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PBL: Neuro Week 2

Terms in this set (84)

What is aseptic meningitis?
Nonpyogenic meningitis - includes viral, fungal, and TB
What are the two most common preceding illness associated with meningitis?
Pneumonia and sinusitis
What is the Kernig's sign?
inability to straighten knee with hip flexion
What is the Brudzinski sign?
neck flexion that produces knee/hip flexion (grab the brain)
What 2 PE signs are positive with meningitis?
Kernig and Brudzinski
Clinical manifestations of meningitis
-Fever
-Chills
-Headache
-Nuchal rigidity (neck stiffness)
-Photosensitivity
-N/V

Viral is not as severe as bacterial

Can progress to AMS, seizures
What should you do before the LP?
Order a head CT to rule out intracranial mass because if the pt has increased intracranial pressure when the LP is performed the negative vacuum can suck the brain through the foramen magnum = BAD!
When should you start empiric therapy for meningitis?
Before LP (takes a few hours to take effect and LP will still be positive for bacteria)

Early ABX has been shown to increase survival rates
What is the empiric therapy for meningitis?
Acyclovir
Dexamethasone
Ceftriaxone
Vancomycin
What are the most common pathogens for bacterial meningitis for infants <1 year old?
GABHS (70%) - Strep. agalactiae
What are the most common pathogens for bacterial meningitis for 1-18 years old?
N. meningitides (petechie rash)
What are the most common pathogens for bacterial meningitis for 18-50 years old?
Strep. pneumo (50%)
N. meningitides
What are the most common pathogens for bacterial meningitis for adults over 50 years old?
S. pneumo
Listeria monocytogenes
What pathogen is associated with meningitis that has a petechiae rash?
N. meningitides
When would you continue the dexamethasone after CSF analysis returns?
If the gram culture showed gram + diplococci --> strep. pneumo

Or in children that have H. flu (reduces hearing loss)
What is the PEP for meningitis?
500mg PO Ciprofloxacin X 1 dose

OR Refampin 600mg PO q12h X 2 days
What type of meningitis do you suspect if the glucose is normal on the CSF analysis?
Viral meningitis
What type of meningitis do you suspect if the elevated WBC count is neutrophils?
Bacterial meningitis
Describe the following results of a NORMAL CSF analysis:

- Opening pressure
- Color/appearance
- Protein (mg/L)
- Glucose (mg/100mL)
- WBC
- Gram stain and culture
- Opening pressure = 5-20cm
- Color/appearance = clear, colorless
- Protein (mg/L) = 18-58
- Glucose (mg/100mL) = 50-80 (70% of serum)
- WBC = 0-5 (no RBCs)
- Gram stain and culture = Negative
Describe the following results of a BACTERIAL CSF analysis:

- Opening pressure
- Color/appearance
- Protein (mg/L)
- Glucose (mg/100mL)
- WBC
- Gram stain and culture
- Opening pressure = Increased >20cm
- Color/appearance = Turbid, cloudy
- Protein (mg/L) = >200 elevated
- Glucose (mg/100mL) = Low <40
- WBC = 100-100,00 with 80% neutrophils
- Gram stain and culture = Positive
What is pleocytosis?
WBC in the CSF
Describe the following results of a VIRAL CSF analysis:

- Opening pressure
- Color/appearance
- Protein (mg/L)
- Glucose (mg/100mL)
- WBC
- Gram stain and culture
- Opening pressure = Normal or mildly increased
- Color/appearance = Clear
- Protein (mg/L) = <100 (normal or mildly increased)
- Glucose (mg/100mL) = Normal
- WBC = 10-300 with lymphocytes
- Gram stain and culture = Negative
Describe the following results of a FUNGAL or TB CSF analysis:

- Opening pressure
- Color/appearance
- Protein (mg/L)
- Glucose (mg/100mL)
- WBC
- Gram stain and culture
- Opening pressure = Normal or mildly increased
- Color/appearance = Fibrin webs
- Protein (mg/L) = Increaesd
- Glucose (mg/100mL) = Decreased
- WBC = 10-300 with lymphocytes
- Gram stain and culture = Negative
What i the difference between meningitis and encephalitis?
Inflammation of the meninges (dura, arachnoid mater, pia mater)

Inflammation of the brain parenchyma
What is the most common pathogen of viral meningitis?
Enterovirus family
What is the tx for viral meningitis?
Supportive care; usually self limiting and resolves within 7-10 days

Antipyretics
IV fluids
Antiemetics
What is the treatment for bacterial meningitis?
- GABHS: Ampicillin + Cefotaxime (to cover Listeria) = used in neonates - 3 month olds

- N. Meningitis and S Pneumo (*2 MC pathogens): Ceftriaxone + Vanco

- L. monocytogenes: Ampicillin + Ceftriaxone + Vanco
What is the most common pathogen of encephalitis?

Name some others.
HSV-1

Enteroviruses
Varicella zoster
Rubeola
Toxoplasmosis, CMV, Rabies
What type of diarrhea does enterotoxins cause?
Watery, voluminous diarrhea = noninvasive diarrhea

NO fecal RBCs or WBCs
How are arboviruses transmitted? From what to what?
Arthropod borne viruses transmitted by insects such as mosquitoes
Name some common arboviruses.

Why are we doing this? Because they pathogens of viral meningitis and encephalitis
St. Louis virus
West Nile
Colorado Tick Fever
Name some enterotoxins.


Why are we doing this? Because they pathogens of viral meningitis and encephalitis
- Staph aureus (contaminated diary, mayo, eggs, and meat)
- Vibrio cholera (abroad and in areas with contaminated water sources)
- Enterotoxigenic E. coli (traveler's diarrhea)
C. diff
What are the expected findings of a CSF analysis if you suspect encephalitis?
- Opening pressure = Normal or mildly increased
- Color/appearance = Clear
- Protein (mg/L) = <100 (normal or mildly increased)
- Glucose (mg/100mL) = Normal
- WBC = 10-300 with lymphocytes
- Gram stain and culture = Negative
What is the most common area of the brain involved in encephalitis?
Temporal lobe
What is the treatment for encephalitis?
If HSV or no meningitis --> valacyclovir

Supportive care: IV fluids, antipyretics, control cerebral edema, seizure prophylaxis, and protect airway
HSV encephalitis has a ____% mortality if untreated
70%
Which normally has cerebral function involvement: meningitis or encephalitis?
Encephalitis

Sensory/motor deficits, speech/movement disorders
What is an aneurysm?
Thin-walled outpouchings that protrude from the arteries
What are the two types of aneurysms?
Saccular or berry - most common

Fusiform - elongated dilatations of large arteries and linked to atherosclerosis

Mycotic - an infected emboli
Where are mycotic aneurysms most commonly found?
distal cerebral arteries
What is the most common location of saccular aneurysms?
Circle of Willis or major branches
What is the most common location of fusiform aneurysms?
in the basilar artery
How do you diagnosis an aneurysm?
CT scan, MR arteriography, angiography
What is the treatment for an aneurysm?
Saccular - clipped
Fusiform - total occlusion
What are the 4 types of intracranial hemorrhages and describe their location?
- Epidural hematoma (btwn skull and dura)
- Subdural hematoma (btwn dura and arachnoid from tearing of the cortical bridging veins)
- Subarachnoid hemorrhage (btwn arachnoid and pia)
- Intracerebral hemorrhage (intraparenchymal)
What intracranial hemorrhage is MC in the elderly?
Subdural hemorrhage
Thundercalp HA described as the worst HA of my life
Subarachnoid hemorrhage
What is Terson syndrome?
Retinal hemorrhage; a result of subarachnoid hemorrhage
Convex, lens-shaped bleed on CT scan of the brain
Epidural hematoma
Concave (crescent-shaped) bleed on Ct of the brain
Subdural hematoma

*Bleeding can cross suture lines
How to diagnose a subarachnoid hemorrhage?
First get a CT

If CT is negative, proceed to get an LP
What will the LP reveal if a subarchonid hemorrhage is present?
Xanthochromia (RBCs)
Increased opening pressure
What should you do after you confirm a SAH?
4-vessel angiography
What should you do after a CT scan with an intracerebral hemorrhage?
NOTHING!

DO NOT get an LP --> can induce brain herniation
What is the cause of an epidural hemorrhage?
MC after temporal bone fracture --> middle meningeal artery is disrupted
What is the cause of an subdural hemorrhage?
MC is blunt trauma, but causes bleeding on the opposite side of the brain = called "contre coup"

Venous bleed
What is the cause of an subarachnoid hemorrhage?
MC berry aneurysm rupture, AVM (arteriovenous malformation)
What is the cause of an intracerebral hemorrhage?
HTN, AVM (arteriovenous malformation)

trauma, amyloid
Epidural hemorrhage picture
Subdural hemorrhage picture
Subarachnoid hemorrhage picture
Intracerebral hemorrhage picture
What clinical manifestation will you see if tentorial herniation occurs with an epidural hemorrhage?
CN III palsy
What type of hemorrhage is associated with lucid intervals?
Epidural, intracerebral
What type of hemorrhage is associated with loss of consciousness?
brief LOC --> epidural, followed with period of lucidness before coma
What type of hemorrhage is associated with hemiaplegia/paresis?
intracerebral
What type of hemorrhage is associated with meningeal symptoms?
subarachnoid

unilateral, occipital HA
What type of hemorrhage is associated with focal neurologic deficits?
epidural and subdural

NOT subarachnoid
Bilateral, tight, band-like
Tension headache

No N/V, or focal neurological sx
What is the difference between a common vs. a classic migraine headache?
Common - migraine with aura
Classic - migraine without aura
What is the pathophysiology of migraines?
Vasodilation of the blood vessel innervated by the trigeminal nerve due to internal carotid constriction
Lateralized, pulsatile, throbbing headache
Migraine
Associated symptoms of migraines
N/V
Photo/phonophobia

Auras -
Triggers for migraines
- Exercise
- Stress
- Fatigue
- OCPs and menstrual cycle
- ETOH
- Chocolate, red wine
Triggers for tension HAs
- stress
- noise
- glare

Not worsened with physical activity like migraines are
Triggers for cluster HAs
- Stress
- ETOh
-Night
Describe an aura
Visual changes are the most common sx

- photopsia (flashes of light)
- teichopsia (zigzag lines of light)
- scotomas (blincpsots that may scintillate)

Usually last <60 min (5-20min) --> then HA comes on

Other sx include weakness aphasia, and numbness
What is the treatment during a mirgraine exacerbation?
Triptans or ergotamines
Dopamine blockers

IV fluids, dark room, silence,
What is the treatment for migraine prophylaxis?
Anti-HTN meds (BBlockes, CCBs)
TCAs (Amytriptiline)
Anticonvulsants (Valproate, Topiramate)
What is the MOA of triptans or ergotamines?

What are the CIs?
serotonin 5HT agonists --> vasoconstriction

CI in anyone with HTN, CAD, PVD, liver or renal dz
Who are cluster headaches most common in?
Young and middle aged men
Severe, unilateral periorbital or temporal pain

Last typically less than 2 hours and spontaneously resolve
Cluster headache
What is treatment for a cluster headache
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What is the prophylactic treatment for a cluster headache?
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