Tutorial for New-Extern “Survival Neurology” Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiang Mai University
Neurology extern should know
• Headache coma and confusional state • Medical • Acute stroke • Tonic-clonic seizure and status epilepticus
I have headache !
? ? ? ?
Patient presents with complaint of a headache Critical first step: Hx taking, physical exam
Red flag signs (+)
Investigation
Red flag signs or alarming signs Meets criteria for primary headache disorder?
Migraine headache Cluster headache and other TACs
(-)
(+)
Other (rare) headache disorder
Secondary headache disorder
Tension-type headache
Headache: Key 1. Identify serious cause Red flag sign? 2. Know common primary headache — Feature of migraine, TTH, trigeminal neuralgia 3. Consult specialist : secondary headache non responder no idea
Abnormal neurological examination
Focal neurologic s/s other than typical visual or sensory aura Papilledema
Normal neurological examination Age
Age> 50
Temporal profile Worsening headache -Mass lesion, SDH, MOH
Sudden onset -SAH, ICH, mass lesion (posterior fossa)
Neck stiffness
Concurrent event
Pregnancy, post partum -Cerebral vein thrombosis, carotid dissection, pituitary apoplexy Headache with cancer, HIV, systemic illness (fever, arteritis, collagen vascular disease)
Provoking activity Triggered by cough, exertion or Valsava -SAH, mass lesion
Worse in the morning -IICP Worse on awakening -Low CSF pressure
!"#$%&'(")*$+,-.,/02 (1 3 4&536678 Tension type headache
Migraine
Cluster headache
Unilateral Throbbing Blur vision with zig zag line
Nausea Sensitive to light
Treatment Life style modification
• Acute treatment • Prophylactic treatment
!"#$%&'()*+,-.%&+ (trigger factors)
/020&
/0%01
%0&+/+
!"#$%&'()*+,-.%&+ (trigger factors)
./&012
&78.297+ 3!$4*5 .!01$ %6"#+
Pharmacotherapy of acute migraine attack Non-specific
• • •
Acetaminophen,
• •
opioids
NSAIDs caffeine
1 tab prn headache
neuroleptic
Specific
• •
Ibuprofen (400)/ Naproxen (250), Diclofenac(25)
Cafergot
Ergotamine(Cafergot) Triptan
1 tab prn headache (moderate to severe) Ergotamine tartrate+ Caffeine
Recommended medication for migraine prevention “EFNS guideline 2009”
Started when high headache frequency, high severity Duration 3-6 months Evers, S et al. European Journal of Neurology 2009, 16: 968–981
TTH diagnostic criteria
•
Headache with bilateral location, pressing/tightening character, no other associated symptoms
• Common triggered by stress “Featureless headache”
Treatment of TTH • Life style modification: stress Acute medication: simple analgesic, NSAIDs, muscle relaxant
• • Prophylactic medication: TCAs, Depakine
• Non-pharmacologic intervention
COMA and ACUTE CONFUSIONAL STATE
Alter mental status
Coma/alter level of consciousness
Other: delirium, aphasia, psychiatric problem
Hx taking/physical exam
clinical classification 1. coma with localizing sign 2. coma without localizing sign but with meningeal sign 3. coma without both localizing and meningeal sign 4. coma with seizure
VARIOUS STATE OF CONSCIOUSNESS Delirium Acute confusional state
2 component of consciousness: arousal and awareness coma, vegetative state, minimally conscious state, and locked-in syndrome.
Practical a
roach
• History taking • as the patient can not talk, then ask their relative or witness • underlying disease is important (DM, atherosclerotic risk, HIV)
• symptoms before and during coma(neurological complain)
• Physical exam • CPOMR (conscious level, pupil, ocular movement, motor response, respiration)
• Meningeal sign, seizure, other neurological symptoms?
clinical classification 1. coma with localizing sign 2. coma without localizing sign but with meningeal sign 3. coma without both localizing and meningeal sign 4. coma with seizure
COMA Localizing sign-no Meningeal sign-yes Severe meningitis
CT with CM in bacterial meningitis
or
Meningitis with complication; hydrocephalus, vasculitis, infarct CT without CM in SAH
Encephalitis Subarachnoid hemorrhage
- CT Brain with contrast - Lumbar puncture MRI Brain in viral encephalitis
Non-structural lesion caused coma • Exogenous- drug, toxin (lead,
thallium, cyanide, methanol, CO), addict substance (heroin, amphetamine)
metabolic; Ca, Na, glucose, hypoxemia, • Endogenous-
hypercapnia, hypothyroid ::: internal toxin; uremia, hepatic encephalopathy
Thesecausesarereversible;ifnolocalizingsign;labscreenfirst Glucose,CBCwithPlt,BUN,Cr,Elyte,Ca,Mg,PO,Oxygensat
Keep in Extern’s Mind Alter mental state 1. Ask history; if obvious history suggest cause, treat immediately (hypoglycemia in DM patient, toxin ingestion) 2. Restore vital signs (Oxygen, (glucose immediately, and otherBP)...then basic lab)taking lab 3. Physical exam: “CPOMR” + “Meningeal sign” -) if coma with no both focal or meningeal sign: metabolic, toxic, drug, diffuse intracranial lesion -) if coma with meningeal sign; do CT brain emergency -) if coma with focal sign; do CT brain emergency -) if coma with sign suggesting to seizure: start AED
Delirium, Acute confusional stat e - good wakefulness - impair orientation - fluctuation of consciousness (usually occur at night) - broader cause than coma
Etiologies -“ I WATCH DEATH “ !
I = Infection
!
W = Withdrawal
!
A = Acute
!
!
!
Metabolic T = Trauma C = CNS Pathology H = Hypoxia
!
!
!
! !
D=
Deficiencies (especially vitamin) E = Endocrinopathies A = Acute
Vascular
T = Toxins H = Heavy
metals
Delirium management •
Monitor VS and I/O
•
Ensure good oxygenation
•
D/C nonessential medications
•
Minimize opioids, Benzodiazepine, etc
•
Repeat PE, further lab, radiologic studies if cause not yet identified
!
Antipsychotic Dosing in Elderly !
Use clinical judgment depending on severity of symptoms for starting dose: !
Haloperidol !
0.5mg
mild
!
1mg
moderate
!
2mg
severe
Acute stroke
when we suspect stroke • when the patient has sudden neurological deficit; symptoms depend on where is the brain is involved
numb • weak, • brain stem sign • cerebellar sign • cortical sign • alter mental state
Acute/sudden neurological deficit
Hx taking/physical exam
Stroke?
ABCD, Neuro sign w/u stroke mimicker; specially hypoglycemia in DM, post-seizure EKG IV NSS, Lab (CBC plt, PT, PTT, INR, BUN/Cr/ elyte
> 3.0-4.5 hours
With in 3.0-4.5 hrs Call stroke fast track
Brain imaging: CT brain Infarct
Hemorrhage
Condition that mimic stroke miscellaneous SAH TGA vertigo MS syncope/presyncope
3.1%
dementia psychogenic migraine confusional state
3.6%
SDH tumour PN palsy toxic/metabolic
18.2%
seizures 0.0%
5.0%
10.0%
15.0%
20.0%
% of all stroke mimics (n=670)
25.0%
30.0%
Stroke can be... Ischemic 75%
TOAST classification
• Large-artery atherosclerosis(emboli/ Hemorrhagic (25%); subarachnoid, intracerebral
HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41
•
thrombosis) Cardioembolism(high-risk/mediumrisk)
• Small-vessel occlusion(lacune) • Stroke of other determine etiology • Stroke of undetermined etiology TOAST, Trial of Org 10172 in Acute Stroke Treatment.
Anterior vs Posterior circulation
“Acute brain attack” ABCD, Neuro sign w/u stroke mimicker; specially hypoglycemia in DM, postseizure EKG IV NSS, Lab (CBC plt, PT, PTT, INR, BUN/Cr/elyte
clinical stroke within 2-4.5 hours
Activate Fast tract for rt-PA
CT Brain non-contrast emergency
CT Brain normal or evidence of acute ischemic stroke IV rtPA if indicated
CT brain, non-contrast • !"#"$%&'($)*+,) -.+)/"012 • 345627")8+91*11:-;!#1<
Hemorrhagic stroke
+=2>?@;'(A*2B sensitivity +C1> 100%
• Minor or subtle signs : loss of lentiform nucleus, loss of insular ribbon, loss of gray-white differentiation and sulcal effacement
Ischemic stroke
Standard treatment in acute ischemic stroke • IV rtPA within 3 hrs : NNT=10 (now 3-4.5 hrs)
• Stroke unit : NNT = 30-40 • ASA within 48 hrs : NNT 140 • Early decompressive surgery for malignant MCA infarction : NNT =2 for death prevent
D1EA$JK/1*+91*!#1< L"*+91* • 1":"$M"<$8>>N$8!"M'O'(K"2+1< • 1":"$M"<$8>>N$8!"M'O012+P;'N +Q; B1":"$R"1S"<+T2)
• !"#"$%-G:"$U:V"'(W;7"2-;+)/" 3-4.5 X)A#<
Brain herniation • Subfalcine (A) (B) •• Uncal Central (C) • Extradural (D) • Tonsillar (E)
Herniation syndrome
Treatment IICP • -G;1;2:Y$V8Z/8[);>;L1<\"<:"2]< 20-30 1<^" • _*`"ab)2-GKc:+d2<:"$:*W>L1
• g5"$h"-G osmotherapy: • Mannitol* 0.25-0.5 g/kg M"
• Km1 10% Glycerol 250 ml M"
• Km1 50% Glycerol 50 ml M"
Treatment IICP • Kc:+d2<:"$-G hypotonic solution • Kc:+d2<7")8L"*11:n+5; g5"$h"-[`1 Q)2K"2-5-;:$ofB:"$K"2-5p*N:q • Hyperventilation +r1-G Pco2 30-35 mmHg BN$8A2Rs-;:"$/*J)"#t;-;!#1<-;Q)< u; v w1;x"y* • 'OJ)$-G steroid
Keep in Extern’s mind Stroke 1. when the sudden neurological deficit occur; suspect stroke...every case 2. check time and onset (eligible for rt-PA??) and exclude mimicker cause (hypoglycemia, seizure) 3. if within 4.5 hours; call resident/neurologist “activate FAST TRACT” can request CT brain emergency 4. check v/s, assess severity, check and follow up neurological signs
Seizure and status epilepticus
Patient come with clinically suspected seizure Known case epilepsy with recurrent seizure
First diagnosed seizure
Status epilepticus
Seizure mimicker
Cause?
Treatment options Treatment cause AED?
Seizure or Not seizure
• Seizure mimicker • pseudo-seizure • convulsive syncope • movement disorder: myoclonus, chorea, paroxysmal dyskinesia
• hypnic jerk
Seizure vs Syncope
Bhidayasiri R. et al. Neurological differential diagnosis 2005
Identify cause of seizure (symptomatic seizure) Acute symptomatic seizure
• • • • • •
Stroke Metabolic disturbances CNS infection Trauma Drug Toxicity Hypoxia
Remote symptomatic seizure
• • • •
Pre-existing epilepsy Ethanol abuse Old CVA Relatively longstanding tumors
What should we do? • Evaluate ABCD, and check basic lab,
intubation or oxygen therapy if indicate
• If seizure is not stop; start AEDs • Complete general, and neuro-exam • Brain imaging if indicate
New proposed definition of SE • Status Epilepticus Cooperative Study group (1998)
• SE > 10 minutes • Lowenstein DH (1999) • SE > 5 minutes
Complication of SE • Acidosis Cerebral edema
• Hypoglycemia • Other: arrhythmia, hyperthermia,
hyperkalemia, DIC, rhabdomyolysis, myoglobinuria, renal failure
Management of SE
Key • treat early as possible step up AED is depended on stage of SE
• • add on therapy is needed • monitor EEG regularly, even if no obvious seizure
Define stage of the status epilepticus Pre-monitory status(0-5 min)
• Early status(5-30 min) • Established status(30-60 min) • Refractory status(>60 min)
Drug used • diazepam, phenytoin(Dilantin), valproic acid(Depakine), levetirazetam(Keppra)
• Phenobarbital, propofol, midazolam, thiopental
• Topiramate(feed)
drug use depend on stage of status
Diazepam • diazepam 10 mg (2-5mg/min) • max 10 mg per dose • can be repeated 2 doses
Phenytoin • Vial: 250 mg/5 ml/vial • 0.9% NaCl (don’t use infusion pump) dose: 20 mg/kg (rate < 1 mg/kg/min) •• starting maintenance: 5-8 mg/kg/day • e.g. weight 50 kg • Dilantin 1000 mg+0.9%NSS 100 cc iv drip in 20 min. then Dilantin 100 mg+0.9%NSS 100 cc iv drip in 15 min
Valproic acid • Vial: 400 mg/4 ml/vial • 0.9% NaCl or 5% Dextrose • starting dose: 20-30 mg/kg (rate < 50 mg/min) • maintenance: 1-2 mg/kg/hr (max 60 mg/kg/day) • e.g. weight 50 kg • Depakine 1000 mg+0.9%NSS 100 cc iv drip in 30 min. then Depakine 100 mg/hr (10 cc/hr)
warning: hepatotoxicity
Midazolam • Vial: 1 mg/ml/vial, 5 mg/ml/vial, 15mg/ 3ml • 0.9% NaCl or 5% Dextrose/w • starting dose: 0.1-0.3 mg/kg bolus (rate < 4 mg/min) • maintenance: 0.05-0.4 mg/kg/hr • e.g. weight 50 kg • Midazolam 5 mg iv bolus then + Midazolam (1:1)iv drip 5 cc/hr (0.1 mg/kg/hr)
Levetiracetam (Keppra) • Vial: 500 mg/5 ml • 0.9% NaCl or 5% Dextrose/w 100 ml • starting dose: 2,000-4,000 mg/kg in 15 min • maintenance: 10-30 mg/12 hr • e.g. weight 50 kg • Keppra 2000 mg iv in 15 min then 1000 mg iv q 12 hour
Propofol • Vial: 10 mg/ml • 5% Dextrose/w • starting dose: 2 mg/kg bolus • maintenance: 5-10 mg/kg/hr • e.g. weight 50 kg • Propofol (2:1) iv 100 mg then 250 mg/hr Consult *#2" is required
Thiopentone Vial: 1 g/vial
•• starting dose: 100-250 mg in 20 min then 50 mg q 2-3 min until seizure stop
• maintenance: 3-5 mg/kg/hr Consult *#2" is required
Phenobarbital 200 mg/4 ml in sterile water 10 ml • Vial: • 5% Dextose • starting dose: 20 mg/kg (rate < 100 mg/min) • maintenance: 1-4 mg/kg/day
Topiramate for SE trial: 500 mg every 12 hours • Clinical noso/orogastric feed for 2 days then 150 mg-750 mg every 12 hours
• Effective dose: 300-1600 mg/day
Monitoring • Tapering off AED • seizure stop > 24 hours suppression on EEG > 24 • Burst hours • Slow tapering off AED • if seizure recur, increase AED dose enough to control seizure
Keep in Extern’s Mind
Seizure 1. Seizure or not seizure: history, neuro exam 2. Identify cause, ABCD management 3.Start AEDs if seizure tend to be recurrent 4. if seizure is going to be status; need to be quick, and follow up the status epilepticus guideline therapy
download slide at... openneurons
