CNS Disorders

Dr Shreedhar PaudelApril, 2009

MENINGITIS

Inflammation of the coverings of the brain• CAUSES– BACTERIAL– VIRAL– TOXINS– MALIGNANCIES

ACUTE BACTERIAL MENINGITIS

• NEONATAL PERIOD: S. PNEUMONAE, E.COLI• 3 MTHS- 3 YEARS : H. INFLUENZAE,

S.PNEUMONIA, N. MENINGITIDES• > 3 YRS : S. PNEUMONIAE, N. MENINGITIDES• IMMUNOCOMPROMISED HOST: LISTERIA,

MYCOPLASMA, CRYPTOCOCCUS

ACUTE BACTERIAL MENINGITIS

• PATHOGENESIS– Routes of infection• Hematogenous spread from distant focus of infection• Local spread of infection from contiguous septic foci• Exogenous infection after trauma

PATHOLOGY– Meninges are infiltrated with inflammatory cells– The cortex of brain shows edema, exudates and

proliferation of microglia– Sub arachnoid space may be filled with purulent

discharge– Exudates may block the foramina of Luschka and

Magendie leading to hydrocephalus– Thrombophlebitis of cerebral vessels may occur

leading to infarction and necrosis– Endotoxic shock and sudden death may be there

if meningococcal meningitis

CLINICAL FEATURES

SYMPTOMS- Acute onset- Fever/ Irritability- Projectile vomiting- Headache/ Bulging fontanel- Seizure- Altered sensorium/ photophobia- Marked neck rigidity

SIGNS• PHOTOPHOBIA , • NECK STIFFNESS,• KERNIG’S SIGN ( extension of knee is limited to less

than 135 degree) • BRUDZINSKI SIGN ( the knees get flexed as neck of

the child is passively flexed) • BULDGING FONTANEL,• ALTERATION OF MENTATION • PAPILLEDEMA, • NEUROLOGICAL DEFICIT• Respiration may be Cheyne-Stokes type

ACUTE BACTERIAL MENINGITIS IN NEONATES AND YOUNG INFANTS

• There will be no signs of meningial irritation till 6 months of age

• Meningotis should be suspected in a newborn in following conditions– Vacant stare– Alternating irritability and drowsiness– Persistent vomiting with fever– Refusal to breast feeding– Poor tone/ poor cry– Shock/ hypothermia/ fever– Seizure/ neurological deficits

COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS

• CNS COMPLICATIONS– SUBDURAL EFFUSION /EMPYEMA, – BRAIN ABSCESS , – HYDROCEPHALUS,

COMPLICATIONS OF ACUTE BACTERIAL MENINGITIS……….

Long term neurological deficits- DEAFNESS / BLINDNESS/ APHASIA- HEMIPLAGIA- OCULAR PALSIES

Systemic complications- SHOCK- MYOCARDITIS- SIADH- STATUS EPILEPTICUS

DIAGNOSIS

• LUMBAR PUNCTURE• CSF FOR BIOCHEMICAL/CYTOLOGICAL

EVALUATION• Turbid CSF with raised pressure, elevated

protein level (>100mg/dl), reduced sugar level (<40 mg/dl or below 50% of blood sugar level), increased cell count (>1000/μL, mostly Neutrophils)

DIAGNOSIS….

• CSF for microbilogy– Gram stain– Culture/ sensitivity

• LATEX AGGLUTINATION, • ELISA, • PCR• CT SCAN

ACUTE BACTERIAL MENINGITISDIFFERENTIAL DIAGNOSIS– MENINGISM ( occur in inflammatory cervical lesion,

apical pneumonia, toxemia due to Hemophilus infection or typhoid fever)

– PARTIALLY TREATED BACTERIAL MENINGITIS– ASEPTIC MENINGITIS– TUBERCULOUS MENINGITIS– CRYPTOCOCCAL MENINGITIS– VIRAL ENCEPHALITIS– POLIOMYELITIS– SUB ARACHNOID HEMORRHAGE– LYME DISEASE (Borrelia infection)

TREATMENT OFACUTE BACTERIAL MENINGITIS

• EMPIRICAL THERAPY– CEFTRIAXONE OR CEFATOXIME OR

COMBINATION OF AMPICILLIN AND CHLORAMPHENICOL FOR 10-14 DAYS

• SPECIFIC ANTIMICROBIAL THERAPY– MENINGOCOCCAL MENINGITIS: PENICILLIN,

CEFOTAXIME OR CEFTRIAXONE– HEMOPHILUS MENINGITIS: CEFTRIAXONE/

CEFOTAXIME

TREATMENT……..

– STAPHYLOCOCCAL MENINGITIS: CLOXACILLIN OR VANCOMYCIN, • ADDITION OF RIFAMPICIN WILL ENHANCE THE

PENETRANCE OF THE CSF

– LISTERIA: AMIPCILLIN AND GENTAMYCIN– PSEUDOMONAS: CEFTAZIDIME AND

GENTAMYCIN, OR TICARCILLIN AND GENTAMYCIN

• DURATION OF TREATMENT: 10 DAYS EXCEPT FOR STAPHYLOCOCCAL MENINGITIS

TREATMENT…..

– STERIOD THERAPY• DEXAMETHASONE 0.15 MG/KG IV 6 HRLY FOR 5 DAYS • FIRST DOSE OF STEROID SHOULD PRECEDE 15 MIN

FROM ANTIBIOTICS • DECREASES THE INCIDENCE OF RESIDUAL

NEUROLOGICAL DEFICITS• ESPECIALLY USEFUL IN H. INFLUENZAE INFECTION

TREATMENT…………

• SYMPTOMATIC TREATMENT– RAISED ICP: OSMOTIC DIURETICS– CONVULSION: DIAZEPAM OR PHENYTOIN– RESTRICTION OF FLUID TO 2/3RD OF

MAINTENANCE TO PREVENT SIADH– NURSING CARE

• TREATMENT OF COMPLICATIONS• FOLLOW-UP AND REHABILITATION

TUBERCULOUS MENINGITIS

• PRIMARY• SECONDARY• PATHOGENESIS• PATHOLOGY: TUBERCLE, BASE AND

TEMPORAL LOBES• STAGES: PRODROMAL, MENINGITIS, COMA• DIAGNOSIS: LP, CT, BACTEC, PCR

TUBERCULOUS MENINGITIS

• D/D: PURULENT MENINGITIS, PARTIALLY TREATED,ENCEPHALITIS, TYPHOID ENCEPHALOPATHY, BRAIN ABSCESS, BRAIN TUMOR, CHRONIC SUBDURAL HEMATOMA, AMEBIC MENINGOENCEPHALITIS.

• TREATMENT: 12MTHS• INITIAL 2 MTHS: HRZE• LATER 10 MTHS: HRE

TUBERCULOUS MENINGITIS

• STEROIDS: DEXAMETHASONE IV- 1-2 WEEKS• ORAL FOR 6 WEEKS AND TAPER SLOWLY• OTHER SUPPORTIVE THERAPY.

ENCEPHALITIS

• DEFINE• ETIOLOGY/ PATHOLOGY : INCLUSION BODIES• VIRAL: MMR,HSV, CMV, EBV, JAPANEASE,

WEST NILE, RABIES, DANGUE• OTHER: RICKETTSIA, FUNGI, TOXOPLASMA,

BACTERIAL, REYES SYNDROME

ENCEPHALITIS

• ONSET: SUDDEN • SIGNS AND SYMPTOMS: FEVER, HEADACHE,

VOMITING, ALTERED MENTAL STATUS, IRRITABILITY, APATHY , COMA

• DECEREBRATION, DECORTICATION, PALSIES, PLAGIAS,

• EXTRAPYRAMIDAL SYMPTOMS: JAPANEASE B• TEMPORAL OR FRONTAL LOBE : HSV

ENCEPHALITIS

• RAISED ICT• HERNIATION• 6TH NERVE PALSY

• DIAGNOSIS• HISTORY OF EXPOSURE• LP• CSF, PCR

ENCEPHALITIS

• MANAGEMENT• SYMPTOMATIC: ICT, FEVER, SHOCK, SEIZURES• HSV: RBC IN CSF, TREATMENT : ACYCLOVIR

REYE’S SYNDROME

• GENERALISED MYOCARDIAL DYSFUNCTION• LIVER, KIDNEY , CNS• INHIBITION OF B-OXIDATION OF FATTY ACIDS• ASPRIN OTHER SALICYLATES, VIRAL INFECTION• HYPERAMMONEMIA, NEUROHYPOGLYCAEMIA• PRESENTATION:• 2MTHS – 15 YEARS• RAPID PROGRESSION

REYE’S SYNDROME

• STAGES• I- MILD CONFUSION• II – DELIRIUM• III – COMA• IV – APNEA, NON REACTING PUPIL• DIAGNOSIS:• HYPERAMMONEMIA, DEARRANGED LFT, EEG-

TRIPHASIC WAVES

REYE’S SYNDROME

• TREATMENT• LOW PROTEIN DIET• TREAT HEPATIC FAILURE• TREAT RAISED ICT• HYPOGLYCAEMIA• VITAMIN K , FFP