Neuro. & Gastro. ~ Short Answer

Question 1.

A 72 year old patient presents to the emergency department with acute left hemiparesis.

A.) What are the most likely differentials?

Show Answer

  • Cerebrovascular accident
    • Ischaemic
      • Embolic
      • Thrombotic
    • Haemorrhagic

(2 marks)

B.) List 10 stroke mimics.

Show Answer

  • Transient ischaemic attacks
  • Carotid artery dissection
  • Seizure (Todd’s paresis)
  • Syncope
  • Complicated migraine
  • Subarachnoid haemorrhage
  • Intra-cranial haemorrhage
    • Subdural haemorrhage
    • Extradural haemorrhage
  • Hypoglycaemia
  • Hyponatraemia
  • Space-occupying lesion (neoplasm or abscess)
  • Hypertensive encephalopathy
  • Hyperosmolar coma
  • Wernicke’s encephalopathy
  • Multiple sclerosis
  • Meningitis/Encephalitis
  • Labyrinthitis
  • Meniere’s disease
  • Bell’s palsy
  • Drugs (Lithium carbamazepine, phenytoin)
  • Conversion disorder

(10 marks)

 C.) For each one describe how you would differentiate it from a CVA.

Show Answer

  • TIA
    • Symptoms resolve within 24 hours
    • No findings on CT
  • Carotid artery dissection
    • Younger patient
    • Major or minor trauma
    • Underlying connective tissue disease
    • Often presents with neck/facial pain
  • Seizure
    • Transient focal neurology following a seizure
  • Syncope
    • No persistent neurological symptoms
  • Complicated migraine
    • Hx of similar episodes
    • Preceding aura
    • Unilateral headache, nausea, vomiting
  • Subarachnoid haemorrhage
    • Sudden onset severe headache
    • CT and LP findings
  • Intra-cranial haemorrhage
    • Hx of trauma
    • CT findings
  • Hypoglycaemia
    • Can cause global neurological or focal dysfunction
    • Bedside BSL
  • Hyponatraemia
    • Usually global neurological dysfunction e. ALOC, seizures
    • Low Na
    • Hx of diuretic use, neoplasia, excessive free water intake
  • SOL (neoplasia/abscess)
    • Focal neurological findings
    • Signs of infection
    • Seen on CT
  • Hypertensive encephalopathy
    • Gradual onset
    • Global neuro dysfunction
    • Headache, delirium
    • Hypertension
    • Cerebral oedema on CT
  • Hyperosmolar coma
    • Global dysfunction
    • Hx DM
    • High BSL and osmolality
  • Wernicke’sencephalopathy
    • X of alcoholism or malnutrition
    • Ataxia, ophthalmoplegia, confusion
  • Multiple sclerosis
    • Gradual onset
    • Hx of previous episodes of neuro dysfunction
    • MRI findings
  • Meningitis/Encephalitis
    • Fever, meningism, global neuro dysfunction
    • LP
  • Labyrinthitis
    • Vestibular symptoms
    • No other focal neuro
    • Mimics posterior CVA
  • Meniere’s disease
    • Recurrentepisodes or vertigo, tinnitus, deafness
    • Mimicsposterior CVA
  • Bell’s palsy
    • Lower motor neurone CN VII
  • Drugs (Lithiumcarbamazepine, phenytoin)
    • Toxidromes
    • Blood levels
  • Conversion disorder
    • No CNS findings
    • Non-anatomic distribution of findings
    • Inconsistent history or exam
    • Diagnosis of exclusion

(10 marks)

D.) What are the recommendations for management of hypertension in patients withischaemic stroke that are:

Show Answer

1. Candidates for thrombolysis

  • BPs > 185 mmHg or BPd > 110 mmHg is a contraindication to lysis
  • Therefore active management to control blood pressure is recommended prior to, during and after lysis
  • Using IV titratable agents

(2 marks)

2. Thrombolysis is not going be given

  • Permissive hypertension unless the BPs > 220 mmHg or BPd > 120 mmHg and then only use IV titratable drugs with extreme caution aiming to reduce BP by 10-25% in first day

(2 marks)

E.) What is the evidence for thrombolysis in stroke?

Show Answer

  • NINDS2
    • Randomised double blind trial of placebo vs rtPA given up to 3 hours after symptom onset
    • No mortality benefit
    • Morbidity benefit at 3 months OR 1.7 or ARR 11-13% or NNT = 8-9
    • Sustained at 1 year
    • Benefit regardless of stroke type
  • ECASS III
    • rtPA to stroke patients up to 4.5 hours
    • found morbidity benefit
    • no mortality benefit
    • increased ICH rate in tPA group
  • IST-3
    • Larger study > 3000 subjects
    • Secondary outcome showed morbidity benefit
  • Standard of care in stroke guidelines in Australia

(6 marks)

 F.) What are the arguments against thrombolysis is stroke?

Show Answer

  • Criticism of evidence
    • Lots of trials prior to NINDS using different lytics, different rtPA doses, different timing showed no benefit and lots stopped due to harm
    • NINDS2
      • Half patients treated within 90 minutes – maybe early treatment effect
      • 4% ICH rate with mortality of 45% (vs 0.6% with 50% mortality in placebo group) but no difference in mortality at 3 months and more patient left severely disable in placebo group
      • Low numbers (312 treated with rtPA) vs very high numbers for lysis in MI with consistent findings of mortality benefit
      • Stroke severity difference between 2 arms favouring the rtPA group
      • Outcome changed during study
      • Measured standard outcome rather than relative outcome within the groups
    • IST-3
      • Secondary outcome e. primary outcome showed no difference; was not powered for this secondary outcome; derived at via adjusted ordinal analysis
      • Not blinded
      • Did not reach subject numbers originally needed in power analysis
    • Drug sponsored trials
    • Low numbers in all trials
    • Meta-analyses
      • does not include trials in which were stopped early due to harm
      • included high statistical and clinical heterogeneity
      • done by same authors as original trials
    • main concern is increased mortality due to ICH

(6 marks)

 G.) What are the inclusion criteria for thrombolysis in stroke?

Show Answer

  • Based on AHA guidelines
    • Measureable diagnosis ofischaemic stroke
      • Use of NIHSS recommended (or stroke score)
    • Stoke symptoms not getting better, minor or isolated and caution is severe stroke (NIHSS > 22) as increased risk of ICH
    • Age > 18
    • Time of symptom onset < 3 hours (can be extended to 4.5 hours if ECASS II criteria met

(4 marks)

 H.) List 8 exclusion criteria for thrombolysis in stroke

Show Answer

  • Symptoms consistent with SAH
  • Seizures with postictal residual neurologic impairment
  • Previous head trauma or stroke in last 3 months
  • Previous MI in last 3 months
  • Previous GI or urinary tract haemorrhage in last 21 days
  • Major surgery in last 14 days
  • Prior ICH
  • Pretreatment BPs> 185 mmHg or BPs > 110 mmHg despite therapy
  • Evidence of active bleeding or acute major fracture
  • BSL < 2.7 mmol/L
  • Use of heparin within last 48h and prolonged APTT
  • Platelet count < 100,000 m3
  • CT shows mulitlobar infarction (hypodensity of more than 1/3 cerebral hemisphere) or haemorrhage or tumour
  • Failure of patient or responsible party to understand risks/benefits/alternatives to lysis after full disclosure

(8 marks)

I.) What is the dose of tPA in thrombolysis for acute stroke?

Show Answer

  • 9mg/kg up to 90 mg
  • 10% dose given as bolus and rest infused over 60 mins

(2 mark)

Author: J Haire

Ref Tintinalli p.1125-33


 

Question 2.

A patient attends to the emergency department following an episode of haematemesis. He is tremulous and confused. He has a past history of liver disease and oesophageal varices secondary to chronic alcohol abuse.

He has the following vital signs:

GCS 13 (E4 M6 V3)

HR 125 /min

BP 95/40 mmHg

Temperature 35.5 °C

O2 Saturation 99 % on 6L O2 by Hudson mask

 A.) What are the 3 issues that need to be addressed in this patient’s resuscitation?

Show Answer

  • Haemorrhagic shock
  • Coagulopathy
  • Control bleeding

(3 marks)

 B.) What are the 2 most likely causes of his haematemesis?

Show Answer

  • Bleeding oesophageal varices
  • Bleeding peptic ulcer

(2 marks)

 C.) List 3 other differential diagnoses

Show Answer

  • Erosive gastritis/oesophagitis
  • Mallory-Weiss syndrome
  • Upper GI malignancy
  • Bleeding from oropharynx
  • Aorto-enteric fistula
  • Bleeding from respiratory tract

(3 marks)

 D.) How would you address his low blood pressure?

Show Answer

  • 2 large bore IVCs
  • Volume replacement with whole blood
  • Aims BPs > 100 mmHg, Map > 65 mmHg, HR < 100 bpm
  • May require massive transfusion if ongoing bleeding

(3marks)

 E.) What other blood products may be warranted in this patient?

Show Answer

  • FFP +/- Vit K for raised INR due to liver failure
  • Platelets due to bone marrow suppression due to alcoholism

(4 marks)

 F.) What medical treatment would you give to address the haematemesis?

Show Answer

  • Octreotide 50 mcg IV bolus then 50 mcg/hr IV infusion
  • And/or Terlipressin 2mg IV q4 hrs
  • And Esomeprazole 80 mg IV bolus then 8 mg/hr IV infusion

(3 marks)

 G.) If the patient has ongoing bleeding despite therapy what other option do you have to control the bleeding in the emergency department?

Show Answer

  • Balloon tamponade with Sengstaken-Blakemore tube

(1 mark)

 H.) How would you apply this?

Show Answer

  • Intubate first to protect airway
  • Test for air leaks
  • Lubricate
  • Attach NGT with silk to tube so that the end is 3 cm proximal to gastric balloon (no oesophageal aspiration port)
  • Head of bed up to 45° or lateral decubitus
  • Anaesthetise oropharynx
  • Pass orally if can to at least 50 cm or whole length
  • suction gastric and oesophageal ports continuously
  • inflate gastric balloon with 50 ml air
  • get CXR to confirm it is below the diaphragm
  • connect manometer to pressure-monitoring outlet of gastric balloon and inflate in 100ml increments of air
  • test pressure; should not be > 15 mmHg; if greater then has migrated into oesophagus to deflate and advance
  • gastric balloon 200-250 ml air
  • clamp inflation and pressure monitoring port and slowly pull is back until resistance e. in cardia and fundus of stomach
  • attach pulley system to apply 0.5-1.0 kg of continuous traction
  • apply suction to oesophageal and gastric ports and if blood obtained then inflate the oesophageal balloon to 35-40 mmHg
  • if still bleeding can add more traction t max of 1.2 kg

(6 marks)

 I.) What are the complications of this device?

Show Answer

  • Airway obstruction
  • Oesophageal rupture
  • Aspiration pneumonitis
  • Pain
  • Ulceration lips, mouth, tongue, nares
  • Oesophageal and gastric mucosal erosions

(4 marks)

J.) What will be needed to provide definitive care for this patient?

Show Answer

  • Urgent endoscopy

(1 mark)

K.) What other conditions may need to addressed in the patient and how?

Show Answer

  • Alcoholwithdrawal
    • Alcohol withdrawal scale
    • Diazepam in 10 mg PO aliquots
  • Prevention ofWernicke’s encephalopathy
    • 300 mg IV thiamine

(4 marks)

 L.) Which inpatient teams will need to be consulted?

Show Answer

  • Gastroenterology for urgent scope
  • Surgery for gastroenterology back-up
  • ICU
  • +/- Haematology

(3 marks)

Author: J Haire

Ref Tintinalli p.543-5 & Roberts & Hedges p. 831-6


 

Question 3.

A previously well 38 y.o man presents with a week of worsening vomiting, diarrhoea and abdominal pain. On the day of presentation to the ED he has become drowsy and confused

Neuro & Gast Table 1 Short Answer

His liver function tests (LFTs) and coagulation profile are shown

Neuro & Gast Table 2 Short Answer

A.) What liver dysfunction pattern is this and why?

Show Answer

  • Hepatocellular pattern
  • Grossly elevated ALT and AST
  • Minor elevation of ALP and GGT

(2 marks)

 B.) Is there an abnormality in the synthetic function of the liver and why?

Show Answer

  • Yes, abnormal synthetic dysfunction
  • Low albumin, protein, glucose, INR and APTT

(2 marks)

C.) What is the most likely cause of this patient’s confusion?

Show Answer

  • Hepatic encephalopathy

(1 mark)

 D.) List 2 other possible causes for his confusion

Show Answer

  • Hypoglycaemia
  • ICH
  • Hyponatraemia
  • Poor hepatic clearance of drugs
  • Sepsis

(2 marks)

E.) What are the most likely causes (with examples) of his condition?

Show Answer

  • Viral hepatitis (A,B, C, D, E)
  • Toxic hepatitis
    • Paracetamol
    • Other medications
    • Herbal remedies
    • Mushroom poisoning e.g. Amanita phalloides

(4 marks)

F.) Name one other rare cause of acute hepatocellular damage

Show Answer

  • Portal vein thrombosis
    • Abdominal trauma, sepsis, pancreatitis, hypercoagulable states
  • Hepatic vein thrombosis (Budd-Chiari syndrome)
    • Abdominal trauma, sepsis, pancreatitis, hypercoagulable states, polycythaemia rubra vera, paroxysmal nocturnal haemoglobinuria, congenital webs of vena cava

(1 mark)

Author: J Haire

Ref: Tintinalli p. 568-71


 

Question 4.

A 55 year old woman presents to your ED following a collapse with loss of consciousness. On arrival in the emergency department she is vomiting and has a GCS of 7 (E1, V2, M4). She is intubated prior to transfer to CT.

Her observations on return from CT are as follows:

Neuro & Gast Table 3 Short Answer

A single slice of her non contrast CT head is shown.

Neuro & Gast Scan 1 Short Answer

A.) At what level is this CT slice taken?

Show Answer

  • Level of 3rd ventricle
  • Just above midbrain

(1 mark)

 B.) What are the major abnormalities shown on this CT?

Show Answer

  • Blood present in:
    • posterior and frontal horns of the lateral ventricles
    • 3rd ventricle
    • sylvian fissure
    • sulci
    • along falx cerebri
  • effacement of sulci indicating raised ICP

(6 marks)

C.) What is the diagnosis and likely cause?

Show Answer

  • SAH
  • Aneurysmal bleed

(2 marks)

D.) List your management priorities

Show Answer

  • Urgent consultation with neurosurgery to consider operative treatment
  • ICU consultation
  • Prevention of secondary brain injury
    • Careful control of BP
      • Aim patients normal BP or BPs <130 mmHg
    • Normothermia
    • Normoglycaemia
  • +/- Vasospasm prophylaxis
    • Nimodipine 60 mg PO q4 hour
    • Less in favour – consult neurosurgery
  • Seizure prevention
    • Clonazepam
    • Phenytoin less in favour
    • Consult neurosurgery
  • Discussion with family

(6 marks)

E.) What is the prognosis?

Show Answer

  • Poor/guarded

(1 mark)

Author: J Haire

Ref: Tintinalli p. 1120-21


 

 

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