Tutorial for Pre-Extern Emergency Neurology

Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiang Mai University

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Neurology extern should know

Medical coma Acute stroke Tonic-clonic seizure and status

epilepticus

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COMA
and ACUTE CONFUSIONAL STATE

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Wakefulness and ascending reticular activating system(ARAS)

>> level <<

drowsiness stuporous semi-coma coma

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VARIOUS STATE OF CONSCIOUSNESS

2 component of consciousness: arousal and awareness

coma, vegetative state, minimally conscious state, and locked-in syndrome.

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Practical approach

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 examination
evaluate location and cause evaluate severity

clinical classication coma with localizing sign coma without localizing sign but with meningeal sign coma without both localizing and meningeal sign

GCS
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CPOMR

CPOMR can help us to

localize the lesion
ARAS is located mainly at the brainstem, and both hemisphere

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Conscious: drowsy, stupor, semi-coma, coma Pupil: dilate, constrict, response to light, uni-bilateral abnormality Ocular movement: dolls eye, eye deviation, nystagmus Respiratory pattern:

The pupil

Parasympathetic control
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Sympathetic control

Pupillary pattern

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Dolls eye Oculocephalic reex

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Motor response and Posture in coma

Decerebrate rigidity bilateral upper and lower limb extensor posture, usually the consequence of bilateral mid-brain lesions

Decorticate posture bilateral exion of the upper limbs and extension of the lower limbs, usually the consequence of an diencephalic lesion (late)

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the Respiratory pattern

Cheyne-Srokes Central neurogenic hyperventilation Apneusis Clustering breathing Ataxic breathing

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Where is it?

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COMA
Localizing sign-no Meningeal sign-yes
Severe meningitis
or
CT with CM in bacterial meningitis

Meningitis with complication; hydrocephalus, vasculitis, infarct

CT without CM in SAH

Encephalitis Subarachnoid hemorrhage

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- 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) Na, glucose, hypoxemia, hypercapnia, hypothyroid ::: internal toxin; uremia, hepatic encephalopathy

Endogenous- metabolic; Ca,

These causes are reversible; if no localizing sign; lab screen rst Glucose, CBC with Plt, BUN, Cr, Elyte, Ca, Mg, PO, Oxygen sat
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Keep in Externs 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, BP)...then taking lab (glucose immediately, and other basic lab) 3. Physical exam: CPOMR + Meningeal sign
-) if coma with no both focal or meningeal sign: metabolic, toxic, drug, diffuse intracranial lesion, SAH, brain stem stroke, stroke with brain herniation -) if coma with meningeal sign; do CT brain emergency -) if coma with focal sign; do CT brain emergency

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Acute stroke

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when we suspect stroke

when the patient has sudden neurological decit; symptoms depend on where is the brain is involved

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weak, numb brain stem sign cerebellar sign cortical sign alter mental state

Stroke can be...

Ischemic 75%

TOAST classication

Large-artery atherosclerosis(emboli/ thrombosis) Cardioembolism(high-risk/mediumrisk) Small-vessel occlusion(lacune) Stroke of other determine etiology Stroke of undetermined etiology

Hemorrhagic (25%); subarachnoid, intracerebral

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

TOAST, Trial of Org 10172 in Acute Stroke Treatment.

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Features of TOAST Classification of Subtypes of Ischemic Stroke

HP Adams, Jr, BH Bendixen, Stroke 1993;24;35-41

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Anterior vs Posterior circulation

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Lacunar stroke syndrome

Pure motor stroke/hemiparesis Ataxic hemiparesis Dysarthria/clumsy hand syndrome Pure sensory stroke Mixed sensorimotor stroke
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Condition that mimic stroke

miscellaneous SAH TGA vertigo MS syncope/presyncope dementia psychogenic migraine confusional state SDH tumour PN palsy toxic/metabolic seizures 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 18.2% 3.6% 3.1%

% of all stroke mimics (n=670)

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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 2-3.5 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
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CT brain, non-contrast

Hemorrhagic stroke
sensitivity 100%

Minor or subtle signs : loss of

lentiform nucleus, loss of insular ribbon, loss of gray-white differentiation and sulcal effacement

Ischemic stroke
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Problems of clinical diagnosis within 6 hours of onset

Do you need a neurologist?

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Approximately 75% of conditions mimicking stroke are neurological

How many of these can be identied by CT? ~15% of non-stroke disorders (e.g. subdural) found by CT rest diagnosed clinically/with other tests CT < 6hrs of ischemic stroke often normal

If CT is normal Often need stroke specialist or neurologist to conrm clinical diagnosis of stroke before thrombolysis: avoid thrombolysis for migraine, focal epilepsy, functional weakness, ischemic decit after subarachnoid hemorrhage!

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

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3-4.5

Anti-platelet in acute ischemic stroke

Aspirin 160-325 mg 48 ( rtPA 24 ) Every 1000 patients treated

13 more patients alive/independent 7 less recurrent ischemic stroke 2 increase symptomatic ICH

acute phase aspirin secondary prevention ( > 2 weeks)

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Anti-coagulant in acute ischemic stroke

: heparin IV drip , LMWH (enoxaparin) SC

acute ischemic stroke

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Extracranial carotid or vertebral dissection Cerebral venous sinus thrombosis Unstable large vessel infarction Cardioembolic clot Arterial dissection

Brain herniation

Subfalcine (A) Uncal (B) Central (C) Extradural (D) Tonsillar (E)

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Herniation syndrome

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Treatment IICP

20-30 (Jugular vein) osmotherapy:

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Mannitol* 0.25-0.5 g/kg 20 4-6 10% Glycerol 250 ml 30-60 4 50% Glycerol 50 ml 4 / Furosemide 1 mg/Kg

Treatment IICP

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hypotonic solution Hyperventilation Pco2 30-35 mmHg steroid

Hemicraniectomy in malignant middle cerebral artery infarction

Malignant MCA infarction : MCA brain herniation Signs

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Contralateral weakness Eye deviate to ipsilateral lesion Global aphasia in dominant hemisphere Hemispatial neglect in nondominant hemisphere Signs of IICP, brain herniation

Hemicraniectomy in malignant MCA infarction

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Keep in Externs mind

Stroke 1. when the sudden neurological decit 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
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Tonic-clonic seizure and status epilepticus

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Seizure and Epilepsy

Seizure

the clinical manifestation of an abnormal and hypersynchronous discharge of a population of cortical neurones

Epilepsy

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a tendency toward recurrent seizures unprovoked by systemic or neurologic insults least two unprovoked seizures at least 24 hours apart.

Acute symptomatic seizure

a seizure occurring after identiable cause (metabolic, stroke, traumatic brain injury or infection)

Seizure or Not seizure

Seizure mimicker pseudo-seizure convulsive syncope movement disorder: myoclonus,
chorea

hipnic jerk
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Convulsive syncope

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Convulsive movements due to syncope Myoclonic, tonic, eye movement Very common,

normal blood donors (12-42%)

Not an epileptic seizure arising in an ischemic cortexcortex is silent Originates in brainstem-ischemic decortication Does not require AEDs

Identify cause of seizure

Acute processes Chronic processes

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Stroke Metabolic disturbances CNS infection Trauma Drug Toxicity Hypoxia

Pre-existing epilepsy Ethanol abuse Old CVA Relatively longstanding tumors

What should we do?

Evaluate ABCD, and check basic lab, Clarify: is it seizure?? If seizure is not stop; consider AEDs Complete general, and neuro-exam Brain imaging if indicate
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intubation or oxygen therapy if indicate

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Status How to dene status... Epilepticus

1981, ILAE (International League against Epilepsy) a seizure that persists for a sufcient length of time or is repeated frequently enough that recovery between attacks does not occur Premonitory status: increase in the usual frequency or severity of their seizures may precede status epilepticus need for emergency management

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Compensated
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Decompensated

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Premonitory tonic-clonic status epilepticus

Buccal midazolam 10 mg(0.15-0.3 mg/kg in Rectal diazepam 10- 30 mg(0.2-0.3 mg/kg in

children), repeated if necessary! children)

Early tonic-clonic status epilepticus

Up to 30 min!
! IV lorazepam, 4 mg bolus(0.07 mg/kg in children), repeated if necessary ! Basic life support airway intubation ! Monitoring : regular neurological observationECG, pulse oximetry ! Investigation: ABG, urea, elyte, glucose, liver enz, ca, mg, full blood count, AED level, blood sam ple for storage, ECG!

NICE (2004), SIGN (2003) and the Royal College of Physicians Consensus Statement (2003) Friday, March 16, 2012

After 30 min!

Established tonic-clonic status epilepticus

! IV phenobarbitone, 20 mg/kg, 100 mg/min or ! IV PHT 10-15 mg/kg, 50 mg/ min or ! Phosphenytoin, 15mg phenytoin equivalent/ kg!

Refractory tonic-clonic status epilepticus Get an anaesthetist

! Thiopentone 100-250 mg iv bolus, further 50 mg bolus every 2-3 minutes until seizure are controlled, then 3-5 mg/kg/hours to maintain a burst suppression pattern on the EEG or ! Propofol 2 mg/kg iv bolus, repeated if necessary, then 5-10 mg.kg/hrs, reducing to 1-3 mg/kg/hrs or ! midazolam., 0.1-0.2 mg/kg bolus to control seizure, repeated if necessary, then 0.05-0.5 mg/kg/hrs!

After 30-60 min!

NICE (2004), SIGN (2003) and the Royal College of Physicians Consensus Statement (2003) Friday, March 16, 2012

Keep in Externs 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

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