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HSVE IIH ICL Pallavi to talk TCH DSA PCA sign Hypothermia Jog to talk PML - PowerPoint PPT Presentation


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HSVE IIH ICL Pallavi to talk TCH DSA PCA sign Hypothermia Jog to talk PML. Case 1. 42/F History since 3 days Fever Headache Confusion No seizures, rash On examination Drowsy, confused (GCS 10/15) Fundi normal No other deficit No neck stiffness. Metabolic lab: WNL

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HSVE

IIH

ICL

Pallavi to talk

TCH

DSA

PCA sign

Hypothermia

Jog to talk

PML



  • 42/F

  • History since 3 days

    • Fever

    • Headache

    • Confusion

  • No seizures, rash

  • On examination

    • Drowsy, confused (GCS 10/15)

    • Fundi normal

    • No other deficit

    • No neck stiffness




  • CSF:

    • Proteins 110

    • Sugar 65 (BSL 135)

    • Cells 26 (95% lympho)

    • HSV PCR sent

  • Started on I/V acyclovir 600 mg 8 hourly

  • Neurostatus same on day 2


  • 3rd day

    • No fever

    • Single SG seizure

    • More drowsy (GCS 7/15)

    • Left hemiparesis

    • At night

      • Right pupil dilated

    • Intubated



  • In view of large area of damage with mass effect

    • Underwent decompression craniotomy

    • Biopsy take from temporal lobe showed F/O encephalitis

  • Next 3 days (Day 4-6)

    • No significant change

    • On ventilator

    • Drowsy (GCS 5-6/15)

    • Developed right III nerve palsy

    • Occasional focal and SG seizures


  • 7th day

    • Unconscious (GCS 4/15)

    • On ventilator

    • Right III nerve palsy

    • Left pupil also became dilated

    • Dense left hemiparesis



  • Further course

    • Continued on I/V acyclovir for 3 weeks

    • Gradually improved

    • Weaned off ventilator

    • Became alert

    • Left hemiparesis improved

    • No seizures

  • Present condition

    • Oriented; independent

    • Right ptosis is persistent; though eye movements and pupillary size are normal


Discussion
Discussion

  • Decompression craniotomy in HSVE

    • Useful option in cases with mass effect and poor response to acyclovir and anti-oedema measurs

    • Some reports suggest that in addition partial resection of temporal lobe is of benefit additional reduction of infectious material can be achieved

      • Child’s Nerv Syst 1999; 15: 84–86

  • Malignant HSVE?



What is new in hsv encephalitis
What is new in HSV encephalitis? in literature

  • Long Term Treatment of Herpes Simplex Encephalitis With Valacyclovir

    • Ongoing trial

  • The purpose of the study is to determine if treatment with oral valacyclovir 2 gm TDS for 90 days is both effective and safe after completing i/v acyclovir treatment and if it can increase survival with or without mild impairment of the brain and mental functions


Case 2
Case 2 in literature


  • 21/F in literature

  • Headache

    • Bilateral

    • Throbbing

    • Increasing severity

  • Occasional vomiting


  • On examination in literature

    • Conscious/oriented

    • Bilateral papilloedema

    • No other deficit

    • No neck stiffness


  • Routine lab: normal in literature

  • CSF

    • Opening pressure 40 cm

    • Proteins 34

    • Sugar 76 (BSL 122)

    • Cells 2 (100% Lympho)


  • Management in literature

    • Drained 30 cc CSF

    • Low salt diet

    • Acetazolamide 1000 mg/d

    • Weight loss 3 kg

  • Improved gradually

  • At present

    • No symptoms

    • No papilloedema



Iih and lateral sinus stenosis
IIH and lateral sinus stenosis in literature

  • By definition IIH is idiopathic

  • Venous disorders can cause rise in intracranial pressure and present with syndrome like IIH

    • Venous sinus thrombosis

    • Duralvenous fistulas

    • Venous sinus compression

  • In many patients with IIH,neuroimaging shows narrowing of the transverse sinuses


Controversy
Controversy in literature

  • Whetherthis abnormality is cause or consequence of increasedintracranial pressure?

  • Cause:

    • Stenoses→ Obstruction to venous outflow → ↑ intracranial venous pressure proximalto the stenosis → reduction in CSF absorption via the arachnoid granulations → ↑ CSF pressure

    • In this setting, a pressure gradient across the stenosis canbe measured

    • Reconstruction of the venous lumen with endovascularstents would be effective in lowering elevated CSF pressure


Controversy1
Controversy in literature

  • Whetherthis abnormality is cause or consequence of increasedintracranial pressure?

  • Consequence:

    • ↑ intracranial CSF pressure → secondary narrowingof sinus lumen by compression

    • It can be reversed bylumbar puncture or shunt surgery procedures



Cause
Cause in literature

  • Endovascular treatment of idiopathic intracranial hypertension

    • Neurology 2008; 70: 641-647

  • Conclusion:

    • Importance of venous sinus disease in etiologyof IIH is underestimated

    • Patients with IIH in whom avenous sinus stenosis is demonstrated by MRV should be evaluated with direct retrograde cerebral venographyand manometry

    • In patients with venous sinus stenosis who do not respond to medical treatment, endovascular stentplacement seems to be an interesting option


Consequence
Consequence in literature

  • Transverse sinus stenoses persist after normalization of the CSF pressure in IIH

    • Neurology 2005; 65: 1090-1093

  • Conclusion:

    • Transverse sinus stenoses, as revealed byMR venography, persist in patients with idiopathic intracranialhypertension after normalization of CSF pressure, suggestingthe lack of a direct relationship between the caliber of sinusand CSF pressure


Repeat mri
Repeat MRI in literature



Case 3
Case 3 controversial with association with more and more neurological diseases


  • Middle aged male controversial with association with more and more neurological diseases

  • H/O pleural effusion 6 months ago

    • Treated with AKT

      • On INH and Rifa at present

    • No respiratory symptoms

    • CXR: normal

  • Presented with 14 days history of

    • Headache

    • Vomiting


  • On examination: controversial with association with more and more neurological diseases

    • Conscious; oriented

    • Fundi: normal

    • Neck stiffness

    • No other deficit

  • CT scan brain:

    • Normal


  • Investigations: controversial with association with more and more neurological diseases

    • CSF:

      • Proteins 176

      • Sugar 45 (BSL 109)

      • Cells 30 (100% L)

    • Hemogram

    • HIV: -ve

    • Metabolic lab: normal



  • His headache gradually reduced controversial with association with more and more neurological diseases

  • Required CSF drainage twice

  • HIV was repeated by ELISA: -ve

  • CD4+ count: 68

  • DNA quantative PCR for HIV: -ve


  • Improved subsequently controversial with association with more and more neurological diseases

  • Discharged on

    • Fluconazole

    • TMP/SMX

    • AKT



Idiopathic cd4 lymphocytopenia icl
Idiopathic CD4 lymphocytopenia (ICL) controversial with association with more and more neurological diseases

  • CD4+T cells <300 or a CD4+ cell count <20% of total T cell on two occasions

  • No evidence of infection on HIV testing

  • Absence of any defined immunodeficiency or therapy associated with depressed levels of CD4+ T cells


  • Dr Pallavi Bhargav controversial with association with more and more neurological diseases


Case 4
Case 4 controversial with association with more and more neurological diseases


  • 40 years old male controversial with association with more and more neurological diseases

  • Presented with sudden onset severe headache

    • Started while taking hot water bath

    • Over vertex and occipital region

    • Associated with nausea

    • No loss of consciousness

  • No past H/O similar headache, trauma, fever

  • C/O DM on OHAs


  • Came to hospital in 1 hour controversial with association with more and more neurological diseases

    • Headache was already subsiding then

    • No neurological deficit

    • No neck stiffness

  • Admitted

  • Received NSAID

  • Non-contrast CT scan brain: normal

  • No headache in next 36 hours

  • Discharged



Mr angio
MR-angio bath


  • When seen bath

    • Comfortable

    • No deficit

  • Investigations

    • Metabolic lab: normal

    • Counts: normal

    • CSF

      • No xanthochromia

      • Protein 83

      • Sugar 98

      • Cells 15 (100% L)


  • What is the diagnosis? bath

    • Thunderclap headache

      • To be investigated for cause

  • Any further investigations?

    • DSA

  • Treatment options?

    • Received indomethacin on SOS basis


DSA bath



Thunderclap headache tch
Thunderclap headache (TCH) bath

  • IHS 2 Diagnostic criteria:

    A. Severe head pain fulfilling criteria B and C

    B. Both of the following characteristics:

    • Sudden onset, reaching maximum intensity in <1 minute

    • Lasting from 1 hour to 10 days

      C. Does not recur regularly over subsequent weeks or months

      D. Not attributed to another disorder (in case of primary)

  • Notes:

    • Headache may recur within the first week after onset

    • In case of primary, normal CSF and normal brain imaging are required


    • Causes of secondary TCH: bath

      • SAH

      • Sentinel hemorrhage

      • Intracerebral haemorrhage

      • Venous sinus thrombosis

      • Arterial dissection (intra- and extracranial)

      • CNS angiitis

      • Reversible cerebral vasoconstriction syndromes

      • Pituitary apoplexy

      • Colloid cyst of the third ventricle

      • CSF hypotension

      • Acute sinusitis




    9 12 2010
    9/12/2010 bath



    Reversible cerebral vasoconstriction syndrome rcv
    Reversible cerebral vasoconstriction syndrome (RCV) bath

    • Relatively newer name

    • Previous names

      • Benign angiopathy of the central nervous system

      • Migrainous angiitis

      • Post-partum angiopathy

      • Call-Fleming syndrome

        • Stroke 1988; 19: 1159-1170


    • Clinical features bath

      • Thunderclap headache

        • Tend to recur for few weeks

      • Focal deficits

        • Strokes

        • Bleeds

        • Posterior reversible leucoencephalopathy

      • Seizures

    • Predisposing factors in 60% patients

      • Pregnancy and puerperium

      • Exposure to drugs


    • Diagnosis bath

      • Angiography (CTA / MRA / DSA) demonstrated multifocal or segmental narrowing

        • Improvement in vasoconstricton in 12 weeks

      • No CT or CSF evidence of SAH

      • Normal or near normal CSF

      • Appropriate clinical history (thunderclap headache)


    • Differential diagnosis bath

      • Posterior reversible leucoencephalopathy syndrome

      • CNS vasculitis

    • Treatment

      • No large studies

      • Nimodepine or verapamil

      • Short course of steroids (mostly in earlier reports)

      • Intra-arterial therapy in severe cases


    • Underdiagnosed bath

      • 83 patients with TCH

        • Neurology 2006; 67: 2164-9

      • 56 patients had thunderclap headache of unknown etiology

      • When these patients underwent MRA, 39% were found to have reversible cerebral vasoconstriction

      • In cases of thunderclap headache, if CT and CSF are normal, a noninvasive angiography should be done


    • 67 patients with RCVS bath

      • Brain 2007; 130 (12): 3091-31

    • 21% of patients who ultimately demonstrated vasoconstriction initially had normal angiographic studies

    • In other words, there was a lag between the onset of symptoms and the presence of vasoconstriction

    • This suggests that cerebral vasoconstriction may begin in smaller distal vessels that extend beyond the resolution of MRA before involving larger proximal cerebral blood vessels


    Bath induced thunderclap headache
    Bath induced thunderclap headache bath

    • Cephalalgia 2008; 28: 524-530

  • 21 patients

  • Bathing was the initial trigger for thunderclap headaches in 9 (43%)

  • 15 (71%) had other non-bath-related attacks

  • 18 (86%) reported that the headache occurred immediately when water was sprayed over their body, with warm water (52%) as the most common

  • 13 (62%) had RCV on imaging

  • Nimodipine was effective in stopping further attacks in 84%



  • Case 5
    Case 5 angio should be done in all to look for not only aneurysm but also for RCV


    • 65/M angio should be done in all to look for not only aneurysm but also for RCV

    • Acute right hemiparesis

    • Clinically

      • Right hemianopia

      • Right hemiparesis

      • Right hypoaesthesia


    Hyperdense pca sign
    Hyperdense PCA sign angio should be done in all to look for not only aneurysm but also for RCV

    • HPCA sign

      • Stroke 2006; 37: 399

    • Detected in >1/3 of all patients with PCA infarct, suiting incidence ofhyperdense MCA

    • This sign may notonly be helpful in the early diagnosis of PCA infarction butmight also act as a prognostic marker in acute PCA territoryischemic stroke


    Case 6
    Case 6 angio should be done in all to look for not only aneurysm but also for RCV


    • Young lady angio should be done in all to look for not only aneurysm but also for RCV

    • H/O electric shock

    • Became unconsciousness

    • When came to casualty had cardiorespiratory arrest

      • Monitor showed asystole

    • Resuscitated

    • Shifted to ICU


    • On examination angio should be done in all to look for not only aneurysm but also for RCV

      • On ventilator and intropic support

      • Unconscious (GCS 3/15)

      • Pupils 3 mm NRL

      • Doll eye movement absent

      • Corneal reflexes absent

    • Diagnosis:

      • Hypoxic brain injury secondary to cardio-respiratory arrest

    • Treatment?


    Therapeutic hypothermia
    Therapeutic hypothermia angio should be done in all to look for not only aneurysm but also for RCV

    • Decreases cerebral metabolic demand

    • Clinical trials and meta-analysis showed improved outcome with hypothermia

      • Resuscitation 2007; 73: 29-39

      • NEJM 2002; 346(22): 1756

    • 16-23% improved outcome

    • Cool up to 33°C (32-34°C) for 12-24 hours

    • To be started within min to hours after arrest


    • Problems angio should be done in all to look for not only aneurysm but also for RCV

      • Technically difficult

      • Ideal induction technique

        • Internal vs. external

      • Target temperature

      • Duration

      • Re-warming rate

    • Complications

      • Shivering

      • Arrhythmias


    Hypothermia technique
    Hypothermia: technique angio should be done in all to look for not only aneurysm but also for RCV

    • Dr. Sameer Jog


    Case 7
    Case 7 angio should be done in all to look for not only aneurysm but also for RCV


    Middle aged male angio should be done in all to look for not only aneurysm but also for RCV

    Immunocompramised

    CD4+ count 55

    On ART

    Presented with 2 months H/O

    Asymmetric ataxia (R>L)

    Dysarthria

    No pyramidal signs/dementia/bladder involvement


    • CSF angio should be done in all to look for not only aneurysm but also for RCV

      • Protein 55

      • Sugar 67

      • Cells 4 (100% L)

    • Treatment

      • Continued on ART

      • Physiotherapy

    • Continued worsening

      • Bed ridden


    • Diagnosis? angio should be done in all to look for not only aneurysm but also for RCV

      • PML



    Hot cross bun appearance
    Hot cross bun appearance angio should be done in all to look for not only aneurysm but also for RCV

    • The sign is due to

      • Selective loss of myelinated transverse pontocerebellar fibers and neurons in pontine raphe

      • Preservation of pontine tegmentum and corticospinal tracts

    • Has been described in

      • MSA-c

      • Parkinsonism due to vasculitis

      • SCA 2

      • SCA 3

      • vCJD

    • Has not been descried in PML till date


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