1 / 33

Neurology

This session will cover the less common signs and symptoms of stroke/TIA, discuss the need for testing (echo, Holter, carotid dopplers), and review CNS infection signs and symptoms.

shaneh
Download Presentation

Neurology

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Neurology What not to miss in the ER Danielle Pirrie CCPA Toronto East General Hospital dpirr@tegh.on.ca

  2. Objectives • Review the less common S/S of stroke/TIA • Discuss need for testing (echo, Holter, carotid dopplers) • Review CNS infection S/S

  3. 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

  4. 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”

  5. Case #1 • P/E: • VS: T 36.7, HR 86, BP 154/92, RR 18 SpO2 94% RA • Neuro exam: CN II-XII normal, no focal weakness, no dysarthria, upgoing toes bilat • DDx • Infection • Stroke • Encephalopathy

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

  7. Stroke

  8. 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

  9. Stroke • Posterior circulation stroke S/S • Acute vision loss • Confusion • Dizziness • Nausea • Memory loss

  10. 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.

  11. 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)

  12. 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

  13. 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

  14. Stroke Summary • If TIA, ensure pt has followup for stroke workup to reduce future risk of stroke • Posterior circulation strokes have many mimics

  15. 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.

  16. Case #2 • P/E • temp of 39.8oC, HR 110, BP 114/72, RR 28, SpO2 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

  17. Case #2 • DDx • Bacterial meningitis • Viral meningitis • Herpes simplex encephalitis • Stroke

  18. 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

  19. 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

  20. HSV on MRI (T2) • Hyperintesity in right temporal lobe • Treatment with acyclovir IV

  21. 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

  22. CNS Infections • Abscesses • Severe HA • Mental status changes • Unilateral weakness/paralyisis • Fever

  23. 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

  24. 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

  25. 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

  26. 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

  27. Case #3 • This came out as “beautiful story run April” • When he tried to spell “road” it was P-F-G-O

  28. Intracranial bleed • CT head showed a lobar hemorrhage.

  29. Intracranial bleeds • Intra-axial bleeds • Within the brain itself (as in previous case) • Hemorrhagic stroke intraparenchymal intraventricular

  30. Intracranial bleed • Causes: • HTN • Trauma • Aneurysm • AV malformation • Tumour • Amyloid angiopathy

  31. Intracranial Bleed • Extra-axial bleeds

  32. Intracranial bleed • All bleeds require discussion with neurosurgery. • Blood in brain can increase ICP • At risk for seizures

  33. Questions?

More Related