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Neuro 3…. Meningitis.. . Encephalitis. Trigeminal Neuralgia. Meningitis. Meningeal inflammation ...around brain and spinal cord. Cause: Viral vs Bacterial vs other…. Classic sx: HA, NV, neck stiffness, fever. epidemiology. WHO:infants <1yr & children 5 -10yr WHEN:

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neuro 3
Neuro 3…



Trigeminal Neuralgia


Meningeal inflammation

...around brain and spinal cord

Cause: Viral vs Bacterial vs other…..

Classic sx: HA, NV, neck stiffness, fever


WHO:infants <1yr &

children 5 -10yr


highest incidence: late Spring to Fall

reflecting peak activity of enteroviral and arthropod-borne infections

Viral Meningitis: definition

Viral (Aseptic) Meningitis:

Meningeal inflammation w/ neg. bacterial cultures w/

No associated neurologic dysfunction


Few viral particles replicate in the nasopharynx with spread/replication in resp. tract lymphatics.

Most viral particles bind to specific receptors on enterocytes & traverse the intestinal lining cells to reach the Peyer's patches in the lamina propia, where they replicate on mucosal surfaces of the respiratory & GI tract

  • -->primary viremia (onset of illness) seeding of other organs (liver/spleen/heart)
  • second viremia(seedingof the CNS during first or second viremia)
  • s/sx of infx
viral meningitis causes
Viral meningitis: Causes
  • Mycobacteria
  • Fungi
  • Spirochetes
  • parameningeal infections
  • Medications
  • (Amox,. Bactrim, NSAIDS, zantac)
  • malignancy


*Enterovirus (esp.Spring/Fall)



other non-poliovirus enteroviruses


  • HSV HIV West Nile virus (WNV)
  • varicella-zoster virus (VZV) Mumps
  • lymphocytic choriomeningitis virus (LCM)
most common cause enteroviruses
Most common cause: Enteroviruses

EV: 85 -95 % viral meningitis

Nonpolio-EV serotypes cycle from year to year

however, certain serotypes have remained prevalent.

Most common 2000-2005: Coxsackieviruses A9, B5, and B1

Echoviruses 6, 9, 13, 18, and 30

<3mo: usually group B coxsackie viruses and parecho viruses

EV 71, closely related to coxsackie virus A16, the viral agent of hand-foot-mouth disease, has emerged as a significant cause of aseptic meningitis, encephalitis, myelitis.


Humans: only known reservoir

Transmission: fecal-oral route. (Rare:droplet inhalation)

Possible Transplacental -> stillbirth, abortion, neonatal infx

risk factors for ev
Risk factors for EV


In temperate climates: most EV infections outbreak during the warmest months; however, sporadic cases can develop throughout the year.

In US: infections more frequent June - October

In tropical and subtropical regions: consistent thru year

  • Host factors:
  • severe nonpolio EV infx if immunodeficient, age extremes
  • risk of chronic meningoencephalitis if child w/ deficient humoral immunodeficiency, especially X-linked agammaglobulinemia

Incubation period for EV infection is approx. 3-6d

other viruses herpes viruses
Other viruses…Herpes viruses
  • All members of the Herpes viridae family can cause aseptic meningitis
  • INFREQUENTLY: CMV, VZV, human herpesvirus (HHV)-6, and Epstein-Barr virus (EBV)
  • Neonatal & CNSinfxs are the most devastating
  • Primary infection is followed by lifelong infection, w/ potential for reactivation
  • Humans are the only reservoir for transmission
  • Infections occur worldwide without seasonal prevalence
  • ? mechanisms of spread to the brain include: hematogenous dissemination, direct extension nasopharyngeal mucosa, or via neurogenic pathways
  • Aseptic meningitis is a rare complication of chickenpox and herpes zoster
  • The syndrome known as zoster sine herpete is characterized by:
  • CSF pleocytosis
  • documented CNS infection with VZV by PCR
  • absence of typical skin lesions

**Decreasedincidence since introduction of varicella vaccine


RARELY CAUSE Aseptic Meningitis

however, aseptic meningitis is the most common neurologic complication seen in patients with primary EBV infection

other causes hhv 6 and hhv 7
  • HHV-6, (roseola or exanthem subitum)
  • common cause of febrile sz & meningitis in infancy
  • HHV-7, (also exanthem subitum)
  • causes febrile seizures in infancy
  • causes meningitis in children
other causes arboviruses
Other causes: Arboviruses

Highest incidence;: tropical, developing regions

US: most common after EV

The incubation period: 1 - 18 days

Most important endemic US arboviruses :

St. Louis encephalitis virus

West Nile virus

Eastern equine encephalitis virus

Western equine encephalitis virus

California encephalitis viruses

Pathogenesis : Viruses are inoculated subcutaneously or intravenously per vecotor (mosquito) bite

Replication in the skin or muscle

-> primary viremia

-> spreads to to the reticuloendothelial system or CNS.

ask about symptoms
HISTORY..ask about exposureAsk about symptoms

?rodents (LCM) ?ticks (Lyme) ?mosquitos

?human contacts

?TB ?sexual activity (HSV-2, HIV, syphilis)

Nonspecific sx:

Fever HA

Nausea & vomiting Photophobia

Nuchal rigidity Altered mental status

(Kernigs/Brudzinski’s usu. neg)

meningeal irritation

Physical Exam….look for

pe examination for nuchal rigidity
PE: Examination for nuchal rigidity
  • Passive or active neck flexion: inability to touch the chin to chest
  • lateral motion less reliable finding
  • Kernig's & Brudzinski's signs were originally developed and tested in patients with severe, late stage meningitis
  • Brudzinski's sign: spontaneous flexion of the hips during attempted passive flexion of the neck.
  • Kernig's sign: inability or reluctance to allow full extension of the knee when the hip is flexed 90º.
  • When LP was performed w/ suspected meningitis :
  • sensitivity extremely low (5% for each sign; 30% for nuchal rigidity)
  • specificity :95% for each sign & 68% for nuchal rigidity.
  • Jolt accentuation of headache more sensitive for dx meningitis.
  • Sensitivity: 97 % & specificity of 60 % for dx of CSF pleocytosis
dx csf
PE.. look for rashDX: CSF
  • Diffuse maculopapular exanthem in mildly ill pt:
  • ?enteroviral infection, primary HIV, or syphilis. ?meningococcal infection & RMSF
  • Parotitis: mumps meningitis in unvaccinated pt.
  • Severe vesicular, ulcerative genital lesions: HSV-2
  • Oral thrush & cervical lymphadenopathy: HIV
  • Asymmetric flaccid paralysis: West Nile Virus
treatment if unclear etiology
TREATMENT: Suspectedviral meningitisTREATMENT: if unclear etiology

Usually self-limited (vs bact.meningitis)

Resolves without specific therapy

  • Consider empiric therapy x 48hrs if Elderly, prior antibiotics, immunocompromised
  • Otherwise, consider observation
  • If suspect HIV: check HIV RNA and HIV antibody
  • If suspect HSV: acyclovir10 mg/kg IV q8hr
  • empiric antibiotics after blood / CSF cultures
  • OR observation with repeat LP in 6 - 24 hrs.
  • If symptomatically improved and culture negative: DC antibiotics w/o repeat LP
  • If persistent SX w/o clear dx: repeat LP
hospitalize if
  • Ill-appearance
  • Signs of encephalitis
    • altered mental status, behavior, or personality
    • motor or sensory deficits
    • speech or movement disorders; hemiparesis; flaccid paralysis; paresthesias;
    • seizures
  • Need for empiric antimicrobial therapy.
  • Need for IV hydration or aggressive pain control.
  • Immunocompromised host.
  • Age younger than one year.
bacterial meningitis purulent meningitis
Bacterial Meningitis“purulent meningitis”
  • Meningitis is an inflammatory disease of the lepto-meninges, the tissues surrounding the brain and spinal cord, and is defined by an abnormal number of WBCs in CSF .
  • Meninges:
  • pia
  • arachnoid
  • dura maters
  • Bacterial meningitis: infx of arachnoid mater and CSF in both the subarachnoid space and cerebral ventricles.
bacterial meningitis causes
Bacterial Meningitis - Causes

There are at least 50 causative bacteria

Community Acquired:

  • Streptococcus pneumo (pneumococcus)
  • Neisseria meningitidis (meningococcus)
  • Listeria monocytogenes (50-60ys, immunideficient)
  • Haemophilus influenzae type b (Hib)
  • Healthcare-associated
  • (after neurosurgery, ventricular drains, w/trauma )
  • usually staphylococci
  • aerobic gram-negative bacilli

Quite ill

Rapid onset

Classic Triad:

*Fever (>38*) (95%x 4d)

*Mental status changes (78%)

*Nuchal rigidity (88% x7d)


Severe, generalized headache



Rash 11-26% N. meningitidis, petechiae and palpable purpura

Arthritis: 7% N. meningitidis,


additional symptoms
Additional Symptoms

Decreased consciousness

Rapid breathing



Bulging fontanelles

Poor feeding



possible complications
Possible Complications

Hearing loss

Brain damage

Loss of vision


Waterhouse-Friderichsen syndrome (WFS) or hemorrhagic adrenalitis (Neisseria meningitidis )


Viral meningitis


Febrile viral syndromes

Drug induced meningitis

bact meningitis dx tests


Blood cx positive

Other lab:CBC, chem

Chest x-ray

(r/o other sites of infx)

Head CT scan (ICP )

(r/o hydrocephalus, abscess or deep swelling)

CSF glucose:

-<40 mg/dL or <1/2 serum

CSF CELL count:

- WBC’s >1000/microL with a predominance of neutrophils

PROTEIN elevated >0.4g/dl

POSITIVE gram stain/culture

H. Influenzae b Gram Stain


laboratory features


Routine blood work is often unrevealing.

WBC: usually elevated, with left shift

Leukopenia: possible w/ severe infection

Platelet count: may be reduced.

Leukopenia and thrombocytopenia = poor outcome

Coagulation studies: may have DIC.

Serum chemistry: may have metabolic acidosis or hyponatremia

Blood cultures often positive (50- 90%)

Obtain Two sets of blood cultures prior to the initiation of antimicrobial therapy

Cultures obtained after antimicrobial therapy are much less likely to be positive, esp. meningococcus

Tests of urine, mucosal surfaces for bacterial antigens are not generally helpful

lumbar puncture


  • Every patient w/suspected meningitis should have CSF obtained unless LP contraindicated.
  • PROs of CT then LP:
  • exclude a mass lesion or increased ICP, which rarely leads to cerebral herniation during LP
  • However, a screening CT scan is not usually necessary
  • Study: CT:24%had abnl finding, but only 5% had mass effect.
  • Abnl CT scan predicted by a suspicious hx/Exam :
  • -immunosuppression
  • -previous CNS disease
          • seizure within the previous week
          • reduced LOC
          • motor or cranial abnormalities, papilledema
  • CONS of CT then LP:2hr delay in dx, 1hr delay in rx.
if lp is delayed
If LP is delayed…


Obtain blood cultures

Start antibiotics empirically before the imaging study

Also give dexamethasone (0.15mg/kg IV q6hr)

shortly before or at the same time as the antibiotics

( rate of hearing loss & other neuro complications, & mortality)

(Adjunctive dexamethasone should not be given after antimicrobial therapy b/c unlikely to improve pt outcome)

Prior administration of antimicrobials tends to have

minimal effects on the chemistry and cytology findings,

but can reduce the yield of Gram stain and culture .

However, a pathogen can still be cultured from the CSF in most patients up to several hours after the administration of antibiotics


Antibiotics - depending on organism

Extremes of age (<3m or >60 yrs)

cover for listeria with ampicillin.

Empiric therapy : rocephin (2grams Q12h) plus vancomycin

Treatment of secondary symptoms including cerebral edema, shock, sz


  • TRUE medical emergency
  • requires immediate admission

Any form of bacterial meningitis that is untreated or treated very late in its course is almost uniformly fatal.


In-hospital mortality 27%

Neurologic deficit at discharge 9 %

independent predictors of adverse outcome:


altered mental status



no RF — 9 %

1 RF — 33 %

2-3 RF — 56 %



B/C uncertain effect of dexamethasone on the CSF penetration of vancomycin:

Begin with vancomycin plus either ceftriaxone or cefotaxime.

If susceptibility studies show intermediate susceptibility (MIC ≥2 mcg/mL) to ceftriaxone and cefotaxime, addrifampin

B/C: vancomycin penetration into the CSF starts at a high level in the presence of bacterial meningitis..

impairment in penetration to a level that will reduce efficacy is not likely in the first few days before susceptibility studies are available.

patient education
Patient Education

Seek immediate medical attention if a child has any of the symptoms

Early treatment is key to good outcome.

Prevention of hflu: HiB vaccine

Prevention of pneumococcal: Prevnar

Prevention, high school students: Menactra

Prophylaxis of household

contacts w/ preventative antibiotics;

highly recommended.

meningitis bacterial vs viral vs encephalitis
Meningitis (bacterial vs viral) vs Encephalitis

Bacterial Meningitis

Very serious

Meningeal irritation

CSF Gram stain positive

CSF WBC >1000/microL (neuts)

CSF glucose <40 mg/dL

Nl brain


  • Viral Meningitis:
  • less severe
  • meningeal irritation
  • fever, HA, NV
  • seizures
  • hemiparesis
  • flaccid paralysis
  • paresthesias
  • resolves w/o specific Rx
  • CSF WBC<500/ microL
  • CSF protein <80 100mg/dL
  • CSF glucose: normal
  • Gram stain negative


Viral, invades brain tissue

altered mental status (confused.. obtunded)

motor or sensory deficits (paresis,  DTRs)

altered behavior & personality speech or movement d/o

No meningeal irritation

Abnl brain function:


Viral Inflammation of the brain

Rare disease

(0.5 per 100,000)

Most common in




encephalitis pathogenesis
Encephalitis: PATHOGENESIS
  • Two viral mechanisms:
  • 1.directly invade brain tissue (acute viral encephalitis)
  • virus cultured from the brain
  • viremia from viral meningitis
  • spread from peripheral nerves (rabies, HSV)
  • 2.Post-infectious encephalitis (autoimmune response)
  • No virus detected
  • hx of illness or vaccination 2-4wk prior to S/S
  • Need neuroimaging to differentiate.
encephalitis s s

subtle to profound…

  • Altered mental status: confused, agitated, obtunded
  • Behavior
  • Personality
  • Speech
  • movement.. Motor or sensory deficits : hemiparesis, cranial nerve palsies, exaggerated DTRs
  • Seizures are common

NO S/S of meningeal irritation: photophobia, nuchal rigidity

VS aseptic meningitis nonspecific, fever, headache, nausea, vomiting, photophobia, nuchal rigidity; nl cerebral function

neonates and young infants
Neonates and young infants

As with other infections in neonates (0-28d) and young infants, the presentation can be nonspecific.

  • Fever (variable )
  • seizure
  • poor feeding
  • Irritability
  • Lethargy
  • In a series of 63 neonates with HSV1 CNS dz:
  • 49% lethargy
  • 57% seizure
  • 63% skin vesicles
  • 44% fever
children and adolescents
Children and adolescents

SS at admission

prospective series of 50 children (6wks-18yrs):

100%:Encephalopathy 80%: Fever

78% Seizure

56% Other Focal

neuro signs

47%  LOC


status epilepticus

cerebral edema

inappropriate ADH

cardiorespiratory failure


defined as depressed or altered LOC (lethargy, extreme irritability, significant change in personality or behavior) x ≥24hr

encephalitis causes
Encephalitis - Causes


Many different viruses

Most cause meningitis or encephalitis

Postinfectiousencephalitis: MMR, VZV, influenza


Geographic location (eg, St. Louis encephalitis in North America, Japanese encephalitis in Asia)



  • Tick Exposure:
  • Colorado tick fever (w. US) or
  • non-viral, ie: Lyme dz or RMSF
encephalitis causes40

Mosquito exposure:

  • Arboviruses (east.equine, west. equine, St. Louis (NA, Midwest/So.US)
  • Venezuelan equine encephalitis


  • WNV (multiple continents including Asia, Africa, Europe, NA)
  • weakness, rash
  • rare < 1999,now most commonly CNS arboviral infx


peds causes

*Enteroviruses—major cause.

clear seasonality (78 % June - October)

*HSV 1/11..5% all age groups but 75% neonatal infection

Epstein-Barr virus—10 %

Arbovirus La Crosse encephalitis: most common arbovirus in children

Seasonal (July - September)usu 5-9yr\o

Arbovirus West Nile virus .. rare

Influenza virus:5 % usually< 5yo

Other viruses MMR: rare b/c vaccinations

physical examination
physical examination

IF Parotitis/mental status changes:Mumps encephalitis

IF Flaccid paralysis: WNV infection

Misdiagnosed as Guillain-Barre syn.

Maculopapular rash 50%

IF Tremors of eyelids, tongue, lips, extremities:

St. Louis encephalitis or WN encephalitis

IF Hydrophobia, aerophobia, pharyngeal spasms, hyperactivity: encephalitic rabies.

Atypical : seizures, cranial nerve palsies, myoclonus

IF Grouped vesicles in a dermatomal pattern: varicella-zoster virus

encephalitis differentials
Encephalitis - Differentials


noninfectious etiologies :

intracranial tumors

collagen vascular disorders


neoplastic diseases

adverse effects of medications

Other non-viral infectious etiologies

Brain abscess


tuberculous meningitis

fungal meningitis (eg, coccidioides


encephalitis diagnostics
Encephalitis - Diagnostics

Lumbar puncture:

Serology test to detect the presence of antibodies


Brain imaging

  • Color: Clear
  • high pressure
  • WBC, usually < 250/mm3.
  • predominance of lymphocytes:
  • early infection -> Ý neuts
  • repeat @ 8 hr: shift to lymphs
  • protein < 150 mg/dL.
  • glucose nl (>50% of blood)
  • red cells : 0
  • (presence suggests HSV-1 )


Etiology in most cases remains undefined


VS bacterial meningitis:

higher WBC (>2000/mm3) w/ neuts predominantly

higher protein concentration (>200 mg/dL) usually hypoglycorrhachia

Culture— Viral culture of CSF routinely ordered but viruses recovered 6%

polymerase chain reaction (PCR) tests for viruses

PCR testing has replaced viral culture of CSF For HSV-1, HSV-2, and enteroviruses

Most important viral etiology to r/o is HSV

usually fatal if untreated



CT/MRI : may or may be abnormal

CT: r/o space-occupying lesions or brain abscess.

MRI:detects demyelination

empiric therapy

no specific therapies for most CNS viral infections.


HSV-1 / VZV :Acyclovir (10 mg/kg IV Q8h) initiated as soon as possible


IF diffuse cerebral edema or intractable seizures: poor neurologic recovery and increased risk of mortality

IF self-limited seizure activity: rapid recovery

IF HSV encephalitis :Even with prompt initiation of acyclovir, significant morbidity and mortality.

one-year mortality:14 %

epilepsy 24%

neuropsychiatric sequelae 22 %

encephalitis pt education
Encephalitis – Pt Education

Mosquito avoidance!

Avoid being outside at dawn and dusk (when mosquitoes are most active)

Wear protective clothing

Use insect repellent

Drain standing water (breeding grounds for mosquitoes)

Vaccinate Animal against rabies

Acute phase lasts up to one week

Full recovery can take several wks - months

trigeminal neuralgia
An extremely painful

inflammation of the

largest nerve in the

skull: Trigeminal Nerve

Trigeminal Neuralgia


Sudden, severe spasms

usually unilateral

Brief 1-3 sec

stabbing or lancinating

recurrent episodes

Facial muscle spasms

continuous dull pain b/t

no nite awakening

… pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve

distribution of pain
Distribution of Pain
  • Distribution of pain usually V2 and/or V3 subdivisions of the trigeminal nerve (5CN)
  • V1 subdivision is involved in <5 % of pt
  • (V1 common in postherpetic neuralgia)
  • Trigger zones in the distribution of the affected nerve may be present and are often located near the midline.
  • Lightly touching these zones often triggers an attack,
  • Pain is triggered by touch or sounds
  • Pain during chewing, eating, drinking, shaving, or brushing teeth

Distribution of pain


FYI detail

The trigeminal nerve (5th NN) is the sensory supply to the face & the sensory & motor supply to muscles of mastication.

It has three major divisions:

Ophthalmic (V1)

Maxillary (V2)

Mandibular (V3)

The nerve starts at the midlateral surface of the pons, and its sensory ganglion (gasserian ganglion) resides in Meckel's cave in the floor of the middle cranial fossa.

triggers of paroxysms
triggers of paroxysms




brushing teeth

cold air



dental procedures

Course: variable

Duration: wks - months,

followed by pain-free intervals.

Recurrence: common,

some have continuous pain.


"pretrigeminal neuralgia" :dull, continuous, aching pain in the jaw evolving eventually into TN.


One of the most frequently seen neuralgias in the elderly.

  • Annual incidence: 4 - 13 per 100,000
  • Approximately 15,000 new cases in US/yr
  • Increases gradually with age
  • Most idiopathic cases >50yr
  • May occur 20’s, 30’s, rarely children
  • M: F ratio =1:1.5

So.. suspect TN if F >50yo w/ sudden, lancinating, spasmodic facial pain


Usually caused by compression of the trigeminal nerve root,

usually w/i a few mm of entry into pons

80-90%:Compression by an aberrant loop of an artery or vein



  • acoustic neuroma
  • Meningioma
  • epidermoid or other cyst
  • rarely a saccular aneurysm or AVM

vascular compression = classicTN

structural lesions = secondary TN

Mechanism: nerve compression -> demyelination in a circumscribed area around the compression -> sx

diagnosis per ihs


Based on Sx: paroxysms of pain in trigeminal nerve pathway

The International Headache Society (IHS) dx criteria:

Paroxysmal attacks of pain

lasting from a fraction of a second to 2”,

affecting one or more divisions of the trigeminal nerve

Pain has at least one of the following characteristics:

Intense, sharp, superficial, or stabbing

Precipitated from trigger areas or by trigger factors

Attacks are stereotyped in the individual patient

There is no clinically evident neurologic deficit

Not attributed to another disorder

trigeminal neuralgia differentials
Trigeminal Neuralgia - Differentials

Dental pain



Temporal arteritis

HSV type I

Cluster or migraine headaches

Posterior fossa tumors

TMJ pain



head CT or MRI:r/o structural lesion (tumor, demyelinating lesions -MS)

high resolution MRI/MRA :identify vascular compression

Consider MRI if:

Patients with trigeminal sensory loss

Patients with bilateral symptoms

Young patients (under the age of 40)

Routine brain imaging identified a only 2° cause of TN in 15%

Insufficient evidence to support or refute the utility of MRI to identify neurovascular compression in classic TN.

electrophysiologic tests
Electrophysiologic tests


  • Trigeminal reflex testing :probably useful for distinguishing classic TN from secondary TN
  • trigeminal evoked potentials: not useful for making this distinction
  • Trigeminal reflex tests includes
  • the blink reflex (obtained by recording from the orbicularis oculi muscles after electrical stimulation of the supraorbital nerve [V1])
  • the masseter inhibitory reflex (obtained after electrical stimulation of the infraorbital [V2] and mental [V3] nerves).
  • Responses are recorded by surface electrodes using standard electromyography equipment.
  • Normal in patients with classic TN.
tn treatment
TN Treatment

Anticonvulsants -

Most common:

1carbamazepine (Tegretol)

2 oxcarbazepine (Trileptal)

4phenytoin (Dilantin)

Other anticonvulsants:

3 lamotrigine (Lamictal)

4 gabapentin (Neurontin)

Antispasticity Agents -

3 baclofen

Tricyclic Antidepressants -





Alcohol injection - temporary pain relief by numbing the affected areas of face

Surgery - goal:

  • either to stop the blood vessel from compressing the trigeminal nerve,
  • or to damage the trigeminal nerve to keep it from malfunctioning.





patient education61
Patient Education

Avoidance of triggers

Coping with pain

Medication side effects

Lab monitoring re: blood dyscrasias

The end