Professional Documents
Culture Documents
SANKET
SHAH
(KESAR SAL)
Available on www.mysarthee.co.cc
NEUROLO!
NORMAL CSF
Constituent Conventional Units
l"cose #$%&$ m'()L
Lactate *$%+$ m'()L
Total ,rotein
L"mbar *-%-$ m'()L
.isternal *-%+- m'()L
/entric"lar 0%*- m'()L
Alb"min 0.0%##.+ m'()L
1' $.2%-.& m'()L
1' in)e3
b
$.+2%$.-2
Oli'oclonal ban)s
(O4)
5+ ban)s not ,resent in
matche) ser"m sam,le
Ammonia +-%6$ '()L
.S7 ,ress"re -$%*6$ mmH
+
O
.S7 vol"me (a)"lt) 8*-$ mL
Re) bloo) cells $
Le"9ocytes
Total $%- monon"clear cells ,er
mm
:
;i<<erential
Lym,hocytes 0$%&$=
>onocytes :$%-$=
Ne"tro,hils None
a
Since cerebros,inal <l"i) concentrations are e?"ilibri"m val"es@
meas"rements o< the same ,arameters in bloo) ,lasma
obtaine) at the same time are recommen)e). However@ there is
a time la' in attainment o< e?"ilibri"m@ an) cerebros,inal levels
o< ,lasma constit"ents that can <l"ct"ate ra,i)ly (s"ch as
,lasma 'l"cose) may not achieve stable val"es "ntil a<ter a
si'ni<icant la' ,hase.
b
1' in)e3 A .S7 1'(m'()L) 3 ser"m alb"min('()L)(Ser"m
1'('()L) 3 .S7 alb"min(m'()L).
CSF IN BACTERIAL
MENINGITIS
The diagnosis of bacterial meningitis is made by
e3amination o< the .S7
In an immunocompetent patient with
*.no 9nown history o< recent hea) tra"ma@
+. a normal level o< conscio"sness@ an)
:.no evi)ence o< ,a,ille)ema or <ocal ne"rolo'ic
)e<icits@
it is consi)ere) sa<e to ,er<orm LB witho"t ,rior
ne"roima'in' st")ies.
If LP is delayed in order to obtain neuroimaging
st")ies@ em,irical antibiotic thera,y sho"l) be initiate) a<ter
bloo) c"lt"res are obtaine).
* O,enin'
,ress"re
C*6$ mmH
+
O
(2$=)
+ Dhite bloo)
cells
*$("L to *$@$$$("LE ne"tro,hils ,re)ominate
(2$=)
: Re) bloo) Absent in nontra"matic ta,
cells
# l"cose 5#$ m'(;l
- .S7(ser"m
'l"cose
5$.#
(0$=)
0 Brotein C#- m'()L
(2$=)
& ramFs stain Bositive in
(C0$=)
6 ."lt"re Bositive in
(C6$=)
2 Late3
a''l"tinatio
n
>ay be ,ositive in ,atients with menin'itis )"e
to S. pneumoniae@ N. meningitidis@ H.
influenzae ty,e b@ E. coli@ 'ro", 4 stre,tococci
*$ Lim"l"s
lysate
Bositive in cases o< 'ramGne'ative menin'itis
** B.R ;etects bacterial ;NA
.
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Use of the CSFserum glucose ratio corrects <or
hy,er'lycaemia that may mas9 a relative )ecrease in the
.S7 'l"cose concentration.
!he CSF glucose concentration is low when the
.S7(ser"m 'l"cose ratio is 5$.0.
A .S7(ser"m 'l"cose ratio 5$.# is hi'hly s"''estive o<
bacterial menin'itis b"t may also be seen in other
conditions@ including fungal, tuberculous, and carcinomatous
meningitis.
The Limulus amebocyte lysate assay is a ra,i) )ia'nostic
test <or the )etection o< 'ramGne'ative en)oto3in in .S7 an)
th"s <or ma9in' a )ia'nosis o< 'ramGne'ative bacterial
menin'itis.
The test has a specificity of "#$100% and a sensitivity
approaching 100%& Th"s@ a ,ositive Lim"l"s amebocyte
lysate assay occ"rs in virt"ally all ,atients with 'ramG
ne'ative bacterial menin'itis@ b"t <alse ,ositives may occ"r.
1& I'!()
Ac"te in<ections o< the nervo"s system are amon' the most
im,ortant ,roblems in me)icine beca"se early reco'nition@ e<<icient
)ecisionGma9in'@ an) ra,i) instit"tion o< thera,y can be li<esavin'.
2& *+FI'I!I)'
Bacterial meningitis is an Ac"te ,"r"lent in<ection within the
s"barachnoi) s,ace.
1t is associate) with a .NS in<lammatory reaction that may
res"lt in )ecrease) conscio"sness@ seiH"res@ raise) intracranial
,ress"re (1.B)@ an) stro9e.
,& +PI*+-I)L)./
."rrently@ the or'anisms most commonly res,onsible <or comm"nityG
ac?"ire) bacterial menin'itis are
Streptococcus pneumoniae (8-$=)@
N. meningitidis (8+-=)@
ro", 4 stre,tococci (8*-=)@
Listeria monocytogenes (8*$=).
H. influenzae now acco"nts <or 5*$= o< cases o< bacterial
menin'itis in most series.
0& +!I)L)./
S. pneumoniae
the most common ca"se o< menin'itis in a)"lts C+$ years o<
a'e
Bre)is,osin' <actors
*) ,ne"mococcal ,ne"monia.
+) coe3istin' ac"te or chronic ,ne"mococcal sin"sitis or
otitis me)ia@
:) alcoholism@
#) )iabetes@
-) s,lenectomy@
0) hy,o'amma'lob"linemia@
&) com,lement )e<iciency@
6) hea) tra"ma with basilar s9"ll <ract"re an) .S7
rhinorrhea.
N. Meningitides
chil)ren an) yo"n' a)"lts between the a'es o< + an) +$.
The ris9 o< invasive )isease <ollowin' naso,haryn'eal coloniHation
)e,en)s on both bacterial vir"lence <actors an) host imm"ne
)e<ense mechanisms
1n)ivi)"als with )e<iciencies o< any o< the com,lement
com,onents@ incl")in' ,ro,er)in@ are hi'hly s"sce,tible to
menin'ococcal in<ections.
Enteric 'ramGne'ative bacilli
common ca"se o< menin'itis in in)ivi)"als with chronic an)
)ebilitatin' )iseases s"ch as )iabetes@ cirrhosis@ or alcoholism an)
in those with chronic "rinary tract in<ections
ramGne'ative menin'itis can also com,licate ne"ros"r'ical
,roce)"res@ ,artic"larly craniotomy.
ro", 4 stre,tococc"s@
,revio"sly res,onsible <or menin'itis ,re)ominantly in neonates@
b"t it has been re,orte) with increasin' <re?"ency in in)ivi)"als
C-$ years o< a'e@ ,artic"larly those with "n)erlyin' )isease
L. Monocytogenes
im,ortant ca"se o< menin'itis in neonates (5* month o< a'e)@
,re'nant women@ in)ivi)"als C0$ years@ an)
imm"nocom,romise) in)ivi)"als o< all a'es.
7oo)borne h"man listerial in<ection
H. influenzae ty,e b
menin'itis in chil)ren has )ecline) )ramatically since the
intro)"ction o< the Hib conI"'ate vaccine
>ore <re?"ently@ H. influenzae ca"ses menin'itis in "nvaccinate)
chil)ren an) a)"lts.
Staphylococcus aureus an) coa'"laseGne'ative sta,hylococci
im,ortant ca"ses o< menin'itis that occ"rs <ollowin' invasive
ne"ros"r'ical ,roce)"res@ ,artic"larly sh"ntin' ,roce)"res <or
hy)roce,hal"s
#& P1!2)P2/SI)L)./
RE77ER HARR1SON 71URE :&0G+
3& CLI'IC1L P(+S+'!1!I)'S
BRESENTAT1ON
1) an ac"te <"lminant illness that ,ro'resses ra,i)ly in a <ew ho"rs
OR
+) s"bac"te in<ection that ,ro'ressively worsens over several
)ays
.LASS1.AL TR1A;
*) <ever@
+) hea)ache@
:) n"chal ri'i)ity
OTHER 1>BORTANT
*) )ecrease) level o< conscio"sness
+) Na"sea@
:) ,roIectile vomitin'@
#) ,hoto,hobia
SeiH"res
*) 7ocal
+) eneralise)
RA1SE; 1.B
*) maIor ca"se o< obt"n)ation an) coma
2) 2$= o< ,atients will have a .S7 o,enin' ,ress"re C*6$ mmH
+
O@
an) +$= have o,enin' ,ress"res C#$$ mmH
+
O.
:) )eterioratin' or re)"ce) level o< conscio"sness@
#) ,a,ille)ema@
-) )ilate) ,oorly reactive ,",ils@
0) si3th nerve ,alsies@
&) )ecerebrate ,ost"rin'@
6) ."shin' re<le3 (bra)ycar)ia@ hy,ertension@ an) irre'"lar
res,irations).
2) .ERE4RAL HERN1AT1ON as a com,lication
S,eci<ic clinical <eat"res
*) rash o< menin'ococcemia@ which be'ins as a )i<<"se
erythemato"s mac"lo,a,"lar rash resemblin' a viral e3anthemE
however@ the s9in lesions o< menin'ococcemia ra,i)ly become
,etechial. Betechiae are <o"n) on the tr"n9 an) lower e3tremities@
in the m"co"s membranes an) conI"nctiva@ an) occasionally on
the ,alms an) soles
.
+) R1.KETT1S1AL RASHGcharacteristic rash within 20 h o< the onset
o< sym,toms. The rash is initially a )i<<"se erythemato"s
mac"lo,a,"lar rash that may be )i<<ic"lt to )istin'"ish <rom that
o< menin'ococcemia. 1t ,ro'resses to a ,etechial rash@ then to a
,"r,"ric rash an)@ i< "ntreate)@ to s9in necrosis or 'an'rene. The
color o< the lesions chan'es <rom bri'ht re) to very )ar9 re)@ then
yellowishG'reen to blac9. The rash ty,ically be'ins in the wrist an)
an9les an) then s,rea)s )istally an) ,ro3imally within a matter o<
a <ew ho"rs@ involvin' the ,alms an) soles
4& *I1.')SIS
CSF
The diagnosis of bacterial meningitis is made by
e3amination o< the .S7
In an immunocompetent patient with
#.no 9nown history o< recent hea) tra"ma@
-. a normal level o< conscio"sness@ an)
0.no evi)ence o< ,a,ille)ema or <ocal ne"rolo'ic
)e<icits@
it is consi)ere) sa<e to ,er<orm LB witho"t ,rior
ne"roima'in' st")ies.
If LP is delayed in order to obtain neuroimaging
st")ies@ em,irical antibiotic thera,y sho"l) be initiate) a<ter
bloo) c"lt"res are obtaine).
* O,enin'
,ress"re
C*6$ mmH
+
O
(2$=)
+ Dhite bloo)
cells
*$("L to *$@$$$("LE ne"tro,hils ,re)ominate
(2$=)
: Re) bloo)
cells
Absent in nontra"matic ta,
# l"cose 5#$ m'(;l
- .S7(ser"m
'l"cose
5$.#
(0$=)
0 Brotein C#- m'()L
(2$=)
& ramFs stain Bositive in
(C0$=)
6 ."lt"re Bositive in
(C6$=)
2 Late3
a''l"tinatio
n
>ay be ,ositive in ,atients with menin'itis )"e
to S. pneumoniae@ N. meningitidis@ H.
influenzae ty,e b@ E. coli@ 'ro", 4 stre,tococci
*$ Lim"l"s
lysate
Bositive in cases o< 'ramGne'ative menin'itis
** B.R ;etects bacterial ;NA
.
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Use of the CSFserum glucose ratio corrects <or
hy,er'lycaemia that may mas9 a relative )ecrease in the
.S7 'l"cose concentration.
!he CSF glucose concentration is low when the
.S7(ser"m 'l"cose ratio is 5$.0.
A .S7(ser"m 'l"cose ratio 5$.# is hi'hly s"''estive o<
bacterial menin'itis b"t may also be seen in other
conditions@ including fungal, tuberculous, and carcinomatous
meningitis.
The Limulus amebocyte lysate assay is a ra,i) )ia'nostic
test <or the )etection o< 'ramGne'ative en)oto3in in .S7 an)
th"s <or ma9in' a )ia'nosis o< 'ramGne'ative bacterial
menin'itis.
The test has a specificity of "#$100% and a sensitivity
approaching 100%& Th"s@ a ,ositive Lim"l"s amebocyte
lysate assay occ"rs in virt"ally all ,atients with 'ramG
ne'ative bacterial menin'itis@ b"t <alse ,ositives may occ"r.
'+U() I-1.I''I'. S!U*/
>R1 is ,re<erre) over .T beca"se o< its s",eriority in
)emonstratin' areas o< cerebral e)ema an) ischemia.
)i<<"se menin'eal enhancement is o<ten seen a<ter the
a)ministration o< 'a)olini"m
5I)PS/
Betechial s9in lesions@ i< ,resent@ sho"l) be bio,sie). The rash o<
menin'ococcemia res"lts <rom the )ermal see)in' o< or'anisms
with vasc"lar en)othelial )ama'e@ an) bio,sy may reveal the
or'anism on ramFs stain.
"& *IFF+(+'!I1L *I1.')SIS
*. /iral menin'oence,halitis@ an) ,artic"larly her,es sim,le3
vir"s (HS/) ence,halitis
+. Ric9ettsial )isease can resemble bacterial menin'itis
:. Ehrlichioses
#. 7ocal s",,"rative .NS in<ections @ incl")in' s"b)"ral an)
e,i)"ral em,yema an) brain abscess
-. S"barachnoi) hemorrha'e
0. chemical menin'itis )"e to r",t"re o< t"mor contents into the
.S7
&. sarcoi)@ systemic l","s erythematos"s (SLE)@ an) 4ehJetFs
syn)rome
6& !(+1!-+'!
.)1L
4acterial menin'itis is a me)ical emer'ency.
The 'oal is to be'in antibiotic thera,y within 0$ min o< a ,atientFs
arrival in the emer'ency room
+mpirical antimicrobial therapy
initiate) in ,atients with s"s,ecte) bacterial menin'itis be<ore the
res"lts o< .S7 ramFs stain an) c"lt"re are 9nown
Antibiotics Use) in Em,irical Thera,y o< 4acterial >enin'itis
an) 7ocal .NS 1n<ections
a
Indication 1ntibiotic
*. Breterm in<ants
to in<ants 5*
month
Am,icillin K .e<ota3ime
+. 1n<ants *%:
mos
Am,icillin K .e<ota3ime or
ce<tria3one
:. 1mm"nocom,e
tent chil)ren C:
mos an) a)"lts
5--
vancomycin K .e<ota3ime or
ce<tria3one
#. A)"lts C-- an)
a)"lts o< any a'e
with alcoholism or
other )ebilitatin'
illnesses
Am,icillin K ce<ota3ime or ce<tria3one
K vancomycin
-. Hos,italG
ac?"ire)
menin'itis@
,osttra"matic or
,ostne"ros"r'ery
menin'itis@
ne"tro,enic
,atients@ or
,atients with
im,aire) cellG
me)iate)
imm"nity
Am,icillin K ce<taHi)ime K
vancomycin
!otal *aily *ose and *osing Interval
1ntimicr
obial
1gent
Child 781 month9 1dult
Am,icillin +$$ (m'(9')()@ ?#h *+ '()@ ?#h
.e<ota3im
e
+$$ (m'(9')()@ ?0h *+ '()@ ?0h
.e<tria3on
e
*$$ (m'(9')()@ ?*+h # '()@ ?*+h
.e<taHi)i *-$ (m'(9')()@ ?6h 0 '()@ ?6h
Antibiotics Use) in Em,irical Thera,y o< 4acterial >enin'itis
an) 7ocal .NS 1n<ections
a
Indication 1ntibiotic
*. Breterm in<ants
to in<ants 5*
month
Am,icillin K .e<ota3ime
+. 1n<ants *%:
mos
Am,icillin K .e<ota3ime or
ce<tria3one
:. 1mm"nocom,e
tent chil)ren C:
mos an) a)"lts
5--
vancomycin K .e<ota3ime or
ce<tria3one
#. A)"lts C-- an)
a)"lts o< any a'e
with alcoholism or
other )ebilitatin'
illnesses
Am,icillin K ce<ota3ime or ce<tria3one
K vancomycin
-. Hos,italG
ac?"ire)
menin'itis@
,osttra"matic or
,ostne"ros"r'ery
menin'itis@
ne"tro,enic
,atients@ or
,atients with
im,aire) cellG
me)iate)
imm"nity
Am,icillin K ce<taHi)ime K
vancomycin
me
/ancomyc
in
0$ (m'(9')()@ ?0h + '()@ ?*+h
Specific 1ntimicrobial !herapy
>enin'ococcal >enin'itis
o Altho"'h ce<tria3one an) ce<ota3ime ,rovi)e a)e?"ate
em,irical covera'e <or N. meningitidis@ ,enicillin remains the
antibiotic o< choice <or menin'ococcal menin'itis ca"se) by
s"sce,tible strains
Bne"mococcal >enin'itis
o Antimicrobial thera,y o< ,ne"mococcal menin'itis is initiate)
with a ce,halos,orin (ce<tria3one@ ce<ota3ime@ or ce<e,ime)
an) vancomycin
o A +Gwee9 co"rse o< intraveno"s antimicrobial thera,y is
recommen)e) <or ,ne"mococcal menin'itis.
o Batients with S. pneumoniae menin'itis sho"l) have a re,eat
LB ,er<orme) +#%:0 h a<ter the initiation o< antimicrobial
thera,y to )oc"ment steriliHation o< the .S7
Listeria >enin'itis
o >enin'itis )"e to L. monocytogenes is treate) with am,icillin
<or at least : wee9s
o The combination o< trimetho,rim L*$%+$ (m'(9')()M an)
s"l<ametho3aHole L-$%*$$ (m'(9')()M 'iven every 0 h may
,rovi)e an alternative in ,enicillinGaller'ic ,atients.
Sta,hylococcal >enin'itis
o >enin'itis )"e to s"sce,tible strains o< S. aureus or coa'"laseG
ne'ative sta,hylococci is treate) with na<cillin
o /ancomycin is the )r"' o< choice <or methicillinGresistant
sta,hylococci an) <or ,atients aller'ic to ,enicillin.
o .S7 sho"l) be monitore) )"rin' thera,y. 1< the .S7 is not
steriliHe) a<ter #6 h o< intraveno"s vancomycin thera,y@ then
either intraventric"lar or intrathecal vancomycin@ +$ m' once
)aily@ can be a))e).
ramGNe'ative 4acillary >enin'itis
o The thir)G'eneration ce,halos,orinsNce<ota3ime@ ce<tria3one@
an) ce<taHi)imeNare e?"ally e<<icacio"s <or the treatment o<
'ramGne'ative bacillary menin'itis@ with the e3ce,tion o<
menin'itis )"e to P. aeruginosa@ which sho"l) be treate) with
ce<taHi)ime@ ce<e,ime@ or mero,enem
o A :Gwee9 co"rse o< intraveno"s antibiotic thera,y is
recommen)e) <or menin'itis )"e to 'ramGne'ative bacilli.
1*:U'C! !2+(1P/
;e3amethasone e3erts its bene<icial e<<ect by inhibitin' the
synthesis o< 1LG* an) TN7 at the level o< mRNA@ )ecreasin' .S7
o"t<low resistance@ an) stabiliHin' the bloo)Gbrain barrier.
The rationale <or 'ivin' )e3amethasone +$ min be<ore antibiotic
thera,y is that )e3amethasone inhibits the ,ro)"ction o< TN7 by
macro,ha'es an) micro'lia only i< it is a)ministere) be<ore these
cells are activate) by en)oto3in.
I'C(+1S+* I'!(1C(1'I1L P(+SSU(+
Emer'ency treatment o< increase) 1.B incl")es
*) elevation o< the ,atientFs hea) to :$%#-O@
2) int"bation an) hy,erventilation (Ba
.O+
+-%:$ mmH')@
:) mannitol.
10& P().')SIS
-)(!1LI!/
>ortality is :%&= <or menin'itis ca"se) by H. influenzae@ N.
meningitidis@ or 'ro", 4 stre,tococciE
*-= <or that )"e to L. monocytogenesE
+$= <or S. pneumoniae.
S+;U+L+
>o)erate or severe se?"elae occ"r in 8+-= o< s"rvivors@ altho"'h
the e3act inci)ence varies with the in<ectin' or'anism.
.ommon se?"elae incl")e
i. )ecrease) intellect"al <"nction@
ii. memory im,airment@
iii. seiH"res@
iv. hearin' loss an) )iHHiness@
v. 'ait )ist"rbances.
'eurocysticercosis
I'!()
Ne"rocysticercosis is the most common ,arasitic )isease o< the .NS
worl)wi)e.
H"mans ac?"ire cysticercosis by the in'estion o< <oo) contaminate) with
the e''s o< the ,arasite . solium .
Clinical Presentation
1. The most common mani<estation o< ne"rocysticercosis is newGonset
,artial seiH"res with or witho"t secon)ary 'eneraliHation.
2. Dhen ,resent in the s"barachnoi) or ventric"lar s,aces@ cysticerci can
,ro)"ce increase) 1.B
3. S,inal cysticerci can mimic the ,resentation o< intras,inal t"mors.
*iagnosis
The lesions o< ne"rocysticercosis are rea)ily vis"aliHe) by >R1 or .T
scans.
A very early si'n o< cyst )eath is hy,ointensity o< the vesic"lar <l"i) on
T+Gwei'hte) ima'es when com,are) with .S7.
Barenchymal brain calci<ications are the most common <in)in' an)
evi)ence that the ,arasite is no lon'er viable.
!reatment
Anticonv"lsant thera,y is initiate) when the ,atient with
ne"rocysticercosis ,resents with a seiH"re.
Antie,ile,tic thera,y can be sto,,e) once the <ollowG", .T scan shows
resol"tion o< the lesion.
Lon'Gterm antie,ile,tic thera,y is recommen)e) when
1)seiH"res occ"r a<ter resol"tion o< e)ema an) resor,tion
+) calci<ication o< the )e'eneratin' cyst.
.ystici)al )r"'s accelerate the )estr"ction o< the ,arasites@ res"ltin' in a
<aster resol"tion o< the in<ection.
alben)aHole *- m'(9' ,er )ay in two )oses <or 6 )ays.
,raHi?"antel -$ m'(9' ,er )ay <or *- )ays@
ACUTE STROKE
MANAGEMENT
*. BR1>AR! STEBS
1fter the clinical diagnosis of stro<e is made = an
or)erly ,rocess o< eval"ation an) treatment sho"l) <ollow
!he first goal is to ,revent or reverse brain inI"ry.
Atten) to the ,atientFs (15C)air>ay= breathing=
circulation@ an) treat hypoglycemia or hyperglycemia i<
i)enti<ie).
Ber<orm an emergency noncontrast head C! scan in
or)er to )i<<erentiate between ischemic stro9e an)
hemorrha'ic stro9eE there are no reliable clinical <in)in's
that concl"sively se,arate ischemia <rom hemorrha'e@
altho"'h
*. a more )e,resse) level o< conscio"sness@
+. hi'her initial bloo) ,ress"re@ or
:. worsenin' o< sym,toms a<ter onset
<avor hemorrha'e@ an) a )e<icit that remits s"''ests
ischemia.
+. >e)ical S",,ort
Dhen ischemic stro9e occ"rs@ the immediate goal is to
o,timiHe cerebral ,er<"sion in the s"rro"n)in' ischemic
,en"mbra.
1ttention is also directed to>ard preventing the
common complications of bedridden patientsN
in<ections (,ne"monia@ "rinary tract@ an) s9in) an) )ee,
veno"s thrombosis (;/T) with ,"lmonary embolism.
*. ,ne"matic com,ression stoc9in's to ,revent ;/TE
+. s"bc"taneo"s he,arin a,,ears to be sa<e as well an)
can be "se) concomitantly.
4eca"se collateral blood flo> >ithin the ischemic brain
is blood pressure dependent@ there is controversy abo"t
whether bloo) ,ress"re sho"l) be lowere) ac"tely.
5lood pressure should be lo>ered if
*. there is mali'nant hy,ertension
+. concomitant myocar)ial ischemia
:. i< bloo) ,ress"re is C*6-(**$ mmH' an) thrombolytic
thera,y is antici,ate).
?hen faced >ith the competing demands of
myocardium and brain@ lowerin' the heart rate with a P
*
G
a)rener'ic bloc9er (s"ch as esmolol) can be a <irst ste, to
)ecrease car)iac wor9 an) maintain bloo) ,ress"re.
Fever is )etrimental an) sho"l) be treate) with anti,yretics
an) s"r<ace coolin'.
Serum glucose sho"l) be monitore) an) 9e,t at 5**$
m'()L "sin' an ins"lin in<"sion.
4etween - TO *$= o< ,atients )evelo, enough cerebral
edema to cause obtundation or brain herniation.
E)ema ,ea9s on the secon) or thir) )ay b"t can ca"se mass
e<<ect <or 8*$ )ays. The lar'er the in<arct@ the 'reater the
li9elihoo) that clinically si'ni<icant e)ema will )evelo,.
?ater restriction and I@ mannitol may be used to
raise the serum osmolarity@ b"t hy,ovolemia sho"l) be
avoi)e) as this may contrib"te to hy,otension an)
worsenin' in<arction.
hemicraniectomy 7craniotomy and temporary removal
of part of the s<ull) mar9e)ly re)"ces mortality@ an) the
clinical o"tcomes o< s"rvivors are acce,table.
Prophylactic suboccipital decompression of large
cerebellar infarcts be<ore brainstem com,ression@ is
,ractice) at most stro9e centers
S,ecial vi'ilance is warrante) for patients >ith
cerebellar infarction.
S"ch stro9es may mimic labyrinthitis beca"se o< ,rominent
vertigo and vomitingE
the ,resence o< hea) or nec9 ,ain sho"l) alert the ,hysician
to consi)er cerebellar stro9e <rom vertebral artery
)issection.
:. 1ntraveno"s Thrombolysis
recombinant tP1 7rtP19
!he time of stro<e onset is )e<ine) as the
*. time the ,atientFs sym,toms be'an or
+. the time the ,atient was last seen as normal.
:. Batients who awa9en with stro9e have the onset
)e<ine) as when they went to be)
A)ministration o< 1ntraveno"s Recombinant Tiss"e Blasmino'en
Activator (rtBA) <or Ac"te 1schemic Stro9e
a
Indication
*. .linical )ia'nosis o<
stro9e
+. Onset o< sym,toms
to time o< )r"'
a)ministration 5A: h
:. .T scan showin' no
hemorrha'e or e)ema
o< CQ o< the >.A
territory
#. A'e CA*6 years
-. .onsent by ,atient
or s"rro'ate
Contraindication
*. S"staine) 4B C*6-(**$
)es,ite treatment
+. Blatelets 5*$$@$$$E
:. H.T 5+-=E
#. 'l"cose 5-$ or C#$$
m'()L
-. Use o< he,arin within #6
h an) ,rolon'e) BTT@ or
elevate) 1NR
0. Recent myocar)ial
in<arction
&. Brior stro9e or hea)
inI"ry within : monthsE
6. ,rior intracranial
hemorrha'e
2. >aIor s"r'ery in
,rece)in' *# )ays
*$. astrointestinal
blee)in' in ,rece)in' +*
)ays
**. >inor stro9e sym,toms
*+. Ra,i)ly im,rovin'
sym,toms
*:. .oma or st",or
1dministration of rtP1
*. 1ntraveno"s access with two ,eri,heral 1/ lines (avoi)
arterial or central line ,lacement)
+. Review eli'ibility <or rtBA
:. A)minister $.2 m'(9' intraveno"sly (ma3im"m 2$ m') as
*$= o< total )ose by bol"s@ <ollowe) by remain)er o< total
)ose over * h
#. 7re?"ent c"<< bloo) ,ress"re monitorin'
-. 7or )ecline in ne"rolo'ic stat"s or "ncontrolle) bloo)
,ress"re@ sto, in<"sion@ 'ive cryo,reci,itate@ an) reima'e
brain emer'ently
0. No other antithrombotic treatment <or +# h
&. Avoi) "rethral catheteriHation <or CA+ h
#. En)ovasc"lar Techni?"es
1schemic stro9e <rom largeAvessel intracranial occlusion
res"lts in hi'h rates o< mortality an) morbi)ity.
Occl"sions in s"ch lar'e vessels Lmi))le cerebral artery
(>.A)@ internal caroti) artery(1.A)@ an) the basilar
artery(4A)M generally involve a large clot volume an)
o<ten <ail to o,en with 1/ rtBA alone.
+ndovascular mechanical thrombectomy has recently
shown ,romise as an alternative treatment o< ac"te stro9e
in
*. ,atients who are ineli'ible <or@ or have
contrain)ications to@ thrombolytics or
+. in those who have <aile) to have vasc"lar
recanaliHation with 1/ thrombolytics.
en)ovasc"lar thrombectomy )evice to restore ,atency o<
occl")e) intracranial vessels >ithin " h of ischemic
stro<e symptoms&
-.Antithrombotic Treatment
Blatelet 1nhibition
As,irin is the only anti,latelet a'ent that has been ,roven
e<<ective <or the ac"te treatment o< ischemic stro9eE
0.Ne"ro,rotection
Ne"ro,rotection is the conce,t o< ,rovi)in' a treatment that
,rolon's the brainFs tolerance to ischemia.
Hy,othermia is a ,ower<"l ne"ro,rotective treatment in
,atients with car)iac arrest an) is ne"ro,rotective in animal
mo)els o< stro9e@ b"t it has not been a)e?"ately st")ie) in
,atients with ischemic stro9e.
&.Stro9e .enters an) Rehabilitation
Batient care in com,rehensive stro9e "nits <ollowe) by
rehabilitation services improves neurologic outcomes
and reduces mortality&
.
Proper rehabilitation of the stro<e patient includes
early ,hysical@ occ",ational@ an) s,eech thera,y.
1t is )irecte) towar)
*. e)"catin' the ,atient an) <amily abo"t the ,atientFs
ne"rolo'ic )e<icit@
+. ,reventin' the com,lications o< immobility
:. ,rovi)in' enco"ra'ement an) instr"ction in
overcomin' the )e<icit.
!he goal of rehabilitation is
*. to ret"rn the ,atient to home an)
+. to ma3imiHe recovery by ,rovi)in' a sa<e@ ,ro'ressive
re'imen s"ite) to the in)ivi)"al ,atient.
Cause
*. thiamine (vitamin 4
*
) )e<iciency
+. ,rolon'e) alcohol@ am,hetamine cons"m,tion res"ltin' in thiamine
)e<iciency.
:. 'astric )isor)ers as carcinoma@ chronic 'astritis@
#. .rohnFs )isease@
-. re,etitive vomitin'@ ,artic"larly a<ter bariatric s"r'ery.
Presentation
Dernic9eFs ence,halo,athy be'ins abr",tly@ "s"ally with
*) eye movement )isor)ers (nysta'm"s@ 'aHe ,alsies@ an)
o,hthalmo,le'ia@ es,ecially o< the lateral rect"s m"scles)@
+) 'ait ata3ia @
:) con<"sion @
#) con<ab"lation @
-) shortGterm memory loss.
The classic tria) o< the syn)rome is
*) ence,halo,athy (brain )ama'e)@
+) o,hthalmo,le'ia (eye ,aralysis)@
:) ata3ia (loss o< coor)ination).
Untreate)@ it may ,ro'ress to Korsa9o<<Fs ,sychosis@ coma an) )eath.
!reatment
Treatment be'ins with intraveno"s or intram"sc"lar inIection o<
thiamine@ <ollowe) by assessment o< central nervo"s system an)
metabolic con)itions.
1n the ,resence o< s"bGclinical thiamine )e<iciency@ a lar'e )ose o< s"'ar
(es,ecially 'l"cose) can ,reci,itate the onset o< overt ence,halo,athyE
there<ore@ correctin' hy,o'lycemia sho"l) not be attem,te) be<ore
thiamine re,lenishment.
Rehy)ration to restore bloo) vol"me sho"l) <ollow@ as nee)e).
Dhen treate) early@ recovery may be ra,i) an) com,leteE tho"'h there
are almost always some minor ne"rolo'ical si'ns that ,ersist
!he 1lcohol ?ithdra>al Syndrome
I'!()
Once the brain has been re,eate)ly e3,ose) to hi'h )oses o< alcohol@
any s"))en )ecrease in inta9e can ,ro)"ce with)rawal sym,toms@ many
o< which are the o,,osite o< those ,ro)"ce) by into3ication.
CLI'IC1L F+1!U(+S
4eca"se alcohol has a short hal<Gli<e@ these with)rawal sym,toms
'enerally be'in within -%*$ h o< )ecreasin' ethanol inta9e@ ,ea9 in
intensity on )ay + or :@ an) im,rove by )ay # or -.
Features include
*) tremor o< the han)s (sha9es or Iitters)E
+) a'itation an) an3ietyE
:) a"tonomic nervo"s system overactivity incl")in' an increase in
,"lse@ res,iratory rate@ an) bo)y tem,erat"reE
#) insomnia@ sometimes accom,anie) by <ri'htenin' )reams.
5) + TO -= o< alcoholics e3,erience with)rawal seiH"res@ o<ten within
#6 h o< sto,,in' )rin9in'
1nFiety= insomnia= and mild levels of autonomic dysfunction may
,ersist to some )e'ree <or #%0 months as a ,rotracte) abstinence
syn)rome@ which may contrib"te to the ten)ency to ret"rn to )rin9in'.
!he term deliriu# tre#ens 7*!s9 re<ers to an "ncommon state o<
intense ac"te with)rawal that incl")es
*. )eliri"m (mental con<"sion@ a'itation@ an) <l"ct"atin' levels o<
conscio"sness)
+. tremor
3. A"tonomic overactivity (e.'.@ mar9e) increases in ,"lse@ bloo)
,ress"re@ an) res,irations).
!(+1!-+'!
!he first step is to ,er<orm a thoro"'h ,hysical e3amination in all
alcoholics who are consi)erin' sto,,in' )rin9in'@ incl")in' a search <or
*. evi)ence o< liver <ail"re@
+. 'astrointestinal blee)in'@
:. car)iac arrhythmia@
#. in<ection@
-. 'l"cose or electrolyte imbalance.
!he second step is to o<<er reass"rance that the ac"te with)rawal is
short live) an) to o<<er a)e?"ate n"trition an) rest.
*. All ,atients sho"l) be 'iven oral m"lti,le 4 vitamins@ incl")in'
-$%*$$ m' o< thiamine )aily <or a wee9 or more.
+. 4eca"se most alcoholics who enter with)rawal are either
normally hy)rate) or mil)ly overhy)rate)@ 1/ <l"i)s sho"l) be
avoi)e) "nless there is evi)ence o< si'ni<icant recent blee)in'@
vomitin'@ or )iarrhea.
:. >e)ications can "s"ally be a)ministere) orally.
!he third step in treatment is to reco'niHe that most with)rawal
sym,toms are ca"se) by the ra,i) removal o< a .NS )e,ressant@ in this
case@ alcohol.
*. Dhile most .NS )e,ressants are e<<ective@ benHo)iaHe,ines have
the hi'hest mar'in o< sa<ety an) lowest cost an) are@ there<ore@ the
,re<erre) class o< )r"'s.
+. 4enHo)iaHe,ines with short hal<Glives are es,ecially "se<"l <or
,atients with serio"s liver im,airment or evi)ence o< ,ree3istin'
ence,halo,athy or brain )ama'e.
!reatment of the patient >ith *!s can be challen'in'@ an) the
con)ition is li9ely to r"n a co"rse o< :%- )ays re'ar)less o< the thera,y
em,loye).
*. The <oc"s o< care is to i)enti<y an) correct me)ical ,roblems an)
to control behavior an) ,revent inI"ries.
+. >any clinicians recommen) the "se o< hi'h )oses o< a
benHo)iaHe,ine (as m"ch as 6$$ m'() o< chlor)iaHe,o3i)e)@
3. Other clinicians recommen) the "se o< anti,sychotic me)ications@
s"ch as halo,eri)ol@ Or olanHa,ine
.eneraliCed >ithdra>al seiCures rarely re?"ire a''ressive
,harmacolo'ic intervention beyon) that 'iven to the "s"al ,atient
"n)er'oin' with)rawal@ i.e.@ a)e?"ate )oses o< benHo)iaHe,ines.
!he rare patient >ith status epilepticus m"st be treate)
a''ressively .
21N1(* )F 1LC2)2)L
71LC2)2)LIS-9
I'!()
Alcohol )e,en)ence is )e<ine) as re,eate) alcoholGrelate) )i<<ic"lties in
at least three o< seven areas o< <"nctionin' that cl"ster to'ether over a
*+Gmonth ,erio).
Alcohol ab"se is )e<ine) as re,etitive ,roblems with alcohol in any one
o< <o"r li<e areasNsocial@ inter,ersonal@ le'al@ an) occ",ational
Not everyone )evelo,s each o< the ,roblems )escribe) below .
'+(@)US S/S!+-
.NS [ BNS
1. a blac+out@ an e,iso)e o< tem,orary antero'ra)e amnesia@ in which the
,erson <or'ets all or ,art o< what occ"rre) )"rin' a )rin9in' evenin'.
+. )ist"rbe) slee,. sometimes )ist"rbin' )reams.
:. snorin' an) e3acerbate slee, a,nea
#. im,aire) I")'ment an) coor)ination@ increasin' the ris9 o< acci)ents an)
inI"ry
5. Heavy )rin9in' can also be associate) with hea)ache@ thirst@ na"sea@
vomitin'@ an) <ati'"e the <ollowin' )ay@ a han'over syn)rome that is
res,onsible <or si'ni<icant <inancial losses in most wor9 environments.
6. peripheral neuropathy
&. cerebellar )e'eneration or atro,hy.
8. 6ernic+e's (o,hthalmo,aresis@ ata3ia@ an) ence,halo,athy)
9. 7orsa+off's (retro'ra)e an) antero'ra)e amnesia) syndromes.
PS8%H9#:8
*. alcohol an)(or )r"' )e,en)ence.
2. schiHo,hrenia
:. manic )e,ressive )isease
TE>BORAR! BS.H1ATR1.
*. an3iety )isor)ers s"ch as ,anic )isor)er.
2. intense sadness lastin' <or )ays to wee9s
3. tem,orary severe an$iety
4. a")itory hallucinations
!he .astrointestinal System
Eso,ha'"s an) Stomach
*. e,i'astric )istress an) 'astrointestinal blee)in'.
+. hemorrha'ic 'astritis.
:. /iolent vomitin' can ,ro)"ce severe blee)in' thro"'h a >alloryG
Deiss lesion
Bancreas an) Liver
*. ac"te ,ancreatitis
+. alcoholGin)"ce) he,atitis@
:. cirrhosis
Cancer
*. breast cancer
+. oral an) eso,ha'eal cancers
:. rectal cancers
2ematopoietic System
*. 1< heavy )rin9in' is accom,anie) by <olic aci) )e<iciency@ there can
also be hy,erse'mente) ne"tro,hils@ retic"locyto,enia@ an) a
hy,er,lastic bone marrowE
+. i< maln"trition is ,resent@ si)eroblastic chan'es can be observe).
:. a ,ossible <alseGne'ative t"berc"lin s9in test
#. mil) thrombocyto,enia
Cardiovascular System
*. a )oseG)e,en)ent increase in bloo) ,ress"re
2. increase) ris9 <or coronary artery )isease
:. an increase) ris9 <or car)iomyo,athy.
#. >"ral thrombi can <orm in the le<t atri"m or ventricle
-. mitral re'"r'itation.
0. Atrial or ventric"lar arrhythmias@ es,ecially ,aro3ysmal tachycar)ia@
can also occ"r a<ter a )rin9in' bin'e in in)ivi)"als showin' no other
evi)ence o< heart )iseaseNa syn)rome 9nown as the Uholi)ay heart.U
This con)ition is observe) transiently in the maIority o< alcoholics
enterin' treatment.
.enitourinary System Changes= SeFual Functioning= and
Fetal *evelopment
>ALE
*. )ecrease erectile ca,acity in men.
+. irreversible testic"lar atro,hy with shrin9a'e o< the semini<ero"s t"b"les@
3. )ecreases in eIac"late vol"me@
4. a lower s,erm co"nt .
7E>ALE
*. amenorrhea@
+. in<ertility@
:. an increase) ris9 o< s,ontaneo"s abortion.
BRENAN.!
*. serio"s conse?"ences <or <etal )evelo,ment.
2. The fetal alcohol syndrome can incl")e any o< the <ollowin'R
<acial chan'es with e,icanthal eye <ol)sE
,oorly <orme) ear conchaE
small teeth with <a"lty enamelE
car)iac atrial or ventric"lar se,tal )e<ectsE
an aberrant ,almar crease
limitation in Ioint movementE
microce,haly with mental retar)ation..
-usculos<eletal
1. s9eletal m"scle wea9ness ca"se) by ac"te alcoholic myopathy
+. increase) ris9 <or <ract"res an) osteonecrosis o< the <emoral hea).
@+(!I.)
*+FI'I!I)'
an ill"sory or hall"cinatory sense o< movement o< the bo)y or
environment@ most o<ten a <eelin' o< s,innin'
P2/SI)L)./
Three sensory systems s"bservin' s,atial orientation an) ,ost"reE
*. The vestib"lar system is
+. the vis"al system (retina to occi,ital corte3)
:. the somatosensory system that conveys ,eri,heral in<ormation
<rom s9in@ Ioint@ an) m"scle rece,tors.
Physiologic @ertigo
This occ"rs in normal in)ivi)"als when
(*) the brain is con<ronte) with an intersensory mismatch amon' the
three stabiliHin' sensory systemsE
(+) the vestib"lar system is s"bIecte) to "n<amiliar hea) movements to
which it is "na)a,te)@ s"ch as in seasic9nessE
(:) "n"s"al hea)(nec9 ,ositions@ s"ch as the e3treme e3tension when
,aintin' a ceilin'E or <ollowin' a s,in.
Pathologic @ertigo
This res"lts <rom lesions o< the vis"al@ somatosensory@ or vestib"lar
systems.
/is"al verti'o
*. ca"se) by new or incorrect eye'lasses or by the s"))en onset o< an
e3traoc"lar m"scle ,aresis with )i,lo,iaE
Somatosensory verti'o@
*. rare in isolation@
+. "s"ally )"e to a ,eri,heral ne"ro,athy or myelo,athy
vestib"lar verti'o
*. The most common ca"se o< ,atholo'ic verti'o
+. involvin' either its en) or'an (labyrinth)@ nerve@ or central
connections.
:. The verti'o is associate) with Ier9 nysta'm"s an) is <re?"ently
accom,anie) by na"sea@ ,ost"ral "nstea)iness@ an) 'ait ata3ia.
#. Since verti'o increases with ra,i) hea) movements@ ,atients
ten) to hol) their hea)s still.
Labyrinthine *ysfunction
This ca"ses severe rotational or linear verti'o.
The <ast ,hases o< nysta'm"s beat away <rom the lesion si)e@
the ten)ency to <all is towar) the si)e o< the lesion@ ,artic"larly in
)ar9ness or with the eyes close).
1cute unilateral labyrinthine dysfunction
*. 1n<ectionG her,es sim,le3 vir"s ty,e *@
+. tra"ma@
:. ischemia.
o ,res"mably )"e to occl"sion o< the labyrinthine branch o< the
internal a")itory artery@ may be the sole mani<estation o<
vertebrobasilar ins"<<iciency E
1cute bilateral labyrinthine dysfunction
o "s"ally the res"lt o< to3ins s"ch as )r"'s or alcohol.
o The most common o<<en)in' )r"'s are the amino'lycosi)e
antibiotics
(ecurrent unilateral labyrinthine dysfunction =
o in association with si'ns an) sym,toms o< cochlear )isease
(,ro'ressive hearin' loss an) tinnit"s)@ is "s"ally )"e to >\ni_reFs
)isease
Positional vertigo
o ,reci,itate) by a rec"mbent hea) ,osition@ either to the ri'ht or to
the le<t.
o 4eni'n ,aro3ysmal ,ositional (or ,ositionin') verti'o (4BB/) o< the
,osterior semicirc"lar canal is ,artic"larly common.
o Altho"'h the con)ition may be )"e to hea) tra"ma@ "s"ally no
,reci,itatin' <actors are i)enti<ie).
4eni'n Baro3ysmal Bositional /erti'o an) .entral Bositional /erti'o
Features 5PP@ Central
*. Latency
:%#$ s NoneR imme)iate verti'o an)
nysta'm"s
+. 7ati'ability
!es No
:. Habit"ation
!es No
#. 1ntensity o<
verti'o
Severe >il)
-. Re,ro)"cibilit
y
/ariable oo)
1 perilymphatic fistula
o sho"l) be s"s,ecte) when e,iso)ic verti'o is ,reci,itate) by
/alsalva or e3ertion
o The con)ition is "s"ally ca"se) by hea) tra"ma or barotra"ma or
occ"rs a<ter mi))le ear s"r'ery.
@ertigo of @estibular 'erve )rigin
The most common ca"se o< ei'hth cranial nerve )ys<"nction is a t"mor@
"s"ally a schwannoma (acoustic neuroma) or a menin'ioma.
a")itory sym,toms are the most common mani<estations.
Central @ertigo
Lesions o< the brainstem or cerebell"m can ca"se ac"te verti'o@ b"t
associate) si'ns an) sym,toms "s"ally ,ermit )istinction <rom a
labyrinthine etiolo'y
7eat"res o< Beri,heral an) .entral /erti'o
Sign or Symptom Peripheral 7Labyrinth9 Central 75rainstem or
Cerebellum9
*. ;irection o<
associate)
nysta'm"s
Uni)irectionalE <ast ,hase
o,,osite lesion
4i)irectional or
"ni)irectional
+. B"rely
horiHontal
nysta'm"s
Uncommon .ommon
:. /ertical
nysta'm"s
Never ,resent >ay be ,resent
#. Severity o<
verti'o
>ar9e) O<ten mil)
-. ;irection o<
<all
Towar) slow ,hase /ariable
0. ;"ration o<
sym,toms
7inite (min"tes@ )ays@
wee9s) b"t rec"rrent
>ay be chronic
&. Tinnit"s
an)(or )ea<ness
O<ten ,resent Us"ally absent
6. Associate)
.NS
abnormalities
None E3tremely common (e.'.@
)i,lo,ia@ hicc",s@ cranial
ne"ro,athies@ )ysarthria)
2. .ommon
ca"ses
4BB/@ in<ection
(labyrinthitis)@ >\ni_reFs@
ne"ronitis@ ischemia@
tra"ma@ to3in
/asc"lar@ )emyelinatin'@
neo,lasm
mi'raine a"ra
;estibular epilepsy@ verti'o secon)ary to tem,oral lobe e,ile,tic activity@
is rare.
Bsycho'enic /erti'o
o 1t sho"l) be s"s,ecte) in ,atients so Uinca,acitate)U by their sym,toms
that they a)o,t a ,rolon'e) ho"sebo"n) stat"s.
o a ,sycho'enic etiolo'y is almost certain when nysta'm"s is absent
)"rin' a verti'ino"s e,iso)e.
*I1.')S!IC +@1LU1!I)'
The sim,lest ,rovocative test <or vestib"lar )ys<"nction is ra,i) rotation
an) abr",t cessation o< movement in a swivel chair.
Batients with sym,toms o< ,ositional verti'o sho"l) be a,,ro,riately
teste) .
A <inal ,rovocative an) )ia'nostic vestib"lar test@ re?"irin' the "se o<
7renHel eye'lasses@ is vi'oro"s hea) sha9in' in the horiHontal ,lane <or
abo"t *$ s. 1< nysta'm"s )evelo,s a<ter the sha9in' sto,s@ even in the
absence o< verti'o@ vestib"lar )ys<"nction is )emonstrate). The
mane"ver can then be re,eate) in the vertical ,lane.
1< the ,rovocative tests establish the )iHHiness as a vestib"lar sym,tom@
an eval"ation o< vestib"lar verti'o is "n)erta9en
-1'1.+-+'!
Treatment o< ac"te verti'o consists o< be) rest (*%+ )ays ma3im"m) an)
vestib"lar s",,ressant )r"'s
Treatment o< /erti'o
1gent
a
*. Antihistamines
>ecliHine
BromethaHine
c c
7or ac"te verti'o only
+. 4enHo)iaHe,ines
;iaHe,am
.lonaHe,am
:. BhenothiaHines
Brochlor,eraHine
c c
7or ac"te verti'o only
1gent
a
#. Anticholiner'ic
d
d
7or motion sic9ness only.
Sco,olamine trans)ermal
-. Sym,athomimetics
d
d
7or motion sic9ness only.
E,he)rine
0. .ombination
,re,arations
d
d
7or motion sic9ness only.
E,he)rine an)
,romethaHine
&. E3ercise thera,y
Re,ositionin'
mane"vers
e
7or beni'n ,aro3ysmal ,ositional verti'o.
/estib"lar rehabilitation
f
6. Other
;i"retics or lowGsalt (* '())
)iet
g
7or >\ni_reFs )isease.
Antimi'raino"s )r"'s
h
h
7or mi'raineGassociate) verti'o
1nner ear s"r'ery
i
i
7or ,erilym,hatic <ist"la an) re<ractory cases o<
>\ni_reFs )isease.
l"cocorticoi)s
c c
7or ac"te verti'o only
.
S/'C)P+
*+FI'I!I)' O I'!()
Syncope@ a transient loss of consciousness and postural tone )"e
to re)"ce) cerebral bloo) <low@ is associate) with spontaneous
recovery.
1t may occ"r suddenly= >ithout >arning@ or may be ,rece)e) by
symptoms of faintness 7LpresyncopeL9&
These sym,toms include
*. li'hthea)e)ness@
+. )iHHiness@
:. a <eelin' o< warmth@
#. )ia,horesis@
-. na"sea@ an)
0. vis"al bl"rrin'
&. occasionally ,rocee)in' to transient blin)ness.
Synco,e may be benign when it occ"rs as a res"lt o< normal
car)iovasc"lar re<le3 e<<ects on heart rate an) vasc"lar tone@ or serious
when )"e to a li<eGthreatenin' car)iac arrhythmia.
Synco,e may occ"r as a single event or may be recurrent.
(ecurrent= uneFplained syncope= particularly in an individual
>ith structural heart disease@ is associate) with a hi'h ris9 o< )eath
(#$= mortality within + years)
C1US+S
1. ;isor)ers o< /asc"lar Tone or 4loo) /ol"me
A. Re<le3 synco,es
*. Ne"rocar)io'enic
+. Sit"ational
o .o"'h
o >ict"rition
o ;e<ecation
o /alsalva
o ;e'l"tition
:. .aroti) sin"s hy,ersensitivity
4. Orthostatic hy,otension
*. ;r"'Gin)"ce) (antihy,ertensive or vaso)ilator )r"'s)
+. B"re a"tonomic <ail"re (i)io,athic orthostatic hy,otension)
:. >"ltisystem atro,hies
#. Beri,heral ne"ro,athy ()iabetic@ alcoholic@ n"tritional@ amyloi))
-. Bhysical )econ)itionin'
0. Sym,athectomy
&. ;ecrease) bloo) vol"me
11. .ar)iovasc"lar ;isor)ers
A. Str"ct"ral an) obstr"ctive ca"ses
*. B"lmonary embolism
+. B"lmonary hy,ertension
:. Atrial my3oma
#. >itral valv"lar stenosis
-. >yocar)ial )isease (massive ac"te myocar)ial in<arction)
0. Le<t ventric"lar myocar)ial restriction or constriction
&. Bericar)ial constriction or tam,ona)e
6. Aortic o"t<low tract obstr"ction
2. Aortic valv"lar stenosis
*$. Hy,ertro,hic obstr"ctive car)iomyo,athy
4. .ar)iac arrhythmias
*. 4ra)yarrhythmias
a. Sin"s bra)ycar)ia@ sinoatrial bloc9@ sin"s arrest@ sic9Gsin"s
syn)rome
b. Atrioventric"lar bloc9
+. Tachyarrhythmias
a. S",raventric"lar tachycar)ia with str"ct"ral car)iovasc"lar
)isease
b. Atrial <ibrillation with the Dol<<GBar9insonGDhite syn)rome
c. Atrial <l"tter with *R* atrioventric"lar con)"ction
). /entric"lar tachycar)ia
111. .erebrovasc"lar ;isease
A. /ertebrobasilar ins"<<iciency
4. 4asilar artery mi'raine
1/. Other ;isor)ers that >ay Resemble Synco,e
A. >etabolic
*. Hy,o3ia
+. Anemia
:. ;iminishe) carbon )io3i)e )"e to hy,erventilation
#. Hy,o'lycemia
4. Bsycho'enic
*. An3iety attac9s
+. Hysterical <aintin'
.. SeiH"res
*IFF+(+'!I1L *I1.')SIS
3 AnAiet% Attac?s and /%'er!entilati"n S%ndr"#e
the sym,toms are not accompanied by facial pallor an) are not
relieved by recumbency.
4 SeiBures
7eat"res that ;istin'"ish eneraliHe) TonicG.lonic SeiH"re <rom Synco,e
Features SeiCure Syncope
*. 1mme)iate
,reci,itatin' <actors
Us"ally none Emotional stress@ /alsalva@
orthostatic hy,otension@
car)iac etiolo'ies
+. Bremonitory
sym,toms
None or a"ra
(e.'.@ o)) o)or)
Tire)ness@ na"sea@
)ia,horesis@ t"nnelin' o< vision
:. Bost"re at onset /ariable Us"ally erect
0& !ransition to
unconsciousness
)ften
immediate
.radual over seconds
#& *uration of
unconsciousness
-inutes Seconds
3& *uration of tonic
or clonic movements
,0$30 s 'ever more than 1# s
4& Facial appearance
during event
Cyanosis=
frothing at
mouth
Pallor
6. ;isorientation an)
slee,iness a<ter event
>any min"tes to
ho"rs
5- min
2. Achin' o< m"scles
a<ter event
O<ten Sometimes
*$. 4itin' o< ton'"e Sometimes Rarely
**. 1ncontinence Sometimes Sometimes
*+. Hea)ache Sometimes Rarely
5 /%'"gl%ce#ia
6 /%sterical Fainting
Lac< of change in pulse and blood pressure or color of the s<in
and mucous membranes )istin'"ish it <rom the vaso)e,ressor <aint.
!(+1!-+'!
SI!+ )F C1(+
Patients >ith syncope should be hospitaliCed >hen there is a
,ossibility that the e,iso)e may have res"lte) <rom a li<eGthreatenin'
abnormality or i< rec"rrence with si'ni<icant inI"ry seems li9ely.
These in)ivi)"als sho"l) be a)mitte) to a be) with continuous
electrocardiographic monitoring.
Patients >ho are <no>n to have a normal heart and for >hom
the history strongly suggests vasovagal or situational syncope
may be treate) as o"t,atients i< the e,iso)es are neither <re?"ent nor
severe.
.+'+(1L
Certain precautions should be ta<en regardless of the cause of
syncope&
?21! ?ILL P1!I+'! *) P
Patients >ith freHuent episodes= or those >ho have eFperienced
syncope >ithout >arning symptoms@ sho"l) avoi) sit"ations in
which s"))en loss o< conscio"sness mi'ht res"lt in inI"ry (e.'.@ climbin'
la))ers@ swimmin' alone@ o,eratin' heavy machinery@ )rivin').
1t the first sign of symptoms@ ,atients sho"l) ma9e every e<<ort to
avoi) inI"ry .
Patients should lower their hea) to the e3tent ,ossible an) ,re<erably
sho"l) lie )own.
Lo>ering the head by bending at the >aist should be avoided
beca"se it may <"rther com,romise veno"s ret"rn to the heart.
()L+ )F (+L1!I@+ O F(I+'*S
Dhen a,,ro,riate@ family members or other close contacts should
be educated as to the ,roblem.
!his >ill ensure appropriate therapy and may prevent delivery
of inappropriate therapy (chest com,ressions associate) with
car)io,"lmonary res"scitation) that may in<lict tra"ma.
P! ?I!2 L)S! C)CI)US'+SS
*. Patients >ho have lost consciousness sho"l) be ,lace) in a ,osition
that ma3imiHes cerebral bloo) <low@ o<<ers ,rotection <rom tra"ma@ an)
sec"res the airway.
+. Dhenever ,ossible@ the ,atient sho"l) be placed supine >ith the head
turned to the side to ,revent as,iration an) the ton'"e <rom bloc9in'
the airway.
:. 1ssessment of the pulse and direct cardiac auscultation may assist
in )eterminin' i< the e,iso)e is associate) with a bra)yarrhythmia or a
tachyarrhythmia.
#. Clothing that fits tightly around the nec< or waist sho"l) be
loosene).
-. Peripheral stimulation@ s"ch as s,rin9lin' col) water on the <ace@ may
be hel,<"l.
0. Patients should not be given anything by mouth or be permitted to
rise until the sense of physical >ea<ness has passed&
SP+CIFIC
The treatment o< synco,e is directed at the underlying cause&
Patients >ith vasovagal syncope
Patients >ith vasovagal syncope sho"l) be instr"cte) to avoi)
sit"ations or stim"li that have ca"se) them to lose conscio"sness an) to
ass"me a rec"mbent ,osition when ,remonitory sym,toms occ"r.
!hese behavioral modifications alone may be sufficient <or
,atients with in<re?"ent an) relatively beni'n e,iso)es o< vasova'al
synco,e@ ,artic"larly when loss o< conscio"sness occ"rs in res,onse to a
s,eci<ic stim"l"s.
+pisodes associated >ith intravascular volume depletion may be
,revente) by salt an) <l"i) loa)in' ,rior to ,rovocative events.
*rug therapy may be necessary when vasova'al synco,e is resistant
to the above meas"res@ when e,iso)es occ"r <re?"ently@ or when
synco,e is associate) with a si'ni<icant ris9 <or inI"ry.
5+!1A1drenergic receptor antagonists (metoprolol@ +-%-$ m' bi)E
atenolol= +-%-$ m' ?)E or nadolol@ *$%+$ m' bi)E all startin' )oses)@
the most wi)ely "se) a'ents
Serotonin reupta<e inhibitors (paroFetine@ +$%#$ m' ?)E or
sertraline@ +-%-$ m' ?))@ a,,ear to be e<<ective <or some ,atients.
5upropion SR (*-$ m' ?))@ another anti)e,ressant@ has also been "se)
with s"ccess.
4ETAGA)rener'ic rece,tor anta'onists an) serotonin re",ta9e inhibitors
are >ell tolerated and are often used as firstAline agents for
younger patients.
2ydrofludrocortisone ($.*%$.+ m' ?))@ a mineralocorticoid=
,romotes so)i"m retention@ vol"me e3,ansion@ an) ,eri,heral
vasoconstriction by increasin' 4ETAGrece,tor sensitivity to en)o'eno"s
catecholamines.
Hy)ro<l")rocortisone is "se<"l <or patients >ith intravascular volume
depletion and for those >ho also have postural hypotension&
Proamatine (+.-%*$ m' bi) or ti))@ an 1LP21Aagonist@ has been "se)
as a <irstGline a'ent <or some ,atients.
2o>ever= in some patients= proamatine and
hydrofludrocortisone may increase resting supine systemic
blood pressure= which may be ,roblematic <or those with hy,ertension.
*isopyramide (*-$ m' bi))@ a vagolytic antiarrhythmic )r"' with
ne'ative inotro,ic ,ro,erties@ an) trans)ermal scopolamine= another
vagolytic@ have been "se) to treat vasova'al synco,e@ as have
theophylline and ephedrine.
Si)e e<<ects associate) with these )r"'s have limite) their "se <or this
in)ication.
*ualAchamber cardiac pacing may be e<<ective <or ,atients with
<re?"ent e,iso)es o< vasova'al synco,e@ ,artic"larly <or those with
,rolon'e) asystole associate) with vasova'al e,iso)es.
Pacema<ers that can be programmed to transiently pace at a
high rate 760$100 beatsmin9 a<ter a ,ro<o"n) )ro, in the ,atientFs
intrinsic heart rate are most e<<ective.
Patients >ith orthostatic hypotension
Patients >ith orthostatic hypotension sho"l) be instr"cte) to rise
slowly an) systematically (s",ine to seate)@ seate) to stan)in') <rom the
be) or a chair.
>ovement o< the le's ,rior to risin' <acilitates veno"s ret"rn <rom the
lower e3tremities.
Dhenever ,ossible@ medications that aggravate the problem
7vasodilators= diuretics= etc.) sho"l) be )iscontin"e).
+levation of the head of the bed Q20$,0 cm 7"$12 in&9R and use of
compression stoc<ings may hel,.
1dditional therapeutic modalities include salt loa)in' an) a variety
o< ,harmacolo'ic a'ents incl")in'
*. sym,athomimetic amines@
+. monamine o3i)ase inhibitors@
:. beta bloc9ers@
#. levo)o,a.
.lossopharyngeal neuralgia
.lossopharyngeal neuralgia is treate) with carbamaCepine@ which
is e<<ective <or synco,e as well as <or ,ain.
carotid sinus hypersensitivity
Patients >ith carotid sinus hypersensitivity sho"l) be instr"cte) to
avoi) clothin' an) sit"ations that stim"late caroti) sin"s barorece,tors.
They sho"l) t"rn their entire bo)y@ rather than I"st their hea)@ when
loo9in' to the si)e.
!hose >ith intractable syncope due to the cardioinhibitory response
to carotid sinus stimulation
sho"l) "n)er'o ,ermanent ,acema9er im,lantation.
N"nc"#'ressi!e
M%el"'aties
C1US+S
The most <re?"ent ca"ses o< noncom,ressive ac"te transverse
myelo,athy (AT>) are
*. s,inal cor) in<arctionE
+. systemic in<lammatory )isor)ers@ incl")in' SLE an)
sarcoi)osisE
:. )emyelinatin' )iseases@ incl")in' m"lti,le sclerosis (>S)E
#. ,ostin<ectio"s or i)io,athic transverse myelitis@
-. in<ectio"s (,rimarily viral) .
I'@+S!I.1!I)'S
A<ter s,inal cor) com,ression is e3cl")e)@ the eval"ation
'enerally re?"ires a l"mbar ,"nct"re an) a search <or "n)erlyin'
systemic )isease
Eval"ation
*. >R1 o< s,inal cor) with an) witho"t contrast
e3cl")e com,ressive ca"ses.
+. .S7 st")iesR
.ell co"nt@ ,rotein@ 'l"cose@ 1' in)e3(synthesis rate@
oli'oclonal ban)s@
/;RLE
ramFs stain@ aci)G<ast bacilli@ an) 1n)ia in9 stainsE
B.R <or /`/@ HS/G+@ HS/G*@ E4/@ .>/@ H1/E
antibo)y <or HTL/G1@ >. ,ne"moniae@ an) .hlamy)ia
,ne"moniaeE
viral@ bacterial@ mycobacterial@ an) <"n'al c"lt"res.
:. 4loo) st")ies <or in<ectionR
H1/E
1' an) 1'> enterovir"s antibo)yE
1'> m"m,s@ measles@ r"bella@
#. 1mm"neGme)iate) )isor)ersR
ESRE
ANAE )s;NAE
rhe"matoi) <actorE
anti,hos,holi,i) an) anticar)ioli,in antibo)iesE
-. Sarcoi)osisR
Ser"m an'iotensinGconvertin' enHymeE
ser"m .aE
+# ho"r "rine .aE
chest 3GrayE
chest .TE
0. ;emyelinatin' )iseaseR
4rain >R1 scan@
evo9e) ,otentials@
.S7 oli'oclonal ban)s@
&. /asc"lar ca"sesR
.T myelo'ramE
s,inal an'io'ram.
CLI'IC1L F+1!U(+ O 5(I+F -1'1.+-+'!
S,inal .or) 1n<arction
Ac"te in<arction in the territory o< the anterior s,inal artery
,ro)"ces
*) ,ara,le'ia or ?"a)ri,le'ia@
+) )issociate) sensory loss a<<ectin' ,ain an) tem,erat"re sense
b"t s,arin' vibration an) ,osition sense@ an) loss o< s,hincter
control (Uanterior cor) syn)romeU).
:) Onset may be s"))en an) )ramatic b"t more ty,ically is
,ro'ressive over min"tes or a <ew ho"rs.
#) Shar, mi)line or ra)iatin' bac9 ,ain localiHe) to the area o<
ischemia is <re?"ent.
-) Are<le3ia )"e to s,inal shoc9 is o<ten ,resent initiallyE with
time@ hy,erre<le3ia an) s,asticity a,,ear.
0) Less common is in<arction in the territory o< the ,osterior s,inal
arteries@ res"ltin' in loss o< ,osterior col"mn <"nction.
The anti,hos,holi,i) antibo)y syn)rome is treate) with
anticoa'"lation.
;raina'e o< s,inal <l"i) has re,orte)ly been s"ccess<"l in some
cases o< cor) in<arction
1n<lammatory an) 1mm"ne >yelo,athies (>yelitis)
Systemic 1n<lammatory ;isor)ers
*) SLE . Res,onses to 'l"cocorticoi)s an)(or cyclo,hos,hami)e
+) SIW'renFs syn)rome@
:) 4ehJetFs syn)rome@
#) /asc"litis
-) sarcoi) myelo,athy G1nitial treatment is with oral
'l"cocorticoi)sE imm"nos",,ressant )r"'s are "se) <or
resistant cases.
;emyelinatin' >yelo,athies
*) >"lti,le sclerosis
+) Ne"romyelitis o,tica (N>O)
o 1ntraveno"s methyl,re)nisolone (-$$ m' ?) <or : )ays)
<ollowe) by oral ,re)nisone (* m'(9' ,er )ay <or several
wee9s@ then 'ra)"al ta,er) has been "se) as initial
treatment.
o A co"rse o< ,lasma e3chan'e is in)icate) <or severe cases
i< 'l"cocorticoi)s are ine<<ective.
Bostin<ectio"s >yelitis
*) >any cases o< myelitis@ terme) ,ostin<ectio"s or ,ostvaccinal@
<ollow an in<ection or vaccination.
+) E,steinG4arr vir"s (E4/)@
:) cytome'alovir"s (.>/)@
#) myco,lasma@
-) in<l"enHa@
0) measles@
&) varicella@
6) r"beola@
2) m"m,s.
Ac"te 1n<ectio"s >yelitis
*) Her,es Hoster
+) HS/ ty,es * an) +@
:) E4/@
#) .>/@
-) rabies vir"s
0) mycobacterial myelitis (most are essentially abscesses)
&) Listeria monocyto'enes@
6) Lyme )isease
2) Sy,hilis
*$) Schistosomiasis
**) To3o,lasmosis
o Her,es Hoster@ HS/@ an) E4/ myelitis are treate) with
intraveno"s acyclovir (*$ m'(9' ?6h) or oral valacyclovir (+
'm ti)) <or *$%*# )aysE
o .>/ with 'anciclovir (- m'(9' 1/ bi)) ,l"s <oscarnet (0$
m'(9' 1/ ti))@ or ci)o<ovir (- m'(9' ,er wee9 <or + wee9s).