Meningitis
Explain the layers of the meninges
Common etiology, and mode of infection.
What is meant by the term Meningism?
What signs can be elicited in a patient with meningitis? Is the sign positive for any other conditions? How sensitive of specific is it for meningitis?
How do you differentiate a viral,bacterial and fungal cause of meningitis?
How do you do a lumbar puncture? What is the contraindications and how to make sure there are no contraindications?
What are the complications of meningitis?
Principles of management.
Cerebrovascular accident
Stroke, stroke in evolution, Transient ischaemic attack and minor stroke.....Define
How many types of stroke? How to differentiate?
What are the typical presentations of stroke?
Will the Babinski reflex be positive in the right foot of a patient with a stroke of the right side of the brain?
What is the most common site affected if a branch of the middle cerebral artery is involved? What would be the signs? What happens if the trunk of the MCA is thrombosed?
A 61 year old man who is a known case of hypercholesterolaemia presents to the A&E department with vomiting, dizziness and numbness on the left side of the face for the past 1 day. On examination,left sided partial ptosis and myosis,diminished gag reflex, dysdiadakokinesia. and past pointing. Based on this information, what do you think the problem is? What other signs would you look for?
How would you manage an emergency case of stroke?
Thats all for now~more complex neurological problem coming soon:D
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2 comments:
Stroke:
TIA/ minor stroke- clinical syndrome charac by acute disruption of blood flow to an area of the brain and corresponding onset of neurologic deficits related to the concerned area of the brain lasting less than 24 hours.
Types of stroke-
1. Ischemic( embolic, thrombotic or cerebral hypoperfusion)-80% of cases
2. Hemorrhagic ( intracerebral or subarachnoid hemorrhage)
In case of embolic and hemorrhagic stroke, stroke dev suddenly and in the latter case, it continues to worsen with time.
In case of thrombotic stroke, it develops more gradually.
Typical presentation- focal neurological deficit related to the artery involved e.g anterior , middle cerebral artery syndrome and brainstem syndrome( posterior circulation)
I dun think the babinski reflex would be positive in the right foot if the lesion is in the right side as it is due to cortical lesion such as internal capsule stroke that is due to damage to the corticospinal tract which descend from precentral gyrus thru internal capsule, midbrain cerebral peduncle and pons and decussate at medullary pyramids to supply contralateral limbs.
In case of a branch of middle cerebral artery involvement, face and arms are most commonly affected with contralateral hemiparesis( superior division), contralateral homonymous hemianopia and Wernicke aphasia( inferior division) while main trunk involvement usually results in contralateral hemiplegia, eye deviation toward the side of the MCA infarct, contralateral hemianopia, and contralateral hemianesthesia.
As for the 61 yo man who presents with left sided partial ptosis and miosis( Horner syndrome), vomiting, dizziness( vestibular nuclei) , diminished gag reflex( IX), dysdiadakokinesia. and past pointing( cerebellar sign), it suggests lateral medullary syndrome due to involvement of left posterior inferior cerebellar artery involvement. So I would look for left-sided loss of facial pain and temperature sensation with contralateral loss of pain and temperature sensation.
For emergency case of stroke, I would say ABC+ depends on the type of stroke u suspect lo…
For ischemic- thrombolytics? ASA together with blood pressure and glucose management as well.
For hemorrhagic- BP control with prevention of vasospasm- nimodipine together with surgery.
Meningitis
Meninges- dura, arachnoid and pia mater
Etiology- irritation of meninges with microbial infection or subarachnoid hemorrhage, drugs….
Meningism- triad of nuchal rigidity, photophobia and headache which reflects the irritation of meninges.
Signs- nuchal rigidity, Kernig and Brudzinski sign. Which my present in case of meningitis and SAH.
To differentiate the cause of meningitis, hmmm, I think mainly from the history of patient together with Csf analysis with lumbar puncture performed which involves insertion of a needle to the spinal canal for the extraction of csf. Contraindication for LP- lncreased ICP which requires fundoscopy and CT.
Complications of meningitis-
1) Raised ICP
2) Hydrocephalus
3) Seizure
Principles of management of meningitis: depends on the cause
For viral- mainly symptomatic
For bacterial- IV Cephalosporins 3rd or 4th generation
For fungal with antifungal- amphotericin
Actually when is steroids indicated? Dunno. Any ideas?
Definition of TIA is the deficits last less than 24 hours
When the deficit last more than 24hrs, but less than 7 days, its called a minor stroke.
Stroke-in-evolution is when more symptoms appeared until a full blown disease happen.
Typical presentation of a stroke patient depends on the arteries involved. In most cases, the affected upper limbs will be hyperflexed while lower limbs hyperextended.
In the case of lateral medullary syndrome, also look for loss of convergence reflex and exagerrated jaw jerk. I got this case for my short case:P
For acute management of ischaemic stroke, thrombolytic should be given as fast as possible before neurological deficit become permanent. rTPA e.g. Alteplase is prefered in M'sia, while for some reason Streptokinase is contraindicated(i forget why). Therefore for any case of stroke a CT must be done and treatment given in 3 hours
Steroids is generally avoided in meningitis except when the disease cause increased in ICP which may cause more serious damage. It is given then tapered off as soon as possible.
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