Neurological Emergencies

Question 1

What are FOCAL OR PARTIAL seizures?

Answer 1

Focal or partial seizures arise from a localized region of the brain and have clinical manifestations that reflect that area of brain. Focal discharges can remain localized or they can spread to nearby cortical areas, to sub-cortical structures and/or transmit through commissural pathways to involve the whole cortex. The latter sequence describes the secondary generalization of focal seizures.

Question 2

What are PRIMARY GENERALIZED SEIZURES?

Answer 2

Primary generalized seizures begin with abnormal electrical discharges in both hemispheres simultaneously.
The manifestations of such widespread epileptiform activity can range from brief impairment of consciousness (as in an absence seizure) to generalized motor activity accompanied by loss of consciousness (generalized tonic-clonic seizure).

Question 3

What are ABSENCE SEIZURES?

Answer 3

The seizures of absence epilepsyare characterized by a temporary loss of consciousness, usually with a sudden cessation of motor activity without falling, and total amnesia for the event.
These seizures are generally brief (most last less than 20 seconds), do not include an aura, and end abruptly without any post-ictal changes.

Question 4

What are GRAND MAL seizures?

Answer 4

May have an aura of abnormal smell, taste, sound or visual changes.
Loss of consciousness
Tonic phase – muscle contraction
Hypertonic phase – extreme muscular contractions
Clonic phase - spasmotic muscular rigidity followed by relaxation
Post-seizure (post-ictal) phase – patient is unresponsive and then awakes feeling confused and fatigued. HA is commonly noted.

Question 5

List FIRST AID for Seizures (8)

Answer 5

1. Cushion head, remove glasses
2. Loosen tight clothing
3. Turn on side (so they don’t aspirate on their vomit)
4. Time the seizure with a watch
5. Don’t put anything in mouth!
6. Look for I.D.
7. Don’t hold down
8. As seizure ends….offer help

Question 6

What is STATUS EPILEPTICUS?

Answer 6

Status epilepticus (SE) is a potentially life-threatening condition in which the brain is in a state of persistent seizure. 
Definitions vary, but traditionally it is defined as one continuous, unremitting seizure lasting longer than 5 minutes or recurrent seizures without regaining consciousness between seizures for greater than 5 minutes.

Question 7

What is SYNCOPE?

Answer 7

Syncope is defined as a transient loss of consciousness and postural tone, characterized by rapid onset, short duration, and spontaneous recovery, due to global cerebral hypoperfusion to the brain that most often results from hypotension.
This definition of syncope differs from others by including the cause of unconsciousness, i.e. transient global cerebral hypoperfusion.
Without that addition, the definition of syncope would include disorders such as epileptic seizures, concussion or cerebrovascular accident.
Many forms of syncope are preceded by a prodromal state that often includes weakness, sweating, a feeling of heat, palpitations dizziness and loss of vision, loss of hearing, nausea and abdominal discomfort, and other phenomena.

Question 8

What is CEREBROVASCULAR DISEASE and the 3 major categories?

Answer 8

Cerebrovascular disease is the most prevalent neurologic disorder in terms of morbidity and mortality.
Cerebrovascular disease is the third leading cause of death in the U.S.
There are 3 major categories of cerebrovascular disease:
► Thrombotic
► Embolic
► Hemorrhagic

Question 9

What factors increase the survival of ischemic tissue?

Answer 9

The survival of ischemic tissue is dependent upon several factors including:
Availability of collateral circulation
Duration of ischemia
Magnitude of reduction of flow
Rapidity of reduction of flow

Question 10

What is CEREBRAL ISCHEMIA?

Answer 10

Cerebral ischemia may be focal or global.
Focal cerebral ischemia follows reduction of blood flow to a localized area that is generally due to an embolus or thrombosis in a large vessel, or vasculitis in medium or small sized vessels.
Focal ischemia may result in a cerebral infarction occurring in a well circumscribed area of necrosis in the distribution of a particular cerebral artery.

Global ischemia and resultant global hypoxia occur when there is a generalized reduction of cerebral perfusion.
This can develop as a consequence of cardiac arrest, shock and severe hypotension.
Global hypoxia results in border zone infarcts, which typically occur at the border of areas supplied by the anterior and middle cerebral arteries, and laminar necrosis, which is related to the short, penetrating vessels.

Question 11

What is CEREBRAL INFARCTION?

Answer 11

Risk factors for stroke include advanced age, hypertension, diabetes mellitus, high cholesterol, tobacco use and atrial fib.
No historical feature definitively distinguishes ischemic from hemorrhagic stroke, although nausea, vomiting, headache and change in the level of consciousness are symptoms that are more common in hemorrhagic strokes then in ischemic strokes.

Question 12

What is the most common cause of thrombotic occlusion?

Answer 12

ATHEROSCLEROSIS - occurring most commonly at the carotid bifurcation or in the vertebrobasilar system

Question 13

What vessel is found to have the greatest degree of compromise in cerebral infarction?

Answer 13

MIDDLE CEREBRAL ARTERY

Question 14

Approximately 80% of strokes are of which type?

Answer 14

ISCHEMIC

Question 15

Which type of stroke has more severe morbidity and mortality rates?

Answer 15

HEMORRHAGIC STROKE

Question 16

The 30 day mortality rate of this type of stroke ranges from 40 to 80%

Answer 16

HEMORRHAGIC

Question 17

Approximately 50% of all stroke deaths occur within how many hours?

Answer 17

The first 48 hours

Question 18

What are the common symptoms of a stroke?

Answer 18

Abrupt onset of monoparesis, hemiparesis, or quadriparesis; monocular or binocular visual loss, visual field deficits, diplopia, dysarthria, ataxia, vertigo, aphasia or a sudden change in the patient’s level of consciousness.
Symptoms can occur along or in some combination.

Question 19

What is DOMINANT HEMISPHERE STROKE?

Answer 19

If the dominant hemisphere (usually left) is involved, a classic syndrome consisting of right hemiparesis, right hemisensory loss, left gaze preference, right visual field cut and aphasia may result.

Question 20

What is NON-DOMINANT HEMISPHERE STROKE?

Answer 20

If the non-dominant (usually right sided) hemisphere is involved, a syndrome of left hemiparesis, left hemisensory loss, right gaze preference and left visual field cut may result.

Question 21

What is an ISCHEMIC STROKE?

Answer 21

Complete occlusion of a cerebral vessel is frequently preceded by fleeting and transient neurologic symptoms - called transient ischemic attacks (TIA’s).
TIAs are important to recognize because they may be clinical markers for an increased risk of subsequent cerebral infarction.
Estimates suggest that 15-30% of all strokes are thought to be of embolic etiology.
The remaining cases have either an undetermined or a combined etiology or else are caused by dissection.
Embolism is the primary etiology of middle cerebral artery (MCA) strokes.

Question 22

What is a HEMORRHAGIC STROKE?

Answer 22

Hemorrhagic stroke is generally due to: intracerebral hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, or epidural hemorrhage.
Intracerebral hemorrhage accounts for approximately 10 to 15% of all strokes and is associated with higher mortality rates than ischemic cerebral infarctions.
Hypertension is the primary underlying cause of most cases of intracerebral hemorrhage.

Question 23

What are the increased risks of a hemorrhagic stroke?

Answer 23

Advanced age
Hypertension (up to 60% of cases)
Previous history of stroke
Alcohol abuse
Use of illicit drugs (i.e. cocaine, other sympathomimetic drugs)

Question 24

Hemorrhagic stroke anticoagulation use

Answer 24

In anticoagulated patients, there can be massive hemorrhage into an area of infarction if a stroke is hemorrhagic. For this reason, even though it may take 10 to 12 hours before the cerebral edema of an early ischemic infarct can be visualized on CT scan, scans are taken immediately to see if there is notable hemorrhage. If there is none, anticoagulation therapy may be started in the absence of contraindications.

Question 25

Cerebellar and brainstem strokes?

Answer 25

Cerebellar and brainstem stokes generally occur as a result of pathology in the vertebral or basilar arteries. When edema in the cerebellum or brainstem occurs, the patient is at high risk for brainstem herniation and compression. Herniation may cause a rapid decrease in the level of consciousness, apnea and death.

Question 26

Signs of cerebellar or brainstem involvement?

Answer 26

``` Gait or limb ataxia Vertigo or tinnitus Nausea and vomiting Hemiparesis or quadriparesis Eye movement abnormalities resulting in diplopia or nystagmus Oropharyngeal weakness or dysphagia ```

Question 27

What is the most frequent cause of clinically significant subarachnoid hemorrhage?

Answer 27

Rupture of a berry (saccular) aneurysm!

Question 28

What is a berry aneurysm?

Answer 28

A berry aneurysm is a thin wall out-pouching from an area on the circle of Willis. The size of a berry aneurysm may range from a few millimeters to 2-3 cm. The etiology of most berry aneurysms is not known.

Question 29

What are the 4 groups of VASCULAR MALFORMATIONS?

Answer 29

Vascular malformations of the brain are classified into 4 principal groups: arteriovenous malformations, cavernous hemangiomas, venous hemangiomas and capillary telangiectasias. The lesion is often recognized clinically between the ages of 10 and 30 years, presenting as a seizure disorder, an intracerebral hemorrhage or a subarachnoid hemorrhage.

Question 30

What is HYPERTENSIVE ENCEPHALOPATHY?

Answer 30

Acute hypertensive encephalopathy is a syndrome arising in a hypertensive patient characterized by diffuse cerebral dysfunction including: headaches, confusion, vomiting, convulsions and possible coma. Rapid therapeutic intervention to reduce the accompanying increased intracranial pressure is required, as the syndrome often does not remit spontaneously. Patients coming to postmortem examination may show an edematous brain with or without transtentorial or tonsillar herniation. Petechiae and fibrinoid necrosis of arterioles in the gray and white matter may be seen microscopically.

Question 31

What is Anisocoria?

Answer 31

Unequal pupil size can be a sign of a brain injury that is more serious than a concussion.

Question 32

What is a skull fracture?

Answer 32

When an individual falls while awake, such as might occur when stepping off a ladder, the site of impact is often in the occipital portion of the skull. In contrast, a fall that follows loss of consciousness as might follow a syncopal episode, may more commonly result in a frontal impact.

Question 33

What are LINEAR SKULL FRACTURES?

Answer 33

Linear skull fractures are usually cause the area of the skull that was struck to bend inward, making the area around it buckle outward. A fracture in which bone is displaced into the cranial cavity by a distance greater than the thickness of the bone is called a displaced skull fracture.

Question 34

What is a BASAL SKULL FRACTURES?

Answer 34

Basal skull fractures are a special category of linear fractures extending through the petrus portion of the temporal bone that leak spinal fluid from an ear. There may be associated hearing loss, instability of gait, and vertigo.

Question 35

What is BATTLE'S SIGN?

Answer 35

Battle’s sign = mastoid ecchymosis. Suspect basilar skull fracture bruising right behind the ear, indicates basal skull fracture until proven otherwise***

Question 36

What are RACCOON'S EYES?

Answer 36

Raccoon's eyes = bilateral periorbital ecchymosis. If the patient is unconscious or has a hx of head trauma, suspect basilar skull fracture. indicates basal skull fracture until proven otherwise***

Question 37

What is traumatic vascular injury? | Which artery is mainly involved?

Answer 37

Trauma to the skull, especially in the region of the temporal bone, can lead to laceration of this artery if the fracture lines crosses the course of a blood vessel. Vessels within the dura, most importantly the middle meningeal artery, are vulnerable to injury, particularly with skull fractures.

Question 38

What is Epidural hematoma?

Answer 38

Epidural hematoma may occur as a result of the rupture of a meningeal artery, usually associated with a skull fracture. This rupture leads to accumulation of arterial blood between the dura and the skull. A fracture that lacerates either the middle meningeal artery (MMA) or a dural venous sinus is present in 85-95% of patients with epidural hematomas.

Question 39

What is SUBDURAL HEMATOMA?

Answer 39

In a subdural hematoma, damage to bridging veins between the brain and the superior sagittal sinus leads to the accumulation of blood between the dura and the arachnoid. Subdural hematomas usually occur due to torn bridging veins and are characteristically found over the fronto-parietal regions of the cerebral hemispheres.

Question 40

What is MENINGITIS?

Answer 40

Meningitis is an acute inflammation of the meninges, the protective membranes covering the brain and spinal cord. The most common symptoms are fever, headache and neck stiffness (nuchal rigidity). Severe headache occurs in almost 90% of cases of bacterial meningitis. Nuchal rigidity occurs in 70% of bacterial meningitis in adults.

Question 41

Meningitis symptoms?

Answer 41

``` photophobia severe HA n/v fever afraid of loud sounds sensitivity to smells ``` Young children often exhibit only nonspecific symptoms such as irritability, drowsiness, or lack of appetite.

Question 42

What is nuchal rigidity?

Answer 42

Nuchal rigidity is the inability to flex the neck forward due to rigidity of the neck muscles. If flexion of the neck is painful but full range of motion is present, than the term, nuchal rigidity, is less applicable. Other symptoms include confusion or altered consciousness, vomiting and an inability to tolerate light or loud noises.

Question 43

What are the signs of meningitis?

Answer 43

Other possible signs of meningitis include the presence of positive Kernig's sign or Brudziński sign. Kernig's sign is assessed with the person lying supine, with the hip and knee flexed to 90 degrees. In a person with a positive Kernig's sign, pain limits passive extension of the knee.

Question 44

What is a positive Brudzinski's sign?

Answer 44

A positive Brudzinski's sign occurs when flexion of the neck causes involuntary flexion of the knee and hip. Although Kernig's sign and Brudzinski's sign are both commonly used to screen for meningitis, the sensitivity of each of these tests is limited.

Question 45

What bacteria causes bacterial Meningitis?

Answer 45

Meningitis caused by the bacterium, Neisseria meningitidis, can often be differentiated from other causes of bacterial meningitis because of a petechial rash that frequently develops with meningococcal meningitis.

Question 46

Which rash is associated with Neisseria meningitidis?

Answer 46

Petechiae Petechiae generally appear as red or purple spots on the skin, caused by a minor bleed from broken capillaries. Petechiae refers to one of the three descriptive types of bleeding into the skin differentiated by size, the other two being purpura and ecchymosis. Petechiae are by definition less than 3 mm. The term is almost always used in the plural, since a single lesion is seldom noticed or significant.

Question 47

What is the clinical significance of Petechiae?

Answer 47

The significance of petechiae in children depends on the clinical context in which they arise. Petechiae in children can occur with simple viral infections. They may be found in several potentially serious and even lethal conditions such as meningococcemia, leukemia and thrombocytopenia. Meningococcemia can cause death within 48 hours of infection.

Question 48

What is Petechiae a sign of?

Answer 48

Petechiae may be a sign of thrombocytopenia when platelet function is inhibited (i.e. as a side effect of medications or during certain infections), or in clotting factor deficiencies. They may also occur when excessive pressure is applied to tissue i.e. when a tourniquet is applied to an extremity or with excessive coughing or vomiting).

Question 49

Viral Meningitis

Answer 49

Viruses that cause meningitis include enteroviruses, herpes simplex virus, varicella zoster virus, mumps virus, measles virus, West Nile virus and HIV. In the United States, about 40,000 new cases of viral meningitis occur each year, the majority of which are attributable to enteroviruses.

Question 50

WBC in viral vs. bacterial?

Answer 50

Lymphocytes - virus | Neutrophils - bacterial