Neurology emergencies Flashcards
(50 cards)
1
Q
causes
raised ICP
A
- tumours
- oedema
- intracranial haemorrhage
- idiopathic intracranial hypertension
- abscesses or infection
2
Q
symptoms
raised ICP
A
Headache:
- constant headache
- nocturnal
- worse on waking
- worse on coughing, straining or bending forward
vomiting
blurred vision
3
Q
signs
raised ICP
A
- papilloedema on fundoscopy
- altered mental state
- visual field defects
- seizures
- unilateral ptosis
- third and sixth nerve palsies
4
Q
pathogens
Bacterial meningitis
A
0-3 months:
- group B streptococcus
- E.coli
- Listeria monocytogenes
3 months - 6 years (NHS)
- Neisseria meningitidis
- Streptococcus pneumoniae
- Haemophilus influenzae
6-60 years:
- Neisseria meningitidis
- Streptococcus pneumoniae
> 60 years:
- Streptococcus pneumoniae
- Neisseria meningitidis
- Listeria monocytogenes
immunosuppressed:
- Listeria monocytogenes
5
Q
presentation
Bacterial Meningitis
A
symptoms:
- headache
- neck stiffness
- fever
- nausea/vomiting
- photophobia
- drowsiness
- seizures
signs:
- purpuric rash
6
Q
CSF findings
bacterial meningitis
A
- cloudy
- low glucose
- high protein
- high polymorphs
7
Q
CSF findings
Viral meningitis
A
- clear/cloudy
- normal/low glucose
- normal/high protein
- high lymphocytes
8
Q
investigations
bacterial meningitis
A
- bloods:
- FBC
- renal function
- glucose
- lactate
- clotting profile
- CRP
- blood cultures
- blood gas
- throat swab for meningococcal culture
- LP
9
Q
contraindications to LP
A
- signs of severe sepsis or rapidly evolving rash
- severe respiratory/cardiac compromise
- significant bleeding risk
- signs of raised ICP:
- focal neurological signs
- papilloedema
- continuous or uncontrolled seizures
- GCS ≤9
10
Q
general Mx
Bacterial Meningitis
A
- IV access
- LP -> if can’t be done within 1 hour then IV abx after culture
- IV abx
- IV dex - if >3months
11
Q
IV abx regieme
Bacterial meningitis
A
- < 3 months → cefotaxime + amoxicillin
- 3 months - 59 years → ceftriaxone
- ≥ 60 years → ceftriaxone + amoxicillin
12
Q
Dexamethasone use
Bacterial meningitis
A
- consider in adults if suspected pneumococcal meningitis
- give in children >3 months if LP suggests bacterial meningitis
- start before or within 12 hours of ABx
- avoid in septic shock, meningococcal septicaemia, or if immunocompromised
- reduce neuro complications and hearing loss
13
Q
Mx of contacts
Bacterial meningitis
A
- oral ciprofloxacin → single dose
- meningococcal vaccination offered
14
Q
causes
viral meningitis
A
- enteroviruses → coxsackie, echovirus
- mumps
- HSV, CMV, herpes zoster
- HIV
- measles
15
Q
RFx
viral meningitis
A
- extremes of age: <5 and elderly
- immunocompromised
- IV drug users
16
Q
Mx
viral meningitis
A
- while waiting LP results - supportive treatment
- any questions of bacterial meningitis or encephalitis → antibiotics
- self-limiting, symptoms improve 7-14 days
- aciclovir if secondary to HSV
17
Q
features
Encephalitis
A
- headache, fever, psychiatric symptoms, seizures, vomitng
- altered mental status
- focal features e.g. aphasia
- subacute onset hemiparesis
18
Q
cause
Encephalitis
A
95% HSV-1
typically affects the temporal and inferior frontal lobes
19
Q
Ix
Encephalitis
A
- CSF
- lymphocytosis
- elevated protein
- PCR for HSV, VZV and enteroviruses
- neuroimaging
- medial temporal and inferior frontal changes
- MRI best
- EEG
- lateralised periodic discharges at 2 Hz
20
Q
Mx
Encephalitis
A
IV aciclovir in all cases of suspected encephalitis
21
Q
definition
Status epilepticus
A
a medical emergency defined as:
- a seizure lasting more than 5 minutes
- multiple seizures without regaining consciousness in the interim
22
Q
Mx
Status epilepticus
A
A-E
- secure airway
- high-concentration oxygen
medication:
1. Benzo first line - repeat after 5 mins
buccal midazolam (10mg)
Rectal diazepam (10mg)
Intravenous lorazepam (4mg)
2. second line - after 2 doses of benzos
IV levetiracetam, phenytoin or sodium valproate
3. third line - call ITU
phenobarbital or general anaesthesia
23
Q
definition
cauda equina syndrome
A
rare but serious conditions where the lubosacral nerve roots that extend below the spinal cord are compressed
24
Q
causes
cauda equina syndrome
A
- most common → central disc prolapse at L4/5 or L5/S1
- others:
- tumours - primary or metastatic
- infection - abscess, discitis
- trauma
- haematoma
25
# presentation
cauda equina syndrome
- low back pain
- bilateral sciatica
- reduced sensation/pins and needles in the perianal area
- decreased anal tone
- urinary dysfunction
26
# investigation
cauda equina syndrome
urgent MRI spine
27
# management
cauda equina syndrome
surgical decompression
28
# 4 types
intracranial haemorrhage
- extradural haemorrhage → between skull and dura mater
- subdural haemorrhage → between dura mater and arachnoid mater
- intracerebral haemorrhage → bleeding into brain tissue
- subarachnoid haemorrhage → bleeding in the subarachnoid space
intracerebral and subarachnoid = strokes
29
# RFx
intracranial haemorrhage
- head injuries
- hypertension
- aneurysms
- ischaemic strokes (progressing to bleeding)
- brain tumours
- thrombocytopenia
- bleeding disorders
- anticoagulants
30
# general presentation
intracranial haemorrhage
sudden onset headache is key feature.
can also present with:
- seizures
- vomiting
- reduced consciousness
- focal neurological symptoms
31
# cause, CT, typical Hx
extradural haemorrhage
Cause:
- between skull and dura mater
- usually due to ruptured middle meningeal artery in the tempoparietal region
- associated with fracture of the temporal bone
CT:
- bi-convex shape and are limited by the cranial sutures
Typical history:
- young patient with traumatic head injury and an ongoing headache
- period of improved neurological symptoms and consciousness followed by a rapid decline over hours as the haematoma gets large and compresses the intracranial contents
32
# cause, CT, typical patient
subdural haemorrhage
- between the dura mater and arachnoid mater
- caused by rupture of the bridging veins in the outermost meningeal layer
- CT - crescent shape and not limited by the cranial sutures
may occur in **elderly** and **alcoholic** patients who have more **atrophy** in their brains, making the vessels more prone to rupture
33
# cause, presentation
intracerebral haemorrhage
- can occur spontaneously or secondary to ischaemic stroke, tumours or aneurism rupture
- presents similarly to ischaemic stroke with sudden-onset focal neurological symptoms such as limb or facial weakness, dysphasia or vision loss
- can happen anywhere in brain
34
# cause, typical history
subarachnoid haemorrhage
- bleeding in the subarachnoid space where the cerebrospinal fluid is, between the pia mater and the arachnoid membrane
- usually a result of a ruptured cerebral aneurysm
- typical history → sudden-onset occipital headache during strenuous activity
35
# headache features
subarachnoid haemorrhage
- thunderclap headache (0-10 within 5 minutes)
- worse headache ever
- “hit on the back of the head”
- may be vomiting
- meningism - from haemorrhage
- next stiffness, photophobia etc
36
# associations
subarachnoid haemorrhage
- family history
- cocaine use
- sickle cell anaemia
- connective tissue disorders e.g.Marfan or Ehlers-Danlos
- neurofibromatosis
- autosomal dominant polycystic kidney disease
37
# principles of Ix and Mx
intracranial haemorrhage
investigations
- immediate head CT to establish diagnosis
- FBC and clotting screen
initial management
- admission to a specialist stroke centre
- discuss with a specialist neurosurgical centre to consider surgical treatment
- consider intubation, ventilation and intensive care if reduced consciousness
- correct clotting abnormalities
- correct severe hypertension but avoid hypotension
extradural/subdural:
- craniotomy/burr holes
38
common neurologic causes of ARDS?
- Traumatic brain injury
- status epilepticus
- neurogenic pulmonary edema.
39
# patho
ARDS
Diffuse alveolar damage causing increased permeability and non-cardiogenic pulmonary edema.
40
# definition
temporal arteritis
systemic vasculitis of unknown cause affecting medium and large arteries
41
# RFx
temporal arteritis
- older >50
- white ethnicity
- female
- strong association with polymyalgia rheumatica
42
# presentation
temporal arteritis
- unilateral headache
- severe
- centred around temple and forehead
- temporal artery may be tender and thickened
- pulse may be reduced or absent
- scalp tenderness e.g. when brushing hair
- jaw claudication
- blurred or double vision
- painless loss of vision
43
# diagnosis
temporal arteritis
based on:
- clinical presentation
- raised inflammatory markers (ESR >50)
- temporal artery biopsy (vascular surgeon)
- shows multinucleated giant cells
- duplex ultrasound scan
- hypoechoic halo sign
- stenosis of temporal artery
44
# Mx
temporal arteritis
- medical emergency - high risk of permanent vision loss -> urgent referral
- **steroids** → started immediately, before confirming diagnosis
- high dose initially - 40-60mg pred
- visual symptoms or jaw claudication - 500-1000mg methylprednisolone
- once controlled, steroids slowly weaned over 1-2 years
- **aspirin** - decreased risk of vision loss or stroke
45
# complications
temporal arteritis
- irreversible vision loss → blockage in blood flow to retina causing ischaemia and rapid onset painless loss of vision
- steroid related complications → weight gain, diabetes, osteoporosis
- cerebrovascular accident (stroke)
46
# patho
Acute bulbar palsy
signs and symptoms linked to impaired function of lower cranial nerves:
- CN IX
- CN X
- CN XI
- CN XII
damage to their lower motor neurone of to the lower cranial nerve itself
→ can be progressive or non-progressive
47
# causes
Acute bulbar palsy
- brainstem strokes and tumours (most common)
- degenerative diseases
- ALS (MND)
- autoimmune diseases
- GBS
- genetic diseases
- kennedy disease
- Brown-Vialetto-Van Laere syndrome
- Fazio-Londe syndrome
48
# Sx
Acute bulbar palsy
- dysphagia
- reduced/absent gag reflex
- slurred speech
- aspirations of secretions
- dysphonia
- dysarthria
- drooling
- difficulty chewing
49
# diagnosis
Acute bulbar palsy
clinical diagnosis
- CSF analysis to rule out MS
- MRI brain to diagnose stroke or tumour
50
# Mx
Acute bulbar palsy
- no known treatment
- symptom management:
- medications for drooling
- feeding tube
- SALT
- condition-specific treatments
