Neurologic Emergencies Case #1 A 67F is hospitalized with a - PDF document

Neurologic Emergencies Case #1 • A 67F is hospitalized with a community-acquired pneumonia. On Day#3 she is feeling much better awaiting discharge when her nurse finds her unresponsive with rhythmic shaking of all limbs. • PMHx: COPD • Meds: Ceftriaxone, NKDA S. Andrew Josephson MD • SH: 100pk yr hx tobacco, no hx EtOH Carmen Castro-Franceschi and Gladyne K. Mitchell Neurohospitalist Distinguished Professor Vice Chairman, Parnassus Programs • FH: No neurologic disease Director, Neurohospitalist Program Medical Director, Inpatient Neurology University of California, San Francisco The speaker has no disclosures Case #1 Case #1 • You are called to the bedside and after 3 • Following Lorazepam 2mg IV x 3 (2 minutes, these movements have not minutes apart), the patient is still having stopped. Options for your next course of these movements (now 7 minutes). What is action are…. your next course of action? A. Continue to wait for the spell to subside B. Administer IV Diazepam C. Administer IV Lorazepam D. Administer IV Fosphenytoin

Status Epilepticus Algorithm: Status Epilepticus Real World • Changing definition and time window 1. Lorazepam 2mg IV q2 minutes up to • Incidence: 100,000 to 150,000 per year nationally 6-8mg or Midazolam 10mg IM* • Contributes to 55,000 deaths per year nationally 2. Fosphenytoin 18-20mg/kg (Dilantin • 12 to 30 percent of epilepsy first presents as status Equivalents) IV • Generalized convulsive status most dangerous 2a. Fosphenytoin additional 10mg/kg or Phenobarbital 3. General Anesthesia with continuous EEG a. IV Midazolam gtt b. IV Propofol gtt Seizure Management: IM Midazolam: RAMPART Once the Spell Stops • Out of hospital non-inferiority trial • Key Question: – 4 mg lorazepam IV vs. 10 mg midazolam IM (the latter using a novel autoinjector) 1 st seizure or known epilepsy • Primary outcome: absence of sz at time of ED arrival without the need for rescue therapy Silbergleit R, et al. N Engl J Med , 2012

Seizure Management: Seizure Management: First Seizure First Seizure • Work-up for provokers • Careful history of the spell: before (including recent events), during, after – Head trauma? – Utox, EtOH history and possible level • Determine all meds patient is on – CBC, Lytes, Ca/Mg/Phos, BUN/Cr, LFTs • Careful neuro exam looking for focal signs – CT (usually with contrast) – Focal exam= Partial seizure= Focal lesion – Very low threshold to LP • Needs outpatient work up including: EEG, MRI, and neurologic consultation Seizure Management: Case #2 Known Epilepsy • 1. Non-compliance • A 50 year-old man is brought in to the ED by his – Determine AEDs including doses girlfriend with several days of paranoia and – Send levels of AEDs if possible unusually aggressive behavior. – Med-Med interactions • General physical exam is normal. Neurologic • 2. Infection examination shows a disoriented man threatening – CXR, urine, blood cx, consider LP the staff • Labs: Lytes, CBC, BUN/Cr, LFTs, Utox all nl • Best to curbside primary neurologist regarding any • CT head negative, CXR negative, U/A negative medication changes to current regimen

What is the next test you would like Lumbar Puncture to order? A. MRI Brain • Opening Pressure 19 cm H 2 0 B. LP • 18 WBCs (94% Lymphocytes) C. Blood Cultures • CSF Protein 58 D. Urinary Porphyrins • CSF Glucose 70 E. EEG • Gram stain negative • Empiric treatment begun MRI Brain HSV-1 Meningoencephalitis • Diagnosis – CSF lymphocytic pleocytosis (can be normal) – EEG (can be normal) – MRI (can be normal) – CSF HSV PCR • If suspected, start IV acyclovir 10-15mg/kg q 8 hours

Meningitis Treatment Treatable Causes of a by the Neurologist Lymphocytic Pleocytosis • Viral • Perform LP immediately after imaging if any CSF infection suspected – Acute HIV – HSV, VZV • Empiric Bacterial Treatment – CMV – Vanco 1 gram IV q6-8 hrs • Bacterial – CTX 2 grams IV q12 hrs – Syphillis – Amp 2 grams IV q4 hrs (if immunosup., >60) – Lyme – Dexamethasone 10mg IV q6 – Leptospirosis Treatable Causes of a Case #2a Lymphocytic Pleocytosis • A 45 year-old woman in Indiana is brought to the • Fungal hospital with fevers, AMS, and progressive • TB weakness • Neoplastic • On neurologic examination the patient is confused and has a flaccid paralysis of all four limbs with • Incompletely treated bacterial meningitis areflexia • Parameningeal Focus • LP with 123 WBCs (76% Ly, 20% PMNs), Protein 54, Glucose 63

What is the most likely diagnosis? WNV Encephalitis A. S. Pneumo Meningitis • Present in around 1 in 150 cases of symptomatic infection with WNV B. WNV Encephalitis C. Poliomyelitis • Anterior Horn Cell involvement classic and unusual in the modern world D. Porphyria • Test with serum WNV IgM E. Eastern Equine Encephalitis • No clear treatment other than supportive care: IVIg has been advocated by some • Prevention is key! Case #3 Case #3 • Exam • A 63yo man comes to the ED with 3 days of inability to walk. The patient reports a 2 – General exam nl with stable vitals week history of tingling in his hands and – Mental status, cranial nerves normal – Motor exam with mild-moderate symmetric feet while also stating that he has been weakness prox>distal in the upper ext., stumbling while walking for five days. distal>prox in the LEs – Sensory exam completely normal – Reflexes 2+ throughout except 0 ankles, plantar response flexor bilaterally

Guillain Barre Syndrome: Case #3: Additional Tests Key Points • Clinically must think in the setting of paresthesias and weakness FVC/MIF: 1.2L, -30 – Normal sensory exam, weakness not always ascending – Areflexia the rule, but not early in the disease Lumbar Puncture: Opening pressure normal, 2 – High protein with no cells on LP the rule, but not early WBC, Zero RBC, Protein 87, Glucose normal in the disease • EMG/NCS for diagnosis – Axonal and Demyelinating forms • Antecedent illness or infection only 30% • Other Variants: Miller Fisher variant w/ GQ1b Ab Guillain Barre Syndrome: Case #4 Key Points • What will kill the patient • A 65 year-old man with a history of DM, – Respiratory Failure: Intubate for less than 20cc/kg HTN presents with 1 day of imbalance and • Frequent MIF/FVC severe vertigo • ICU or stepdown care always • Examination shows R>L severe ataxia of – DVT/PE: SQ heparin the limbs with inability to walk due to – Autonomic instability: cardiac (telemetry), ileus • Treatment imbalance. Power is normal throughout. – IVIg or Pheresis, NOT steroids – The earlier the better

Which of the following most Normal CT Brain reliably distinguishes central from peripheral vertigo? A. Severe vomiting B. Inability to walk C. Inability to sit upright without falling to one side D. Presence of nystagmus E. Slurred speech CT Brain 24 hours later Case #4 (con’t) • Patient discharged from the ED • BIBA 24 hours later after respiratory arrest at home, now in coma

Emergent ICP Management Emergent CPP Management • Step 1: Head of bed to 30 degrees • Step 2: Hyperventilation Cerebral Perfusion Pressure (CPP) – Cerebral vasoconstriction with decreased P a CO 2 – Onset rapid – Lasts only 1-2 hours as buffering occurs • Step 3: Mannitol 1 gram/kg IV (50-100g) CPP = MAP - ICP – Removes brain water – Tolerance develops, must follow serum osms • Step 4: Barbiturates (bolus then infusion) • Consider ventriculostomy if indicated! Cerebellar Ischemic Stroke Cerebellar Hemorrhage • Maximal swelling: 3-5 days • Life-threatening emergency • Decompression indicated if patient • When the neurosurgeons will intervene decompensates – 3cm rule? • Will only see on MRI – Patient deteriorating? • “Malignant Meniere’s”

Which of these historical points is most useful to differentiate SAH Case #5 from benign headache syndromes? • A 32M comes to the emergency room with A. Associated nausea/vomiting the “worst headache of his life” for 8 hours B. Associated photophobia • Non contrast CT is normal C. Severity of pain D. Peak time to maximal pain E. Pain location SAH Diagnosis SAH Treatment • CT sensitivity greatest early • Urgent Blood Pressure Management • LP sensitivity greatest late • Etiology – What do you look for? – 1. Aneurysm • Xanthrochromia? • Need to secure with clipping or coiling ASAP • Blood that fails to clear? – ISAT trial (Lancet 2005) – 2. Trauma

SAH Complications Case #6 • 1. Vasospasm (4-21 days) • A 65 year old man with a history of HTN – Prevention: Nimodipine 30mg PO q2 (60mg q4) presents 2 hours after the sudden onset of – Monitoring: Transcranial Dopplers (TCDs), angiograms right hemiparesis – Treatment: HHH, Endovascular • 2. Hydrocephalus • Exam shows normal vitals except bp 185/95 – Treatment: HOB up, drainage with EVD • Neurologic examination • 3. Cerebral Salt Wasting – Somnolent, Dysarthric – Check frequent Na – Replace Na with NaCl tabs or 3% NaCl – Plegic Right face, arm and leg Non-contrast CT Differential Diagnosis for ICH • Hypertensive* • Septic emboli • Trauma* • Venous thrombosis • Drugs • Coagulopathy • Amyloid Angiopathy • Ischemic Stroke with transformation • Tumor • …and many others • Vascular Malformation