Sz, Stroke and Infections Flashcards
1
Q
define these types of seizure
Absence:
Myoclonic:
Tonic:
Clonic :
Atonic :
Tonic-clonic :
A
Absence: petite mal sz –cessation of activities, blank stare
Myoclonic: brief shock like contraction of m.
Tonic: ↑ in muscle contraction (extension)
Clonic : prolonged repetitive contractions
Atonic : loss of muscle tone
Tonic-clonic : sequence of tonic followed by clonic
2
Q
dx of SZ
A
FS Glu – hypoglycemic common cause of seizure
Head CT/MRI - Evaluation for underlying cause of SE
EEG
- Evaluation for continuing Sz activity
- Distinguish between types of epilepsy
3
Q
define types of SZ & causes
provoked
unprovoked
focal
generalized
A
Provoked – have an underlying cause
- Hemorrhagic ischemia / stroke
- Encephalopathy
- Drugs/alcohol
Unprovoked – no underlying cause
- Prior stroke, vascular malformation
- Dementia
- Brain tumors
Focal - one cerebral hemisphere
Generalized –BOTH hemispheres
4
Q
define status epilpeticus
A
Continuous Sz OR Repeated Sz w/o resumption of consciousness
Sz duration: 15-30 min
Practically: ≥2 discrete Sz lasting ≥5 min
5
Q
status epilpticus sz can be divided into what 2 categories
A
convulsive
nonconvulsive
6
Q
tx of convulvive SZ
first IV
second IV
NO IV access
when stable
A
FIRST IV – benzos IV Lorazepam/ diazepam
- Wait 3 mins and give more benzo
SECOND IV – anticonvulsants
- Fosphenytoin / phenytoin
- Valproic acid/ Levetiracetam
NO IV Access: IM / IN/ Buccal Midazolam
- Rectal Diazepam
+/- airway management + Continuous EEG
Once Stable: Midazolam/ Propofol/ Pentobarbital infusion
7
Q
GCSE: –> irreversible neuronal injury
A
- Cardiorespiratory dysfunction
- Hyperthermia
- Metabolic derangements
8
Q
GCSE sequelae:
A
Cardiac arrythmias
Hypoventilation/hypoxia
Systemic manifestations
Aspiration pneumonitis
Neurogenic pulmonary edema
Respiratory failure
9
Q
age afected by febrile sz
A
6m – < 5y ,
Peak age: 18m
10
Q
define 2 types of febrile SZ
A
Simple (more common) generalized sz
- <15 min, no recurrence in 24 hrs
Complex (focal) >15 min w/ Multiple Sz in 24h
- Younger kids OR Dev. Issues
11
Q
si/sx of febrile SZ
A
happen QUICK
- Generalized tonic – clonic
- Staring w/ change in muscle tone
- Jerking movements w/o prior stiffening
- Focal stiffness or jerking
12
Q
RF for febrile SZ
A
- Temp >38°C
- Viral infection
- Recent immunization(MMR, DTap)
- FHx/ Neurodevelopmental delays
13
Q
tx of febrile sz
>5 min
not controlled w/ first line
rectal diazapam if at risk for??
A
Sx >5 min
- IV Diazepam or Lorazepam
- Buccal Midazolam / IN Lorazepam
- Cardiorespiratory support
febrile status epilepticus not controlled w/ benzo –> Fosphenytoin
Rectal diazepam if at risk for:
- Recurrent OR prolonged febrile Sz
- Very low threshold for febrile Sz
14
Q
febrile sz- EEG & LP should be done??
A
LP: Concern for CNS infec.
- <12
- Prolonged complex febrile
- Febrile status epilepticus
- pretreated w/ abx
- Sz after 2nd day of illness
EEG: Febrile status epilep
15
Q
most common cause of embolic stroke
A
AFIB
16
Q
most common cause of ICH/ ischemic stoke
A
Hypertension
17
Q
define causes of hemhorragic stoke and list examples
A
•Bleeding into the cranial cavity
- Intracerebral hemorrhage (ICH)
- Subarachnoid hemorrhage (SAH)
18
Q
define causes of ischemic stoke and list example
A
Too little blood supply (oxygen and nutrients) to a part of the brain
-
Thrombosis (atherosclerosis)
- Large Vessels (classic) – suddenly develop paralysis
- _Small Vessel_s (indolent symptoms/dementia)
- Embolism (cardioembolisms)
- Systemic hypoperfusion – not enough perfusion to entire brain due to systemic issue such as hypoperfusion
19
Q
____and_____ strokes can develop hemorrhagic conversion
A
Thrombotic and embolic strokes can develop hemorrhagic conversion
20
Q
define SAH
A
Rupture of arterial aneurysms that lie at base of brain
Bleeding from vascular malformations that lie near the pial surface –>AV malformations
- Where CSF fluid would travel
21
Q
pathophys of SAH
A
Blood is released directly into CSF under arterial pressure–> Blood spreads quickly though CSF –> rapidly ↑ICP
- Death or coma if bleeding continues
- Bleeding lasts only a few seconds but rebleeding is common
22
Q
Abrupt onset, sudden, severe, widespread HA (“thunderclap” HA) “worst HA of my life”
A
SAH
23
Q
pathophys of ICH
A
Derived from arterials or small arteries bleeding directly into the brain –> forms localized hematoma that spreads along white matter pathways
- Accumulation of blood over minutes to hours
24
Q
RF for SAH
A
HTN
ETOH
Smoking
25
RF for ICH
* HTN
* ETOH
* Cocaine/amphetamines
* Advancing age
26
si/sx of ICH
Symptoms increase gradually over minutes to hours
* do not begin abruptly and are not maximal at onset
27
ICH si/sx basd on location
## Footnote
putamen & internal capsule
cerebellum
left temporal lobe
**putamen & internal capsule** --\> contralateral limb motor and/or sensory signs
**cerebellum --\>** difficulty walking
**left temporal lobe** --\> aphasia
* Headache
* Vomiting
* ↓ consciousness if hematoma large enough to ↑ICP
28
Coma is a complication of what type of stroke
SAH
29
thrombotic stroke can be divided into what 2 categories
give examples of each
**Large Vessel Disease**
_Extracranial aa:_
* Internal carotid arteries
* Vertebral arteries
_Intracranial aa:_ Circle of Willis & proximal branches
**Small Vessel Disease:** AKA Lacunar infarcts
_Intracerebral arteries arise from:_
* distal vertebral artery
* basilar artery
* middle cerebral artery stem
* Circle of Willis
30
# define Lacunar Infarcts
cause
mechanisms
Small (0.2 to 15mm in diameter) – mostly asymptomatic due to size
Non-cortical infarcts, _discovered incidentally_
_Caused_ by occlusion of single penetrating branch of an artery
_Mechanisms_ for occlusions are most likely from:
* lipohyalinosis (rather than typical thrombosis/embolism
* but can also be from typical athersclerosis
31
Lacunar Infarcts are what type of stroke
thrombolic small vessel ischemic stroke
32
define Cerebellar tasks
Cerebellar tasks
* Romberg
* heel to shin
* finger to nose
33
when speaking w/ a stroke pt is it MOST important to ???
this is due to what about medication admin??
establish the time of onset of stroke symptoms
\*Therapeutic window for IV thrombolysis- 4.5 hrs from symptom onset
34
tx of acute stroke
**Thrombolysis** w/n 4.5 hrs (best if \<60min)
* thrombolysis (Alteplase = tPA)
**BP management**: thrombolysis tx only \<185/\<110
**Fluid management (IVNS)**
* ↓intravascular volume
* avoid excess free water - exacerbate cerebral edema
**Tx hypoglycemia** (can cause focal neurologic deficits that mimic stroke and can cause neuronal injury)
**Tx hyperglycemia** (may augment brain injury)
**Admit to telemetry**
35
ischemic stroke ongoing tx
**Mechanical thrombectomy** --\> large artery occlusion in the anterior circulation w/in 24hours of symptom onset
**Aspirin** w/in 48 hours of onset
High intensity **statin therapy**
**HTN management**
36
work - up of cause of stroke
cardioembolic
astherscolerosis
**Cardioembolic**
* Heart Rhythm Monitoring - EKG, continuous telemetry, holter monitor – assess for Afib
* _Transesophageal echo_
**Assess for atherosclerosis / risk**:
* Bilateral carotid US --\> i_nt carotid a. stenosis_
37
secondary prevention of stroke tx
atheroscleosis
Afib
**Atherosclerosis**:
* Clopidogrel (Plavix) or Aspirin + ER dipyridamole (Aggrenox)
* OR just Aspirin
**For afib:** Anticoagulation
* Warfarin (Coumadin)
* Dabigatran (Pradaxa)
* Rivaroxaban (Xarelto)
* Apixaban (Eliquis)
38
List TOAST Classification for stroke
**Large Artery atherosclerosis** –
* Carotid a.
* Vertebral a.
* Circle of Willis
**Cardioembolic** – Afib/ flutter
_Small Vessel occlusion:_
* Atherosclerosis
* Lacunar infarct
**Undetermined other etiology**
**Undetermined etiology**
* Two or more causes identified
* Negative evaluation
* Incomplete evaluation
39
causes of systemic hypoperfusion
Cardiac pump failure (ex. arrest, arrythmia)
DEC CO (ex. MI, PE, hemorrhage)
Iatrogenic (ex. aggressively lowering BP)
Encephalopathy
40
identify and describe complication of systemic hypoperfusion
**Watershed infarct -** most severe global ischemia
Occurs in border zone regions b/w major cerebral supply arteries
* Cortical blindness
* Stupor
* Weakness of the shoulders and thighs, sparing face, hands and feet “man-in-a-barrel
41
imaging options for stroke & thir pros and cons
**Non-Contrast Head CT** \>48hrs– r/o bleed, other causes (Rapid)
* _Will NOT demonstrate acute stroke_; takes 24-48h to show up on CT
**MRI brain** : \<48 hrs Sensitive & Detects early, evolving cerebral infarction
* Limited by availability, cost, claustrophobia
42
identify classifications of stroke on NIH stroke scale
0 – no stroke sx
1-4 minor stroke
5-15 mod stroke
16-20 mod-severe stroke
21-42 severe stroke
43
High-risk cardiac sources of embolic stroke
* **\*\*Afib and paroxysmal Afib**
* Rheumatic mitral or aortic valve disease (dilated chambers)
* Bioprosthetic and mechanical heart valves (immediate post-procedure
* Atrial or ventricular thrombus
* Sinus node dysfunction (atrial thrombus)
* Sustained atrial flutter (atrial thrombus)
* _Recent MI_ (↓ inotrope and/or ventricular wall stunning post reperfusion)
* Dilated cardiomyopathy
* Infective endocarditis
44
Other Potential Cardiac Source of Embolic Stroke
* \*Patent foramen ovale
* Mitral annular calcification
* Atrial septal aneurysm
45
MC cause of Thrombotic stroke
artery invilved?
•Atherosclerosis (internal carotid aa.)
46
MC cause of embolic stroke
Afib
47
MC cause of thromboembolic stroke
carotid a. stenosis --\> second leading cause of ischemic stroke after Afib
48
second leading cause of ischemic stroke after Afib
carotid a stenosis
49
differentiate b/w CVA and TIA
**Transient ischemic attack (TIA)** – “mini stroke” like ischemia – no death of brain tissue
* neurologic sx are temporary \< 24hours.
**Cerebrovascular accident** (CVA = infarction) – causing long lasting death of brain tissue (\>24 hours
50
Goals of stroke rehab
* Functional restoration
* Community reintegration
* Maximize quality of life
51
initial stroke rehab interventions
* Assess ability to swallow (aspiration is a large risk)
* Patient and caregiver education
* Motor assessment, activation, exercises
52
deficits addressed during stroke rehab
**Language**:
* _aphasia_ – speech pathologist, computer (or ipad) based modalities
* _Dysarthria_ – articulatory treatment
**Cognition**
* Attention/ Concentration
* Perception / Memory / Executive functioning
**Swallowing**
53
common pathogens responsible for bactera meningitis
**N. meningitidis:** no predisposing conditions & Occurs in outbreaks
* High-risk groups: individuals who live in close quarters
**S. pneumoniae**
* Infection: PNA, OM, Sinusitis
* Asplenia
* Hypogammaglobulinemia
* Complement deficiency
* Alcoholism
* DM
* Listeria
S. aureus
54
classic triad of bacterial meningitis
Classic triad:
* •Fever
* •HA (worse w/ movements)
* •Nuchal rigidity
55
lost si/sx of meningeal irritation
* Neck stiffness: Resistance in flexion (touch chin to chest)
* Kernig’s sign & Brudzinski’s sign
* Jolt accentuation of HA
* Meningococcal rash
56
define positive kernig & brudzinski signs
**Kernig’s sign** – pt supine w/ hip flexed to 90 --\>
* knee cannot be fully extended (+)
**Brudzinski’s sign** – passive flexion of neck causes flexion of legs & thighs
57
meningitis : Head CT/MRI: Prior to LP if:
* Head trauma
* Concern for mass lesion
* Immunocompromised state
* Known malignancy
* Focal neurologic findings
58
compare / contrast LP in bacterial vs viral meningitis
**Bacterial**
* ↑OP \>20m
* ↑cell count (_PMNs, L shift)_ \>1000
* ↑protein \>100
* ↓glucose \<10
**Viral**
* ↓OP \<20
* cell count (_Lymphocytes_) 5-500
* protein 5—150
* glucose normal
59
common pathogens responsible for viral meningitis
* **Enteroviruses**
* VZV
**•HSV**
* EBV
* Arthropod viruses
* HIV
60
tx of bacterial meningitis
**Broad spectrum abx**
* vanco + ceftriaxone or cefotaxime
* OR vanco + ampicillin + 3rd gen ceph
**LP is delayed** --\> Obtain Blood Cx & Start empiric antibiotics
**ICU admission**
**Dexamethasone**
61
tx of viral menigitis
none
_Hospitalized, severe cases w/ HSV, EBV, VZV_
IV Acyclovir
62
bacterial meningitis prevention
**Vaccination**
**Chemoprophylaxis of close contacts**
_In meningococcal disease:_ Rifampin
* Alt: Ciprofloxacin, Azith, CTX
_H. influenzae:_ unimmunized \<6 yr Rifampin
63
name 2 types of viral encephalitits and their causes
Sporadic --\> herpesvirus
Endemic --\> arbovirus (ex. WNV)- summer
64
si/sx of viral encephalitiis
**Like viral meningitis + sx of brain tissue involvement:**
* Altered consciousness
* Seizures
* Focal neuro- findings
Meningeal signs: variable
65
si/sx of viral encephalitis
## Footnote
**HSV**
**WNV**
**St Louis or WNV**
**mumps**
**rabies**
**VZV**
**HSV encephalitis:** Frontotemporal region:
* Olfactory hallucinations, Anosmia
* Bizarre behavior, Memory disturbance
Hemiparesis, Aphasia, Seizures
**WNV encephalitis:**
* Motor manifestations -\> acute poliomyelitis-like paralysis
* Maculopapular rash
**St Louis or WNV encephalitis:**
* Tremors of the eyelids, tongue, lips, extremities
**Mumps**: --\> Parotitis
**Rabies**:
* Hydrophobia, aerophobia
* Pharyngeal spasms, hyperactivity
**VZV**: grouped vesicles in dermatomal pattern
66
dx of viral enceph
**CSF studies:** CSF profile similar to viral meningitis
* lymphocyte predominance
* Viral PCR
* Viral specific Ab
* Viral Cx
**MRI**: ↑ signal in R temporal lobe confined predominantly to the _gray matter_
**EEG**
67
tx of viral encephalitis
HSV OR Severe EBV, VZV encephalitis:
CMV encephalitis:
**HSV OR Severe EBV, VZV encephalitis:** Acyclovir
**CMV encephalitis:** Ganciclovir +/or Foscarnet
68
tyopes of cerebral edema and their causes
**Vasogenic** (BBB breakdown) --\> Peritumor edema
**Cellular**
* Insult of glial, neuronal & endothelial cells
* Traumatic brain injury, Stroke
**Interstitial** (Disruption of CSF outflow) – meningitis
**Osmotic (osmolarity)** - Hyponatremia, DKA
69
in cerebral edema Prompt identification is crucial bc??
IF untreated --\>
brainstem compression & herniation --\> death
70
tx of cerebral edema
ICP monitoring & management:
* Positioning
* **Hyperosmolar therapy**: Mannitol, Hypertonic NS
* Antipyretics
* Sedatives, Paralytics
* Modulation of PcO2
* Surgical intervention
**Glucocorticoids** --\> vasogenic edema
*NO hypotonic IVFs*
71
brain stem herniation is a complication of what dz??
cerbral edema
72
RF for brain abcess
**•Otogenic (Paranasal sinusitis)**
**•Dental**
* Cardiopulmonary (cyanotic heart dz, ToF, PFO, endocarditis)
* Head injury
* Neurosurgical procedures
73
typical presentation & triad of si/sx in brain abcess
**Typical presentation:** expanding intracranial mass lesion
**Triad**
* headache
* •fever
* •focal neuro- deficit:
74
dx of brain abcess
**Stereotactic needle aspiration** --\> gram stain & cx
**Head CT/MRI:** Focal areas of hypodensity surrounded by ring enhancement
75
tx of brain abcess
**Neurosurgery drainage + abx**
* Empiric abx (_Metronidazole, Vanco, Ceftriaxone_)
**Glucocorticoids**: Dexamethasone- prevent cerebral edema
**Anticonvulsant ppx** – to prevent SZ
76
Infection within epidural space around spinal cord
•Hematogenous or direct spread
Dx? most common pathogen??
Spinal epidural abscess
S. aureus
77
si/sx of spinal epidural abcess
Stage 1: _Back pain & fever, HA_
Stage 2: _radicular pain_
Stage 3:
* _Spine tenderness_
* _Spinal irritation_
* _Sensory deficits_
Stage 4: hemiplegia/quad
78
tx of spinal epidural abcess
IV abx & Surgical drainage
* Vancomycin & 3rd generation Cephalosporin
* or Cipro-
79
causes of intrcranial epidural abcess
Staph. Aureus
Gram negatives
Streptococcus
Anaerobes
80
define Subdural empyema & most liekly cause
Infection in the space between dura & arachnoid
* Usually from infected paranasal sinuses
_Sinusitis_
81
si/sx of subdural emypema
* HA
* Fever
* Neuro deficits
* Stiff neck
* ICP
82
bacterial meningitis si/sx of nuchal rigidity shoes reistance to \_\_\_\_
FLEXION
83
pt w/ AMS & focal neuro findings?
viral encephalitis
