Neuro (NEW) Flashcards

1
Q

Meningitis background

A

Epidemiology

  • bacterial
  • > peak in neonates and elderly
  • > high rate in children
  • viral
  • > more common than bacterial

Aetiology

  • bacterial
  • > s. pneumoniae (most common/decreasing incidence)
  • > h. influenza b (decreasing influence)
  • > n. meningiditis (any age)
  • > l. monocytogenes (neonates/old/immunocomp/alcohol)
  • > GBS (neonates)
  • > e. coli (neonates)
  • > gram negative rods (skull fracture/neurosurgery)
  • viral
  • > enterovirus (most common)
  • > HSV 1 and 2
  • > varicella zoster
  • > west nile
  • > HIV

Pathophys

  • haematogenous spread most common
  • microbe enters subarachnoid space and proliferates
  • inflammation
  • > increased permeability of BBB and influx inflamm cells
  • > oedema and raised ICP
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2
Q

Meningitis clinical manifestations

A

Hx

  • Presenting complaint
  • > acute or gradual onset
  • > headache
  • > neck stiffness
  • > photophobia
  • > fever
  • > altered mental status
  • > seizures
  • > vomiting
  • Neonate
  • > any non specific sign of infection
  • > jaundice
  • > hypothermia
  • > apnoea
  • > bulging fontanelle
  • Elderly
  • > altered mental status
  • Viral screen
  • > sore throat (enterovirus)
  • > sores around mouth/genitals (herpes)
  • > shingles (varicella)
  • Exposures
  • > antecedent illness
  • > trauma or infection around head
  • > sick contacts
  • > immunosuppression (corticosteroids, alcohol)
  • > travel
  • > animal/insect bites
  • Vaccination hx

Exam

  • vitals
  • > sepsis/shock
  • > cushings triad
  • assess level of consciousness/confusion
  • rash
  • > petechial/purpuric (meningococcal/enterovirus)
  • > maculopapular (early meningococcal/enterovirus)
  • meningism
  • > nuchal rigidity (resistance to passive neck flexion)
  • > kerning’s (resists straitening flexed knee w. hips flexed)
  • > brudzinskis (neck flexion causes knee/hip flexion)
  • papilloedema/bulging fontanels
  • > raised ICP
  • focal signs
  • > CN III, IV, VI palsies (eye movements)
  • > facial palsies
  • > hemi/quadriparesis
  • source of infection
  • > sinusitis
  • > mastoiditis
  • > otitis media
  • > pneumonia
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3
Q

Investigations meningitis

A

Consider CT before LP if signs of raised ICP
-oedema and hydrocephalus common in meningitis

Lumbar puncture

  • opening pressure raised
  • cell count and differential
  • > higher WCC in bacterial
  • > pleocytosis bacterial
  • > mononuclear cells classically in viral (not always)
  • protein
  • > raised in bacterial/normal or raised in viral
  • glucose
  • > low in bacterial (CSF:serum glucose <0.4)
  • > may be low in viral (CSF:serum glucose >0.5)
  • lactate
  • > high in bacterial
  • > helps rapidly distinguish aseptic from bacterial
  • gram stain
  • > much faster than culture
  • > sensitivity varies by etiological organism
  • culture
  • > high sensitivity but low after antibiotics
  • PCR multiplex for viral and bacterial pathogens
  • > rapid
  • > highly sensitive and specific
  • latex agglutination for n. meningitis capsular antigen
  • > rapid results
  • > little utility
FBC
-leukocytosis 
-DIC (anaemia and thrombocytopaenia)
Metabolic panel (glucose, electrolytes, CMP)
-all may be low
CRP
-normal excludes bacterial when gram stain negative
Coags
-evidence of DIC
Blood culture
-may be positive in bacterial
Consider procalcitonin
->sensitive and specific for bacterial
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4
Q

Meningitis treatment

A

Bacterial

  • neonate <2mths
  • > benzylpenicilin 60mg/kg IV
  • > cefotaxime/ceftriaxone 50mg/kg IV
  • > no steroids
  • adults and child >2mnths
  • > cefotaxime/ceftriaxone 2g (child 50mg/kg) IV
  • > dexamethasone 10mg (0.15mg/kg) IV before antibiotics
  • notifiable disease and contact tracing/prophylaxis
  • > h. influenza
  • > s. pnuemoniae
  • > n. meningiditis
  • audiology follow up 2 months post discharge
  • monitor neurodevelopment

Viral

  • treat with antibiotics and steroids until confirmed
  • supportive care
  • > hydration
  • > analgesia
  • > antipyretics
  • > anti-emetics
  • aciclovir if
  • > HSV
  • > varicella
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5
Q

Reversible cerebral vasoconstriction syndrome overview

A

Epidemiology

  • can occur at any age
  • > most common in middle age
  • much more common in women

Aetiology

  • unknown
  • majority
  • > post partum
  • > post adrenergic/serotinergic drug

Pathophys

  • reversible cerebral artery narrowing
  • outcome
  • > parenchymal oedema
  • > stroke
  • > convexal SAH

Clinical manifestations

  • thunderclap headache
  • > last for a few hours
  • > recurrence is common shortly after
  • > long term recurrence is rare
  • following trigger
  • > exertion
  • > emotions
  • > sex
  • nausea
  • photosensitivity
  • HTN
  • seizure/stroke symptoms may occur

Investigations

  • MRI
  • > often normal
  • > parenchymal oedema/haemorrhage
  • > convexal SAH
  • > bilateral watershed infarcts
  • MRA
  • > sausage on a string arteries
  • consider
  • > LP as thunderclap work up
  • > FBC/EUCs/ESR for differentials

Management

  • supportive
  • > analgesia
  • > BP
  • > seizures
  • > stroke
  • disease recurrence is unusual
  • > avoid triggers for several weeks
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6
Q

Spontaneous intracerebral haemorrhage background

A

Epidemiology

  • approx 15% strokes
  • incidence increases with age
  • risk factors
  • > HTN
  • > anticoagulation/antiplatelets (mainly warfarin)
  • > high alcohol intake

Aetiology

  • Hypertensive vasculopathy (most common)
  • Cerebral amyloid antipathy (older adults)
  • AV malformation (children)

Pathophys

  • Penetrating arteries exposed to pressure of parents
  • > basilar penetrators (pons/mid brain)
  • > thalamostriate off PCA (thalamus)
  • > lenticulostriate off MCA (putamen/caudate)
  • > cerebellar
  • Expanding clot and perilesional oedema
  • > rising ICP/decreased perfusion/ischaemia/herniation
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7
Q

Spontaneous intracerebral haemorrhage findings and specific management

A

General presentation

  • may occur due to trigger or spontaneous
  • signs and symptoms progress gradually
  • headache
  • vomiting
  • meningism if intraventricular blood
  • altered mental status/LOC (late sign)
  • occasionally
  • > seizures
  • > arrhythmias and trops

Syndromes

  • putamen (most common)
  • > hemiplegia/hemisensory loss
  • > homonymous hemianopia
  • > gaze palsy
  • internal capsule
  • > dysarthria
  • > hemiplegia/hemisensory loss
  • thalamus
  • > hemiparesis/hemisensory loss
  • > upward gaze palsy with fixed miosis
  • > inward peering or preference to ipsilateral
  • pontine
  • > coma (RAS)/paraylysis/miosis
CT non con
->ischaemic vs haemorrhagic stroke
->midline shift
->estimate haemorrhage volume
->subarachnoid expansion
->predict haemorrhage expansion 
CT agnio
-underlying aetiology
->aneurysms/vascular malformation?
->micro bleed location (amyloid vs HTN)
-predict haemorrhage expansion (spot sign)

Specific management

  • BP
  • > treat if hypertensive
  • > aggressive treatment favoured if SBP>220
  • ICP
  • > maintain head at 45 degrees
  • > mild sedation
  • > consider monitoring/mannitol/CSF drainage
  • Anticoag/antiplatelet ceased and reversal
  • > warfarin = FFP + vitamin K
  • > UFH = protamine
  • > aspirin = desmopressin
  • Surgery
  • > haematoma excavation for cerebellar or hydrocephalus
  • > craniotomy for supratentorial bleed is controversial
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8
Q

Aneurysmal SAH evaluation

A

Hx

  • thunderclap headache following trigger
  • > exercise
  • > emotions
  • > sex
  • vomiting/LOC/nuchal rigidity
  • may develop seizure
  • may report sentinel bleed
  • risk factors
  • > family hx
  • > smoking/heavy alcohol
  • > HTN
  • > polycystic kidney disease/connective tissue disease
  • > simpathomimetics/anti-coags/anti-platelets

Exam

  • altered level of consciousness
  • HTN
  • meningism
  • eyes
  • > tersons
  • > papilloedema
  • > CN III/VI palsy
  • neurological signs
  • > nearly any

Investigations

  • CT non con
  • > SAH
  • follow with CT angio or DSA
  • LP if negative CT
  • > high opening pressure
  • > RBC count maintained across viles
  • > xanthochromia
  • ECG and troponins
  • > cardiac complications
  • FBC
  • > anaemia?
  • > thrombocytosis?
  • Coags
  • EUCs
  • > hyponatraemia
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9
Q

ddx and symptomatic causes seizures

A

Some Crazy People Try To Mimic Real Seizure Movements

  • syncope
  • cardiac arrhythmia with syncope
  • psychological
  • > psychogenic
  • > panic attack
  • TIA
  • Transiant global amnesia
  • Migraine with aura
  • Rigors
  • Sleep disorder
  • > narcolepsy
  • > cataplexy
  • Movement disorder
  • > tics
  • > tremor
  • > chorea

SHITTEDD

  • stroke
  • haematoma/haemorrhage
  • > epidural/subdural
  • > subarachnoid
  • infection
  • > meningitis/encephalitis
  • > abscess
  • TBI
  • tumour
  • encephalopathy
  • drugs and alcohol
  • degenerative
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10
Q

ddx dizziness

A

Vertigo

  • Big 3
  • > BPPV
  • > vestibular neuritis
  • > cerebellar stroke/posterior circulation ischaemia
  • Peripheral
  • > Menieres
  • > labyrinthine concussion
  • Central
  • > vestibular migraine
  • > acoustic neuroma/posterior fossa tumours
  • > MS

Syncope/presyncope (TROPICS)

  • TIA
  • Reflex vasovagal
  • Orthostatic hypotension
  • Panic
  • Intoxication/ingestion
  • Cardiac
  • Seizure

Balance (PIES)

  • Peripheral neuropathy
  • Injury
  • Eyes
  • Spinal pathology
  • > spondylosis
  • > cord compression
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11
Q

DDX bilateral lower limb weakness

A
Head
-stroke
Spinal
-FAINT
Nerves
-peripheral neuropathy
Muscles
-MG
-alcoholic myopathy
-myositis
Systemic illness
-infections
-anemia
-hypothyroid
-electrolyte abnormality
-heart disease
Meds
-beta blockers/chemo/opioids

Spinal cord compression (FAINT)

  • Fractured vertebrae
  • > osteoporosis
  • > steroids
  • > tumour infiltration
  • Abscess
  • Intervertebral disc
  • > discitis
  • > herniation
  • Neoplasia
  • > primary (meningioma)
  • > secondary (breast/lung/kidney/prostate)
  • Trauma
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