Seizures, Hematomas, Hemorrhages

Question 1

Tx for status epilepticus?

Answer 1

• ABCS’s + thiamine and dextrose
• Naloxone (stim resp centers)
• premonitory: diazepam (repeat 15m later)
• early status: IV lorazepam
• established status: phenobarbital bolus +/- phenytoin infusion

Question 2

Tx for refractory status epilepticus?

Answer 2

> 30 min**; general anesthesia using thiopentone + artificial ventilation

• Do not taper until 12 h after seizure

Question 3

EEG in pseudostatus?

Answer 3

no abn

Question 4

Confirm dx of status epilepticus?

Answer 4

EEG

titrate anesthesia until burst suppression is achieved

Question 5

Patients who do not need lifelong meds after sz:

Answer 5

• Patient that had one seizure after alcohol
• On baclofen for days and suddenly stops taking it
• Had closed head trauma but no SAH or no cracked skull
• May need AEDs for 2 weeks but then can get off

Question 6

Patients who need antiepileptics for life:

Answer 6

o Brain tumor resected with radiation
o Patient with HIV with low CD4 and had first seizure (Need to image and LP to determine if have infection, meningitis, toxo)

Question 7

Patients in ER for seizure who do not need LP:

Answer 7

o Taking baclofen for days and then suddenly stops

o Patient with much alcohol

Question 8

Patients in ER for seizure who NEED LP

Answer 8

Homeless man with DTs

Pt w/ new onset seizures should consider LP much more importantly than patient with hx of seizures

Question 9

When is depakote CI in status epilecticus?

Answer 9

if bleed in brain – can cause increased bleeding

Question 10

EPIDURAL/EXTRADURAL HEMATOMA:

MC cause?

Answer 10

tear in wall of meningeal artery, esp MCA; because arterial –> fast expansion
(usually asstd w skull frx)

Question 11

EPIDURAL/EXTRADURAL HEMATOMA:

Cause if in posterior fossa?

Answer 11

venous sinus is torn

Question 12

EPIDURAL/EXTRADURAL HEMATOMA:

CT?

Answer 12

bulging, convex pattern

Question 13

EPIDURAL/EXTRADURAL HEMATOMA:

s/s in anterior vs posterior fossa?

Answer 13

ant fossa:

• CONTRAhemiparesis
• Dilated then nonresponsive IPSI pupil
• CN3 compression and impending transtentorial herniation

Question 14

EPIDURAL/EXTRADURAL HEMATOMA:

management?

Answer 14

Immediately stabilize and intubate, and move to surgical interventions

You cannot simply rely on cerebral dehydration (elevation of head, etc)

Question 15

SUBDURAL HEMATOMA:
MC cause?
MC location?

Answer 15

stretching or tearing of veins that drain from the surface of the brain to the dural sinuses

over the lateral cerebral convexities

Question 16

SUBDURAL HEMATOMA:

Who is particularly prone?

Answer 16

Elderly and alcoholic w/ cerebral atrophy are particularly prone (bridging veins “hanging” loose)

Question 17

SUBDURAL HEMATOMA:

CT?

Answer 17

hyperdense cresentric collection across the entire hemispheric convexity

Question 18

ACUTE SUBDURAL HEMATOMA:

S/s?

Answer 18

ipsalat pupil dilation
contralat hemiparesis
**w/in 72h

Question 19

Chronic SUBDURAL HEMATOMA:

When do you see symptoms?

Answer 19

~21d after injury

**likely in pt >50 w/ no evidence of head trauma; incr risk if overdraining VP shunt

Question 20

SAH:

etiology?

Answer 20

o Rupture of aneurysm (congenital weakening in Circle of Willis) o AVM
o Trauma
o Vessel weakness from infection (mycotic aneurysms)
o Coagulopathies

*30-40% mortality in first few days –> significant risk of re-bleed in first 6 weeks

Question 21

SAH:

s/s?

Answer 21

• Sudden severe HA+ photophobia
• N/V
• Meningismus (Neck stiffness, Kernig’s sign)
•  Severe hemorrhages: incr ICP = decr consciousness + papilledema + retinal hemorrhages (–> vessel spasm)

Question 22

SAH:

systemic s/s?

Answer 22

decr HR 
incr BP 
incr temp (hypothalamic damage?) 
pulmonary edema 
cardiac arrhythmias

Question 23

SAH:
tx?
complications?

Answer 23

Bed rest + analgesia + NIMODIPINE

hydrocephalus

Question 24

SAH 2/2 AVM may present with…

Answer 24

epilepsy

Question 25

ICH:

etiology?

Answer 25

HTN w/ microaneurysm (Charcot-Bouchard aneurysm)

Bleeding tumors

Blood and blood vessel disorders (AVM, vasculitis, amyloid)

Trauma

Question 26

ICH:

presentation?

Answer 26

focal neurological signs depending on the site
Sz
features of incr ICP

Question 27

ICH:
dx?
complications?

Answer 27

CT

hydrocephalus, coning

Question 28

ICH:

tx?

Answer 28

• anti-HTN drugs
• anticonvulsants
• correct coagulopathy
• mannitol for incr ICP

*srx: evacuate hematoma, ventr drainage