Danielle Pirrie CCPA Toronto East General Hospital dpirrteghonca Objectives Review the less common SS of strokeTIA Discuss need for testing echo Holter carotid dopplers Review CNS infection SS ID: 914691
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Slide1
Neurology
What not to miss in the ER
Danielle
Pirrie
CCPA
Toronto East General Hospital
dpirr@tegh.on.ca
Slide2Objectives
Review the less common S/S of stroke/TIA
Discuss need for testing (echo,
Holter
, carotid
dopplers
)
Review CNS infection S/S
Slide3Case # 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
Slide4Case #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”
Slide5Case #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
Slide6Stroke
CT scan showed a left parietal stroke relating to Wernicke’s area
Slide7Stroke
Slide8Stroke
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
Slide9Stroke
P
osterior
circulation stroke S/S
Acute vision loss
Confusion
Dizziness
Nausea
Memory loss
Slide10Stroke/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.
Slide11Stroke/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)
Slide12Stroke/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
Slide13Stroke 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
Slide14Stroke Summary
If TIA, ensure
pt
has
followup
for stroke workup to reduce future risk of stroke
Posterior circulation strokes have many mimics
Slide15Case #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.
Slide16Case #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
Slide17Case #2
DDx
Bacterial meningitis
Viral meningitis
Herpes simplex encephalitis
Stroke
Slide18Case #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
Slide19CNS 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
Slide20HSV on MRI (T2)
Hyperintesity
in right temporal lobe
Treatment with acyclovir IV
Slide21CNS 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
Slide22CNS Infections
Abscesses
Severe HA
Mental status changes
Unilateral weakness/
paralyisis
Fever
Slide23CNS 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
Slide24Case #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
Slide25Case #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
Slide26Case #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
Slide27Case #3
This came out as “beautiful story run April”
When he tried to spell “road” it was P-F-G-O
Slide28Intracranial bleed
CT head showed a lobar hemorrhage.
Slide29Intracranial bleeds
Intra-axial bleeds
Within the brain itself (as in previous case)
Hemorrhagic stroke
intraventricular
intraparenchymal
Slide30Intracranial bleed
Causes:
HTN
Trauma
Aneurysm
AV malformation
Tumour
Amyloid
angiopathy
Slide31Intracranial Bleed
Extra-axial bleeds
Epidural
Subdural
Subarachnoid
Intracranial bleed
All bleeds require discussion with neurosurgery.
Blood in brain can increase ICP
At risk for seizures
Slide33Questions?