NeuroCheck Flashcards
(44 cards)
How would you check for meningitis in an infant
Check for a full or bulging anterior fontanelle (Sign of raised ICP)
check fontanelle when calm and in supine and upright positions
this usually closes at 13 months
between 4 and 24 months
Also for petechial or purpuric rash
temp
What should septic work up of a febrile unwell infant include
full blood examination
blood sugar level
lactate and C-reactive protein at baseline
blood culture
urine microscopy, culture and sensitivities.
+/- Lumbar puncture +/- chest xray
IF a prehospital dose of antibiotic is required for an infant with ?meningitis what would you give
Current Australian guidelines suggest use of either ceftriaxone 50 mg/kg (for children >1 month of age) or benzylpenicillin 60 mg/kg
GIVE ceftx if delay in sending child in to hospital as ben pen can sometimes be ineffective against neisseria
Would you give dexamethasone in a child with ?meningitis
current guidelines suggest that in children aged >2 months with a high clinical suspicion of meningitis, dexamethasone (0.15 mg/kg IV) could be considered.12,22 Dexamethasone should be given 15 minutes prior to parenteral antibiotics or within one hour of the first antibiotic dose.12
Most common causes of infant meningitis
Strep pneumo
Neisseria meningitidis
Haemophilus Influenze type B
Ecoli and group B strep less common
IF you’re in a rural area and infant needs transfer who do you contact?
EMergency Paediatric retrieval service
If CSF comes back with gram pos dipplococuss how does that change mx
likely strep pneumo
ADD VANC IV
Ongoing seizures in an infant
phenytoin 20 mg/kg Loading
History questions when considering headaches associated with ?raised ICP
Is the headache worse on getting up from lying down or with postural change?
Are there associated symptoms of tinnitus?
Is there associated nausea and sometimes (projectile) vomiting?
The visual symptoms can also be a result of raised ICP placing pressure on the optic nerve. Relevant questions include:
Is the visual obscuration transient (as reported by Irene)?
Is there horizontal diplopia (may be intermittent)?
Is the vision blurred?31,32
Papilloedema
Differential diagnosis for papilloedema
intracranial mass
venous malformation (especially dural venous sinus thrombosis)
idiopathic intracranial hypertension (IIH)
malignant hypertension
Why might you get a sixth nerve palsy in Raised ICP
False localising
Compression of CN6 as it enters the midbrain, caused by raised ICP, results in the abduction deficit seen. It is important to remember the cause is compression rather than ischaemia as in an ischaemic CN6 palsy.
IF worried about raised ICP and eye issues - what investigations?
Neuroimaging, ideally magnetic resonance imaging (MRI) with magnetic resonance venography (MRV), would help to identify any intracranial lesion including a dural venous sinus thrombosis. In the absence of an MRI, computed tomography (CT) with CT venography (CTV) are sufficient. Following neuroimaging to exclude an intracranial lesion, a lumbar puncture to measure opening cerebrospinal fluid (CSF) pressure is required.
Risk factors for Idiopathic ICH
Irene has several risk factors in her presentation that are commonly seen in a diagnosis of IIH including:
>90% of cases are women of childbearing age
recent or longstanding weight gain
certain medications (eg COCP, vitamin A derivatives, withdrawal from corticosteroids, lithium, tetracyclines
Management of Idiopathic ICH
acetozalmide via neurologist
Weight reuction
Opthalmology referral for monitoring of vision
neurology – commencement of acetazolamide initially in tolerated doses up to 1 g daily to control symptoms and reduce production of CSF. Acetazolamide is a carbonic anhydrase inhibitor that can reduce CSF production. Various trials have shown improvements in symptoms and visual function with maximally tolerated doses of acetazolamide (maximum 4 g/day). A neurologist may prescribe topiramate; however, there are ocular side effects so this is not first-line treatment.35
ophthalmology – documentation of optic nerve function including vision and visual fields. Figure 3 shows a typical visual field in this case (enlarged blind spot). Optic nerve function requires monitoring for worsening, should medical treatment not effectively reduce CSF pressure.
allied health – gradual weight loss is an important aspect of treating IIH; it must be done in an appropriate and safe manner. A dietitian and/or counsellor may assist patients to achieve weight loss.
The general practitioner’s (GP) role is to oversee specialist management, as patients with IIH will initially present to their GPs for follow-up on discharge from hospital.
What other management is there for refractory raised ICH
Intracranial shunt
and optic nerve sheath fenestration
Red flags in headache
New onset, specific setting. New headache in the setting of cancer (metastases), human immunodeficiency virus infection (opportunistic infection), postmanipulation or trauma of the neck, or associated with mild head trauma in the elderly (subdural haematoma)
New headache that is persistent
Focal signs or symptoms (other than the typical visual or sensory aura of migraine)
Headache with focal neurological signs that precede or outlast the headache (the rare exception is hemiplegic migraine)
Headache that is progressive (may suggest a mass lesion)
Headache of sudden onset (may indicate a bleed either into the subarachnoid space or the cerebral parenchyma)
Headache with rash (may indicate meningococcal meningitis or Lyme disease)
Persistent unilateral temple headache in adult life (may indicate cranial arteritis)
Headache with a raised erythrocyte sedimentation rate (may be an indication of cranial arteritis, collagen disease or systemic infection)
Headache with papilloedema (raises the suspicion of raised intracranial pressure due to a mass lesion or benign intracranial hypertension)
Nonmigraine headaches in pregnancy or postpartum (cerebral vein thrombosis can occur during or just after pregnancy)
Headache triggered by cough or straining (may be an indication of either a mass lesion or a subarachnoid bleed)
Headache clearly triggered by changes in posture (may indicate low cerebrospinal fluid [CSF] pressure, for instance due to spontaneous CSF leak)
Headache associated with pressing visual disturbances (may indicate conditions such as glaucoma or optic neuritis)
Headaches that have primary characteristics, but with unusual features
Common DDx of headache
Primary or tension-type headaches are the most common causes of headaches. Other causes of headaches by decreasing frequency include migraines, head trauma, idiopathic stabbing headaches, exertional headache, vascular disorders, intra-cranial haemorrhage or brain tumours.41
What history questions in headache
headache characteristics, timing, constancy, aggravating factors, associated nausea and vomiting, severity and history of any prior headaches.
A history of associated symptoms is important, including other neurological symptoms, seizures, recent falls/trauma, constitutional symptoms, as well as previous medical, family and surgical history
Examination in headache
- Vital signs (BP)
- Fundoscopy (pappilloedema)
- Cranial nerve examination
- Peripheral nerve examination
Brain tumour headache symptoms
is one that starts in early morning before the patient rises from bed and disappears soon after the patient gets up. The headache is often initially mild but can become progressively more frequent, severe and of longer duration. However, only a small proportion (17%) of patients present with this symptom.42 According to lifetime prevalence studies, only a minority (0.7%) of headaches in patients presenting to general practice are caused by brain tumours.43
The presenting symptoms related to a glioma are determined by the tumour’s size, location and rate of growth. The usual presenting symptoms of glioblastoma multiforme (GBM) include a short duration of increased intracranial pressure (headache, nausea, vomiting) and/or focal neurological symptoms that reflect the tumour. Presenting symptoms, and the proportion of presenting patients, are headaches (19–34%), hemiparesis (14–41%), seizures (17–31%), cognitive deficits (15–22%), speech deficits (6–32%), visual disturbance (3–15%), ataxia (9%) and cranial nerve deficits (9%).42
What are MEdicare indications for a brain MRI
What are contraindications
The permissible Medicare Benefits Schedule indications for brain MRI include unexplained seizure(s) and chronic headache with suspected intracranial pathology.
artificial cardiac pacemakers, metallic foreign body in the eye or joint replacement
MRI is more sensitive than CT
but usually CT head is imaging investigation of choice
