Week 22 - Case 1-4 Flashcards
what is papilloedema and what is it a sign of
this is a sign of raised intracranial pressure.
Papilledema is a disease entity that refers to the swelling of the optic disc due to elevated intracranial pressure (ICP). This term should be distinguished from disc edema which specifies a broader category of optic disc swelling secondary to other etiologies.
what may happen to visual fields in raised intracranial pressure
restricted visual fields
what nerve pasly is indicative of raised ICP
sixth nerve palsy
increased tone and brisk reflexes are what kind of motor neurone sign
UMN sign
what should one reduce with migraines
one should reduce caffeine consumption
what is first line acute treatment for migraines
simple analgesia such as paracetamol or NSAIDs
the addition of an anti-emetic may be beneficial for those prone to sickness
what are first line options for migraine prevention
propranolol, topiramate or amitriptyline
what can be used as a prevent cluster headaches
verapamil
is prednisolone used in migraines or cluster headache spells
prednisolone is not used in migraine, although can be used to abort spells of cluster headache
what is metoclopramide
an anti emetic
does topiramate cause weight loss
yes
what is recommend in tension type headaches. medication wise
amitryptiline 10mg at night to try and reduce the headache
what can meningitis be caused by
bacteria, viruses or fungi
in the UK, community acquired bacterial meningitis in adults and older children is usually caused by what strains
Streptococcus pneumoniae and Neisseria meningitides
what strain causes meningitis but mainly in patients over 50 yrs of age and in the immunocompromised
listeria monocytogenes
how are TB and meningitis related
TB can disseminate and cause meningitis
what are the most common causes of meningitis in neonates
In neonates, the most common causes are group B streptococcus, E. coli, and occasionally Listeria monocytogenes.
when is healthcare associated bacterial meningitis mainly seen after
neurosurgery or cranial trauma and in the presence of internal or external ventricular veins
what are the most common strains associated with healthcare associated bacterial meningitis
Staphylococci or aerobic gram-negative bacilli are the most common causes of these.
what are the 3 viral causes of meningitis
enteroviruses
mumps virus (and other paramyxoviruses)
herpes simplex virus (primary HSV infection or disseminated HSV)
what is the most common fungal cause of meningitis
Cryptococcus neoformans
in who is cryptococcus meningitis most commonly seen
in patients with severe deficiencies in cell-mediated immunity, such as patients with HIV
how to patients with bacterial meningitis present
typically present with a fever over 38 degrees, severe headache, nausea, neck stiffness and a change in mental status usually of sudden onset and are acutely unwell
what are the less common manifestations of bacterial meningitis
seizures, aphasia, or hemi- or monoparaesis, coma, cranial nerve palsy, rash and papilledema
in what cases is the classic meningococcal rash seen
seen in patients with Neisseria meningitides meningitis (meningococcal disease).
what percentage of patients with meningococcal infection present with sepsis with or without meningism
10-20%
what is kernig’s sign
position the patient on their back with their hips flexed to 90 degrees
this test is positive if there is pain on passive leg extension at the knee joint
what is Brudzinkski’s sign
position the patient on their back and passively flex their neck.
this is positive if the patient involuntarily bends their knees
what are the main differential diagnoses for meningism beside bacterial meningitis
viral meningitis
fungal meningitis
tuberculous meningitis
drug-induced meningitis
encephalitis
malignancy
CNS abscess
HIV infection
subarachnoid haemorrhafge
when should a lumbar puncture be done in suspected meningitis
should be performed within 1 hour of arrival at the hospital if it is safe and the patient is haemodynamically stable
what should be commenced immediately after a LP
antibiotics
what should happen if a LP cannot be performed in one hour of arrival to hospital
blood cultures should be taken, antibiotics started and an LP when sadde
what laboratory investigations are you going to request for suspected meninigitis
Bloods:
- Blood cultures
- FBC, U+E, LFTs, and clotting screen – to rule out coagulation abnormalities, inflammatory markers may be raised, and platelets may be low.
- Meningococcal and pneumococcal PCR
- Glucose – to compare with the CSF
- HIV test
Throat swab:
- Microscopy, culture, and sensitivity
CSF:
- Microscopy, culture, and sensitivity
- Viral PCR
- Protein
- Glucose
- Lactate
which intervertebral space will you aim to insert your needle into for a LP
between L3 and L4 or L4 and L5 because this is below the level at which the spinal cord terminates
what should you make sure the patient doesnt have before an LP
make sure the patient is not taking anticoagulants or have a clotting disorder
when should a head CT be performed before an LP
Immunocompromised state
History of central nervous system (CNS)infection, masses, or stroke
New-onset seizure
Papilledema
Altered consciousness
Focal neurologic deficit
what do patients with bacterial meningitis urgently require for treatment
IV antibiotic treatment with agents that penetrate the CSF well and cover the likely pathogens according to history
what is the first line antibiotic treatment for community acquired meningitis
ceftriaxone IV with additional amoxicillin IV if listeria is likely
what is the alternative treatment for community acquired meningitis if there is severe penicillin allergy
Chloramphenicol IV.
what is treatment for strongly suspected bacterial meningitis
Dexamethasone IV 10mg four times daily for four days can be started within 12 hours of antibiotics commencement.
what is given for confirmed meningococcal meningitis
oropharyngeal eradication is required either ceftriaxone or a single dose of ciprofloxacin alongside treatment.
what are the treatment options for viral meningitis
there currently are no proven beneficial treatments for viral menigitis
Once the diagnosis of viral meningitis is made, antibiotics should be stopped. Some clinicians treat herpes meningitis with acyclovir or valaciclovir, but to date, there is limited evidence for this to be effective. Treatment should be supportive with analgesia and fluids if necessary.
what is characterisically seen in patients with raised ICP headaches
her headaches are made worse by straining or bending over
what are the typical examination findings of raised ICP
Papilloedema, restricted visual fields and enlarged blind spots are all typical of raised intracranial pressure.
if there is right sided pronator drift what does this indicate
a left hemisphere space occupying lesion
what may be given if there is a significant amount of oedema and swelling seen on a head CT
dexamethasone
what are extradural haemorrhages usually a result of
an arterial bleed which is vulnerable to trauma on the temporal region of the head
what is the pattern of consciousness with extra dural haemorrhages
patients may regain consciousness following a brief period of impaired consciousness at the time of injury
this initial loss of consciousness is usually the result of cerebral concussion
when does the level of consciousness begin to deveop
when the haemotoma develops
what does the lucid interval in extra dural haemorrhages risk
frequently results in delayed or missed diagnosis with catastropic consequences.
describe the typical clinical presentation of a subdural haematoma
Unlike extra-dural haematomas, sub-dural haematomas are venous in origin and hence they may occur even after a trivial injury in a vulnerable subject. Elderly patients, alcoholics and other debilitated people are at higher risk. The haematoma develops very sowly (a venous ooze) and hence the latent period between the injury and clinical presentation may be weeks or even months. Headache, drowsiness and confusion are common in the late stages. Fluctuating level of consciousness for a variable period is typical of SDHs as the haematoma contracts and expands due to osmotic effects.
what are the two classifications of brain tumours
Primary brain tumours: arise from the intracranial structures such as meninges (meningioma) or glial cells (gliomas or astrocytomas). Meningiomas are usually slow growing. Whereas gliomas show a range of growth with multiforme being the worst.
Secondary metastases: from primary tumours usually arising from bronchus, breast, stomach, prostate, thyroid or kidneys
what does a generalised myoclonic seizure described as
early morning shakines
what is standard practice in the UK for people who have developed seizures
MRI brain
what is the most common antiepileptic medication
lamotrigine
what is the rule with seizures and the DVLA
in the UK this patient would have to refrain from driving until he is seizure free for one year
A 24 year old man presents to A+E with severe right sided headaches at night. The brief headaches wake him from sleep several times per night and have been going on for the last 2 weeks. During the headache his eye waters and his nose feels blocked. He describes the headaches as the most severe he’s ever had. Neurological examination is normal. He is otherwise fit and well. He smokes 20 cigarettes per day and does not drink alcohol. He works shifts as a safety operative in a nuclear power plant. What is the likely cause of his headaches?
cluster headaches
what type of headaches make people wake from their sleep
cluster headaches
what are brief recurrent nocturnal headaches suggestive of
cluster headaches
what are daily featureless headaches usually suggestive of
tension headaches
what do sharp shooting pains around the face suggest
trigeminal neuralgia
what does whoosing tinnitus and pain worse on standing suggest
features of low CSF pressure headaches
The following CSF results are obtained in a patient presenting with acute headache, fever and neck stiffness:
Opening Pressure: 28cm (nr <20cm)
CSF white cell count – 566 (90% neutrophils) (nr <4WBC)
CSF protein – 1.1g/L (nr <0.4g/L) CSF glucose – 2.8mmol/L (nr >50% plasma gluc)
Plasma glucose 6.1mmol/L
What is the most likely diagnosis?
bacterial meningitis
The basic clinical syndrome is consistent with meningitis. The CSF pattern of raised pressure, neutrophilic leucocytosis and low glucose is highly suggestive of a bacterial aetiology.
A 24 year old woman attends her GP due to episodes noted by her new boyfriend. He describes her as seeming to stare into space and chew her lip for 1-2 minutes. She then seems confused for about 5minutes before returning to normal. The patient sometimes feels that she knows when an attack is going to happen but finds it hard to describe this feeling.
What is the most likely diagnosis?
focal impaired awareness seizures
what are the typical characteristics of focal impaired awareness seizures
loss of awareness coupled with what sound like orofacial automatisms.
a brief postictal period of confusion is common after such events
A 52 year old man with known advanced alcoholic liver disease is admitted to A+E with a low GCS following a witnessed generalized tonic clonic seizure at home.
What is the most appropriate initial investigation?
Blood glucose
In any patient presenting with altered conscious level a blood glucose is a vital initial test. In this patient hypoglycaemia could be the cause of both the seizure and the reduced GCS. Patients with advanced liver disease are at increased risk of hypoglycaemia due to faulty hepatic gluconeogenesis.
