Meningitis
Dana Alnimri
= inflammation of leptomeningites (2inner layers )
Meninges= 3 protective layers around the brain + spinal cord .
Causes : infectious /non-infectious
Bacterial meningitis :
= acute urulent infection within subarachnoid space . Associated with CNS inflammatory reaction that
causes—> high ICP , low consciousness level , seizures, stoke .
SYMP: headache + fever + neck stiffness— + photophobia / phonophobia / petechiea on trunk, mucus,
membranes, extremities.
rash of meningococcemia—> diffuse erythematous maculopapular
rash - rapidly become petechial
Diagnosis :
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skin rash seen only in late stages…when
bacteria infect blood ( septicaemia )
history + physical exam
Blood cultures
CSF exam by lumbar puncture ( needle between L3-L4)
CT/MRI
Physical exam :
High ICP (intracranial
pressure) signs :
*Low level of consciousness
*Papiledema, dilated pupils
* decerebrate posturing
* cushing reflex ( bradycardia,
hypertension, irregular respiration
Kernig’s sign
Brudzinski sign
Tumbler test
Management : (!! Medical emergency)
empirical anti microbial therapy : antibiotic
Within 60 min of arrival - combination of
Dexamethasone third- or fourth-generation
cephalosporin (e.g., ceftriaxone) + vancomycin
+ acyclovir .
Specific therapy —> penicillin G ( of resistance
found —> ceftriaxone )
ACUTE VIRAL MENINGITIS :
etiology —> enteroviruses, HSV type 2 (HSV-2), HIV, arboviruse.
Clinical signs : headache , fever, unchallenged rigidity , malaise , myalagia, anorexia,
nausea, vomiting, abdominal pain, diarrhea , drowsiness , seizures.
!! Stupor, coma, marked confusion don’t occur in viral meningitis
Lab tests : CSF - polymerase chain reaction - viral culture - CBC( liver function test ESR- C-reactive protein- electrolytes- glucose - creatine kinase - amylase- lipase ) CT /MRI
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Treatment :
Symptomatic therapy ( analgesics -antiemetics- antipyretics )
FLUID + electrolytes status monitor
Empirical therapy
Oral / IV acyclovir
Dana Alnimri
if seriously ill —> IV acyclovir (15-30 mg/kg / day 3 times )
… then oral acyclovir (800 mg 5 times ) / valacyclovir 7-14 days .
if less ill —> oral drug
Vaccination
CSF in bacterial meningitis: high
WBC- low glucose- high protein
In aseptic meningitis: protein Normal/
slightly elevated, glucose normal,
increase in mononuclear cells.
“lymphocytic pleocytosis is present.”
empyema :
= collection of pus between dura and arachnoid membranes .
Causes: streptococci, staphylococci, enterobacteria ,
SYMP : fever, vomiting, impaired consciousness, and rapid development of neurologic signs suggesting widespread
involvement of one cerebral hemisphere , seizures .
Diagnosis : contrast-enhanced MRI / , if MRI is not available, contrast-enhanced CT— blood culture — lumbar puncture is
contraindicated in patients with meningeal signs mass lesion is excluded .
Treatment : - surgical drainage
- antibiotics ( eg; ceftriaxone, metronidazole, vancomycin )
- Mannitol / dexamethasone if ICP is high
- Hemicraniectomy may be required if intracranial pressure cannot be otherwise controlled
Prognosis : Awake and alert patients have a good prognosis in the majority of the cases.
Stuporous and comatose patients have high mortality.
Older age patients have the worst prognosis.
Dana Alnimri
Intervertebral disc herniation :
Intervertebral disks:
= localized displacement of disc material,Cartilage,..)
Flat, round disks that
eyond the limits of intervertebral disc space.
sit between the
Also known as “ Schmorl’s nodes”
vertebrae and act as
Imaging : X-ray ( does not show herniation nut rule out other problems), CT , MRI”best”
the spine’s shock
herniated disc=slipped/prolapsed disc
absorbers
Symp: lower back pain , neck pin, difficulty bending over
It is divided into 4 stages:
1) Degenration/bulging
2) Prolapse/ protrusion
3) Extrusion
4) Sequestration
Types:
Hansen type I (nucleus pulposus degeneration and extrusion).
• Hansen type II (annulus fibrosis degeneration and protrusion).
Clinical finding : sciatica by history, ipsilateral SLR , crossed SLR , ankle dorsiflextion weakness, great toe extensor
weakness, sensory loss, Parian radiate down below the knee , sharp pain on one body side.
Treatment: NSAIDs -muscle relaxants , physical activity !! Avoid bed rest
!! Side effect of NSAIDs = gastrointestinal toxicity
Patients improve writhing 4-6 weeks
SLR = straight leg raising test
patient supine elevate leg between
30-60 degree , positive when pain
radiate to leg
Epidural steroid injection if not improved after 6 weeks
Surgery : microdiscetomy
Causes :
Sitting for long period in same position - being overweight - lifting heavy objects - repitive bending /twisting motions
-smoking
Dana Alnimri
STROKES :
ISHCEMIC STROKE :
classes : a) TIA (lasts 30 min-24hrs)
B) Reversible ischemic neurologic deficit
C) Evolving stroke is a stroke that is worsening.
D) Completed stroke is one in which the maximal deficit has occurred.
Risk factors: age, HTN, smoke,DM , hyperlipedemia, CAD, previous/family history of stroke …
Causes : atherosclerosis, atrial fibrillation with clot emboli, septic emboli from endocarditis
Symp :
Thrombotic stroke —> patient awakens from sleep with the neurologic defici
Emboli stroke —> onset is very rapid ( Clinical features depend on the artery that is occluded) MCA is
most common affected …causing : Contralateral hemiparesis and hemisensory loss — Aphasia —Apraxia,
contralateral body neglect, confusion .
Lacunae stroke : includes 4 major syndromes ( motor, sensory, ataxic hemiparesis, clumsy hand
dysarthria)
Diagnosis : CT scan of head , MRI “more sensitive” , ECG (for MI/fibrillation cause of embolmic stroke ),
MRA (for aneurysms )
Complications : cerebral edema (1-2 days causing mass effects), hemorrhage , seizures
Treatment : Acute : airway , oxygen, IV fluids , thrombolytic therapy t-PA “within 3 hrs”, (!!! Don’t give tPA if time of stroke in unknown because if after 3 hrs / has HTN bleed trauma… it will increase risk fro
hemorrhage ), aspirin within 24 hrs ( clopidogrel if contraindicated, if both not give ticlopidine)
If stroke patient in ED : do CT, ECG, CBC,
PT, PTT, serum electrolytes , glucose ,
bilateral carotid ultrasound, echo
If stroke is caused by emboli from a
cardiac source, anticoagulation is the
treatment
Hemorrhagic Stroke : ( intracerebral hemorrhage + SAH )
Dana Alnimri
ICH :
Causes : HTN (sudden increase in BP) , Ischemic stroke may
convert to a hemorrhagic stroke, amyloid angiopathy, anticoagulant, brain tumors
Locations : basal ganglia - pons - cerebellum
Types : intracerebral - subarachnoid strokes
Symp: a.Abrupt onset of a focal neurologic deficit that worsens steadily over 30 to 90 minutes
b. Altered level of consciousness, stupor, or coma
c. Headache, vomiting
d. Signs of increased ICP
Diagnosis : CT scan , coagulation panel and platelets
Complications: Increased ICP , Seizures, Rebleeding, Vasospasm, Hydrocephalus , SIADH
Treatment : ICU admission — ABC — BP reduction (high BP cause further bleeding) if
systolic>169-180 / diastolic>105 “nitroprusside”— mannitol +diuretics to reduce ICP
Brain tumors :
Dana Alnimri
clinical presentation : isidous onset ->headache-> seizure-> mental,behavioral,personality
changes, lateral icing/focal neurological deficits—>increased ICP “intracranial pressure”
Tests: X-ray, EEG, perimetery.audiometer, CSF,
Biopsy
Treatment :surgery, brachytherapy, radiotherapy,
Chemotherapy, Gamma-knife
Types :
Astrocytoma : most common glioma
Cerebral astrocytoma”>in adults “ ….behavioral changes, seizures, hemiparesis, language
difficulty .
Cerebelllar astrocytoma “>in children” …hemisphere , ataxia (=disorders affect speech,
balance and coordination ) .
Brain stem “children”…pons,CN deficits .
Has 4 grades : (1) pilocytic : in children &young adults
(2)diffuse / fibrillary :common in cerebral hemisphere in young adults , benign , complete
resection not possible
(3)anaplastic
(4) glioblastoma multiforme
Gliomas imaging : high grade—> appear as contrast enhancing mass lesions arise in white
matter + surrounded by edema
Low grade —> diifusely infiltrate brain tissue
Dana Alnimri
Meningioma : 2nd most common brain tumor (usually benign)
- Originate from arachnoid cells , female:male ration 3:2 , spinal meningioma *10 in women .
- Occur with NF-2
- Rare in children ( more in boys)
Etiology: radiotherapy , head trauma , viral infection, estrogen receptors
Symp: some are asymptomatic “found by MRI”
Symp acccording to tumor location
Diagnosis : cranial CT scan , angiography “hyper vascular mass “, MR angiography &
venography.
! Growth rate : <1 cm /year
Surgery : complete resection …. For recurrence: reresection
Pituitary adenoma :3rd most common
- often asymptomatic
- common in adults … not hereditary except MEN-1 “multiple endocrine neoplasia”
Symp:
compression of neural +vascular structures : headache , hypopituitarism , visual
symp(visual loss-visual field abnormality like bitemporal hemianopsia ) ,papilledema”rare” , may
enlarge with pregnancy
Hemianopsia= loss
Optic chiasm compression: bitemporal hemianopsia
of one half of a
Optic nerve compression : ipsilateral blindness
vertical visual field
Optic tract compression : controlateral homonymous hemianopsia
Dana Alnimri
Diaphragm sella : as tumor grows forward sella…compress basal dura…headache …affected
pain sensitive intracranial structures .
Hypothalamus +thalamus : CSF accumulation—> hydrocephalus
Treatment : -Trans-sphenoidal surgery
- Radiotherapy
- Bromocriptine to block prolactin-secreting tumours
- Somatostatin analogues (e.g. ocreotide) to block growth hormone-secreting tumours
Acoustic Neuroma (AKA Vestibular Schwannoma)
= tumours of the Schwann cells surrounding the auditory nerve that innervates the inner ear. - -They occur around the “cerebellopontine angle” and are sometimes referred to as
cerebellopontine angle tumours.
- They are slow-growing but eventually grow large enough to produce symptoms and become
dangerous.
- usually unilateral. Bilateral acoustic neuromas are associated with neurofibromatosis type 2.
Classic symptoms of an acoustic neuroma are:
Hearing loss
Tinnitus
Balance problems
! They can also be associated with a facial nerve palsy.
Dana Alnimri
Aneurysm :
why they develop ? Atherosclerosis- hypertension-sickle cell anemia -congenital/familial inherited
-trauma-infection-cigarettes -alcoholWho get them ? 40-60 years — female
Symptoms: headache- facial pain- meningeal irritation (neck pain stiffness)-seizures-alterions in
consciousness-visual symp(blurry vision- diplopi)
Diagnosis ; history — CT &MRI -lumbar puncture -angiography
Management: surgical. “Clipping-coiling “ —— medical
SAH :neurological emergency
most common cause : head trauma - rupture a saccular aneurysm …others; bleeding
AVM, cigarettes, HTN, mycotic aneurysm
Saccular aneurysm “berry”
Size 2-3 cm
Giant >2.5 cm. …3 most locations : (1)terminal internal carotid artery-(2) MCA(3) top of basilar artery
They cause symp by compressing brain \cranial nerves
Symptoms: if unruptured ->asymptotic
With rupture -> high BP causing headache and vomiting - falls unconscious immediately-neck stiffened“rarely patient suddenly become conscious without any complaint “… if bleed massive patient will die in
minute to hrs
Drowsiness - confusion-amnesia with severe headache persist several days
Headache —> “worst headache of my life “+ sudden onset
!! Occipital &posterior cervical pain indicate PICA / anterior inferior cerebella’s artery aneurysm AICA
3rd nerve palsy “potosis. , diplopia ..) = post communicating &post cerebral arteries
!! If pain behind the eye
6th nerve palsy = aneurysm in cavernous sinus
—> MCA aneurysm
Unilateral blindness = aneurysm in circle of Willis at origin of ophthalmic nerve
Diagnosis : CT scan - lumbar puncture if remain doubtful do cerebral angiography
Delayed neurological deficits : 4 causes “complications”
1) rerupture /rebleed
2) hydrocephalus :cause stupor and Coma, develop over few daysweeks causing progressive drowsiness /
slowed mention with incontinence ( it may clear or need ventricular drainage)
Treatment: permenant ventricular shunting
3) Vasospasm : causes symptomatic ischemia & infarction ( appear 4-14 days after hemorrhage)
Treatment: calcium channel antagonist nimodipine(60mg PO every 4 h)
!! Nimodipine can cause hypotension which will worsen cerebral ischemia in the patient
Dana Alnimri
4) hyponatremia : develop in first 2 weeks after SAH
( both ANP & BNP have role in producing “cerebral salt wasting syndrome) !! Should not be treated
with free water restriction as this may increase risk of stroke
Changes associated with SAH :
ECG changes (like MI)
Elevation of troop in/CPK (MB) levels
Fall in EF% and heart failure
Structural myocardial lesions
Excessive discharge of sympathetic neurons
Hypoanteremia
D.insipidus
Albuminuria, glycosuria, leukocytosis
Management:
Bed rest, maintain clear airway , manage BP, give fluids , monitor hypoanteremia
Steroids for head and neck pain
Early repair
Clipped / coiled
!! Hunt Hess scale before management
Surgical repair ( requires craniotomy and brain retraction )
Endovascular techniques (placing platinum, coils with on aneurysm via catheter
passed from femoral artery )
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Dana Alnimri
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GCS :Examination to evaluate the level of
consciousness by:* Eyeresponse(maxscore=4)
* Verbalresponse(maxscore=5)
* Motorresponse(maxscore=6)
Minor brain injury 13-15
NIHSS: measure of stroke-related
neurologic deficits that, when
measured at 24 h,“assess severity of
stroke using 11 categories “
Moderate brain injury 9-12
Severe brain injury 3-8
(GCSscoreof<8=intubation)
HUNT HESS scale: to classify the
The ASPECTS (Alberta Stroke Program
severity of a subarachnoid hemorrhage
Early CT Score): 10-point scoring system
based on the patient's clinical
for assessing middle cerebral artery
condition
(MCA) stroke patient .
Dana Alnimri
ASITN :
MRS
ASITN -SYR collateral flow grading
The Modified Rankin Scale = used to
system for determining angiographic
measure the degree of disability in
collateral grade on pretreatment
patients who have had a stroke
angiography .
KNosp :
systems to determine the likelihood of
cavernous sinus invasion by pituitary
macroadenomas.
TICI : thrombolysis in cerebral
infarction for determining the
response of thrombolytic therapy for
ischemic stroke
Dana Alnimri
Fisher :
designed to predict risk of cerebral arterial vasospasm in patients with
aneurysmal subarachnoid hemorrhage (aSAH) based on radiographic
distribution of subarachnoid hemorrhage. The Fisher scale is entirely
radiographic and typically determined at presentation.