Neurology What not to miss in the ER - PowerPoint Presentation

Slide1

Neurology

What not to miss in the ER

Danielle

Pirrie

CCPA

Toronto East General Hospital

dpirr@tegh.on.ca

Slide2

Objectives

Review the less common S/S of stroke/TIA

Discuss need for testing (echo,

Holter

, carotid

dopplers

)

Review CNS infection S/S

Slide3

Case # 1

78yo male, minimal English, from a rehab hospital (for minor) deconditioning, 2 day

hx

of being confused, telling translator that he is in his village in Serbia, being chased by bandits in masks.

PMHx

:

HTN,

previous left MCA stroke 7

yrs

ago left with minor right arm weakness,

high cholesterol

Slide4

Case #1

By the next day, his speech (when talking with family) was like word salad, not making any sense.

But he could tell me in English that he was fine and “want to go home”

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Case #1

P/E:

VS: T 36.7, HR 86, BP 154/92, RR 18 SpO

2

94% RA

Neuro

exam: CN II-XII normal, no

focal weakness, no

dysarthria,

upgoing

toes

bilat

DDx

Infection

Stroke

E

ncephalopathy

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Stroke

CT scan showed a left parietal stroke relating to Wernicke’s area

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Stroke

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Stroke

Typical anterior circulation stroke S/

S

Unilateral weakness

Slurred speech

Decreased LOC

Other anterior circulation stroke S/S

Cognitive impairment

Difficulty with speech, word finding difficulty

Weakness or clumsiness

Changes of sensation

Visual losses – hemianopia

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Stroke

P

osterior

circulation stroke S/S

Acute vision loss

Confusion

Dizziness

Nausea

Memory loss

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Stroke/TIA

Dizziness

Usually associated with other brainstem S/S such as double vision, dysarthria, ataxia, dysphasia.

DDx

: benign paroxysmal positional vertigo, migraine, Meniere’s, low BP, vestibular

neuronitis

, acoustic

tumours

, medications, anxiety, etc.

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Stroke/TIA

Aphagia

/dysphagia

Can be completely non-verbal or simply word finding difficulty

Damage to frontal lobe results in problems speaking (expressive)

Damage to temporal lobe results in problems understanding (receptive)

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Stroke/TIA

Decrease LOC

Most likely to be caused by a brain stem stroke or hemorrhagic stroke

Brain stem stroke difficult to diagnose on CT scan

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Stroke workup

CT scan

Carotid

dopplers

If 70-99% stenosis and TIA or

nondisabling

stroke, may be candidate for surgery or stenting.

Echocardiogram

Holter

monitoring

N Engl J Med July 1, 2010

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Stroke Summary

If TIA, ensure

pt

has

followup

for stroke workup to reduce future risk of stroke

Posterior circulation strokes have many mimics

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Case #2

27yo female comes into ER with fever, headache, fatigue and loss of appetite,

After a few hours of waiting in the waiting room, her boyfriend notices that she is trying to use a pop can as a cell phone, that she is speaking gibberish and not making any sense. She is then brought into a room and examined.

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Case #2

P/E

temp of 39.8

o

C, HR 110, BP 114/72, RR 28, SpO

2

98% RA

CN: PERLA 3+, left visual field defect, no facial asymmetry

Motor: no focal deficits, no neck stiffness

Labs

CBC: WBC 10.4,

Hb

140,

Plt

247

Normal electrolytes, LFT, RFT

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Case #2

DDx

Bacterial meningitis

Viral meningitis

Herpes simplex encephalitis

Stroke

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Case #2

Anytime there is HA, mental status changes and fever, need to do LP

CSF analysis:

Glucose: 2.7 (normal)

Protein: 0.4 (normal)

Culture did not grow anything

CT scan head normal

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CNS Infections

Herpes Simplex

Encephalitis

Typically HSV-1

S/S: fever, headache, psychiatric or mental changes, seizure, vomiting, focal weakness, memory loss.

CSF: mononuclear lymphocytes, high RBC, protein normal or high, glucose normal or low, send for viral cultures and PCR

CT may be negative

Need MRI to diagnose definitively

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HSV on MRI (T2)

Hyperintesity

in right temporal lobe

Treatment with acyclovir IV

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CNS Infections

Meningitis

May be bacterial, viral, tubercular, or fungal

Bacterial meningitis: children under 2.

s/s: evolve over hours, starts with URTI s/s then develop fever, lethargy, N/V, stiff neck, photophobia

CFS: high

polymorphonuclear

leukocytes, high protein, low sugar

Urgent management is vital as severe cortical damage can result from any delay in treatment

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CNS Infections

Abscesses

Severe HA

Mental status changes

Unilateral weakness/

paralyisis

Fever

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CNS Infection Summary

Low threshold for LP in

pts

with fever and mental status changes

Treat empirically for HSV-1 to ensure no irreversible brain damage

Abscesses are usually seen on CT

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Case #3

73yo male, sudden onset of L HA while at home

Pt

took 2 ASA for pain but it did not resolve so he took 2 more ASA 2 hours later

Approx

1

hr

after, he suddenly noticed not being able to read the computer screen and having decreased vision on the right side

Slide25

Case #3

PMHx

:

A-fib for which he takes ASA

HTN

Dyslipidemia

Prior small right occipital lobar bleed in 2007

ETOH

approx

3 drinks/day

Smokes a pipe

Son is a neurologist in NY state

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Case #3

PE:

VS normal except for irregular pulse

CN mostly normal except for right visual field defect

No motor, sensation, coordination deficits

Normal verbal

Visual acuity

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Case #3

This came out as “beautiful story run April”

When he tried to spell “road” it was P-F-G-O

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Intracranial bleed

CT head showed a lobar hemorrhage.

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Intracranial bleeds

Intra-axial bleeds

Within the brain itself (as in previous case)

Hemorrhagic stroke

intraventricular

intraparenchymal

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Intracranial bleed

Causes:

HTN

Trauma

Aneurysm

AV malformation

Tumour

Amyloid

angiopathy

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Intracranial Bleed

Extra-axial bleeds

Epidural

Subdural

Subarachnoid

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Intracranial bleed

All bleeds require discussion with neurosurgery.

Blood in brain can increase ICP

At risk for seizures

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Questions?