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CNS Disorders

CNS Disorders. Dr Shreedhar Paudel April, 2009. MENINGITIS. Inflammation of the coverings of the brain CAUSES BACTERIAL VIRAL TOXINS MALIGNANCIES. ACUTE BACTERIAL MENINGITIS. NEONATAL PERIOD: S. PNEUMONAE, E.COLI 3 MTHS- 3 YEARS : H. INFLUENZAE, S.PNEUMONIA, N. MENINGITIDES

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CNS Disorders

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  1. CNS Disorders Dr ShreedharPaudel April, 2009

  2. MENINGITIS Inflammation of the coverings of the brain • CAUSES • BACTERIAL • VIRAL • TOXINS • MALIGNANCIES

  3. ACUTE BACTERIAL MENINGITIS • NEONATAL PERIOD: S. PNEUMONAE, E.COLI • 3 MTHS- 3 YEARS : H. INFLUENZAE, S.PNEUMONIA, N. MENINGITIDES • > 3 YRS : S. PNEUMONIAE, N. MENINGITIDES • IMMUNOCOMPROMISED HOST: LISTERIA, MYCOPLASMA, CRYPTOCOCCUS

  4. ACUTE BACTERIAL MENINGITIS • PATHOGENESIS • Routes of infection • Hematogenous spread from distant focus of infection • Local spread of infection from contiguous septic foci • Exogenous infection after trauma

  5. PATHOLOGY • Meninges are infiltrated with inflammatory cells • The cortex of brain shows edema, exudates and proliferation of microglia • Sub arachnoid space may be filled with purulent discharge • Exudates may block the foramina of Luschka and Magendie leading to hydrocephalus • Thrombophlebitis of cerebral vessels may occur leading to infarction and necrosis • Endotoxic shock and sudden death may be there if meningococcal meningitis

  6. CLINICAL FEATURES SYMPTOMS - Acute onset - Fever/ Irritability - Projectile vomiting - Headache/ Bulging fontanel - Seizure - Altered sensorium/ photophobia - Marked neck rigidity

  7. SIGNS • PHOTOPHOBIA , • NECK STIFFNESS, • KERNIG’S SIGN ( extension of knee is limited to less than 135 degree) • BRUDZINSKI SIGN ( the knees get flexed as neck of the child is passively flexed) • BULDGING FONTANEL, • ALTERATION OF MENTATION • PAPILLEDEMA, • NEUROLOGICAL DEFICIT • Respiration may be Cheyne-Stokes type

  8. ACUTE BACTERIAL MENINGITIS IN NEONATES AND YOUNG INFANTS • There will be no signs of meningial irritation till 6 months of age • Meningotis should be suspected in a newborn in following conditions • Vacant stare • Alternating irritability and drowsiness • Persistent vomiting with fever • Refusal to breast feeding • Poor tone/ poor cry • Shock/ hypothermia/ fever • Seizure/ neurological deficits

  9. COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS • CNS COMPLICATIONS • SUBDURAL EFFUSION /EMPYEMA, • BRAIN ABSCESS , • HYDROCEPHALUS,

  10. COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS………. Long term neurological deficits - DEAFNESS / BLINDNESS/ APHASIA - HEMIPLAGIA - OCULAR PALSIES Systemic complications - SHOCK - MYOCARDITIS - SIADH - STATUS EPILEPTICUS

  11. DIAGNOSIS • LUMBAR PUNCTURE • CSF FOR BIOCHEMICAL/CYTOLOGICAL EVALUATION • Turbid CSF with raised pressure, elevated protein level (>100mg/dl), reduced sugar level (<40 mg/dl or below 50% of blood sugar level), increased cell count (>1000/μL, mostly Neutrophils)

  12. DIAGNOSIS…. • CSF for microbilogy • Gram stain • Culture/ sensitivity • LATEX AGGLUTINATION, • ELISA, • PCR • CT SCAN

  13. ACUTE BACTERIAL MENINGITIS DIFFERENTIAL DIAGNOSIS • MENINGISM ( occur in inflammatory cervical lesion, apical pneumonia, toxemia due to Hemophilus infection or typhoid fever) • PARTIALLY TREATED BACTERIAL MENINGITIS • ASEPTIC MENINGITIS • TUBERCULOUS MENINGITIS • CRYPTOCOCCAL MENINGITIS • VIRAL ENCEPHALITIS • POLIOMYELITIS • SUB ARACHNOID HEMORRHAGE • LYME DISEASE (Borrelia infection)

  14. TREATMENT OFACUTE BACTERIAL MENINGITIS • EMPIRICAL THERAPY • CEFTRIAXONE OR CEFATOXIME OR COMBINATION OF AMPICILLIN AND CHLORAMPHENICOL FOR 10-14 DAYS • SPECIFIC ANTIMICROBIAL THERAPY • MENINGOCOCCAL MENINGITIS: PENICILLIN, CEFOTAXIME OR CEFTRIAXONE • HEMOPHILUS MENINGITIS: CEFTRIAXONE/ CEFOTAXIME

  15. TREATMENT…….. • STAPHYLOCOCCAL MENINGITIS: CLOXACILLIN OR VANCOMYCIN, • ADDITION OF RIFAMPICIN WILL ENHANCE THE PENETRANCE OF THE CSF • LISTERIA: AMIPCILLIN AND GENTAMYCIN • PSEUDOMONAS: CEFTAZIDIME AND GENTAMYCIN, OR TICARCILLIN AND GENTAMYCIN • DURATION OF TREATMENT: 10 DAYS EXCEPT FOR STAPHYLOCOCCAL MENINGITIS

  16. TREATMENT….. • STERIOD THERAPY • DEXAMETHASONE 0.15 MG/KG IV 6 HRLY FOR 5 DAYS • FIRST DOSE OF STEROID SHOULD PRECEDE 15 MIN FROM ANTIBIOTICS • DECREASES THE INCIDENCE OF RESIDUAL NEUROLOGICAL DEFICITS • ESPECIALLY USEFUL IN H. INFLUENZAE INFECTION

  17. TREATMENT………… • SYMPTOMATIC TREATMENT • RAISED ICP: OSMOTIC DIURETICS • CONVULSION: DIAZEPAM OR PHENYTOIN • RESTRICTION OF FLUID TO 2/3RD OF MAINTENANCE TO PREVENT SIADH • NURSING CARE • TREATMENT OF COMPLICATIONS • FOLLOW-UP AND REHABILITATION

  18. TUBERCULOUS MENINGITIS • PRIMARY • SECONDARY • PATHOGENESIS • PATHOLOGY: TUBERCLE, BASE AND TEMPORAL LOBES • STAGES: PRODROMAL, MENINGITIS, COMA • DIAGNOSIS: LP, CT, BACTEC, PCR

  19. TUBERCULOUS MENINGITIS • D/D: PURULENT MENINGITIS, PARTIALLY TREATED,ENCEPHALITIS, TYPHOID ENCEPHALOPATHY, BRAIN ABSCESS, BRAIN TUMOR, CHRONIC SUBDURAL HEMATOMA, AMEBIC MENINGOENCEPHALITIS. • TREATMENT: 12MTHS • INITIAL 2 MTHS: HRZE • LATER 10 MTHS: HRE

  20. TUBERCULOUS MENINGITIS • STEROIDS: DEXAMETHASONE IV- 1-2 WEEKS • ORAL FOR 6 WEEKS AND TAPER SLOWLY • OTHER SUPPORTIVE THERAPY.

  21. ENCEPHALITIS • DEFINE • ETIOLOGY/ PATHOLOGY : INCLUSION BODIES • VIRAL: MMR,HSV, CMV, EBV, JAPANEASE, WEST NILE, RABIES, DANGUE • OTHER: RICKETTSIA, FUNGI, TOXOPLASMA, BACTERIAL, REYES SYNDROME

  22. ENCEPHALITIS • ONSET: SUDDEN • SIGNS AND SYMPTOMS: FEVER, HEADACHE, VOMITING, ALTERED MENTAL STATUS, IRRITABILITY, APATHY , COMA • DECEREBRATION, DECORTICATION, PALSIES, PLAGIAS, • EXTRAPYRAMIDAL SYMPTOMS: JAPANEASE B • TEMPORAL OR FRONTAL LOBE : HSV

  23. ENCEPHALITIS • RAISED ICT • HERNIATION • 6TH NERVE PALSY • DIAGNOSIS • HISTORY OF EXPOSURE • LP • CSF, PCR

  24. ENCEPHALITIS • MANAGEMENT • SYMPTOMATIC: ICT, FEVER, SHOCK, SEIZURES • HSV: RBC IN CSF, TREATMENT : ACYCLOVIR

  25. REYE’S SYNDROME • GENERALISED MYOCARDIAL DYSFUNCTION • LIVER, KIDNEY , CNS • INHIBITION OF B-OXIDATION OF FATTY ACIDS • ASPRIN OTHER SALICYLATES, VIRAL INFECTION • HYPERAMMONEMIA, NEUROHYPOGLYCAEMIA • PRESENTATION: • 2MTHS – 15 YEARS • RAPID PROGRESSION

  26. REYE’S SYNDROME • STAGES • I- MILD CONFUSION • II – DELIRIUM • III – COMA • IV – APNEA, NON REACTING PUPIL • DIAGNOSIS: • HYPERAMMONEMIA, DEARRANGED LFT, EEG- TRIPHASIC WAVES

  27. REYE’S SYNDROME • TREATMENT • LOW PROTEIN DIET • TREAT HEPATIC FAILURE • TREAT RAISED ICT • HYPOGLYCAEMIA • VITAMIN K , FFP

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