Info

Í00-200

Bacterial nimingif i.s

> 1000 (PMN)

< so

Around 100

> 200

Viral or aseptic meningitis

>100 (I.)

Normal

. Normal or slightly increased

Normal or slightly increased

Pseudotumor cerebri

Normal

Normal

Normal

> 200

Giiilktin-Barre syndrome

«-■100 (L)

Normal

> 100

Normal

Cerebral hemorrhage''

Bloody (RBC)

Normal

> 45

> 7.00

Multiple sciei oms'í

Norma) or slightly increased (L) .

Normal

Normal or slightly. .. mc-reased-

Normal

Main cell type is put in paren!bests after the number (1 ^ lymphocytes, PMN polymorphonuclear neutrophils, RBCred. blood, cells). ' Think oí subarachnoid hemorrhage, but .thesame findings also may occur after an iatracerebral hemorrhage.

■■ On electrophoresis. of cerbrospinal fluid, look for oligodoual tvands due to Increased SgCi production and an increased level of myelin . basic protein (MBP) during active- demyelmation.

Main cell type is put in paren!bests after the number (1 ^ lymphocytes, PMN polymorphonuclear neutrophils, RBCred. blood, cells). ' Think oí subarachnoid hemorrhage, but .thesame findings also may occur after an iatracerebral hemorrhage.

■■ On electrophoresis. of cerbrospinal fluid, look for oligodoual tvands due to Increased SgCi production and an increased level of myelin . basic protein (MBP) during active- demyelmation.

Important points:

1. Do not do lumbar puncture in patients with, acute head trauma or signs of intracranial hypertension until you. have a CT/MRI.You may cause death.

2. Tuberculosis and fungal meningitis have low glucose (< 50) with high cells (> 100), which are predominantly lymphocytes. Watch for a positive India ink preparation for Cryplococcus sp.

Multiple sclerosis: look for insidious onset of neurologic symptoms in women aged 20 4-0 with exacerbations and remissions. Common presentations include paresthesias and numbness, weakness and clumsiness, visual disturbances (decreased vision and pain due to optic neuritis, diplopia due to cranial nerve involvement), gait disturbances, incontinence or urgency, and vertigo. Also look for emotional lability or other menial status changes. Inlet nuclear ophthalmoplegia and scanning speech are classic; Babinski's sign may be positive. MRI, the most sensitive diagnostic tool, shows demyelmation plaques. Look for increased lg(¡ or oligo-clonal bands and possibly myelin basic protein in the cerebrospi nal flu id/freatment is not very effective but includes corticosteroids and interferons.

Guillara-Barré syndrome: look for history of mild, infection or imnnmization roughly 1 week before onset of symmetric, distal weakness, paralysis, or mild paresthesias with loss of deep tendon reflexes in affected areas. As the ascending paralysis and weakness progress, respiratory paralysis- may occur. PaijerUs must he watched carefully; usually spirometry is used to follow inspiratory ability. Intubation may be required. Diagnosis depends on clinical signs and symptoms, analysis of cerebrospinal fluid (usually normal except; for markedly increased protein), and nerve conduction velocities (slowed). Disease usually stops spontaneously. Plasmapheresis reduces the severity and length of disease. Do «or use steroids; you may make the patient worse.

Nerve conduction velocities: slowed by demyelination (Guillam - Barre, multiple sclerosis). Repetitive stimulation can assess fatigability. Myasthenia gravis is characterized by increasing fatigue with stimulation, Hat on lamhert syndrome by decreasing fatigue with stimulation.

Electromyography (EMG): measures the electrical (contractile) properties of muscle. Lower motor neuron lesions are associated with fasciculations and fibrillations at rest. When the dis ease is in the muscle itself, no electrical activity is seen at rest (which is normal), but amplitude is decreased with contraction of die muscle.

Syncope: the most common cause (after stress, fear, or other emotional states) is vasovagal. Other causes include cardiac events (especially arrhythmias; get an EXG), transient .ischemic attacks (consider carotid artery duplex scan), and neurologic disorders (especially seizures; consider CT or MRf of head if other neurologic symptoms arc present).

localizing pathology of the central nervous system

Decreased or no reflexes, fa$ck:uiatiom . -Lowyr motor neuron disease (or possibly a muscle prohiem)

Hyperreflexia Upper motor nniron lesion (cord or brain)

Apathy, inattention, or uninhibited, labile af&et FtoiUal lobes

Broca's (motor) aphasia Dominant frontal; lobe*

Wernicke s (sensory) aphasia . Dominant temporal lobe*

Memory impairment or aggressive sexual behavior Temporal lobes

Inability to read, write name, or do math Dominant parietal lobe*

Ignoring one side of body, trouble: with dressing Ncmdommant parietal lobe*

Visual hallucinations or illusions Occipital lobes

Crania! nerves 3 and 4 Midbrain

Cranial nmcs 9, JO, 11, and 17. Medulla

Ataxia, dysarthria, nystagmus, intention Cerebellum tremor, dysmerra, scanning speech

* Left sidt? is dominant in >95% of population (99% of right-banded people and 60-70% of left-handed people).

For delirious or unconscious patients in the emergency department with no history of trauma, think, first of hypoglycemia (give glucose), opioid overdose (give naloxone), and thiamine deficiency (give (hi.twine before giving glucose in a suspected alcoholic). Other common causes are alcohol, illicit drugs, prescription medications, diabetic ketoacidosis, stroke, and epilepsy or postictal state.

.De.lir.iimi vs. dementia (See table, top of next page.)

DEURÏUM

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