NEUROLOGY EMERGENCIES NILESH PATEL, DO, FACOEP, FAAEM PROGRAM DIRECTOR, ST. JOSEPH’S REGIONAL MEDICAL CENTER, IR, JANUARY 16, 2016
NEUROLOGY EMERGENCIES
NILESH PATEL, DO, FACOEP, FAAEMPROGRAM DIRECTOR, ST. JOSEPH’S REGIONAL MEDICAL CENTER, IR, JANUARY 16, 2016
DISCLOSURES• CSL BEHRING• PAID SPEAKER/CONSULTANT• KCENTRA, 4 FACTOR PCCs
SUBARACHNOIDHEMORRHAGE
HEMORRHAGIC - SAHCircle of Willis
SAH: CLINICALSudden onsetAneurysm / AVMSentinel headachesNo lateralizing symptoms50-55 years of age
SIGNIFICANT SAH RF’SFirst degree relative with aneurysmConnective Tissue DiseaseAD Polycystic Kidney Disease
SUBARACHNOID HEMORRHAGECT-97.5% SENSITIVE
LPXANTHOCHROMIA
Comparison of RBC's in CSF tubes
TREATMENTSupportive, Surgical
Consider Nimodipine for vasospasm
CT/LP100%
Perry et al. Annals EM(2008)
HEMORRHAGIC CVA10-15% CVA's - Higher mortalitySudden onset/Progressive deficitsRF: HTN, Coagulopathies, Stimulant use, Anticoagulant therapy, Thrombolytic therapyTx: Prevention of secondary brain injury
NEURO
NEURO
RISK OF INTRACRANIAL BLEED WITH TPA?5.2%
NEURO
TARGET CEREBRAL PERFUSION PRESSURE ?>70 mmHG
CEREBELLAR INFARCT Vomiting Dizziness CN VI palsyBrain stem compression
CLINICAL PEARLVertigo/Nausea with Crossed Findings
4 D’s
POSTERIOR CVA
4D’S
PUPILS ASSESSMENTPinpoint = Pontine (Decerebrateposturing/coma)Dilated = PutamenAnisocoria, Miosis, Sluggish = Thalamus
ACUTE ISCHEMICSTROKE
ISCHEMIC CVA>80% Of ALL STROKES
EMBOLIC Cardiogenic (Cardiomyopathy, VD, AFIB, MI)Septic emboli, Air/fat embolus
THROMBOTICAtherosclerosis
Gradual onset of FNDISCHEMIC CVA
Tx: Prevention of secondary injury
2013 SCIENTIFIC ADVISORY AHA, ASA GUIDELINES
CEREBRAL CIRCULATIONANTERIOR
Carotid system
80% of the brain
Optic n, retina, fronto-parietal & anterior temporal lobes
Vertebral arteriesPOSTERIOR
Anterior cerebral artery
Middle cerebral artery
20% of the brain (posterior fossa, thalamus)
Portions of parietal lobes and occipital lobes
ACA CVAContralateral sensorimotor deficitsMotor deficit leg > armFrontal lobe personality changes
MCA CVAContralateral sensorimotor deficitsMotor deficit arm > legMay see receptive (Wernicke's) or expressive (Broca's) aphasia
PCA CVACrossed deficitsCerebellar deficitsCranial nerve deficitsMay have LOC, nausea & vomiting
Small, deep and well localized infarcts
LACUNAR INFARCTS
Pons, IC, basal ganglia, thalamusHTN,DMSensory or motor defect or ataxic hemiparesisNO altered consciousness or language deficit
TRANSIENT ISCHEMIC ATTACKS (TIAs)
Complete resolution within 1 h (80% 7-10 min)30-35% have CVA < 5 yearsMost commonly EMBOLICClinical clue Amaurosis fugax
Pure motor deficitBELL'S PALSY
Unilateral facial paralysis, tears, hyperacusisMale = female prevalence, increased with pregnancyCentral 7 th lesions = forehead SPARED (crossed innervation)
MANAGEMENTSteroids - must start early (ideally within 24 hours but still recommended for patients within one week of onsetEye care - artificial tearsAntivirals (valacyclovir) failed to show improvement
Focal and scattered myelin destructionMULTIPLE SCLEROSIS
Presentation : scattered focal neurologic deficitsMultiple physician visitsTypically see relapsing and remitting courseF/M 2.5/1; onset 25-30 y/o
MS PRESENTATIONMC sx Optic neuritis FatigueExacerbations persist for weeks to monthsUhthoff's phenomenon: Temporary worsening of MS signs and symptoms due to small increases in body temperature (hot bath, etc)
CSF: Pleocytosis, elevated proteinMSMRI:
Sensitive for detection of lesionsLesions appear hyper -intense or bright white Multiple peri - ventricular white matter lesionsTreatment Steroids, Interferon
Brain AbscessPyogenic parenchymal infectionHA/fever/focal neuro deficitStreptococcus milleri (50%)
RING ENHANCING LESION
DX: CT/MRITx: Abx /neurosurgery
BACK PAIN ,FEVER, FOCAL NEURO DEFICIT IN IVDA?
Epidural Abscess
CRANIALINFECTIONS
CAN I DIFFERENTIATE MENINGITIS FROM ENCEPHALITIS?WHEN DO I GIVE ACYCLOVIR?
Meningitis Encephalitis
HA + +
Fever + +
AMS + +
Meningeal irritation + -
Onset Typically acute Typically insidious
ABX 4 ABMVancomycin
+3rd G Cephalosporin
ABX 4 ABMAdd Ampicillin
Extremes of age, Chronic alcohol abuse
Immunosupression
MENINGITIS - SPECIAL POPULATION
Neonate - group B sterp & gram negative bacilli, Listeria, E.coliAmpicillin + Gentamycin or Cefotaxime
ABX 4 ABMCSF SHUNTHead trauma Neurosurgery
ENCEPHALITISGive ACYCLOVIR if:
Cognitive deficitsPsych sx
Nonconvulsive sz.
ENCEPHALITISCSF suggestive viral
+Negative gram stain
meningitis/ normal
CSF RBC highly suggestive for HSV encephalitis
TRANSVERSE MYELITISSpinal cord dysfunction W/O evidence of cord compressionUnknown etiology (30% post viral)Thoracic cord involved 60-70%MRI to rule out other causesTreatment Supportive (role of steroids unclear)
GUILLAIN–BARRE/LANDRY'S SYNDROMEMC sx acute symmetric weaknessAscending motor weakness, areflexiaAutonomic dysfx: Urinary retentionRespiratory muscle & CN involved lateHistory of infection : viral; C. jejuniin 15-40%
GBSCSF HAS ELEVATED PROTEIN; NORMAL WBC Check forced vital capacity (FVC] to monitor respiratory status
intubation required 30%; IV lG and plasma exchange may shorten course
Variant Miller FischerDescending paralysis, areflexia, opthalmoplegia
MYASTHENIA GRAVISAutoimmune disease Antibodies vs. acetylcholine receptors at the neuromuscular junctionBimodal (female 20-40 y/o; male 50/70 y/o)Assoc thymic dysfunction in 75%Hallmark : fatigability and muscular weakness
MGMuscle weakness worsens with exerciseExtraocular muscles: ptosis, diplopia , blurred vision
Edrophonium (Tensilon): inhibits AChE , give 1-2 mg IVWeakness improve within 1-2 minutes, lasts for 10 mins
DIFFERENTIAL DIAGNOSISBeware of cholinergic crisis during treatment Similar presentation to myasthenic crisisAcetylcholine excess Weakness, respiratory failure SLUDGE
Tensilon test may worsen symptoms
STATUS EPILEPTICUSMedication non- compliance (50%)Alcohol withdrawal (20%)Acute CNS insult: trauma, CVA, infectionDrug intoxication
SEIZURES, PETIT MALOnset: 5-12 yearsSudden onset, no aura, last 3-20 secondsChild unaware, maintains postural toneSeizure suddenly ends and previous activity continuesCharacteristic 3/second spike & wave EEG abnormality
MIGRAINE HEADACHEOnset puberty, female > maleUsually unilateral, progress to bilateralPin the DX!!!!!!!Complex migraine mimics CVSClassic migraine : +aura; 15% typically visualCommon migraine: No aura, 80% of all migraines
MIGRAINE TREATMENT: ABORTIVE
NSAIDs/ acetaminophen-first line
Work well at onset of headache, often not helping when seen in ED hours later
Dihydroergotamine- tried and true (watch for nausea)Triptans (selective 5HT1 receptor antagonists)
Phenothiazines - safe and more effective than narcotics
Dystonic reactions are always a riskParenteral narcotics
MIGRAINE TREATMENT: PROPHYLACTIC
55-65% effectiveBeta - adrenergic blockers (propanolol)Calcium channel blockersTricyclic antidepressantsAnti-convulsantsMonoamine oxidase inhibitors
CLUSTER HASharp periorbital pain short duration
Clinical pearl
High flow 02 Sumatriptan
CLUSTER HEADACHESMales (20's), smokersConjunctival injection, tearingNasal congestion or rhinorrheaFacial flushingRecurrence over days, then not for 6-12 monthsHolds hand to the eye, rocking, rubbing head or pacing30% have partial Horner's
GIANT CELL ARTERITISAKA Temporal arteritisInflammation of branches of external carotid artery Temporal artery tender 50% of the timeRisk of sudden, permanent vision lossSeen in elderly
TEMPORAL ARTERITISBlood studies - elevated ESR, CRPOthersTemporal artery biopsy - false negatives due to skipped lesions Treatment with corticosteroids
PSEUDOTUMOR CEREBRIAka Benign intracranial Hypertension (BIH) or idiopathic intracranial hypertension (IIH)Young obese female with irregular menses(8:1 F:M)Nonspecific headache with visual complaintsPrimarily in young, obese woman of childbearing ageHeadache (CDH), transient visual obscurations (seconds), pulsatile intracranial noises, double visionTypically visual acuity and color are preserved, but optic nerve-related visual field defects are present in > 90% of patients (e.g, enlarged blind spots, generalized constriction, and inferior nasal field loss)Several predisposing factors have been identified, including the use of oral contraceptives, anabolic steroids, tetracycline, and vitamin A
SPINE
MSALS Cauda equinaEpidural AbscessVertebral OsteomyelitisSyringomyelia
CENTRAL CORD SYNDROME Most common incomplete injury
Hyperextension injury, ligamentumflavum bucklesOlder patients with DJD
Upper extremity weakness >Lower extremity weakness
Sensory loss variable 50-75% recover
ANTERIOR CORD SYNDROME
Dense bilateral motor paralysis and loss of sense of pain and temperature
CX: Forced flexion, disk/bone herniation cord contusion or compression of anterior spinal artery
Preserve touch, position, and vibrationPoor prognosis
BROWN - SEQUARD SYNDROMEHemisection of the cordUsually Penetrating injuryIpsilateral muscle paralysis and loss of position, vibration and touchContralateral loss of pain and temp
BROWN - SEQUARD SYNDROME
COMPLETE SPINAL CORD LESIONSTOTAL LOSS OF SENSORY, AUTONOMIC AND VOLUNTARY MOTOR INNERVATION DISTAL TO LESIONNeurogenic shock - BP and Pulse
Loss vasomotor tone - Vasodilate, Pooling GI, LEImpaired symp tone - Bradycardic
Spinal shock - flaccidity (loss of muscle tone) and loss of reflexes
May be transient (less than 24 hours)
Resp failure - paralysis intercostal muscles (C5 - T3)
CAN'T PEE, WEAKNESS, AREFLEXIA, CROSSED STRAIGHT LEG RAISECentral disc herniation – Cauda equina
NEURO
CAUDA EQUINA SYNDROMEUsually due to midline rupture of intervertebral disk at L4-5 levelDx MRITx Decompression
CAUDA EQUINA SYNDROME+/- Low back painUrinary retention is the most consistent finding (90% sensitive)Radicular painBilateral lower extremity weaknessUrinary or fecal incontinenceSaddle anesthesia, loss of rectal tone
NEURO2 CAUSES OF STROKE WHEREHEPARIN IS INDICATED?
Carotid artery dissectionCVST
A patient presenting with AMS and acidosis
AMSCLINICAL PEARL
THINK SEIZURE
RED FLAGS: HAFever
Eye pain/Tearing
Sudden onset
Nausea, Vertigo
Enclosed space/AMS
Tender face; ESR
Pregnancy
Trauma
NEUROB6INH OVERDOSE?
NEURO
HSV
THE MOST COMMON CAUSE OF VIRAL ENCEPHALITIS IS ....
FAST FACTSMC cx focal neurodisease?
TOXO
Ring enhancing lesions?
TOXO
Single isolated lesion
CNS lymphoma
AIDS
NEUROWERNICKE'S
AMS+ATAXIA+ NYSTAGMUS
SPINAL CORD COMPRESSION
Back pain + CancerCLINICAL PEARL
Steroids
CAUDA EQUINACLINICAL PEARLMC presentation Urinary retention with overflow incontinence
NEUROTINNITUS, HEARING LOSS, AURAL FULLNESS, VERTIGOMENIERE'S DISEASE
NEURO60 YO FEMALE WITH UNILATERAL HEADACHE, LOSS OF VISION, ESR > 50TEMPORAL ARTERITIS
NEURO
Seizure/AMS with temporal lesion on CTHSV ENCEPHALITIS
NEURO70 YO RECENT MEMORY LOSS - ALL ELSE NORMALTRANSIENT GLOBAL AMNESIA