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Malpractice and pitfalls in neurological emergencies Prof. Mona Hussein
- 1. Common pitfalls and malpracticein Neurological emergencies: Interactive cases Dr Mona Hussein, Neurology Assistant Professor, Beni-Suef University
- 2. 1. Acute hemiplegia 2.Acute quadriplegia 3. Acute headache 4. New onset seizure Interactive cases:
- 3. Case (1): AcuteHemiplegia
- 4. Male patient,36 years old, not known to be diabetic or hypertensive, with no past history of any medical disease. The patient developed acute headache and Rt sided weakness 10 hours duration following exposure to severe emotional stress. There was no associated paresthesia, cranial nerves affection or sphincteric troubles. Blood pressure for this patient was 170/90 Presentation title 4 CASE (1)
- 5. What should youdo first for this patient?
- 6. Choose one answer 1.Consider him psychogenic and just do reassurance 2. Urgently give the patient antiplatelet or full anticoagulation 3. Urgently refer the patient for receiving thrombolytic therapy 4. CT brain 5. MRI brain with diffusion 6. MRI cervical 7. Another answer Presentation title 6
- 7.
- 8. Intracerebral hemorrhage Transverse myelitis Sinus thrombosis Clinicallyisolated syndrome Hypoglycemia Multiple sclerosis Psychogenic Presentation title 8 Ischemic stroke
- 9. What should youdo first for this patient? 1. Consider him psychogenic and just do reassurance 2. Urgently give the patient antiplatelet or full anticoagulation 3. Urgently refer the patient for receiving thrombolytic therapy 4. CT brain 5. MRI brain with diffusion 6. MRI cervical 7. Another answer Presentation title 9
- 10. If you considered thepatient psychogenic You will miss: 1. Intracerebral hemorrhage 2. Cerebral venous sinus thrombosis 3. Ischemic stroke 4. Multiple sclerosis 5. Transverse myelitis 6. Clinically isolated syndrome 7. Hypoglycemia Presentation title 10
- 11. If you gavethe patient full anticoagulation You may cause a great harm to the patient if he had: 1. Intracerebral hemorrhage 2. Large venous infarction 3. Large ischemic infarction Presentation title 11
- 12. If you referredthe patient for receiving thrombolytic therapy He is not indicated because therapeutic window for thrombolytic therapy in ischemic stroke is 4.5 hours Presentation title 12
- 13. If you firstlydid CT brain You will miss: 1. Cerebral venous sinus thrombosis 2. Ischemic stroke 3. Multiple sclerosis 4. Transverse myelitis 5. Hypoglycemia Presentation title 13
- 14. If you firstlydid MRI brain with diffusion You will miss 1. Cerebral venous sinus thrombosis 2. Transverse myelitis 3. Hypoglycemia Presentation title 14
- 15. If you firstlydid MRI cervical You will miss: 1. Intracerebral hemorrhage 2. Cerebral venous sinus thrombosis 3. Ischemic stroke 4. Multiple sclerosis 5. Hypoglycemia Presentation title 15
- 16. What you shoulddo sequentially? “ • ”
- 17. Do MRI cervical DoMRI brain with diffusion with MRV If normal: Random blood sugar If there was no hypoglycemia:
- 18. It these investigationswere normal; Can you consider the patient psychogenic??? Presentation title 18
- 19.
- 20. WHEN TO THINKOF PSYCHOGENIC HEMIPLEGIA ?? 1. Posture of spastic hemiplegia 2. Non-neuroanatomic mouth deviation 3. Discrepency between findings on standing and supine position 4. Motor aphasia with good reading and writing 5. Cogwheel “givingway” weakness 6. Pain is produced by maneuvers that should not be painful 7. Disproportionate response to routine examination such as collapsing, grimacing, guarding, groans, tremors
- 21. Case (2): AcuteQuadriplegia
- 22. Male patient38 years old, not known to be diabetic or hypertensive, had no history of any chronic disease The patient gives a history of having severe gastroenteritis lasting for 3 days followed by acute weakness affecting both upper and lower limbs, P=D There was no associated sensory deficit, cranial nerves involvement or sphincteric troubles. Planter reflex was equivocal Presentation title 22 CASE (2)
- 23. What should youdo first for this patient?
- 24. Choose one answer 1.EMG and NC 2. MRI Cervical 3. MRI brain with MRV 4. CSF analysis 5. Another answer Presentation title 24
- 25.
- 26. EXPECTED SCENARIOS 1. Hypokalemicparalysis 2. Gullian barre syndrome 3. Myositis 4. Transverse myelitis 5. Multiple sclerosis 6. Sinus thrombosis Presentation title 26
- 27. What should youdo first for this patient? 1. EMG and NC 2. MRI Cervical 3. MRI brain with MRV 4. CSF analysis 5. Another answer Presentation title 27
- 28. If you firstlydid EMG and NC You will miss: 1. Transverse myelitis 2. Multiple sclerosis 3. Sinus thrombosis 4. Hypokalemic paralysis NB. EMG and NC may be normal in the first two weeks of Guillian barre syndrome Presentation title 28
- 29. If you firstlydid MRI cervical You will miss: 1. Hypokalemic paralysis 2. Gullian barre syndrome 3. Myositis 4. Multiple sclerosis 5. Sinus thrombosis Presentation title 29
- 30. If you firstlydid MRI brain with MRV You will miss 1. Hypokalemic paralysis 2. Gullian barre syndrome 3. Myositis 4. Transverse myelitis Presentation title 30
- 31. If you firstlydid CSF analysis You will miss 1. Hypokalemic paralysis 2. Myositis You can`t also confirm the diagnosis of: 1. Gullian barre syndrome 2. Multiple sclerosis 3. Transverse myelitis 4. Sinus thrombosis Presentation title 31
- 32. What you shoulddo sequentially? “ • ”
- 33. MRI brain withMRV If normal Do MRI cervical If normal: Serum k and CPK If normal:
- 34. It these investigationswere normal; can you consider the patient psychogenic??? Presentation title 34
- 35.
- 36. Case (3): AcuteHeadache
- 37. Male patient,48 years old, not known to be diabetic or hypertensive, didn’t have any history of chronic disease The patient developed acute severe headache, nausea, and blurred vision following severe emotional stress The patient reported that he didn’t experience such headache before Fundus examination didn’t reveal any abnormalities Presentation title 37 CASE (3)
- 38. What should youdo first for this patient?
- 39. Choose one answer 1.Reassurance, give him analgesic and let him go home 2. CT brain 3. MRI brain with diffusion 4. CSF analysis 5. Another answer Presentation title 39
- 40.
- 41. Intracerebral hemorrhage Posterior reversible encephalopathysyndrome (PRES) Sinus thrombosis Reversible cerebral vasoconstriction syndrome (RCVS) Encephalitis Subarachnoid hemorrhage Acute hypertensive crisis Presentation title 41 Ischemic stroke
- 42. What should youdo first for this patient? 1. Give him analgesic and antiemetic and let him go home 2. CT brain 3. MRI brain with diffusion 4. CSF analysis 5. Another answer Presentation title 42
- 43. If you justgave the patient analgesic You will miss: 1. Acute hypertensive crisis 2. Subarachnoid hemorrhage 3. Intracerebral hemorrhage 4. Cerebral venous sinus thrombosis 5. Ischemic infarction 6. Posterior reversible encephalopathy syndrome (PRES) 7. Reversible cerebral vasoconstriction syndrome (RCVS) 8. CNS infection Presentation title 43
- 44. If you firstlydid CT brain You will miss: 1. Acute hypertensive crisis 2. Cerebral venous sinus thrombosis 3. Ischemic infarction 4. Posterior reversible encephalopathy syndrome (PRES) 5. Reversible cerebral vasoconstriction syndrome (RCVS) 6. CNS infection Presentation title 44
- 45. If you firstlydid MRI brain with diffusion You will miss 1. Acute hypertensive crisis 2. Subarachnoid hemorrhage 3. Cerebral venous sinus thrombosis Presentation title 45
- 46. If you firstlydid CSF analysis You will cause a great harm to the patient if he had: 1. Large Intracerebral hemorrhage 2. Large venous infarction 3. Large ischemic infarction Presentation title 46
- 47. What you shoulddo sequentially? “ • ”
- 48. Do CSF analysis DoMRI brain with diffusion with MRV with MRA If normal CT brain to exclude subarachnoid hemorrhage If normal: Measure BP Whether it was elevated or not do:
- 49. Case (4): Newonset seizures
- 50. Male patient61 years old, known to be hypertensive, presenting with new onset generalized tonic clonic seizures lasting less than 3 minutes followed by post-ictal confusion Neurological examination didn’t reveal any lateralization Presentation title 50 CASE (4)
- 51. What should youdo first for this patient?
- 52. Organic seizure ornot ? • Myoclonus • Focal fits • GTCs: Loss of consciousness, Upward rolling of eyeball Tongue biting, teeth clenching Frothy secretions Epileptic cry, cyanosis Urine incontinence Self traumatization Presentation title 52
- 53. Organic versus pseudoseizure Presentationtitle 53 Pseudoseizures Organic seizures +/- Gradual Sudden Onset Common Never Retained conscious in generalized seizures Common Rare Pelvic thrusting, thrashing, rolling movements Never Common Cyanosis Never Common Tongue biting and injury, other injury Common Rare Resistance to eye opening Uncommon Usual Stereotyped attacks Common Often Relation to emotional stress Absent Usual Post-ictal confusion Never Usually Ictal EEG abnormalities
- 54. American epilepsy society 0-5 min.:Stabilization phase 5-20 min.: initial therapy phase 20-40 min.: second therapy phase 40-60 min.: third therapy phase
- 55. EXPECTED SCENARIOS IF ORGANICSEIZURES
- 56. EXPECTED SCENARIOS 1. Metaboliccauses (Hypo or hyperglycemia - hypo or hypernatremia - Hypo or hypercalcemia - Hypo or hypermagnesemia - Hepatic or renal disorders - Thyroid disorder) 2. Cerebral venous sinus thrombosis 3. Ischemic stroke 4. Intracerebral hemorrhage 5. Subarachnoid hemorrhage 6. CNS infection 7. PRES or RVCS 8. Brain tumor 9. Psychogenic Presentation title 56
- 57. What should youdo? 1. Ask about drug intake or toxin exposure 2. Full metabolic profile (serum Na, Ca, Mg, FBS, thyroid, liver & kidney functions) 3. MRI brain with MRV 4. CSF analysis if metabolic profile and brain imaging were normal or if encephalitis or subarachnoid hemorrhage were suspected Presentation title 57
- 58.
- 59. In acute hemiplegia:you should firstly check blood sugar before doing brain imaging In acute quadriplegia: you should check serum K and CPK before doing spinal cord or brain imaging In acute headache: you should check blood pressure before doing brain imaging In new onset seizures: you have to initiate drug therapy if the seizures exceeded 5 minutes In new onset seizures: you have to ask about drug history and toxin exposure, do full metabolic profile, and brain imaging