NeurologyWhat not to miss in the ER

Danielle Pirrie CCPA

Toronto East General Hospital

dpirr@tegh.on.ca

Objectives

Review the less common S/S of stroke/TIA

Discuss need for testing (echo, Holter, carotid dopplers)

Review CNS infection S/S

Case # 1

78yo male, minimal English, from a rehab hospital (for minor) deconditioning, 2 day hx of being confused, telling translator that he is in his village in Serbia, being chased by bandits in masks.

PMHx: HTN,

previous left MCA stroke 7 yrs ago left with minor right arm weakness,

high cholesterol

Case #1

By the next day, his speech (when talking with family) was like word salad, not making any sense.

But he could tell me in English that he was fine and “want to go home”

Case #1

P/E: VS: T 36.7, HR 86, BP 154/92, RR 18 SpO2

94% RA

Neuro exam: CN II-XII normal, no focal weakness, no dysarthria, upgoing toes bilat

DDx Infection

Stroke

Encephalopathy

Stroke

CT scan showed a left parietal stroke relating to Wernicke’s area

Stroke

Stroke Typical anterior circulation stroke S/S

Unilateral weakness

Slurred speech

Decreased LOC

Other anterior circulation stroke S/S Cognitive impairment

Difficulty with speech, word finding difficulty

Weakness or clumsiness

Changes of sensation

Visual losses – hemianopia

Stroke

Posterior circulation stroke S/S Acute vision loss

Confusion

Dizziness

Nausea

Memory loss

Stroke/TIA

Dizziness Usually associated with other brainstem

S/S such as double vision, dysarthria, ataxia, dysphasia.

DDx: benign paroxysmal positional vertigo, migraine, Meniere’s, low BP, vestibular neuronitis, acoustic tumours, medications, anxiety, etc.

Stroke/TIA

Aphagia/dysphagia Can be completely non-verbal or simply

word finding difficulty

Damage to frontal lobe results in problems speaking (expressive)

Damage to temporal lobe results in problems understanding (receptive)

Stroke/TIA

Decrease LOC Most likely to be caused by a brain stem

stroke or hemorrhagic stroke

Brain stem stroke difficult to diagnose on CT scan

N Engl J Med July 1, 2010

Stroke workup

CT scan

Carotid dopplers If 70-99% stenosis and TIA or nondisabling

stroke, may be candidate for surgery or stenting.

Echocardiogram

Holter monitoring

Stroke Summary

If TIA, ensure pt has followup for stroke workup to reduce future risk of stroke

Posterior circulation strokes have many mimics

Case #2

27yo female comes into ER with fever, headache, fatigue and loss of appetite,

After a few hours of waiting in the waiting room, her boyfriend notices that she is trying to use a pop can as a cell phone, that she is speaking gibberish and not making any sense. She is then brought into a room and examined.

Case #2

P/E temp of 39.8oC, HR 110, BP 114/72, RR 28,

SpO2 98% RA

CN: PERLA 3+, left visual field defect, no facial asymmetry

Motor: no focal deficits, no neck stiffness

Labs CBC: WBC 10.4, Hb 140, Plt 247

Normal electrolytes, LFT, RFT

Case #2

DDx Bacterial meningitis

Viral meningitis

Herpes simplex encephalitis

Stroke

Case #2

Anytime there is HA, mental status changes and fever, need to do LP

CSF analysis: Glucose: 2.7 (normal)

Protein: 0.4 (normal)

Culture did not grow anything

CT scan head normal

CNS Infections

Herpes Simplex Encephalitis Typically HSV-1

S/S: fever, headache, psychiatric or mental changes, seizure, vomiting, focal weakness, memory loss.

CSF: mononuclear lymphocytes, high RBC, protein normal or high, glucose normal or low, send for viral cultures and PCR

CT may be negative

Need MRI to diagnose definitively

HSV on MRI (T2)

Hyperintesity in right temporal lobe

Treatment with acyclovir IV

CNS Infections

Meningitis May be bacterial, viral, tubercular, or fungal

Bacterial meningitis: children under 2. s/s: evolve over hours, starts with URTI s/s

then develop fever, lethargy, N/V, stiff neck, photophobia

CFS: high polymorphonuclear leukocytes, high protein, low sugar

Urgent management is vital as severe cortical damage can result from any delay in treatment

CNS Infections

Abscesses Severe HA

Mental status changes

Unilateral weakness/paralyisis

Fever

CNS Infection Summary

Low threshold for LP in pts with fever and mental status changes

Treat empirically for HSV-1 to ensure no irreversible brain damage

Abscesses are usually seen on CT

Case #3

73yo male, sudden onset of L HA while at home

Pt took 2 ASA for pain but it did not resolve so he took 2 more ASA 2 hours later

Approx 1 hr after, he suddenly noticed not being able to read the computer screen and having decreased vision on the right side

Case #3

PMHx: A-fib for which he takes ASA

HTN

Dyslipidemia

Prior small right occipital lobar bleed in 2007

ETOH approx 3 drinks/day

Smokes a pipe

Son is a neurologist in NY state

Case #3

PE: VS normal except for irregular pulse

CN mostly normal except for right visual field defect

No motor, sensation, coordination deficits

Normal verbal

Visual acuity

Case #3 This came out as

“beautiful story run April”

When he tried to spell “road” it was P-F-G-O

Intracranial bleed

CT head showed a lobar hemorrhage.

Intracranial bleeds

Intra-axial bleeds Within the brain itself (as in previous case)

Hemorrhagic strokeintraventricularintraparenchymal

Intracranial bleed

Causes: HTN

Trauma

Aneurysm

AV malformation

Tumour

Amyloid angiopathy

Intracranial Bleed

Extra-axial bleeds

Epidural Subdural Subarachnoid

Intracranial bleed

All bleeds require discussion with neurosurgery.

Blood in brain can increase ICP

At risk for seizures

Questions?