L7: Neuro emergencies pt 1 Flashcards
(91 cards)
1
Q
Inflammatory disease of leptomeninges
A
bacterial meningitis
2
Q
Bacteria access the CNS by…
A
- Bloodstream
- Contiguous spread
→ Inflammation damages the blood-brain barrier causing ↑ permeability→ alterations in protein and glucose transport→ Progressive cerebral edema with ↑ ICP and ↓ cerebral perfusion→ neurologic damage
3
Q
Possible complications of bacterial meningitis
A
septic shock
DIC
acute respiratory distress syndrome
long term neuro: AMS
impaired cognition
sensorineural hearing loss
4
Q
Labs for Bacterial meningitis
A
Positive Blood cultures X2 (before antibiotics) CBC with differential CMP, ESR, CRP Serum glucose→ compare to CSF glucose \+/- coag studie LP
5
Q
Gold standard for diagnosing bacterial meningitis
A
LP with CSF analysis
6
Q
G+ diplococci on gram stain is
A
pneumococcal
7
Q
G- diplococci on gram stain is
A
meningococcal
8
Q
G+ rods and coccobacilli on gram stain is
A
L monocytogenes
9
Q
G- cooccobacilli on gram stain is
A
H influenzae
10
Q
Bacterial meningitis presentation
A
Progressively→ days or following a febrile illness
Acutely→ signs and symptoms of sepsis, rapid over several hours, cerebral edema
HA (severe and generalized), Photophobia, N/V/A
Focal neurologic deficits
Weakness, cranial nerve palsies. Seizures
Altered mental status, Nuchal rigidity
Papilledema associated with ↑ ICP→ grade 1 to 4
Classic triad → Fever + nuchal rigidity + Altered mental status
11
Q
N meningitis bacterial meningitis appears
A
Petechial rash and palpable purpura
(+) Kernig’s sign, Brudzinski’s sign
(+) Jolt accentuation test
12
Q
Kernig’s sign
A
Inability/reluctance to allow full extension of knee when hop is flexed at 90 degrees
13
Q
Brudzinksi’s sign
A
Spontaneous flexion of hops during attempted passive flexion of neck
14
Q
Jolt accentuation test
A
Patient rotates head horizontally at a frequency of two times per second
(+) → exacerbation of an existing headache
15
Q
Predictive of adverse outcomes in bacterial meningitis
A
altered mental status, seizures, and/or hypotension
16
Q
Mainstay of treatment for bacterial meningitis
A
Dexamethasone .15mg/kg q 6 hours x 4 days
+
empiric IV antibiotics
immediately after blood cultures and LP
17
Q
Dexamethasone helps bacterial meningitis by and if….
A
Decrease rate of hearing loss. neurologic sequelae ,morbidity and mortality
Benefit only in pneumococcal meningitis
Only continue if gram stain or blood cultures (+) for S. pneumoniae
+/- add Rifampin if steroid continued
Initiated shortly before/same time as antibiotic therapy (or it does not improve outcome)
18
Q
2 types of injury most likely to have bacterial meningitis contiguous strep
A
Basilar skull fracture
Penetrating trauma/post-neurosurgery
19
Q
Who gets blood cultures (without LP) stat instead of blood cultures + LP STAT when there’s suspicion for bacterial meningitis
A
Immunocompromised History of CNS disease New onset seizure Papilledema Altered consciousness Focal neuro deficit
These ppl get a CT next, then an LP if no CI
20
Q
Bacterial meningitis types that we vaccinate against
A
S. pneumoniae
N. meningitidis
H. influenza
21
Q
Post-Exposure prophylaxis for bacterial meningitis
A
Cipro
Rifampin
Ceftriaxone* (pregnant patients)
22
Q
Your patient has pneumococcal meningitis as shown by gram stain/blood cultures
A
Continue the dexamethasone
Add rifampin
Targeted abx
23
Q
Your patient has non-pneumococcal meningitis as shown by gram stain/blood cultures
A
Discontinue dexamethasone
Targeted abx
24
Q
The gram stain or culture cam back negative but other CSF findings consistent with bacterial meningitis
A
Continue empiric antibiotic therapy + dexamethasone
25
Aseptic meningitis aka
"Viral meningitis" but it isn't always viral
26
Clinical evidence of meningeal inflammation but bacterial cultures are negative
Aseptic meningitis
27
Aseptic meningitis presentation
```
Similar presentation to bacterial meningitis
Symptoms less severe→ supportive care
Complete recovery with no sequela
Generally non-specific
Headache, Fever, N/V
+/-Photophobia
+/- Nuchal rigidity
```
28
Labs for aseptic meningitis
```
Follow same diagnostic approach as bacterial meningitis
Blood cultures X2 (before antibiotics)
+/-CT? (same criteria as bacterial)
CBC with differential, CMP, ESR, CRP
+/-Other (clinical suspicion)
```
29
Most common cause of viral aseptic meningitis
Enterovirus
30
Viral causes of aseptic meningitis
Enterovirus (*most common*)→ Coxsackie, echovirus
(summer and autumn)
HSV-2, VZV, mumps,
HIV, West Nile virus,, EBV, CMV
31
Causes of infectious non-viral meningitis
Rare
Mycobacteria
Fungi→ Cryptococcus, coccidioidomycosis
Spirochetes→ Treponema pallidum, Borrelia burgdorferi
32
Malignancy as a cause of aseptic meningitis
Direct invasion of the meninges (uncommon)
| Leukemia, lymphoma, melanoma, breast, lung, GI cancers
33
Drug induced aseptic meningitis can be caused by
Rare
Delayed hypersensitivity reaction vs. direct meningeal irritation
NSAIDs, TMP-SMX, chemotherapy,
phenazopyridine (pyridium)
34
Aseptic meningitis + travel
TB
35
Aseptic meningitis + ticks exposure
Borrelia burgdorferia
36
Aseptic meningitis + sexual activity
HSV-2
syphilis
HIV
37
Aseptic meningitis or encephalitis + unvaccinated + parotitis
Mumps
38
Aseptic meningitis + diffuse, maculopapular exanthema in mildly ill patient
Enteroviral infection
Primary HIV
Syphilis
39
Aseptic meningitis + oropharyngeal thrush + cervical LAD
Primary HIV
40
Aseptic meningitis or encephalitis + Asymmetric flaccid paralysis
West nile virus
41
If you've got aseptic meningitis and bacterial meningitis has been ruled out (aka CSF)
Discontinue empiric antibiotics
42
Viral Aseptic meningitis treatment
```
self limiting
supportive
analgesia
antipyretics
severe/immunocompromised get acyclovir
```
43
Drug induced Aseptic meningitis treatment
Discontinue meds and it'll resolve in a few days
44
Meningitis vs encephalitis
Meningitis→ preservation of cerebral function. Fever,headache, and meningismus more common.
Encephalitis→ abnormalities in brain function more common: AMS, seizures, motor or sensory deficits personality changes, speech or movement disorders
Meningoencephalitis→ unclear which→ +/- photophobia, nuchal rigidity
45
Arboviruses (2)
Can cause encephalitis
*West Nile Virus*
St. Louis encephalitis
Transmitted by mosquitos so more common in summer
46
Most common cause of fatal encephalitis
HSV-1
| causes epilepsy
47
Other causes of encephalitis
```
Influenza
Lyme disease
Rocky Mountain spotted fever
syphilis
Uncommon→ VZV, EBV, HIV, mumps, measles, rubella, rabies
```
48
West nile virus is found in
Africa
Asia
Europe
US
49
St. Louis virus is found in
Midwest/Southwest US
50
Lyme disease is found in
Wooded areas and Colorado
51
Primary infection in encephalitis
Due to direct viral invasion of CNS
Cultured from brain tissue
Neuronal involvement
52
Post-infectious encephalitis
Acute disseminated encephalomyelitis (ADEM)
No virus detected
Neurons are spared
Perivascular inflammation/demyelination
Typically occurs as initial infection is resolving
53
Encephalitis presentation
Headache, Fever
Altered mental status (subtle to unresponsive)
Confused, agitated, obtunded
Seizures (common)
Focal neurologic deficits
Hemiparesis, CN palsies, ↑ DTRs
Photophobia and nuchal rigidity (rare, may be seen in meningoencephalitis)
54
Encephalitis + tongue/lip/eye tremors
St. Louis virus
55
Encephalitis + hydrophobia, hyperactivity, pharyngeal spasms
Rabies
56
CSF findings indicative of HSV-1 as a cause of encephalitis
RBC
Decreased CSF/blood glucose
(also: temporal lobe changes on MRI)
57
MRI with contrast of encephalitis will show
+/- abnormalities acutely
3-4 days for changes:
Hydrocephalus→ bacterial, fungal, parasitic etiology
Temporal lobe changes (MRI) → HSV
58
Do serology for encephalitis if...
not improving or no pathogen identified→ IgM antibody serum and CSF testing for West Nile, mumps, EBV
59
Do a brain biopsy of encephalitis if...
Last resort
| etiology still unknown
60
Encephalitis prognosis
Initial diffuse cerebral edema or intractable seizures→ poor neurologic recovery, increased mortality
Elevated initial ICP → prognostic for bad outcome
Serial ICP→ document to show improvement
HSV most important to identify and treat→ fatal, causes epilepsy
61
Encephalitis management
Empiric→ Acyclovir 10 mg/kg IV q8 hours
Seizure prophylaxis/control
Increased ICP→ diuretics→ mannitol, furosemide
62
Encephalitis management
Empiric→ Acyclovir 10 mg/kg IV q8 hours
Seizure prophylaxis/control
Increased ICP→ diuretics→ mannitol, furosemide
63
Common viral causes of meningitis
```
Coxsackie
HSV-2
HIV
Mumps
Measles
```
*but all can still cause encephalitis*
64
Common viral causes of encephalitis
West Nile Virus
HSV-1
CMV
Influenza
*but can still cause meningitis*
65
Focal area of infection with a collection of pus resulting from infection, trauma, or surgery in the brain
Cerebral abscess
66
3 ways you could get a cerebral abscess
1. Direct spread→ typically a single abscess. Otitis media, mastoiditis, meningitis, head/facial trauma, sinusitis, dental infection, post neurosurgical or spinal procedure.
2. Hematogenous spread→ multiple abscesses and bacteremia. Infections: chronic pulmonary, skin, pelvic, intraabdominal, bacterial endocarditis. Following esophageal dilatation.
3. No site/underlying condition→ 20-40%
67
Cerebral abscess in inferior temporal lobe and cerebellum from direct spread is caused by
subacute or chronic otitis media, mastoiditis
68
Cerebral abscess in frontal lobes from direct spread is caused by
frontal or ethmoid sinuses, dental infection
69
Hematogenous spread causes abscesses in the _____
MULTIPLE ABSCESSES
| so everywhere
70
Cerebral abscess presentation
Nonspecific→ diagnostic delay
***Unilateral headache***
(unless multiple abscesses)
→ Sudden or gradual onset
→ Severe pain, not relieved with OTC pain medications
Fever (45-50%)
Nuchal rigidity (15%) → More common in occipital lobe abscess
Altered mental status→ severe cerebral edema→ bad sign
Increased intracranial pressure→ Vomiting
Focal neurologic deficits (50%)
Seizures (25%)
Papilledema (25%) → Late finding
71
An immigrant from Mexico might have a cerebral abscess caused by
Cysticercosis→ Taenia solium, pork tapeworm larvae→ Common in immigrants from Mexico
72
An immunocompromised patient could get a cerebral abscess caused by
Toxoplasma gondii
Listeria monocytogenes
Nocardia asteroides
73
Fungal cerebral abscesses...
Multiple abscesses
Poor outcomes
Cryptococcus
Coccidioides
Aspergillus
Candida
74
Diagnostic workup for cerebral abscess
Blood cultures X2 (before antibiotics)
CBC with diff, CMP
MRI without contrast→ 1st choice
CT-guided aspiration or surgical excision for cultures
CT with contrast
75
What does a cerebral abscess look like on MRI without contrast?
*Ring-enhancing lesion*
Early (1-2 weeks) → lesion poorly demarcated, localized edema, acute inflammation, no tissue necrosis
Late (>2 weeks) → necrosis and liquefaction, lesion surrounded by fibrotic capsule
76
Managing a cerebral abscess
CT-guided aspiration or surgical excision
Neurosurgery involvement
*IV* Antibiotics empirically→ based on suspected origin, gram stain→ culture results→ 4-8 weeks
*oral don’t penetrate*
MRI→ Track regression/progression
77
With a cerebral abscess, it's necessary to use _____ because _____
*IV* Antibiotics empirically
Oral abx don't penetrate
78
What's an intracranial abscess? How do you get one?
1/10 of epidural abscess
Localized lesion with central collection of pus surrounded by wall of inflammatory tissue +/- calcified
Tight attachment of dura at foramen magnum→ Rapidly spreads caudally
Complication of neurosurgery
Fetal monitoring probes→ osteomyelitis of skull→ spread
Less common: sinusitis, otitis, mastoiditis
79
Intracranial abscess presentation
Signs and symptoms from infection and expanding abscess
Fever, headache, lethargy, N/V
Secondary to sinusitis→ +/- purulent drainage from nose or ear
Can compress the brain→ Increased ICP, papilledema, +/- focal neurologic changes
Can mimic intracranial mass lesions: metastatic tumors, hematomas, brain abscess, meningioma
80
Intracranial abscess diagnostics
CBC with diff, ESR – can be variable
MRI w/contrast (1st choice), CT with contrast
CT guided aspiration or open drainage→ stains and cultures
81
Intracranial abscess management
Neurosurgery→ burr holes, craniotomy
Empiric antibiotics once abscess sample obtained (1-2 days max), sooner if immunocompromised or concerning
→ Contiguous spread→ Metronidazole + ceftriaxone/cefotaxime
→ Other→ Vancomycin + Metronidazole + Ceftriaxone/Cefotaxime/Ceftazidime
Repeat MRI 4-6 weeks→ monitor. Good prognosis with tx
82
Spinal epidural abscess presentation and progression
Initial manifestations may be non-specific
Classic triad→ fever, spinal pain, neurologic deficits
+/- Fever absent→ delay in diagnosis
Progression of symptoms:
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)
83
```
fever
+
spinal pain
+
neurologic deficits
```
Spinal epidural abscess "classic triad"
84
Diagnostics for spinal epidural abscess
CBC with diff
ESR →elevated or normal
MRI w/contrast entire spine ASAP→ first line
→ Positive early in course of infection
→ “skip lesions” down spine
→ Differentiates epidural soft tissue edema from abscess
CT with contrast→ 2nd line
CT guided extraction of pus from abscess for culture
85
Skip lesions on MRI with contrast of entire spine
Epidural abscess
86
Epidural abscess prognosis
Death due to sepsis or complications – 5%
Irreversible paraplegia – up to 22%
Some degree of neurologic damage related to duration of deficit
87
Epidural abscess treatment
Blood cultures x2
Empiric antibiotics ASAP once diagnosis is suspected (after blood cultures!)
→ Vancomycin + cefotaxime/ceftriaxone/cefepime/ceftazidime
x 4-8 weeks
Early surgical decompression and drainage
MRI in 4-6 weeks→ follow up
88
At risk of spinal epidural abscess
Immunocompromised→ HIV, DM, alcoholism
Direct Inoculation→ Epidural catheter, paraspinal injection, trauma
Hematogenous→ tattooing, acupuncture, bacteremia, IVDU, hemodialysis
89
Spinal epidural abscess pathophysiology
Bacteria gain access→ Hematogenous spread, Direct extension (osteomyelitis), Direct inoculation into spinal canal (epidural catheter)
Longitudinal extension
Acutely, granulation tissue +/- pus
More common in thoracolumbar area
Damages spinal cord→ direct compression, thrombosis of vessels, bacterial toxins/inflammation, interrupt arterial blood supply
90
Most common cause of spinal epidural abscess
S aureus
91
Other causes of spinal epidural abscess
G- bacilli > Streptococci > Coag neg staph (more common after spinal manipulation)
