[J24] CNS Infection

1 Definition:
- meningitis: inflammation of the arachnoid and pia mater due to causes
(bacterial/viral/fungal)
- encephalitis: inflammation of the brain parenchyma; usually also lead to aseptic
meningitis
2 Clinical features
- meningitis: fever, neck stiffness, photophobia, phonophobia, seizure (more
common in children), petechiae, rash, AMS/coma
For meningococcus: petechiae, oral ulcer, conjunctivitis, rash
- P/E: check for Brudzinski’s sign (ask px to flex neck, see flexion of hip and knee)
Kernig’s sign: resistance of extension of knee when hip + knee both flexed to 90
degrees
3 Dx/Ix: CBC, ESR, CRP, CT brain, Lumbar puncture
- Interpretation: normal opening pressure < 20 mm H2O
- Differentiation of bacteria/viral/tuberculous meningitis
Bacterial: turbid CSF, high protein, low glucose (cf serum), high WBC (neutrophil pre),
high opening pressure
Viral: clear CSF, normal or high protein, normal glucose, high WBC (lymphocyte pre),
high opening pressure
Tuberculous: slightly yellow CSF, high protein, low glucose, high WBC (neutrophil
pre), high opening pressure
Traumatic tap: numerous RBC but protein, glucose all normal, few or absent WBC (BC
cleared by 4 collecting tubes)
Subarachnoid hemorrhage: numerous RBC not to be cleared by four collecting tubes

C/I to LP:
- infection/abscess of skin overlying the area for puncture
- thrombocytopenia < 50000
- increased ICP (esp in children)
- focal neurological signs
- fluctuating conscious levels
- congenital lesion at puncture site
- spinal block
- coagulopathies

4 Tx
- viral: supportive (rest, IV fluid hydration, darkened room, analgesia; appropriate
antivirals when indicated)
- bacterial: Rx depending on the causative organisms
- prophylaxis to close contacts: ciprofloxacin (one 500 mg dose), rifampicin,
ceftriaxone (250 mg IM once)

[J25] stroke
1 Definition
- Stroke: cerebrovascular disease that lasted more than 24 hours and is usually
accompanied with permanent neurological deficits
- Transient ischemic attack: cerebrovascular disease that lasted within 24 hours
and did not result in any permanent neurological deficits
2 D/dx
- Ischemic (thrombotic vs embolic, 85%;
thrombotic: atherosclerosis, cerebral artery dissection, vasculitis, fibromuscular
dysplasia, syphilis, congenital heart disease, hypercoagulable state;
embolic: AF, MI, arrhythmia, fat and septic emboli, atrial myxoma (rare))
hemorrhagic (15%): HT, AVM, amyloidosis, bleeding diathesis (e.g. coagulopathy),
exogenous anti-coagulant use, diabetes mellitus, cocaine use/cigarette smoking

3 Clinical features
- thrombotic ischemic stroke: sx wax and wane, gradual onset of sx
- embolic ischemic stroke: sudden onset of sx, may have prior hx of TIA, ECG may
show AF
- hemorrhagic stroke: usually a/w HT, accompanied w/ increased ICP sx (headache,
vomiting, seizure, nausea, coma), and Cheyne-stokes respiration, may lead to
hydrocephalus and SIADH

4 P/E
- Anterior cerebral a.: sensorimotor loss on contralateral lower extremity, gait
disturbance; if bilateral – abulia, primitive reflexes, bowel and bladder incontinence
- Middle cerebral a.: contralateral UL hemiplegia, sometimes homonymous
hemianopia, L-side  language deficits; R-side  spatial deficits
- Posterior cerebral a.: contralateral homonymous hemianopia w/ macular sparing, if
bilateral visual agnosia

- Internal carotid a. : contralateral sensory loss, ipsilateral blindness, aphasia, denial

hemineglect
- Vertebrobasilar a.: contra. pain and temperature loss, ips. paresthesia of face,
diplopia, nystagmus, dysphagia
5 Dx/Ix
- CBC, blood glucose, electrolytes, ESR, CRP, cardiac enzymes
- ECG, Echocardiogram
- CT brain (most important)
- Clotting profile, toxicology

6 Tx
- Supportive: admission, bed rest, elevate head, oxygen, control of HT <140 mm Hg
- Thrombotic:
anti-coagulation (heparin), prophylaxis of thrombotic events (aspirin, clopidogrel,
ticlopidine); carotid endarterectomy if stenosed > 70% or >50% w/ Sx
thrombolytic therapy (C/I: current/hx of intracranial bleed, recent bleeding diathesis,
recent GI/GU bleed, uncontrolled HT, minor focal neurological deficits, major
neurological deficits, recent LP, presence of aneurysm)
- Embolic: anticoagulation, prophylaxis (aspirin, ticlopidine, clopidogrel), tx of
underlying cause
- Hemorrhagic: control of BP, ICP (mannitol), seizure prophylaxis (anticonvulsant)
[J26] Headache/neuralgia
1 Migraine
1.1 Clinical features
- differentiation: w/o preceding aura (more common) and w/ preceding aura (less
common)
- +/- visual disturbances (scomata, hemianopsia, visual hallucinations)
- characteristics: usually unilateral and pulsating pain, a/w nausea, vomiting,
photophobia,
aggravated by physical activities, caffeine, excessive sleep, alcohol, foods
usually resolve on own, attacks may be precipitated by physical activities and resolve
on its own
1.2 Epidemiology
- 3x women than men
1.3 Dx: clinical diagnosis (refer to criteria in ICD-10/11)
Other tests: CBC, ESR, CRP, CT brain LP, radiographs of C-spine or sinuses to rule out
other causes
1.4 Tx:
supportive: rest, hot shower, cold compress, massage, biofeedback
Rx: panadol, metoclopramide, ergotamine (w/ caffeine), sumatriptan (C/I: CAD, PVD,
2 mo of MAOI usage, uncontrolled HT)

2 Cluster headache
2.1 Clinical features: unilateral headache, piercing or exploding
may a/w ips. lacrimation, ptosis, nasal congestion, nausea, diaphoresis, bradycardia
may be ppt by alcohol, bright light, emotional stress, menstrual cycle change in
women
2.2 Dx: clinical
2.3 Tx: 100% oxygen (supportive), sumatriptan, dihydroergotamine; prophylaxis:
verapamil, lithium

3 Tension headache
3.1 Definition: episodic vs chronic
Episodic: self-limiting
Chronic: chronic contracture of neck muscles
3.2 Clinical features: pain is bilateral, of dull and aching quality.
Not + by physical activities
a/w depression, anxiety, poor posture, excessive caffeine intake
3.3 Dx: clinical
3.4 Tx: NSAIDs, prophylaxis: TCA

4 Trigeminal neuralgia
- Causes: idiopathic, 2nd to cerebellopotine angle tumor and MS
- Clinical: electric shocking type of pain along V2 distribution, usually unilateral, last
several sec, ++ by activities employing facial muscles, - - food intake
- Dx: MRI to look for CPA tumors
- Tx: carbamazepine, IV opioid analgesia, electrical ablation of the affected nerve if
refractory

5 Temporal arteritis
- Features: severe headache, claudication of the masseter, temporalis muscles, visual
disturbances (amaurosis fugax, scomata)
- P/E: scalp tenderness, pulsating temporal a., decreased VA, diplopia, LoW,
generalized weakness
- Ix: CBC, ESR, CRP, ALP level (exp. Elevation), temporal artery biopsy inpx (look for
giant multinucleated cells)
- Tx: prednisolone (1st line), azathioprine, methotrexate

[J29] Delirium, epilepsy, coma and brain death

1 Definition: delirium – alteration in consciousness, attention and cognition, with
reduced ability of focusing, sustaining or shifting attention.
Seizure: burst of electrical activities that resulted in involuntary movement/LoC or
both

2 Causes
- Serum electrolyte disturbance (hypo/hyper-Na; hypoCa; hypoMg), hypoglycemia,
drugs (e.g. amphetamine, cocaine, theophylline), IEM, CNS infection, vascular, stress
(metabolic, trauma, chemical, infection/inflammation, vascular, stress, IEM)

3 Clinical features
- abrupt onset, lasting 1-5 mins
- status epilepticus: seizures lasting for > 30 mins or >= 2 seizures w/o lucid interval
between

4 Ix
- CBC, ESR, CRP, electrolyte, blood glucose, toxicology, anticonvulsant level (check for
compliance, +/- dosage), radiographs, CTB
5 Tx
- Ensure ABC (supportive whenever necessary)
- Thiamine and glucose for hypoglycemic
- For status epilepticus: diazepam/phenytoin/phenobarbital, vitamin B6 for isoniazid-
indued seizures