Intracranial Pressure/Vascular

Question 1

Subarachnoid hemorrhage

Answer 1

Pathophysiology:

• usually 2/2 ruptured aneurysm or AVM
• -> Berry aneurysm (75%)
• follows acute elevations in bp
• AVM (usually bleeds in 2nd-4th decade)
• (+) loss of consciousness 2/2 decreased cerebral bloodflow + concussive effects of rupture

Clinical:

• WHOL
• LOC, N/V, nuchal rigidity
• BP rises 2/2 hemorrhage
• meningeal irritation –> febrile
• focal signs uncommon
• preretinal globular subhyaloid hemorrhage
• CT: acute bleed
• CSF: xanthrochromia

Dx/Rx:

• complications: recurrent hemorrhage, arterial vasospasm, hydrocephalus, seizures
• rx: rest, analgesics, bp to <160/100
• CCBs decrease likelihood of vasospasm

Question 2

Hypertensive encephalopathy

Answer 2

Pathophysiology:

• pheochromocytoma
• malignant HTN
• BP 250/150 will lead to cerebral edema

Clinical:

• severe, throbbing pain
• lethargy
• hemiparesis
• +/- focal seizures

Dx/Rx: anti-hypertensive therapy

Question 3

Giant cell arteritis

Answer 3

Pathophysiology:

• subacute granulomatous infection in superficial temporal artery or vertebral artery
• W>M; >50 yo

Clinical:

• malaise
• fever
• weight loss
• unilateral or bilateral HA localized to the scalp over temporal arteries
• pain/stiffness in the jaw
• involvement of ophthalmic artery –> blindness

Dx/Rx:

• dx: biopsy, ESR
• rx: PREDNISONE

Question 4

Mass lesion

Answer 4

Pathophysiology:

• brain tumor
• subdural hematoma
• abscess

Clinical:

• bifrontal, worse ipsilaterally
• aggravated by increased icp
• maximal in the AM
• (+) N/V

Dx/Rx:
- tumor debulking

Question 5

Idiopathic increased ICP

Answer 5

Pathophysiology:

• pseudotumor cerebri
• diffuse increased in ICP
• F»»>M; onset 20s
• most patients are obese
• a/w vit A
• 2/2 decreased resorption of CSF

Clinical:

• HA
• papilledema
• pulsatile tinnitus
• diplopia

Dx/Rx:

• acetazolamide
• furosemide

Question 6

Trigeminal neuralgia

Answer 6

Pathophysiology:

• facial pain syndrome that develops mid to later in life
• 2/2 microvascular compression of nerve

Clinical:

• pain in V1, V2, V3 regions
• lightning-like, stabbing
• transient pain
• stimulated by sensory input

Dx/Rx: carbamazepine

Question 7

Postherpetic neuralgia

Answer 7

Pathophysiology:

• dermatomal distribution s/p herpes zoster eruption of local pain/tenderness
• occurs >50y
• increased incidence with increased age

Clinical:

• constant, severe stabbing pain or burning
• decreased cutaneous sensation to pin prick

Dx/Rx: amytriptylline

Question 8

Migraine

Answer 8

Pathophysiology:

• intracranial vasoconstriction + extracranial vasodilation
• “spreading depression” in bloodflow during the aura with increased flow during attack
• (?) serotonergic transmission

Clinical:

• -> Classic migraine: with aura!
• visual alterations
• throbbing unilateral HA
• remission common in pregnancy
• N/V, photo/phonophobia, irritability
• gradual onset, spontaneous resolution
• -> Common migraine: without aura!
• bilateral and periorbital
• throbbing pain +/- scalp tenderness
• vomiting may terminate HA

Dx/Rx:

• analgesics
• 5-HT agonists
• metaclopramide

Question 9

Cluster HA

Answer 9

Pathophysiology:

• M>F; age of onset around 25
• precipitated by EtOH

Clinical:

• brief, unilateral, severe
• a/w conjunctival injection, lacrimation, nasal stuffiness, Horner’s syndrome

Dx/Rx:

• imitrex
• 100% O2 for 10-15 mins