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

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