[ppt]neurology board review - school of medicine - lsu … october... · web viewneurology board...
TRANSCRIPT
![Page 1: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/1.jpg)
Neurology Board Review
October 27, 2011
![Page 2: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/2.jpg)
Test Question
Pumpkins only come in one color, orange. A. True B. False
![Page 3: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/3.jpg)
Meningitis
![Page 4: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/4.jpg)
Epidemiology
Most common causes of bacterial meningitis in the developed world: Pneumococcus (4-5/100,000 children
annually) Meningococcus (2.5/100,000 children
annually) Introduction of Hib vaccine in 1988
decrease in invasive disease by 99%
![Page 5: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/5.jpg)
![Page 6: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/6.jpg)
Neonatal Disease
Group B Strep Predominant neonatal meningitis pathogen Maternal genital tract is pathogen source of
both early and late disease IAP▪ Before:▪ 1-4 neonatal infections/1,000 live births▪ 75% with early-onset disease
▪ After:▪ 80% reduction in early-onset disease▪ No change in late-onset disease
![Page 7: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/7.jpg)
Neonatal Disease
Group B Strep Early disease (1st 7 days after birth)▪ Sepsis▪ PNA▪ Less commonly meningitis (5-10% cases)
Late Disease (3-4 wks of age)▪ Bacteremia▪ Meningitis▪ Less commonly skeletal infections, adenitis,
cellulitis
![Page 8: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/8.jpg)
Neonatal Disease
Gram Negative Disease Rare! E. Coli most common Sources:▪ Maternal genital tract▪ Nosocomial infection
Risk factors:▪ Prematurity▪ Maternal intrapartum infection▪ PROM
![Page 9: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/9.jpg)
Neonatal Disease
Herpes Simplex Transmission via infected birth canal▪ 75% caused by HSV-2▪ >50% infection rate with active primary infection▪ <5% infection rate with recurrent genital herpes
Presentation:▪ Skin, eyes, mucous membranes▪ CNS disease▪ Disseminated disease
Often NO maternal history or clinical evidence
![Page 10: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/10.jpg)
Neonatal Disease
Listeria Maternal infection from food-borne source▪ Unpasteurized cheese/ milk▪ Prepared ready-to-eat meats▪ Undercooked poultry▪ Unwashed raw veges
Can precipitate abortion, preterm delivery, or early-onset disease
Early onset disease▪ Sepsis▪ Papular truncal rash
![Page 11: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/11.jpg)
Neonatal Disease
Listeria (con’t) Late onset disease ▪ Asymptomatic vaginal or fecal carriage▪ Exposure during delivery Meningitis
![Page 12: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/12.jpg)
Non-Neonatal Bacterial Pathogens Streptococcus pneumoniae
Leading pathogen causing meningitis in infants and young children in developed countries
Children <1yo highest risk Pathogenesis▪ Nasopharyngeal colonization bacteremia seeding
of the choroid plexus meningitis (7-valent) conjugate vaccine introduction in
2000▪ Decrease in invasive pneumococcal infections by
vaccine-serogroup isolates by 75% (age <24mos)
![Page 13: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/13.jpg)
Non-Neonatal Bacterial Pathogens Neisseria meningitidis
Occurs in otherwise healthy individuals▪ Highest age-specific incidence: <1 yo▪ 2/3 of cases seen in children <5 yo
Meningitis most common clinical presentation▪ Fulminant presentation with high fatality
98% sporadic cases, however outbreaks do occur▪ 1/3 community based▪ 2/3 in colleges, primary/secondary schools, and
nursing homes
![Page 14: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/14.jpg)
Question #1
All of the following increase risk of colonization with Neisseria meningitidis EXCEPT for: A. Exposure to active or passive smoking B. Concomitant URI C. Crowding D. Recent antibiotic use E. Pneumococcal carriage
![Page 15: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/15.jpg)
Non-Neonatal Bacterial Pathogens Neisseria meningitidis (con’t)
Nasopharyngeal carriage/ colonization infection▪ Increased risk of colonization▪ Crowding▪ Exposure to active and passive smoking▪ Pneumococcal carriage▪ Concomitant URI (esp. Flu A)
▪ Increased risk of infection▪ Anatomic/ functional asplenia▪ Terminal complement deficiency▪ Lab exposure▪ Travel to epidemic/ hyperendemic regions
![Page 16: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/16.jpg)
Less Common Bacterial Pathogens Non-neonatal Gram-negative bacilli
Nosocomial in origin Most patients have predisposing factors▪ Neurosurgery/ head trauma within the past month▪ Presence of a neurosurgical device▪ CSF leak
Mycobacterium tuberculosis Most common cause of meningtits in sub-Saharan
Africa▪ Likely due to the high prevalence of HIV
In US, most cases arise in urban cities in lower-income groups▪ ¼ of pediatric cases occur in foreign-born children (Mexico)
![Page 17: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/17.jpg)
Less Common Bacterial Pathogens Mycobacterium tuberculosis (con’t)
Tends to be a complication of primary infection in child <5 yo
Droplet inhalation dissemination from the lungs to lymphatics and bloodstream primary infection
Borrelia burgdorferi Usually affects children living in Lyme-endemic
regions▪ Southern New England▪ Eastern mid-Atlantic▪ Upper Midwest▪ Northern California
![Page 18: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/18.jpg)
Less Common Bacterial Pathogens Borrelia burgdorferi (con’t)
Transmission▪ Deer tick (Ixodes scapularis or pacificus)▪ May through August
Chronic basilar meningitis occurs most commonly at the early disseminated phase of infection
Rickettsia rickettsii Cases reported in all states except for Maine, Alaska,
and Hawaii Transmission▪ Tick (Dermacentor variabilis or andersoni)▪ May through August
![Page 19: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/19.jpg)
Less Common Bacterial Pathogens Rickettsia rickettsii
Diagnosis most often made in children <15 yo
More likely to cause encephalopathic signs and symptoms
Worse outcome for children diagnosed after 5 days of symptoms
![Page 20: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/20.jpg)
Aseptic Meningitis
Syndrome of meningeal inflammation in which common bacterial pathogens have not been identified
Definitive agent established in 1 out of 4 patients Most common agents are viral▪ Enteroviruses
![Page 21: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/21.jpg)
Aseptic Meningitis
Enteroviruses Transmission is fecal-oral Most children not severely ill▪ Non-specific febrile illness▪ +/- Meningeal signs
Benign course without sequelae Noninfectious aseptic meningitis
Vasculitis (Kawasaki, SLE) Drugs (NSAIDs, IVIg, Bactrim)
![Page 22: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/22.jpg)
Clinical Manifestations
INFANTS < 1MO OLD
Fever Hypothermia Lethargy Irritability Poor feeding Vomiting Apnea Seizures Sepsis-like picture
INFANTS > 1 MO OLD AND YOUNG CHILDREN
Fever Lethargy Irritability Mental status
changes* Vomiting* Seizures*
![Page 23: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/23.jpg)
Clinical Manifestations
OLDER CHILDREN
Malaise Myalgia HA Photophobia Neck stiffness Anorexia Nausea Fulminant sepsis/
multi-organ involvement
![Page 24: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/24.jpg)
History
![Page 25: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/25.jpg)
Question #2 An 11 yo male presents in July with a 10 day history of
fever, myalgias and HA. Mom also mentions that he has a rash over his right calf. Over the past 1-2 days, his HA has been worsening and he has been complaining of a stiff neck and sensitivity to light. On PE, he has positive Kernig and Brudzinski signs along impairment of right eye abduction. The most likely cause of this boy’s symptoms is: A. Coxsackievirus B. Herpes Simplex C. Borrelia burgdorferi D. Rickettsia rickettsii E. Mycobaterium tuberculosis
![Page 26: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/26.jpg)
Physical Exam Initial evaluation
Vital signs Cardiopulmonary status Assessment of consciousness (GCS)
Complete physical exam Fontanelle in infants palpated in the sitting
position Head circumference Meningismus▪ Infants: paradoxic irritability▪ Older child: positive Kernig and Brudzinski signs
![Page 27: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/27.jpg)
Kernig Sign
![Page 28: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/28.jpg)
Brudzinski Sign
![Page 29: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/29.jpg)
Physical Exam Complete physical exam (con’t)
Funduscopic exam Cranial nerves▪ CN 3, 4, or 6 palsy seen with Lyme and bacterial
meningitis Cardiac▪ JVD myocarditis, pericardial effusion
Joints▪ Involvement in GBS and meningococcal disease
Skin▪ Rashes (viral exanthem, erythema migrans, petechiae/
purpura, vesicles)
![Page 30: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/30.jpg)
Question #3 A 5 yo female arrives in the ER with a 2 day history of
fever, irritability and poor PO intake. This afternoon, her mother had difficulty waking her from her nap. She also noticed the appearance of a dark rash on her extremities, so she immediately brought her to the ED. You suspect meningococcal disease. All of the following would be a contraindication to immediate LP EXCEPT: A. PTT of 50 (normal <35.9) B. Focal neurologic findings on exam C. BP of 50/30 with a RR of 10 D. Fever of 104F E. Coma
![Page 31: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/31.jpg)
Diagnosis LUMBAR PUNCTURE
Except if contraindicated:▪ Focal neurologic deficits▪ Signs of increased ICP▪ Uncorrected coagulopathy▪ Cardiopulmonary compromise
CSF studies▪ Gram stain ▪ Culture▪ Cell count/ differential▪ Glucose▪ Protein
![Page 32: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/32.jpg)
Diagnosis
Electrolytes Hyponatremia (SIADH) Serum glucose (compare to CSF glucose)
CBC and Coags Leukopenia, thrombocytopenia, and
coagulopathy seen in meningococcal and rickettsial infection
+/- Leukocytosis with pneumococcal infection
Blood culture
![Page 33: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/33.jpg)
CSF Analysis
![Page 34: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/34.jpg)
Question #4 A 5 yo F from Mexico presents with a history
and PE consistent with meningitis. Due to her CSF findings and country of origin, TB meningitis is suspected. TST is placed and is positive. She received the BCG vaccine before she moved to the US. Your medical student asks if the positive TST is a result of the BCG vaccination. Your response is: A. Yes, the BCG vaccine frequently causes false
positive TSTs B. No, a positive TST result is more likely to represent
infection
![Page 35: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/35.jpg)
Traumatic Lumbar Puncture Frankly bloody CSF should NOT be
used to make clinical decisions!! Repeat LP should be attempted in these
situations Do not “correct” CSF for presence of RBC
1 WBC≠ 1000 RBC
![Page 36: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/36.jpg)
Man
agem
ent
![Page 37: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/37.jpg)
Antibiotic Choice and Duration Infants <2mos
Amipcillin (300mg/kg/d divided q6) PLUS Cefotaxime (200-300mg/kg/d divided
q6) +/- Acyclovir (60mg/kg/d divided q8)▪ If HSV is a concern
Vancomycin (60mg/kg/d divided q6) ▪ If gram stain suggests pneumococcus in
young infants
![Page 38: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/38.jpg)
Antibiotic Choice and Duration Infants and children >2mo
Vancomycin (60 mg/kg/d divided q6) PLUS Ceftriaxone (100mg/kg/d divided q12-24) OR Cefotaxime (200-300mg/kg/d divided q6)
Duration Meningococcus: 7 days Listeria, GBS, pneumococcus: 14 days Lyme: 14-28 days Gram negative enteric bacilli: minimum of 21
days HSV: 21 days
![Page 39: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/39.jpg)
Adjunctive Corticosteroids?? Data suggests that for children
beyond neonatal age groups, corticosteroids may be beneficial for Hib meningitis and could be considered in pneumococcal meningitis
Dexamethasone 0.6mg/kg/d divided q6 for 4 days First dose before or concurrently with
Abx Not recommended with viral
meningitis
![Page 40: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/40.jpg)
Complications Shock
70% of patients with bacterial meningitis require fluid resuscitation
Seizures Occur in 20-30% of patients with bacterial
meningitis within the first 72h of illness Focal complications
CN palsy, monoparesis, hemiparesis, gaze preference, visual field defects, ataxia, and aphagia
Usually the result of vascular injury
![Page 41: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/41.jpg)
Complications
Cerebral edema Increased intracellular fluid volume
increased ICP Treatment (depends on severity)▪ Fluid restriction▪ Diuretics▪ Mannitol▪ Corticosteroids
Subdural effusion If symptomatic or empyema suspected
drainage
![Page 42: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/42.jpg)
Complications
SIADH True incidence unclear (7-89%) Diagnosis suggested by:▪ Na< 135▪ Serum osm <270▪ Urine osm >2x serum osm▪ UNa >30▪ Absence of clinical findings of hypovolemia or
dehydration Initial treatment: moderate fluid restriction
![Page 43: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/43.jpg)
Prophylaxis for Exposures Meningococcus
Who?▪ Household contacts (500-800x higher risk than
general population!!)▪ Children who attend child care or nursery school with
the index case▪ Those with intimate contact 7 days before illness▪ Passengers seated next to an infected individual on
an airline flight >8h What?▪ Children: Rifampin▪ Adults: Rifampin, Cipro, Ceftriaxone
![Page 44: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/44.jpg)
Prophylaxis for Exposures Hib
Who?▪ Household un/underimmunized children <4yo▪ Household immunocompromised individuals▪ Attendees/ staff at a child care center if more
than 2 cases of invasive Hib occur within 60 days
What?▪ Rifampin
![Page 45: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/45.jpg)
Prognosis 5-10% of children with bacterial meningitis
die Neonates:▪ GBS 10%▪ E.Coli 20%
• Neurologic sequelae (highest in pneumococcal disease) Intellectual defecits (IQ<70) Hydrocephalus Spacticity Blindness
![Page 46: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/46.jpg)
Prognosis
Neurologic sequelae (con’t) Hearing loss▪ Occurs in 30%▪ Can be uni/bilateral▪ ALL children who have bacterial meningitis
should have their hearing evaluated before d/c
Developmental F/U necessary for all children with meningitis!
![Page 47: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/47.jpg)
Seizures
![Page 48: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/48.jpg)
Intro
Seizures are abnormal and excessive discharge of neurons, usually accompanied by behavioral or sensorimotor manifestations
Epilepsy – occurrence of 2 or more unprovoked seizures 50% of those with epilepsy have learning
difficulties 30 to 50% have mental health and
behavioral issues
![Page 49: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/49.jpg)
Diagnosis and Causes
Start at the very beginning….a very good place to start
History▪ Development, Fam hx, describe the event and
surrounding events, precipitating factors, medications, etc
Physical▪ Global development, dysmorphic features,
neurocutaneous skin findings, head circumference, thorough neuro exam!, etc
![Page 50: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/50.jpg)
Is it a seizure?
![Page 51: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/51.jpg)
Causes of Epilepsy
65 to 70% remain unknown “Idiopathic” – normal physical and
development, no cause found after complete investigation
“Probably symptomatic or cryptogenic” – signs of abnormal brain function
“Symptomatic” – result of an identifiable brain lesion
![Page 52: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/52.jpg)
![Page 53: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/53.jpg)
Infants Children AdolescentsBrain
malformationMetabolic disease
Mesial temporal sclerosis
Infections Developmental diseases
Degenerative diseases
Metabolic disorders
Idiopathic/genetic
syndromes
Trauma
Hypoxic-ischemic
encephalopathy
Infections Tumors
Intracranial hemorrhage
Cortical dysplasias
Familial neonatal
convulsions
Degenerative disorders
Causes by Age
![Page 54: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/54.jpg)
Classification of Epileptic Seizures Partial seizures – abnormal activation of a
limited number of neurons; often can localize the focus Preceded by an aura Automatisms Autonomic symptoms Motor signs Psychic symptoms 1) Simple partial 2) Complex partial = associated with loss of
consciousness
![Page 55: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/55.jpg)
Classification of Epileptic Seizures Generalized seizures – caused by a
global synchronous activation of neurons and always impairs consciousness 1) Absence seizures = frequent, brief, abrupt
losses of consciousness, often accompanied by eyelid flickering; end abruptly with resumption of normal activity▪ EEG = 3-Hz spike and wave, symmetric and
synchronous▪ Can be induced by hyperventilation or photic
stimulation
![Page 56: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/56.jpg)
![Page 57: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/57.jpg)
Classification of Epileptic Seizures
2) Myoclonic seizures – brief contractions of a muscle, muscle group, or several muscle groups caused by a cortical discharge▪ Action, noise, startle, photic stimulation or
percussion can provoke
3) Clonic seizures – jerking that often is asymmetric and irregular▪ Occur more in neonate, infants, or young
children
![Page 58: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/58.jpg)
Classification of Epileptic Seizures
4) Tonic seizures – sustained muscle contraction without a clonic phase▪ Occur at any age▪ Assoc. with diffuse cerebral damage
5) Tonic-clonic (grand mal) – 3 phases:▪ Tonic = lasts 10 to 30 seconds▪ Clonic = lasts 30 to 60 seconds▪ Postictal = a state of confusion and fatigue
for 2 to 30 minutes; diffuse slowing on EEG
![Page 59: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/59.jpg)
Question #5 You get a call in the middle of the night from
concerned parents who just witnessed their 5 year-old son screaming in bed, and when they got to his room, his right arm and hand were shaking and his eyes rolled back. The episode lasted 30 seconds, and then he was confused with drooling and had trouble talking for the next 5 to 10 minutes.
The MOST likely diagnosis is:A. Benign rolandic epilepsyB. Juvenille myoclonic epilepsyC. Frontal lobe epilepsyD. Night terrorsE. Pseudoseizures
![Page 60: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/60.jpg)
Epileptic Syndromes Major Focal Epilepsies
1) Benign partial epilepsy (benign rolandic epilepsy) ▪ Most common partial epilepsy in children▪ Ages 3 to 13▪ Tonic or clonic activity with paresthesias of the lower
face (often unilateral and associated with drooling and dysarthria)
▪ Occur at night, activated by sleep▪ Rarely generalize▪ EEG = centrotemporal sharp waves▪ Perform neuroimaging to rule outparasagittal tumor
![Page 61: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/61.jpg)
Major Focal Epilepsies 2) Temporal lobe
epilepsy – partial seizures in childhood, followed by a seizure free period until adolescence, when seizures reappear▪ 35% have a history of
febrile seizures▪ Preceded by aura,
psychic symptoms, or automatisms
![Page 62: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/62.jpg)
Major Focal Epilepsies 3) Frontal lobe epilepsy – short, frequent partial
seizures that tend to occur in clusters, mostly at night▪ Bizarre automatisms, jacksonian motor seizures▪ Complex partial status epilepticus▪ Todd’s paralysis
4) Parietal lobe epilepsy – simple partial seizures with somatosensory symptoms such as paresthesias, apraxia, and distortion of body image; visual phenomena
5) Occipital lobe epilepsy - simple elementary visual symptoms (patterns or flashes of light or colors)
![Page 63: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/63.jpg)
Major Generalized Idiopathic Epilepsy Syndromes 1) Childhood absence epilepsy –
numerous seizures occur every day Ages 3 to 10 3-Hz spike-and-wave on EEG Photic stim and hyperventilation Tx with ethosuximide
2) Juvenille absence epilepsy – less frequent seizures Puberty 80% have tonic-clonic seizures as well
![Page 64: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/64.jpg)
Major Generalized Idiopathic Epilepsy Syndromes 3) Juvenille myoclonic epilepsy (Janz
syndrome) – upper limb myoclonic jerks that occur after waking (“morning myoclonus”); also have generalized tonic-clonic Age 8 to 18 Sleep deprivation, alcohol,
hyperventilation, and photosensitivity are triggers
+ fam hx in 40%
![Page 65: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/65.jpg)
Major Generalized Idiopathic Epilepsy Syndromes 4) Benign neonatal convulsions –
short tonic, clonic, or apneic seizures that begin 2 to 5 days after birth in normal infants 15% of patients develop epilepsy in the
future Familial cases – seizures occur on 2nd or
3rd day
![Page 66: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/66.jpg)
Question #6 You are seeing a 6-month-old female in clinic for
“strange episodes” that the mother has noticed over the past few weeks. She describes them as her head dropping to her chest and sudden flexing of her arms. These episodes occur several times a day, but mostly right after she wakes up.
Which of the following are you most likely to tell the mother regarding the prognosis of this condition?A. It will resolve on its own and her daughter will have no
cognitive deficitsB. Medication has no effect on cognitive outcomeC. There is no likely known causeD. Her daughter has a high chance of developing an epileptic
syndromeE. She should avoid having her daughter near flashing lights
![Page 67: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/67.jpg)
Major Generalized Symptomatic Epilepsy Syndromes 1) Infantile spasms – symmetric, bilateral, brief, and
sudden contractions of the axial muscle groups Age 5 to 12 months Clusters soon after awakening or on falling asleep Sudden loud noises or tactile stimulation but not photic
stimulation may precipitate them Can be up to several hundred a day EEG = hypsarrhythmia 75% are symptomatic (brain lesion) Tuberous sclerosis is single most common cause Early control with meds is assoc. with better outcome 60% develop other epileptic syndromes (ie, Lennox-
Gastaut) Significant neurocognitive sequelae
![Page 68: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/68.jpg)
Major Generalized Symptomatic Epilepsy Syndromes
2) Lennox-Gastaut syndrome – diffuse slow spikes and waves on EEG, mental retardation, and multiple types of generalized seizures (absence, tonic, and atonic) Age 2 to 8 years Poor prognosis for neurocognitive
outcome and seizure control IQ deteriorates EEG pattern tends to resolve
![Page 69: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/69.jpg)
Question #7 A 14-month-old male is seen in the ER
because he developed a fever of 103° F this morning and subsequently was found in his crib after naptime with his eyes rolled back, right arm jerking, and unresponsive. The episode lasted for 3 minutes.
Of the following, which is closest to his risk of developing future epilepsy:A. 0%B. 1%C. 30%D. 15%E. 9%
![Page 70: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/70.jpg)
Major Generalized Symptomatic Epilepsy Syndromes
3) Febrile seizures
![Page 71: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/71.jpg)
Major Generalized Symptomatic Epilepsy Syndromes
Febrile seizures continued…. Occur in 5% of children between 3 months and 6 years Can recur in up to 30 to 50%, especially if the
first seizure occurred during the 1st year of life No significant increase in risk of future epilepsy
(1% vs. 0.5% in normal kids without febrile sz)▪ However, 2 to 13% of kids with atypical febrile
seizures subsequently develop epilepsy Usually no ancillary testing is required
![Page 72: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/72.jpg)
Status epilepticus
Neurologic emergency Continuous seizure or the occurrence of
serial seizures, between which there is no return to consciousness, lasting more than 30 minutes
May potentially harm the brain Oxygen deficiency causing cell damage
Mortality is 5% Always measure glucose, electrolytes,
calcium, and magnesium
![Page 73: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/73.jpg)
Question #8 You are working the night shift in the ER and a mother
brings in her 5 year-old daughter due to difficulty walking since this morning. She has been complaining of some tingling in her legs. On physical exam, she is afebrile and her vitals are stable. The remainder of her exam is normal except she has an ataxic gait, muscle strength is 3/5 in upper and lower extremities, and you are unable to elicit deep tendon reflexes. Upon further history, mom states that she was treated with abx 2 weeks ago for diarrhea.
Of the following, the MOST likely etiology for this girl’s symptoms is:A. SalmonellaB. ShigellaC. Clostridium difficileD. Campylobacter jejuniE. Rotavirus
![Page 74: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/74.jpg)
Guillain-Barre Syndrome
![Page 75: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/75.jpg)
Pathophysiology
Immune-mediated condition of the peripheral nervous system usually presenting as a rapidly evolving, symmetric polyradiculoneruopathy
Preceded by URI or AGE Multi-focal areas of inflammation
(spinal roots and peripheral nerves), followed by demyelination
![Page 76: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/76.jpg)
Pathophysiology Viruses most commonly involved:
CMV EBV Herpesviruses HIV
Bacterial agents Campylobacter jejuni* Typhoid Paratyphoid Listeria Mycoplasma pneumoniae
Other events Surgery Vaccines
![Page 77: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/77.jpg)
Differential Diagnosis CNS Disease
Meningitis Encephalopathy Neoplasm
Peripheral nervous system disorders Drug toxicities GBS Tick paralysis Diptheria
Neuromuscular junction/muscle disorders Botulism Myasthenia gravis Neuromuscular blocking agents Acute inflammatory myopathies Metabolic myopathies
![Page 78: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/78.jpg)
Clinical Features Progressive ascending weakness Symmetrically decreased deep tendon reflexes Occurs in all age groups
Rare in infants Develops over hours to weeks Signs and symptoms
Flaccid weakness Ataxia Sensory disturbance Autonomic dysfunction▪ Tachycardia, bradycardia, HTN, orthostasis
Cranial nerve involvement (33%)▪ Miller-Fisher = opthalmoplegia, areflexia, ataxia
![Page 79: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/79.jpg)
Question #9 Which of the following is the typical CSF
analysis seen in Guillain-Barre syndrome?A. Elevated protein, cell count >50 cells/mm3 mostly
lymphocytesB. Elevated protein, cell count >50 cells/mm3 mostly
neutrophilsC. Decreased protein, cell count <10 cells/mm3
mostly monocytesD. Elevated protein, cell count <10 cells/mm3 mostly
monocytesE. Decreased protein, cell count >50 cells/mm3
mostly monocytes
![Page 80: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/80.jpg)
Diagnosis CSF
Elevated protein (80 to 200 mg/dL) Cell count < 10 cells/mm3, predominantly
monocytes Nerve conduction studies
Absent or reduced F waves Absent nerve action potentials Prolonged latencies
EMG Muscle denervation
![Page 81: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/81.jpg)
Management Supportive 20% require mechanical ventilation
Respiratory compromise may occur rapidly Airway care and CPT
IVIG Daily for 5 days Shortens duration and severity
Plasmapheresis 4 double-volume plasma exchanges
No role for steroids
![Page 82: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/82.jpg)
Question #10 A mother brings in her 4 yo boy secondary to
complaints of frequent falling. She attributes this to his toe-walking and his large calves. He falls while walking toward the exam table, and you notice that he has to use his hands to climb up his legs in order to get back into a standing position. The most appropriate INITIAL diagnostic test for this boy would be: A. Muscle biopsy B. Creatine kinase (CK) C. Electromyography D. Gene testing E. Lumbar puncture
![Page 83: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/83.jpg)
Duchenne muscular dystrophy
![Page 84: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/84.jpg)
Question #11
What is the mode of inheritance for DMD? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant E. Mitochondreal
![Page 85: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/85.jpg)
Pathogenesis
X-lined recessive mutation in the gene that encodes dystrophin Can be a deletion, point mutation or
duplication Dystrophin bridges the inner surface
of the sarcolemma to the protein F-actin Without dystrophin, glycoprotein
structure of the sarcolemma in less stable muscle damage initiation of an inflammatory cascade further muscle damage, necrosis and fibrosis
![Page 86: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/86.jpg)
Pathogenesis
Proximal muscles involved first Skeletal and cardiac muscle affected
primarily
![Page 87: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/87.jpg)
Clinical Features Progressive and predictable loss of muscle
function Muscles affected at birth▪ Boys may walk later than siblings (but by 18mos)▪ Toe-walking common▪ Running, jumping and hopping are awkward and
difficult Clinical symptoms manifest b/t 3-5 yo▪ Lumbar lordosis▪ Trendelenburg gait▪ Fall more and have difficulty rising▪ Gower manuver
![Page 88: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/88.jpg)
Gower Manuver
![Page 89: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/89.jpg)
Clinical Features Progressive and predictable loss of muscle
function (con’t) Wheelchairs full time b/t 8-12 yo Spinal curvature >20 degrees ~3-4 yrs after losing
ambulation Pulmonary function begins to deteriorate @ 9-11
yrs old▪ 5-10% decline in FVC yearly
Upper extremity function declines in the mid-teens ▪ Lost ability to care for self
Die in late teens/ early 20s secondary to cardiac and/or respiratory complications
![Page 90: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/90.jpg)
Clinical Features
Increased risk for cognitive deficits Motor and language delay Poor attention span Immaturity Features of OCD
![Page 91: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/91.jpg)
Laboratory Evaluation
Biochemical analysis Increased creatine kinase ▪ Causes:▪ Trauma▪ Inflammatory muscle disorders▪ Idiopathic myositis▪ RA▪ SMA▪ Muscular dystrophies*
Increased AST, ALT and LDH▪ GGT to help distinguish b/t a hepatic and muscle
source
![Page 92: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/92.jpg)
Laboratory Evaluation
Electromyography Changes non-specific and not helpful in
establishing the diagnosis of DMD DNA analysis
~65% of boys with DMD have gene deletion
Additional 5-10% have a duplication These boys do NOT require muscle
biopsy to confirm diagnosis!▪ Remaining 10-20%, however, do require
muscle biopsy
![Page 93: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/93.jpg)
Laboratory Evaluation
Muscle Biopsy Histologic changes depend on age of boy
and muscle selected▪ Young age muscle less affected (localized
areas of inflammation and muscle degeneration/ regeneration)▪ Older age muscle fibers replaced by fibrous
and fatty tissue Immunohistochemical staining shows
that dystrophin is absent or nearly absent
![Page 94: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/94.jpg)
Management Initial goals:
Genetic counseling Psychosocial support for the patient and family
Rehabilitation Early goals:▪ Promoting mobility▪ Swimming▪ Biking
▪ Maintaining good ankle position ▪ PT▪ Orthotic devices
▪ School accommodations
![Page 95: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/95.jpg)
Management Rehabilitation (con’t)
As mobility declines:▪ Watch for weight gain/ obesity▪ Mobility equipment and accessibility for home and school▪ Transportation▪ OT for help with ADLs
Eventually, the team expands to include▪ Cardiology▪ Pulmonology▪ Ortho▪ GI▪ Nutrition
![Page 96: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/96.jpg)
Question #12 You are seeing an 8 yo obese M with DMD in
your office. He has a rehabilitation team that works with him three times per week, but Mom wants to know if there are any medications that may help improve her son’s ambulation and not cause weight gain. You recommend: A. Baclofen B. Prednisone C. Lorazepam D. Deflazacort E. Phenytoin
![Page 97: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/97.jpg)
Management Corticosteroids
Delay the progression of muscle weakness Two choices:▪ Prednisone▪ Efficacious but is associated with excessive weight gain
▪ Deflazacort▪ Equally efficacious but not associated with weight gain
Long term benefits▪ Improved ambulation▪ Preservation of pulmonary and cardiac function▪ Reduction in the incidence of scoliosis▪ Maintenance of arm function
![Page 98: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/98.jpg)
Management
Corticosteroids (con’t) Side Effects (deflazacort)▪ Increase in appetite▪ Decrease in height▪ Asymptomatic posterior, subcapsular
cataracts▪ Reduced bone mineral density▪ No significantly increased risk of long bone fractures
HTN, glucosuria, increased infection risk or gastric ulcers not seen
![Page 99: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/99.jpg)
Pediatric head injury
![Page 100: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/100.jpg)
![Page 101: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/101.jpg)
Scalp hematomas and lacerations Uncommon to lose enough blood to
cause shock or hypovolemia from a lac
Cephalohematoma Subperiosteal Follows suture lines
Subgaleal hematoma Can cross suture lines and lead to significant blood loss and
hypovolemia
![Page 102: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/102.jpg)
Skull Fractures
Linear, depressed, or basilar CT scan preferred over x-ray if brain
injury is suspected 50% of brain injuries occur in the
absence of skull fractures
![Page 103: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/103.jpg)
Linear Skull Fracture 75% of all skull
fractures Pain control and
outpatient observation
< 2years, neurosurg consult and follow-up If < 1 year, sign of
possible abuse A “growing fracture” –
lepomeningeal cyst or brain tissue extends through the fracture
![Page 104: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/104.jpg)
Depressed Skull Fracture Occur with higher
impact forces Require neurosurg
evaluation Elevation when the
fragment is depressed greater than skull thickness
Higher risk for developing seizures Often on AEDs
prophylactically
![Page 105: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/105.jpg)
Basilar Skull Fracture Battle sign –
ecchymoses behind the ear
Hemotympanum (fracture of the temporal bone)
Racoon eyes – periorbital ecchymoses
CSF leak Head CT should be
performed Require obs in the
hospital
![Page 106: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/106.jpg)
Question #13
A 14-year-old male hit his head on a tree trunk during a skiing accident 6 hours ago. He had no loss of consciousness and has been stable until now. He suddenly becomes lethargic and unable to follow commands.
![Page 107: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/107.jpg)
Question #13
His head CT shows→
The MOST likely diagnosis is:A. Epidural
hematomaB. Subdural
hematomaC. Subarachnoid
hematomaD. Arteriovenous
malformationE. Cerebral contusion
![Page 108: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/108.jpg)
Intracranial injuries Occur in 6 to 30% of children who present
with blunt trauma Epidural hematoma
Rapid hemorrhage Tears of meningeal arteries or veins Convex Assoc. with temporal bone fractures Lucent period for several hours, followed by
rapid deterioration in mental status Close obs and neurosurg consult Prognosis is good after surgical evacuation(no
cerebral damage)
![Page 109: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/109.jpg)
Intracranial injuries
Subdural hematomas More common in
children Tears of bridging
veins Concave If unconscious,
immediate surgical intervention
![Page 110: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/110.jpg)
Intracranial injuries
Diffuse axonal injury Rapid acceleration or deceleration
injuries MVA, falls, severe shaking Should be suspected if presents with
diffuse subarachnoid bleeding and cerebral edema
Develop ICP
![Page 111: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/111.jpg)
Intracranial injuries
Traumatic Brain Injury Primary insult – occurs at time of impact Secondary insult – occurs 1 to 5 days
later▪ Significant cause of morbidity
Management▪ Maintenance of patient’s PaO2 at >
100mmHg▪ Systolic BP >5th percentile to prevent poor
cerebral perfusion
![Page 112: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/112.jpg)
Concussion Trauma-induced alteration in mental
status with or without loss of consciousness
![Page 113: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/113.jpg)
Concussion
Generally do not have structural damage to the brain
Neuroimaging studies are normal Postconcussion syndrome =
headaches, depression, anxiety, behavioral problems, dizziness, amnesia, irritability, hyperactivity, and sleep difficulties
![Page 114: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/114.jpg)
Concussion
Second impact syndrome A patient is still symptomatic from
concussion, and receives a second concussion
Can develop diffuse axonal injury Cerebral edema Brain herniation Coma Death
![Page 115: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/115.jpg)
Question #14 A 15-year-old male sustains a head injury while playing
football in a Saturday night game. He was nonresponsive for 3 minutes. Over the next hour, he complained of headache and dizziness. You see him 3 hours later in the ER and he has returned to baseline. He has no previous head injury. He asks you when he can play in the game next Saturday, because it’s a biggest game of the season and he invited a girl to come watch him play.
Your BEST response is:A. He doesn’t have to wait that long, he can suit up and
practice tomorrowB. He should refrain from any contact sports in the futureC. He can play in the game if asymptomatic at practice on
FridayD. He can play in the game if his CT scan is normalE. He can play in a game again after a 1-week symptom free
period 1 month from now
![Page 116: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/116.jpg)
![Page 117: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/117.jpg)
![Page 118: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/118.jpg)
Triage of Head InjuryQuestions to AskCry immediately
“goose egg” or scalp hematomaBleeding or fluid from nose or ear
Fall greater than 3 feetAge of child
History of recent head injury
Call me back if…Change in mental status
SeizuresPersistent or increasing headache
Protracted vomiting (more than 2 to 3 times)
![Page 119: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/119.jpg)
Hospital Care
Immobilize cervical spine Obtain GCS score
<9- intubate immediately Place orogastric tube
NG contraindicated because could possibly penetrate base of skull
Normal ventilation Keep CO2 35mmHg (prevent
vasoconstriction and to maintain adequate cerebral perfusion)
![Page 120: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/120.jpg)
![Page 121: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/121.jpg)
Hospital Care
Fluid management Maintain systolic blood pressure in the
normal range with 20cc/kg of isotonic crystalloid in boluses to prevent hypotension
If BP is normal, but increased ICP as well as uncal herniation are suspected→ Mannitol (0.5 to 1g/kg) Hypertonic saline has also been used Cushing triad▪ HTN, bradycardia, and irregular breathing
![Page 122: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/122.jpg)
SIADH Can develop in children with TBI
Especially subdural or subarachnoid hemorrhage
Decreased UOP Hyponatremia Low serum osmolality High urine osmolality Can result in lethargy, altered mental
status, seizures, coma Fluid restrict to 2/3 maintenance If Na <120, correct with 3% saline
![Page 123: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/123.jpg)
Neuroimaging
90% of CT scans obtained in alert children after minor head injury are negative
Radiation from head CT is 300 times that of CXR
AAP says (1999)… Observe child who has had no LOC Observe or conduct head CT for those
experiencing LOC
![Page 124: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/124.jpg)
Neuroimaging Palchak and assoc. (2003) says CT if…
Abnormal mental status Signs of skull fracture Scalp hematoma in child <2 Vomiting Headache
Haydel and Shembakar (2003) says in kids with head injury and LOC these are indicators… Headache Emesis Intoxication Seizure Short-term memory loss Evidence of trauma above the clavicles
![Page 125: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/125.jpg)
Children Under 2
Higher risk for intracranial injury Especially infants
Parietal and temporal scalp hematomas were highly associated with skull fractures and intracranial injury, but not frontal hematomas
![Page 126: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/126.jpg)
Nonaccidental trauma
All kids get CT of head Ophtho consult Skeletal survey if under 2
![Page 127: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/127.jpg)
Cervical Spinal Cord Injury Contusions, hemorrhage, fracture,
ligamentous sprain, “stingers”, and muscular strains
Occur with trauma to the top of the head when the neck is in flexion
![Page 128: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/128.jpg)
Question #15 The most sensitive indicator of
neurocognitive outcome in cases of severe head injury is:A. Head CT findingsB. Absence of short-term memory lossC. Duration of comaD. Avoidance of hypotension during hospitalizationE. Patient’s response to stimuli (“AVPU” Alert,
Verbal, Painful, Unresponsive) per ATLS guidelines
![Page 129: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/129.jpg)
Consequences of Head Injury Chronic headaches, depression, anxiety,
difficulties with expressive language and working memory, behavioral changes, ADHD
Children have better prognosis than adults GCS >8 have good long-term outcomes Duration of coma
Most sensitive indicator of neurocognitive outcome
< 2 weeks have considerably better outcomes
![Page 130: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/130.jpg)
Migraine
![Page 131: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/131.jpg)
Evaluation No support for routine laboratory studies or LP Routine EEG not recommended Role of neuroimaging
NOT indicated in children with recurrent HAs and a normal neuro exam
Should be considered:▪ Recent onset of severe HA▪ Change in type of HA▪ Neurologic dysfunction
Should be done with an abnormal neurologic exam or with coexistence of seizures
![Page 132: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/132.jpg)
![Page 133: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/133.jpg)
Management
First step: appreciate the degree of disability
Treatment regimen must balance biobehavioral strategies with pharmocologic measures
![Page 134: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/134.jpg)
Acute treatments are the mainstay of migraine management!
1. Take the medication as soon as possible
2. Take the appropriate dose
3. Have the medication available at the location where the patient usually has the HAs
4. Avoid analgesic overuse (>3-5 doses/ week)
![Page 135: [PPT]Neurology Board Review - School of Medicine - LSU … October... · Web viewNeurology Board Review. October ... arboviruses, EBV, rabies, ... of 103° F this morning and subsequently](https://reader035.vdocument.in/reader035/viewer/2022070607/5a9ed50c7f8b9a8e178bebb6/html5/thumbnails/135.jpg)
**Use should be limited to patients whose HAs occur with sufficient frequency (@ least 3/mo) or severity to warrant daily treatment**