1. Neurology What not to miss in the ER Danielle Pirrie CCPA Toronto East General Hospital dpirr@tegh.on.ca

2. Objectives  Review the less common S/S of stroke/TIA  Discuss need for testing (echo, Holter, carotid dopplers)  Review CNS infection S/S

3. 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

4. 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”

5. Case #1  P/E:  VS: T 36.7, HR 86, BP 154/92, RR 18 SpO 2 94% RA  Neuro exam: CN II-XII normal, no focal weakness, no dysarthria, upgoing toes bilat  DDx  Infection  Stroke  Encephalopathy

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

7. Stroke

8. 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

9. Stroke  Posterior circulation stroke S/S  Acute vision loss  Confusion  Dizziness  Nausea  Memory loss

10. 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.

11. Stroke/TIA AAAAphagia/dysphagia CCCCan be completely non-verbal or simply word finding difficulty DDDDamage to frontal lobe results in problems speaking (expressive) DDDDamage to temporal lobe results in problems understanding (receptive)

12. 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

13. 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 N Engl J Med July 1, 2010

14. Stroke Summary  If TIA, ensure pt has followup for stroke workup to reduce future risk of stroke  Posterior circulation strokes have many mimics

15. 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.

16. Case #2  P/E  temp of 39.8 o C, HR 110, BP 114/72, RR 28, SpO 2 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

17. Case #2  DDx  Bacterial meningitis  Viral meningitis  Herpes simplex encephalitis  Stroke

18. 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

19. 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

20. HSV on MRI (T2)  Hyperintesity in right temporal lobe  Treatment with acyclovir IV

21. 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

22. CNS Infections  Abscesses  Severe HA  Mental status changes  Unilateral weakness/paralyisis  Fever

23. 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

24. 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

25. 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

26. 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

27. Case #3  This came out as “beautiful story run April”  When he tried to spell “road” it was P-F-G-O

28. Intracranial bleed  CT head showed a lobar hemorrhage.

29. Intracranial bleeds  Intra-axial bleeds  Within the brain itself (as in previous case)  Hemorrhagic stroke intraventricularintraparenchymal

30. Intracranial bleed  Causes:  HTN  Trauma  Aneurysm  AV malformation  Tumour  Amyloid angiopathy

31. Intracranial Bleed  Extra-axial bleeds EpiduralSubduralSubarachnoid

32. Intracranial bleed  All bleeds require discussion with neurosurgery.  Blood in brain can increase ICP  At risk for seizures

33. Questions?