drugs for contiguous spread

A

Metro + Ceftriaxone/cefotaxime

108
Q

All other tx (post-neuro surgery/trauma) aka direct source

A

Vanco + Metro + Ceftriaxone/cefotaxime/ceftazidime

covering for MRSA

109
Q

Prognosis of IEA

A

very good

110
Q

SEA

A

Spinal epidural abscess

- in the spine, below foramen magnum

111
Q

Pathophys of SEA

A

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
Q

Most common area of SEA

A

thoracolumbar area

113
Q

Microbes involved in SEA

A

s. aureus
Gram neg bacilli
strep
Coag neg staph (more common following spinal manipulation)

114
Q

SEA risk factors

A 
 Diabetes mellitus 
 Alcoholism
 HIV
 Epidural catheter
 Paraspinal injection 
 Trauma
 Tattooing
 Acupuncture 
 Bacteremia 
 IV drug abuse 
 Hemodialysis
115
Q

Presentation of SEA: triad

A

fever
spinal pain
neuro deficit

116
Q

Sx of SEA

A

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
Q

Dx of SEA

A

 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
Q

Tx for SEA

A

blood cx x 2
Empiric abx ASAP (after cx)
Early surgical decompression and drainage
F/u MRI in 4-6 weeks

119
Q

Abx for SEA

A

Vanco + (cefotaxime or ceftriazone or cefepime or ceftazidime)

120
Q

Prognosis of SEA

A 
death (5%)
irreversible paraplegia (22%)
related to duration of deficit

EMed Exam 2 (6 decks)

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