Dr David Eagle Neurological Emergencies Content Based

Dr David Eagle Neurological Emergencies

Content Based on 3 cases from A&E and Ward 21 (Neurology): Acute presentation, history and examination findings Initial Management Guidance Key learning points

Case 1 – Back Pain Cover Sheet Text: 62 year old man. Back pain for 5 months after heavy lifting, more severe last 2 weeks, now unbearable. Not seen GP, taken Paracetamol to some effect. YAS History: Severe back pain, unable to weight-bear. Required Entonox and Morphine 10 mg to transport.

Case 1 – Back Pain Formal Clerking Pc: 5 month history of low back pain, 2 weeks of increasing severity, 3 days of being unable to stand. Hx. Pc: Well until December 2012. Sudden onset of low back pain while lifting shopping onto bus just before Xmas. Variable pain over next 4 months, taken Paracetamol, avoided too much rest, not seen GP. Last 2 weeks pain much more severe and difficulty mobilizing. Last 3 days been unable to stand, just lying on living room floor. . .

Case 1 – Back Pain Hx. Pc continued: Currently severe (10/10) low back/left buttock pain. . . ▪ ▪ ▪ Dull ache with sharp twinges on movement, Radiates down left leg to knee, Exacerbated by movement, no comfortable position, Relieved slightly by simple analgesia, Associated with weakness in both legs Left > Right, altered sensation both feet Left > Right. No recent bladder or bowel change, no recent diarrhoea or LRTI, eating and drinking, systemically well. PMHx: HTN, otherwise well. Meds & Allergies: Nil regular, no known drug allergies.

Case 1 – Back Pain Soc Hx: Retired builder. Lives with wife in a house with stairs, supportive family close by. Ex-smoker of 20 pack years, stopped 5 years ago. Occasional drinker. Fam Hx: Nil relevant. On Examination: Obs: all stable A, B, C, D: all NAD Abdo: soft and non-tender, no organomegally, BS present, no AAA palpable, no renal angle tenderness, increased BMI CNS: II XII all NAD

Case 1 – Back Pain Examination continued: PNS: Right Left All NAD Lower Limb: Inspection - - Tone Increased Power 3 -4/5 1/5 throughout ++, downward plantar ++, upward plantar Upper Limb: Reflexes Sensation Co-ordination Inconsistent reporting ? reduced up to knees Unable due to reduced power PR: Peri-anal sensation intact, normal tone

Case 1 – Back Pain Anything missing? Impression? Clonus +++ Impression: UMN spinal lesion Discussion with Neurology & Neurosurgery Urgent MRI Spine: Cord compression at T 11 Partial destruction of T 11 with vertebral tumour – mets or myeloma L 3 disc herniation To neurosurgery that night for debulking and fixation At 5 days: Pain free, no return of function PSA 600+ CT Thorax, Abdo, Pelvis: prostate ca with widespread mets Referral to Urology & palliation

Case 1 – Back Pain Learning points: Focussed neuro exam UMN vs LMN – locating the lesion Suspected cord compression guidelines

Case 2 – “Not himself” Cover Sheet Text: 71 year old man. ? previous TIA, increasing memory loss. 1 day history of confusion/odd behaviour. Seen by BAT: ROSIER: 0 No focal neurology. Wife states “not his usual self”. Appears confused, delirious, fluctuating, agitated. ? delirium, ED to see. . .

Case 2 – “Not himself” Formal Clerking Pc: 1 day history of sudden onset odd/inappropriate behaviour on background of mild memory loss. Hx. Pc: Well recently – no infections, no cough, fever, diarrhoea, SOB. Banged his head on kitchen cupboard 2 days ago but only mild. Sudden onset behaviour change yesterday afternoon while wife was at shops, “not himself”, including: ▪ Stood to watch TV for 2 hours. ▪ Went for meal out, made very unusual meal choices, didn’t fasten trousers after bathroom visit, episode of urinary incontinence. ▪ Sat up all night watching ‘inappropriate’ TV.

Case 2 – “Not himself” Hx. Pc continued: Himself denies headache, nausea, vomiting or change in behaviour. PMHx: GORD, high cholesterol, migraines with aura (used to be 1 every 2 years, 2 in last month). Meds & Allergies: Simvastatin, Omeprazole, Aspirin; no known drug allergies. Social Hx: Lives with wife who is well. Retired electrical engineer. 12 units alcohol per week, ex-smoker of 20 pack years. Family Hx: Nil relevant.

Case 2 – “Not himself” On examination: Obs: s. O 2: 95%, HR: 100, apyrexial Patient dismissive and mildly uncooperative throughout but maintained attention and consistent conscious level A, B, C: slight crackles right base CBG: 8. 1 AMTS: 8/10 (incorrect address and WWII dates – would have known) CNS: II XII all NAD (unable to perform fundoscopy) PNS: all NAD Gait: NAD

Case 2 – “Not himself” Differential? Possible causes: Cerebrovascular: frontal stroke (? bleed secondary to lesion). Infective: encephalitis, meningitis (neuro TB, syphilis). Toxic: CO, acute withdrawal, opiods. Metabolic/Endo: hypoglycaemic (metabolic encephalopathy, thyrotoxicosis, Addision’s) Paraneoplastic Any cause of delirium Acute psych disorder

Case 2 – “Not himself” Investigations: Urine dip: -ve FBC, U&Es, LFTs, B 12, ferritin: all NAD. Folate: 4. 5 (slightly low) CXR: nil acute CT head: ▪ Intracerebral haematoma medial frontal lobe on right, ▪ Previous small infarction left frontal lobe. Admitted to stroke Discharged after 4 weeks rehab Out-patient MRI/MRA

Case 2 – “Not himself” Learning points: Diagnosis easily missed – subtle symptoms, diagnosis reliant on collateral history. BAT assessment ROSIER score (ie weakness, visual field and speech disturbance) driven – will therefore miss frontal lobe and cerebellar strokes. CT head justified on detail of history and clear acute onset.

Case 3 – Headache, Fever & Seizures Formal Clerking Pc: 22 year old man, normally fit and well. 5 day history of generally unwell, fever, headache and seizures today. Hx. Pc: Well recently – no foreign travel, symptoms of infection or bites. 5 days ago began with general flu-like symptoms – generalised headache, myalgia, runny nose, feverish, anorexia, nauseated. Had taken some Paracetamol to little effect. Today, increasingly drowsy, headache more severe. @ 15: 00 partial seizure, starting with left hand shaking, progressed up arm to involve all left side, lasting <2 mins, resolved spontaeuously. 2 x futher seizures – one in Ambulance, one in A&E.

Case 3 – Headache, Fever & Seizures Hx. Pc continued: Not noticed a rash, no neck stiffness, mild photophobia. Med. Hx: Usually fit & well, no history of cold sores. Meds & Allergies: Nil regular; no known drug allergies. Social Hx: Lives with girlfriend who has been well. Works in a call centre. Occasional light drinker, non-smoker, denies any recreational drug use. Family Hx: Nil relevant.

Case 3 – Headache, Fever & Seizures On examination: Obs: temp: 38. 7, else NAD A, B, C: NAD D: drowsy but easily rousable, GCS 14 – slightly confused speech CBG: 4. 3 Abdo soft & non-tender Marked dysarthria CNS: left-sided facial droop with forehead sparing, drooling & watering left eye, else NAD

Case 3 – Headache, Fever & Seizures Examination continued: PNS: Right Left All NAD Tone Normal Reduced Power 5/5 2/5 throughout + + Normal Reduced fine touch Tone Normal Reduced Power 5/5 4/5 throughout +, downward plantar Normal Upper Limb: Reflexes Sensation Lower Limb: Reflexes Sensation

Case 3 – Headache, Fever & Seizures Impression? Likely viral encephalitis Investigations: Urine dip: -ve FBC, U&Es, LFTs: all NAD. Blood cultures sent CT Head: NAD Immediate Management: Rectal Diazepam followed by Phenytoin infusion IV Aciclovir (10 mg per kg) TCI Neurology

Case 3 – Headache, Fever & Seizures At 5 days: CSF: raised lymphocytes only, negative viral PCR MRI: right-sided temporal, parietal and frontal hyperintensities consistent with encephalitis On 14 day course of IV Aciclovir, initial improvement, relapse at 3 days (as aciclovir incorrectly switched to oral), improved on return to IV. Complete recovery by discharge

Case 3 – Headache, Fever & Seizures Learning points: Mortality if untreated roughly 70%. Prognosis dependent on early recognition at treatment. Target starting Aciclovir within 30 mins of attendance – don’t wait for imaging/LP. Suspect in anyone with altered behaviour/new seizures/focal neurology with infective prodrome.