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- Parenchymal hemorrhage
- Simple-partial
Venous Sinus ThrombosisPresentation: headache (often acute, thunderclap), papilledema (increased ICP), focal neurologic symptoms, seizures, and mental status changes Note: important to distinguish from arterial thrombosis/hemorrhage because of different clinical implications Ddx: may need to do LP prior to MRI if subarachnoid hemorrhage in Ddx Diagnosis: CT with contrast only 20% sensitivity / MRI with MR venography is gold standard Treatment: heparin for cerebral venous thrombosis and cerebral sinus thrombosis (even with hemorrhagic lesions) because it can open vessels and reduce edema and ICP. Then target INR 2.0 to 3.0 with warfarin for ≥ 6 mos. / catheter-guided thrombolysis in severe cases / lateral or transverse sinus thrombosis may require more aggressive treatments and/or stents Prognosis: with proper treatment, 70% recover fully, 20% with sequelae, 10% mortality < 30 days Intracranial Hemorrhage avoid lowering BP with known cerebral ischemia, but if necessary, a reasonable goal would be to reduce a diastolic > 120-130 mm Hg by no more than 20% in the first 24 h / Nitroprusside increases ICP by cerebral vasodilation / 1 in 5 will be related to warfarin use Subarachnoid hemorrhage (SAH) Accounts for 4% of patients presenting to ER with severe headache / 1 in 10,000 / females:males 2:1 / 50s and 60s Causes: ruptured cerebral aneurysm (APKD, fibromuscular dysplasia, Marfan’s, Ehlers-Danlos type IV, AVM, coarctation of aorta, stroke, trauma) / Presentation: sudden-onset, intensely painful, often with neck stiffness (other meningeal signs), fever, N/V, fluctuating level of consciousness / may be heralded by milder sentinel headaches / can cause seizure from cortical irritation Diagnosis: CT without contrast (contrast can irritate cortex causing seizures) 95% sensitive if ≥ 12 hrs and ≤ 24 hrs LP may reveal frank RBC’s or xanthochromia (100% sensitive ≥ 12 hrs) or elevated ICP / presence of bilirubin distinguishes xanthochromia from traumatic LP 4-vessel MRA is done later and can detect aneurysms ≥ 5 mm Angiography has 80-90% success in finding (if negative, can repeat in 1 to 6 weeks) ECG (QT prolongation with deep, wide inverted T waves) (25-100% of cases) Treatment: prevent ICP by raising head of bed, limiting IVF, treating HTN / can give nimodipine (60 mg q 4 x 21 days) and Dilantin / neurosurgery or interventional radiology / for patients with worsening neurological deficits triple-H (hypertension (CVP 8-12), hypervolemia, hemodilution (Hct 30) Course: hydrocephalus occurs in 15-20% cerebral vasospasm occurs 3 to 12 days after in ~ 1/3 (detected by transcranial Doppler) rebleeding more with aneurysm, same or other aneurysms extension into parenchyma (more with AVM) LV dysfunction // from “cardiac stun” of catecholamine release/response // these changes usually resolve Parenchymal hemorrhageHypertension, tumor, amyloid angiopathy (elderly) Lethargy and headache / focal motor and sensory Dx: same as SAH Rx: similar to SAH absence, status epilepticus, febrile seizures, alcoholic seizures Seizure Pharmacology partial (simple or complex) 2o generalized Note: both types of partial seizures may generalize Differential: CVA (CNS hypoperfusion) or syncope (may have a few spasms prior to passing out) Work up: CBC, electrolytes, calcium, glucose, ABG’s, LFT’s, renal panel, RPR, ESR and toxicity screen / EEG, CT, MRI Simple-partialcan have postictal focal deficit lasting 1-2 days (Todd’s paralysis) Complex-partial (50% or more) EEG: unilateral or bilateral spikes over temporal lobes (70-80%) Stereotyped automatisms (frequent) / altered mental status, consciousness or responsiveness, confusion, emotional reactions, déjà vu, feelings of detachment, hallucinations / postictal confusion common Frequency: every day or every few weeks, months Treatment: Dilantin, Tegretol, VPA Jacksonian seizure – rhythmic twitching marches proximally to entire limb Generalized (absence, tonic, myoclonic, atonic, GTC) GTC or generalized tonic-clonic almost always under a minute During seizure: loss of consciousness, neck/back extension then 1-2 minutes of clonic movements / cyanosis, incontinence
Akinetic – brief (type of myoclonic SZ) Specific Types of Seizures Absence seizures Begin in childhood, often subside before adulthood, often familial EEG: characteristic 3 Hz – S + SWC – during one second hyperventilation can precipitate absence seizures usually have 10s to 100s per day / last 5-10 seconds / amnesia before and after
repetitive seizures without return to baseline > 30 mins / anticonvulsant/alcohol withdrawal, other drug abuse, noncompliance with seizure meds, metabolic, infection, trauma / 20% mortality / all too easy to miss in ICU with patients on ventilator, either actively sedated or with baseline low-consciousness from underlying disease Treatment: same as seizure but faster and may need to intubate / IV Ativan, load Dilantin, try phenobarbital if that fails / also consider IV sedative like midazolam or pentobarbital Ictal bradycardia syndrome epileptic discharges profoundly disrupt normal cardiac rhythm, resulting in cardiogenic syncope during the seizure Diagnosis: ambulatory EEG/ECG monitoring Treatment: cardiac pacemaker + antiepileptics Download 3.95 Mb. Share with your friends:
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