Symptom To Diagnosis - Headache Flashcards
1
Q
Headaches are classified into ?
A
Primary and secondary.
2
Q
Primary headaches:
A
Syndromes unto themselves rather than signs of other diseases.
Although potentially disabling they are reliably NOT life threatening.
3
Q
Secondary headaches:
A
Symptoms of other illnesses –> Potentially dangerous.
4
Q
Single most important question when developing a DDX for a headache?
A
Is this headache new or old?
5
Q
Chronic headaches tend to be?
A
Primary.
6
Q
New-onset headaches tend to be?
A
Secondary.
7
Q
Old headaches - 2 categories:
A
- Primary.
2. Secondary.
8
Q
Old headaches - Primary:
A
- Tension headaches.
- Migraine headaches.
- Cluster headaches.
9
Q
Old headaches - Secondary:
A
- Cervical degenerative joint disease.
- Temporomandibular joint syndrome.
- Headaches associated with substances or their withdrawal –> Caffeine, nitrates, analgesics, ergotamine.
10
Q
New headaches - 2 categories:
A
- Primary.
2. Secondary.
11
Q
New headaches - Primary:
A
- Benign cough headache.
- Benign exertional headache.
- Headache associated with sexual activity.
- Benign thunderclap headache.
- Idiopathic intracranial HTN (pseudotumor cerebri).
12
Q
New headaches - Secondary:
A
- Infectious.
- Vascular.
- Space-occupying lesions.
- Medical morning headaches.
13
Q
New headaches - Secondary - Infectious:
A
- URI.
- Sinusitis.
- Meningitis.
14
Q
New headaches - Secondary - Vascular:
A
- Temporal arteritis.
- SAH.
- Parenchymal hemorrhage.
- Malignant HTN.
- Cavernous sinus thrombosis.
15
Q
New headaches - Secondary - Space-occupying lesions:
A
- Brain Tumors.
2. Subdural hematoma.
16
Q
New headaches - Secondary - Medical morning headaches:
A
- Sleep disturbance.
2. Night-time hypoglycemia.
17
Q
Severe or quality is more important in distinguishing a new from an old headache?
A
Quality.
–> Severe headache that is identical in quality to chronic headaches is less worrisome than a mild headache that is dissimilar to any previous headaches.
18
Q
Migraine headache - Textbook presentation:
A
- Women in their teens or 20s.
- Unilateral, throbbing, severe enough to make it impossible to do work during an attack.
- Occasionally preceded by about 20 min of flickering lights in a visual field (aura). Patients usually find it necessary to lie in a dark, quiet room.
19
Q
Auras in migraines:
A
33-75% of patients with migraines have auras.
20
Q
Of ALL people with migraine:
A
18% –> ALWAYS have auras.
13% –> SOMETIMES have auras.
8 –> Have auras WITHOUT headaches.
21
Q
Auras are usually?
A
Visual, precede the headache, and last for about 20 min.
22
Q
Descriptions of auras:
A
- Frequently, patients will initially describe a blind spot.
- Auras usually involve one part of the visual field.
- Scintillating scotoma often occur –> Flashing lights, spots of light, zigzag lights, or squiggles.
23
Q
Criteria for migraines without aura:
A
- A patient must have at least 5 attacks that last 4-72hrs.
- Headache must have 2 of the following qualities:
a. Unilateral pain.
b. Pulsating pain.
c. Moderate to severe pain (must limit activity).
d. Aggravated by routine physical activity. - And have 1 of the following associated symptoms:
a. Nausea and/or vomiting.
b. Photophobia or phonophobia.
24
Q
Criteria for migraines with aura:
A
- DEFINITION: Recurrent disorder manifesting in attacks of reversible focal neurologic symptoms that usually develop gradually over 5-20min and lasting less that 60min.
- Usually follow the aura symptoms.
- Must have at least 2 attacks.
25
...% of patients with migraine headaches have NON pulsatile headaches.
50%.
26
...% of patients with migraine headaches have BILATERAL headaches.
40%.
27
A recent systematic review suggested the mnemonic POUNDing as a diagnostic test for migraines:
1. Is the headache Pulsatile.
2. Does it last between 4 and 72hOurs without medications?
3. Is it Unilateral?
4. Is there Nausea?
5. Is it Disabling?
If 4/5 is YES --> LR+ 24.
28
When differentiating migraines from tension headaches, ... is an important clue to migraines.
NAUSEA.
29
9 Indications for imaging in people with headaches:
1. Abnormal neurologic exam or symptoms that are atypical for aura, especially dizziness, lack of coordination, numbness or tingling, or worsening of headache with the Valsalva maneuver.
2. Increasing frequency of headaches or a change in headache quality or pattern.
3. Headaches that awaken the patient from sleep.
4. New headaches in patients over 50.
5. 1st headache, worst headache, or abrupt-onset headache.
6. New headache in patients with cancer, immunosuppression, or pregnancy.
7. Headache associated with loss of consciousness.
8. Headache triggered by exertion.
9. Special consideration should be given to a person who is receiving warfarin therapy.
30
MC headaches?
Tension headaches.
31
Tension headache - Textbook presentation:
Generally occur a few times each month and are described as bilateral and squeezing.
--> Usually relieved with OTC analgesics and are seldom severe enough to cause real disability.
32
IHS definition of episodic tension headache?
1. Recurrent episodes of headache lasting minutes to days.
2. Pain is typically pressing/tightening in quality, of mild/moderate intensity, bilateral in location and does NOT worsen with routine physical activity.
3. Nausea is ABSENT.
4. Photophobia/phonophobia may be present.
33
1-year prevalence of tension headaches is?
63% --> Men.
| 86% --> Women.
34
IHS criteria differentiate headaches as?
1. Episodic or chronic.
| 2. With or without associated tenderness of pericranial muscles.
35
EBD of tension headaches - Common?
MC --> It is the default diagnosis in almost every patient with a mild to moderate headache syndrome.
36
EBD of tension headaches - IHS diagnostic criteria:
1. At least 10 previous headaches.
2. Duration of 30min to 7 days.
3. 2 of the following:
a. Pressing or tightening (non pulsating) quality.
b. Mild/moderate in severity (inhibits but does not prevent activity).
c. Bilateral.
d. Not aggravated by routine activity.
4. No nausea or vomiting.
5. Photophobia/phonophobia may be present, but not both.
37
Headache due to unruptured CNS aneurysm?
Classic presentation of a headache caused by a CNS aneurysm is a unilateral and throbbing headache that is NEW in a middle-aged patients.
38
CNS aneurysm may present in 3 ways:
1. Asymptomatic detection.
2. Acute rupture or acute expansion.
3. Chronic headache.
39
EBD of unruptured CNS aneurysms:
111 patients referred for therapy of unruptured aneurysms --> 54 had symptoms at diagnosis.
Of the 54 with symptoms --> 35 (64%) had chronic symptoms.
In 18 of these 35 --> Symptom was chronic headache without neurologic signs.
40
EBD of unruptured CNS aneurysms - Headache bilateral/unilateral?
Divided equally between unilateral and bilateral.
41
EBD of unruptured CNS aneurysms - Neuroimaging:
Contrast-enhanced CT and MRA --> Very sensitive means of detecting CNS aneurysms.
- -> Aneurysms >1cm --> 100%.
- -> Aneurysms Lower.
42
EBD of unruptured CNS aneurysms - Traditional angiography:
1. GOLD STANDARD.
2. Usually required prior to repair.
3. There are case reports of small aneurysms being missed on traditional angiography and being seen on CT and MRA.
43
Morning headache?
Edema forms around the CNS lesion while the patient is supine at night leading to headaches from increased intracranial pressure in the morning.
44
MC substances of which the withdrawal may cause morning headaches?
1. Caffeine.
2. Alcohol.
3. Carbon monoxide.
45
Intracranial neoplasms - Textbook presentation:
Brain tumors classically present with progressive morning headaches associated with focal neurologic deficits.
46
Brain tumors are classified as?
1. Metastatic.
2. Primary extra-axial.
3. Primary intra-axial.
47
Metastatic brain tumor from?
37% --> Lung.
19% --> Breast.
16% --> Melanoma.
48
Primary extra-axial brain tumors:
80% --> Meningioma.
10% --> Acoustic neuroma.
7% --> Pituitary adenoma.
49
Primary intra-axial brain tumors:
47% --> Glioblastoma.
| 39% --> Astrocytoma.
50
Metastatic brain tumors are about ... times more common than primary ones.
7
51
Intracranial neoplasms generally present with ...?
Focal signs --> Seizure, signs of increased intracranial pressure (headache).
52
Although the presenting symptoms of an intracranial neoplasm vary with type of tumor, the MC symptoms are:
50% --> Headache.
Seizure.
Hemiparesis.
Change in mental status.
53
EBD of intracranial neoplasms - Role of history?
NOT particularly helpful in making a diagnosis of intracranial neoplasms.
54
EBD of intracranial neoplasms - One very good report retrospectively studied 111 patients with brain tumors. Symptoms were NON SPECIFIC:
```
48% --> Headaches.
17% --> Classic brain tumor headache (severe, worse in the morning, associated with nausea/vomiting).
77% --> Met the criteria for tension headaches.
9% --> Migraine-like headaches.
MC qualities were:
67% --> Intermittent.
68% --> Frontal.
72% --> Bilateral.
```
55
EBD of brain tumors - Neuroimaging - Contrast-enhanced CT:
1. Reasonable choice for screening in low suspicion patients.
2. Sens is around 90%.
56
EBD of brain tumors - MRI with contrast?
PROCEDURE OF CHOICE --> Sens is around 100% and the detail provided often suggests a likely pathology.
57
Medical morning headaches - Textbook presentation:
1. Various diseases can cause headaches that occur predominantly in the morning.
2. Headaches are generally worse upon awekening and then improve as the day progresses.
3. More common symptoms of the underlying disease (daytime HYPOGLYCEMIA with overly controlled DM or daytime somnolence with OSA) are present.
58
Medical morning headaches - Most rigorously defined morning headaches are?
Those caused by disturbed sleep. The sleep disturbance can be of almost any etiology.
59
Primary sleep disturbance:
1. OSA.
| 2. Periodic leg movement of sleep (PLMS).
60
Abnormal sleep duration:
1. Excessive sleep.
2. Interrupted sleep.
3. Sleep deprivation.
61
Secondary to another disease:
1. Chronic pain.
| 2. Depression.
62
EBD of medical morning headaches:
1. Recognition of the OSA and nighttime hypoglycemia can be difficult since the clinical clues are NON SPECIFIC.
2. Nighttime hypoglycemia --> DM.
3. OSA --> Diagnosis with polysomnography - ALSO info about PLMS.
63
Headaches associated with substances or their withdrawal - Textbook presentation:
These are headaches that occur in close temporal relation to substance exposure or substance withdrawal.
--> They resolve when culprit substance is no longer used.
64
Many substances can cause headaches acutely, with long-term use, or after their withdrawal:
1. Acute exposure --> Nitrites ("hot dog headache"), MSG ("Chinese restaurant syndrome"), carbon monoxide.
2. Long term exposure --> Analgesics.
3. Withdrawal from acute exposure (alcohol).
4. Withdrawal from chronic exposure (caffeine, opioids).
65
EBD of caffeine withdrawal headaches - IHS criteria:
1. Bilateral or pulsating (or both) headache.
2. >200mg caffeine daily for >2wks.
3. Headaches within 24h of the last caffeine intake and are relieved within 1h by 100mg caffeine.
4. Headache resolves within 7d of total caffeine withdrawal.
66
An average cup of coffee contains?
About 100mg of caffeine.
| Premium coffees may contain more. A 12oz coffee at Starbucks contains 375mg of caffeine.
67
The average adult American ingests approx. ...mg of caffeine daily.
280mg.
68
Headaches when patients sleep later than usual or mainly on weekends or vacations?
Caffeine withdrawal headache should be considered.
69
EBD of substance withdrawal headaches - Carbon monoxide poisoning presentation:
Runs the spectrum from mild headache to headache with nausea, vomiting, and anxiety to coma and cardiovascular collapse.
70
EBD of carbon monoxide - Various aspects of patient's history that increase suspicion of this diagnosis?
1. Headache occurs only in a single location and resolves when the patient is removed from this setting.
2. Multiple family members/roommates have similar symptoms.
3. Carbon monoxide poisoning is MC in the WINTER.
71
EBD of carbon monoxide poisoning - Diagnosis:
An elevated carboxyHb level makes the diagnosis.
| ABG measurements and pulse ox do NOT detect CO poisoning.
72
What is a thunderclap headache?
Headache that begins at its peak intensity.
73
Rare diseases that can occasionally present with a thunderclap headache:
1. Cerebral venous sinus thrombosis.
2. Pituitary apoplexy.
3. Carotid dissection.
4. Spontaneous intracranial hypotension from CSF.
74
Bottom line about thunderclap headaches:
Assume to be caused by a sunarachnoid hemorrhage (SAH) until proven otherwise.
75
SAH - Textbook presentation:
1. Midde-aged with worst headache of his life.
2. Vomiting soon after beginning of headache.
3. Then focal neurologic symptoms.
4. Soon patient loses consciousness.
5. If patient is alert at the time of medical assessment --> Focal neurlogic signs and meningismus on physical exam.
76
SAH is primarily caused by?
Rupture of a saccular aneurysm in or near the circle of Willis (=85%).
77
Saccular aneurysms are present in about ...% of the population.
4%.
78
Largest saccular aneurysms (>1cm) rupture at a rate of about ...%/year.
0.5
79
Vast majority of saccular aneurysm ruptures occur in persons ...-... yo.
40-65yo.
80
SAH carries a mortality of about ...%.
50%.
81
It is generally accepted that anywhere from ...%-...% of patients will have a warning or sentinel headache in the weeks preceding the SAH.
10% to 50%.
82
Warning or sentinel headaches is caused by?
1. Likely caused by expansion or small leak from an aneurysm.
2. This headaches is usually thunderclap as SAH but resolves within 24hr.
3. About 50% of patients with warning headaches actually seek medical care.
83
EBD of SAH - SAH accounts for ...-...% of headaches presenting to the ED.
1-4%.
84
EBD of SAH - Among headaches presenting to the ED, SAH accounts for?
12% --> Worst headache of life.
| 25% --> Worst headache of life + neurologic findings.
85
EBD of SAH - Prevalence of various symptoms of SAH:
90% --> Headache.
74% --> Stiff neck.
60% --> Change in mental status.
27% --> Stupor or coma.
86
EBD of SAH - Initial diagnostic test:
```
NON contrast head CT.
Sens varies with the time since the onset of symptoms:
First 12h --> 97%.
12-24h --> 93%.
Falls as low as 80% after 2 weeks.
```
87
EBD of SAH - Next to angiography?
CSF exam for RBC and XANTHOCROMIA (result of oxyHb and later bilirubin) --> Most accurate diagnostic method.
88
EBD of SAH - Importance of correct diagnosis:
1. About 25% with SAH are initially MISDIAGNOSED.
2. Patients with less severe clinical presentations are most commonly misdiagnosed.
3. Patients who are initially misdiagnosed are only ABOUT HALF as likely to have a good or excellent outcome.
89
EBD of SAH - Bottom line:
All patients in whom SAH is suspected should undergo a NON CONTRAST head CT.
LP should be done in a patient with a normal head CT and even only minimal suspicion of SAH.
90
Cough headaches:
1. MC in men 3:1.
2. More common in older patients (mean age 67).
3. Last <1min.
91
Exertional headache:
1. MC in men (90%).
2. Mean age 24.
3. Bilateral + throbbing.
4. Sometimes related to migraines - some patients may induce migraines with physical activity.
5. Lasts from 5min to 24h.
92
Sexual headache:
1. MC in men (85%).
2. Mean age 41.
3. Lasts <3h.
93
Sexual headache - Can occur as 3 types:
Dull type --> Dull headache worsening with sexual excitement.
Explosive type --> SAH-like headache occurring at orgasm.
Postural headache --> Postural headache develops after coitus.
94
Benign thunderclap headache - Textbook presentation:
1. Present in a way indistinguishable from SAH.
2. Diagnosis is made after normal results are obtained on CT scan and lumbar puncture.
3. Headaches occasionally recur in an unpredictable way.
95
Benign thunderclap headache frequently recur over?
1-2 wk and then intermittently over years.
96
Benign thunderclap headache - In the best study of these headaches:
1. SAH developed in none of the 71 patients studied.
2. Headaches generally lasted from 8 to 72hr.
3. 51 (72%) of the patients had their headaches unrelated to cough, sexual activity, or exertion.
4. 17% of the patients had recurrent, similar headaches.
97
EBD of benign thunderclap headache:
1. Diagnosed when there is a suspicious clinical presentation and SAH is ruled OUT.
2. CT + LP should be performed in ALL patients prior to diagnosis.
3. Because benign thunderclap headaches are clinically indistinguishable from SAH, they can only be diagnosed after SAH has been ruled out.
98
Intracerebral hemorrhage - Textbook presentation:
Generally presents in older, hypertensive patients with acute-onset headache and focal neurologic symptoms and signs.
99
Intracerebral hemorrhage accounts for about ...% of strokes being less common than embolic and thrombotic strokes.
10%.
100
MCC of intracerebral hemorrhage:
HTN.
101
Other causes of intracerebral hemorrhage, besides HTN?
1. Amyloid angiopathy.
2. Saccular aneurysm rupture.
3. AV malformation rupture.
102
Among patients with HTN, which races have the highest risk of hemorrhagic CVAs?
Asians + Blacks.
103
AV malformations are present in ...% to ...% of the population and usually present in persons between the ages of ... and ... years.
0.01% to 0.05%.
| 20-40.
104
EBD of intracerebral hemorrhage - Symptoms:
1. Headache + Focal neurologic signs.
2. 60% --> Thunderclap-type headache.
3. 50% --> Vomiting.
4. 10% --> Seizures.
105
EBD of intracerebral hemorrhage - Imaging:
Non contrast CT and MRI --> equally accurate in making this diagnosis with sensitivities of nearly 100%.
--> MRI may be better at detecting hemorrhagic transformation of ischemic strokes.
106
Temporal arteritis - Textbook presentation:
1. White women >50.
2. Bilateral, throbbing headache.
3. Jaw claudication.
4. Polymyalgia rheumatica.
5. Beading + Tenderness over the temporal arteries.
6. ESR usually UP.
107
Although the MC presentation is a new headache, temporal arteritis can present with non specific manifestations of a chronic inflammatory disorder:
1. Fever.
2. Anemia.
3. Fatigue.
4. Weight loss.
5. Elevated ESR or CRP.
108
Temporal arteritis relationship with polymyalgia rheumatica:
15% of patients with PR --> Have temporal arteritis.
| 40% of patients with temporal arteritis --> Have PR.
109
EBD of temporal arteritis - LR+ for signs/symptoms:
4. 2-6.7 --> Jaw claudication.
3. 4-3.5 --> Diplopia.
4. 6 --> Beaded temporal artery.
4. 3 --> Enlarged temporal artery.
3. 0 --> Scalp tenderness.
2. 6 --> Temporal artery tenderness.
2. 0 --> Any temporal artery abnormality.
110
EBD of temporal arteritis - Few combinations of signs/symptoms have been found to have very high LR+:
Headache + Jaw claudication --> 7.0
| Scalp tenderness + Jaw claudication --> 17.0
111
Bottom line about temporal artery biopsy in temporal arteritis:
Because clinical signs and symptoms are NOT highly predictive, temporal artery biopsy should be used in any patient in whom the clinical suspicion is even moderate.
112
EBD of temporal arteritis - Temporal artery US:
1. Has been used as a diagnostic tool.
2. Inflamed arteries have a hypoechoic halo around the lumen.
3. Most studies have found this finding to be insensitive and NOT specific enough to avoid biopsy.
113
EBD of temporal arteritis - Temporal biopsy:
1. Gold standard.
2. ALWAYS recommended to establish the diagnosis.
3. Treatment should NOT be delayed to perform a biopsy in a patient in whom temporal arteritis is suspected.
114
Subdural hematoma - Textbook presentation:
Older patients with a history of falls and neurologic deterioration.
115
Classic triad of chronic subdural hematoma:
1. Headache.
2. Somnolence.
3. Change in mental status.
116
Acute subdural hematomas mean?
Within 24h of injury.
117
Subacute subdural hematomas mean?
1-14d after injury.
118
What is difficult to diagnose, acute, subacute, or chronic subdural hematoma?
Chronic.
Acute + Subacute generally pose little diagnostic problem --> Usually produce evolving, focal neurologic deficits.
Chronic can present with subtle symptoms, weeks to months after trauma and can pose a real diagnostic challenge.
119
Risk factors for subdural hematomas:
1. Frequent falls.
2. Alcoholic dependence.
3. Use of anticoagulant medications such as warfarin or aspirin.
120
EBD of subdural hematoma - Diagnosis requires?
HIGH INDEX OF SUSPICION because the presenting symptoms are often subtle.
121
EBD of subdural hematoma - Mean age at diagnosis is?
70yr.
122
EBD of subdural hematoma - MC presenting symptoms:
1. Falls.
| 2. Progressive neurologic deficits.
123
EBD of subdural hematoma - Neuroimaging:
1. CT scan and MRI are both effective means of diagnosing chronic subdural hematoma.
2. Caution with NON contrast head CT --> Blood in a chronic subdural hematoma can sometimes be isodense with cortical tissue.
124
Meningitis - Textbook presentation:
Classically meningitis presents with the acute onset of the triad of headache, fever, and a stiff neck.
Meningitis may occur in the setting of a cluster of cases.
125
DDX of headache + fever:
1. Viral infections and almost any other febrile illness.
2. Meningitis (bacterial, fungal, viral, or parasitic).
3. Encephalitis.
4. Sinusitis.
5. CNS abscess.
6. Septic cavernous sinus thrombosis.
126
Mortality rates vary by organism but community-acquired bacterial meningitis has a mortality rate of about ...%.
25%.
127
EBD of meningitis - Prevalence of various exam features:
95% --> At least 2 of the findings of headache, fever, stiff neck, or mental status changes.
87% --> Headache.
83% --> Stiff neck.
77% --> Temperatures >38.
69% --> Change in mental status.
33% --> Focal neurologic findings.
34% --> Those who had imaging done had an abnormal CT scan.
128
EBD of meningitis - Patients with suppressed immune system and the elderly are ...?
LESS likely to have a stiff neck.
129
EBD of meningitis - Lumbar puncture:
The only means of making a definitive diagnosis.
130
EBD of meningitis - Contraindications to LP:
```
Whenever there is suspicion of increased ICP.
Perform CNS imaging first.
1. CNS mass.
2. Elevated ICP.
3. Bleeding diathesis.
```
131
EBD of meningitis - Findings associated with mass effect on CT scan are:
1. Age >60.
2. Immunocompromise.
3. Pre-existing CNS disease.
4. Seizures within the previous week.
5. Abnormal level of consciousness.
6. Inability to answer 2 consecutive questions or follow 2 consecutive commands correctly.
7. Gaze palsy, abnormal visual fields, facial palsy, arm or leg drift, aphasia.
132
IHS definition of episodic tension headache?
1. Recurrent episodes of headache lasting minutes to days.
2. Pain is typically pressing/tightening in quality, of mild/moderate intensity, bilateral in location and does NOT worsen with routine physical activity.
3. Nausea is ABSENT.
4. Photophobia/phonophobia may be present.
133
1-year prevalence of tension headaches is?
63% --> Men.
| 86% --> Women.
134
IHS criteria differentiate headaches as?
1. Episodic or chronic.
| 2. With or without associated tenderness of pericranial muscles.
135
EBD of tension headaches - Common?
MC --> It is the default diagnosis in almost every patient with a mild to moderate headache syndrome.
136
EBD of tension headaches - IHS diagnostic criteria:
1. At least 10 previous headaches.
2. Duration of 30min to 7 days.
3. 2 of the following:
a. Pressing or tightening (non pulsating) quality.
b. Mild/moderate in severity (inhibits but does not prevent activity).
c. Bilateral.
d. Not aggravated by routine activity.
4. No nausea or vomiting.
5. Photophobia/phonophobia may be present, but not both.
137
Headache due to unruptured CNS aneurysm?
Classic presentation of a headache caused by a CNS aneurysm is a unilateral and throbbing headache that is NEW in a middle-aged patients.
138
CNS aneurysm may present in 3 ways:
1. Asymptomatic detection.
2. Acute rupture or acute expansion.
3. Chronic headache.
139
EBD of unruptured CNS aneurysms:
111 patients referred for therapy of unruptured aneurysms --> 54 had symptoms at diagnosis.
Of the 54 with symptoms --> 35 (64%) had chronic symptoms.
In 18 of these 35 --> Symptom was chronic headache without neurologic signs.
140
EBD of unruptured CNS aneurysms - Headache bilateral/unilateral?
Divided equally between unilateral and bilateral.
141
EBD of unruptured CNS aneurysms - Neuroimaging:
Contrast-enhanced CT and MRA --> Very sensitive means of detecting CNS aneurysms.
- -> Aneurysms >1cm --> 100%.
- -> Aneurysms Lower.
142
EBD of unruptured CNS aneurysms - Traditional angiography:
1. GOLD STANDARD.
2. Usually required prior to repair.
3. There are case reports of small aneurysms being missed on traditional angiography and being seen on CT and MRA.
143
Morning headache?
Edema forms around the CNS lesion while the patient is supine at night leading to headaches from increased intracranial pressure in the morning.
144
MC substances of which the withdrawal may cause morning headaches?
1. Caffeine.
2. Alcohol.
3. Carbon monoxide.
145
Intracranial neoplasms - Textbook presentation:
Brain tumors classically present with progressive morning headaches associated with focal neurologic deficits.
146
Brain tumors are classified as?
1. Metastatic.
2. Primary extra-axial.
3. Primary intra-axial.
147
Metastatic brain tumor from?
37% --> Lung.
19% --> Breast.
16% --> Melanoma.
148
Primary extra-axial brain tumors:
80% --> Meningioma.
10% --> Acoustic neuroma.
7% --> Pituitary adenoma.
149
Primary intra-axial brain tumors:
47% --> Glioblastoma.
| 39% --> Astrocytoma.
150
Metastatic brain tumors are about ... times more common than primary ones.
7
151
Intracranial neoplasms generally present with ...?
Focal signs --> Seizure, signs of increased intracranial pressure (headache).
152
Although the presenting symptoms of an intracranial neoplasm vary with type of tumor, the MC symptoms are:
50% --> Headache.
Seizure.
Hemiparesis.
Change in mental status.
153
EBD of intracranial neoplasms - Role of history?
NOT particularly helpful in making a diagnosis of intracranial neoplasms.
154
EBD of intracranial neoplasms - One very good report retrospectively studied 111 patients with brain tumors. Symptoms were NON SPECIFIC:
```
48% --> Headaches.
17% --> Classic brain tumor headache (severe, worse in the morning, associated with nausea/vomiting).
77% --> Met the criteria for tension headaches.
9% --> Migraine-like headaches.
MC qualities were:
67% --> Intermittent.
68% --> Frontal.
72% --> Bilateral.
```
155
EBD of brain tumors - Neuroimaging - Contrast-enhanced CT:
1. Reasonable choice for screening in low suspicion patients.
2. Sens is around 90%.
156
EBD of brain tumors - MRI with contrast?
PROCEDURE OF CHOICE --> Sens is around 100% and the detail provided often suggests a likely pathology.
157
Medical morning headaches - Textbook presentation:
1. Various diseases can cause headaches that occur predominantly in the morning.
2. Headaches are generally worse upon awekening and then improve as the day progresses.
3. More common symptoms of the underlying disease (daytime HYPOGLYCEMIA with overly controlled DM or daytime somnolence with OSA) are present.
158
Medical morning headaches - Most rigorously defined morning headaches are?
Those caused by disturbed sleep. The sleep disturbance can be of almost any etiology.
159
Primary sleep disturbance:
1. OSA.
| 2. Periodic leg movement of sleep (PLMS).
160
Abnormal sleep duration:
1. Excessive sleep.
2. Interrupted sleep.
3. Sleep deprivation.
161
Secondary to another disease:
1. Chronic pain.
| 2. Depression.
162
EBD of medical morning headaches:
1. Recognition of the OSA and nighttime hypoglycemia can be difficult since the clinical clues are NON SPECIFIC.
2. Nighttime hypoglycemia --> DM.
3. OSA --> Diagnosis with polysomnography - ALSO info about PLMS.
163
Headaches associated with substances or their withdrawal - Textbook presentation:
These are headaches that occur in close temporal relation to substance exposure or substance withdrawal.
--> They resolve when culprit substance is no longer used.
164
Many substances can cause headaches acutely, with long-term use, or after their withdrawal:
1. Acute exposure --> Nitrites ("hot dog headache"), MSG ("Chinese restaurant syndrome"), carbon monoxide.
2. Long term exposure --> Analgesics.
3. Withdrawal from acute exposure (alcohol).
4. Withdrawal from chronic exposure (caffeine, opioids).
165
EBD of caffeine withdrawal headaches - IHS criteria:
1. Bilateral or pulsating (or both) headache.
2. >200mg caffeine daily for >2wks.
3. Headaches within 24h of the last caffeine intake and are relieved within 1h by 100mg caffeine.
4. Headache resolves within 7d of total caffeine withdrawal.
166
An average cup of coffee contains?
About 100mg of caffeine.
| Premium coffees may contain more. A 12oz coffee at Starbucks contains 375mg of caffeine.
167
The average adult American ingests approx. ...mg of caffeine daily.
280mg.
168
Headaches when patients sleep later than usual or mainly on weekends or vacations?
Caffeine withdrawal headache should be considered.
169
EBD of substance withdrawal headaches - Carbon monoxide poisoning presentation:
Runs the spectrum from mild headache to headache with nausea, vomiting, and anxiety to coma and cardiovascular collapse.
170
EBD of carbon monoxide - Various aspects of patient's history that increase suspicion of this diagnosis?
1. Headache occurs only in a single location and resolves when the patient is removed from this setting.
2. Multiple family members/roommates have similar symptoms.
3. Carbon monoxide poisoning is MC in the WINTER.
171
EBD of carbon monoxide poisoning - Diagnosis:
An elevated carboxyHb level makes the diagnosis.
| ABG measurements and pulse ox do NOT detect CO poisoning.
172
What is a thunderclap headache?
Headache that begins at its peak intensity.
173
Rare diseases that can occasionally present with a thunderclap headache:
1. Cerebral venous sinus thrombosis.
2. Pituitary apoplexy.
3. Carotid dissection.
4. Spontaneous intracranial hypotension from CSF.
174
Bottom line about thunderclap headaches:
Assume to be caused by a sunarachnoid hemorrhage (SAH) until proven otherwise.
175
SAH - Textbook presentation:
1. Midde-aged with worst headache of his life.
2. Vomiting soon after beginning of headache.
3. Then focal neurologic symptoms.
4. Soon patient loses consciousness.
5. If patient is alert at the time of medical assessment --> Focal neurlogic signs and meningismus on physical exam.
176
SAH is primarily caused by?
Rupture of a saccular aneurysm in or near the circle of Willis (=85%).
177
Saccular aneurysms are present in about ...% of the population.
4%.
178
Largest saccular aneurysms (>1cm) rupture at a rate of about ...%/year.
0.5
179
Vast majority of saccular aneurysm ruptures occur in persons ...-... yo.
40-65yo.
180
SAH carries a mortality of about ...%.
50%.
181
It is generally accepted that anywhere from ...%-...% of patients will have a warning or sentinel headache in the weeks preceding the SAH.
10% to 50%.
182
Warning or sentinel headaches is caused by?
1. Likely caused by expansion or small leak from an aneurysm.
2. This headaches is usually thunderclap as SAH but resolves within 24hr.
3. About 50% of patients with warning headaches actually seek medical care.
183
EBD of SAH - SAH accounts for ...-...% of headaches presenting to the ED.
1-4%.
184
EBD of SAH - Among headaches presenting to the ED, SAH accounts for?
12% --> Worst headache of life.
| 25% --> Worst headache of life + neurologic findings.
185
EBD of SAH - Prevalence of various symptoms of SAH:
90% --> Headache.
74% --> Stiff neck.
60% --> Change in mental status.
27% --> Stupor or coma.
186
EBD of SAH - Initial diagnostic test:
```
NON contrast head CT.
Sens varies with the time since the onset of symptoms:
First 12h --> 97%.
12-24h --> 93%.
Falls as low as 80% after 2 weeks.
```
187
EBD of SAH - Next to angiography?
CSF exam for RBC and XANTHOCROMIA (result of oxyHb and later bilirubin) --> Most accurate diagnostic method.
188
EBD of SAH - Importance of correct diagnosis:
1. About 25% with SAH are initially MISDIAGNOSED.
2. Patients with less severe clinical presentations are most commonly misdiagnosed.
3. Patients who are initially misdiagnosed are only ABOUT HALF as likely to have a good or excellent outcome.
189
EBD of SAH - Bottom line:
All patients in whom SAH is suspected should undergo a NON CONTRAST head CT.
LP should be done in a patient with a normal head CT and even only minimal suspicion of SAH.
190
Cough headaches:
1. MC in men 3:1.
2. More common in older patients (mean age 67).
3. Last <1min.
191
Exertional headache:
1. MC in men (90%).
2. Mean age 24.
3. Bilateral + throbbing.
4. Sometimes related to migraines - some patients may induce migraines with physical activity.
5. Lasts from 5min to 24h.
192
Sexual headache:
1. MC in men (85%).
2. Mean age 41.
3. Lasts <3h.
193
Sexual headache - Can occur as 3 types:
Dull type --> Dull headache worsening with sexual excitement.
Explosive type --> SAH-like headache occurring at orgasm.
Postural headache --> Postural headache develops after coitus.
194
Benign thunderclap headache - Textbook presentation:
1. Present in a way indistinguishable from SAH.
2. Diagnosis is made after normal results are obtained on CT scan and lumbar puncture.
3. Headaches occasionally recur in an unpredictable way.
195
Benign thunderclap headache frequently recur over?
1-2 wk and then intermittently over years.
196
Benign thunderclap headache - In the best study of these headaches:
1. SAH developed in none of the 71 patients studied.
2. Headaches generally lasted from 8 to 72hr.
3. 51 (72%) of the patients had their headaches unrelated to cough, sexual activity, or exertion.
4. 17% of the patients had recurrent, similar headaches.
197
EBD of benign thunderclap headache:
1. Diagnosed when there is a suspicious clinical presentation and SAH is ruled OUT.
2. CT + LP should be performed in ALL patients prior to diagnosis.
3. Because benign thunderclap headaches are clinically indistinguishable from SAH, they can only be diagnosed after SAH has been ruled out.
198
Intracerebral hemorrhage - Textbook presentation:
Generally presents in older, hypertensive patients with acute-onset headache and focal neurologic symptoms and signs.
199
Intracerebral hemorrhage accounts for about ...% of strokes being less common than embolic and thrombotic strokes.
10%.
200
MCC of intracerebral hemorrhage:
HTN.
201
Other causes of intracerebral hemorrhage, besides HTN?
1. Amyloid angiopathy.
2. Saccular aneurysm rupture.
3. AV malformation rupture.
202
Among patients with HTN, which races have the highest risk of hemorrhagic CVAs?
Asians + Blacks.
203
AV malformations are present in ...% to ...% of the population and usually present in persons between the ages of ... and ... years.
0.01% to 0.05%.
| 20-40.
204
EBD of intracerebral hemorrhage - Symptoms:
1. Headache + Focal neurologic signs.
2. 60% --> Thunderclap-type headache.
3. 50% --> Vomiting.
4. 10% --> Seizures.
205
EBD of intracerebral hemorrhage - Imaging:
Non contrast CT and MRI --> equally accurate in making this diagnosis with sensitivities of nearly 100%.
--> MRI may be better at detecting hemorrhagic transformation of ischemic strokes.
206
Temporal arteritis - Textbook presentation:
1. White women >50.
2. Bilateral, throbbing headache.
3. Jaw claudication.
4. Polymyalgia rheumatica.
5. Beading + Tenderness over the temporal arteries.
6. ESR usually UP.
207
Although the MC presentation is a new headache, temporal arteritis can present with non specific manifestations of a chronic inflammatory disorder:
1. Fever.
2. Anemia.
3. Fatigue.
4. Weight loss.
5. Elevated ESR or CRP.
208
Temporal arteritis relationship with polymyalgia rheumatica:
15% of patients with PR --> Have temporal arteritis.
| 40% of patients with temporal arteritis --> Have PR.
209
EBD of temporal arteritis - LR+ for signs/symptoms:
4. 2-6.7 --> Jaw claudication.
3. 4-3.5 --> Diplopia.
4. 6 --> Beaded temporal artery.
4. 3 --> Enlarged temporal artery.
3. 0 --> Scalp tenderness.
2. 6 --> Temporal artery tenderness.
2. 0 --> Any temporal artery abnormality.
210
EBD of temporal arteritis - Few combinations of signs/symptoms have been found to have very high LR+:
Headache + Jaw claudication --> 7.0
| Scalp tenderness + Jaw claudication --> 17.0
211
Bottom line about temporal artery biopsy in temporal arteritis:
Because clinical signs and symptoms are NOT highly predictive, temporal artery biopsy should be used in any patient in whom the clinical suspicion is even moderate.
212
EBD of temporal arteritis - Temporal artery US:
1. Has been used as a diagnostic tool.
2. Inflamed arteries have a hypoechoic halo around the lumen.
3. Most studies have found this finding to be insensitive and NOT specific enough to avoid biopsy.
213
EBD of temporal arteritis - Temporal biopsy:
1. Gold standard.
2. ALWAYS recommended to establish the diagnosis.
3. Treatment should NOT be delayed to perform a biopsy in a patient in whom temporal arteritis is suspected.
214
Subdural hematoma - Textbook presentation:
Older patients with a history of falls and neurologic deterioration.
215
Classic triad of chronic subdural hematoma:
1. Headache.
2. Somnolence.
3. Change in mental status.
216
Acute subdural hematomas mean?
Within 24h of injury.
217
Subacute subdural hematomas mean?
1-14d after injury.
218
What is difficult to diagnose, acute, subacute, or chronic subdural hematoma?
Chronic.
Acute + Subacute generally pose little diagnostic problem --> Usually produce evolving, focal neurologic deficits.
Chronic can present with subtle symptoms, weeks to months after trauma and can pose a real diagnostic challenge.
219
Risk factors for subdural hematomas:
1. Frequent falls.
2. Alcoholic dependence.
3. Use of anticoagulant medications such as warfarin or aspirin.
220
EBD of subdural hematoma - Diagnosis requires?
HIGH INDEX OF SUSPICION because the presenting symptoms are often subtle.
221
EBD of subdural hematoma - Mean age at diagnosis is?
70yr.
222
EBD of subdural hematoma - MC presenting symptoms:
1. Falls.
| 2. Progressive neurologic deficits.
223
EBD of subdural hematoma - Neuroimaging:
1. CT scan and MRI are both effective means of diagnosing chronic subdural hematoma.
2. Caution with NON contrast head CT --> Blood in a chronic subdural hematoma can sometimes be isodense with cortical tissue.
224
Meningitis - Textbook presentation:
Classically meningitis presents with the acute onset of the triad of headache, fever, and a stiff neck.
Meningitis may occur in the setting of a cluster of cases.
225
DDX of headache + fever:
1. Viral infections and almost any other febrile illness.
2. Meningitis (bacterial, fungal, viral, or parasitic).
3. Encephalitis.
4. Sinusitis.
5. CNS abscess.
6. Septic cavernous sinus thrombosis.
226
Mortality rates vary by organism but community-acquired bacterial meningitis has a mortality rate of about ...%.
25%.
227
EBD of meningitis - Prevalence of various exam features:
95% --> At least 2 of the findings of headache, fever, stiff neck, or mental status changes.
87% --> Headache.
83% --> Stiff neck.
77% --> Temperatures >38.
69% --> Change in mental status.
33% --> Focal neurologic findings.
34% --> Those who had imaging done had an abnormal CT scan.
228
EBD of meningitis - Patients with suppressed immune system and the elderly are ...?
LESS likely to have a stiff neck.
229
EBD of meningitis - Lumbar puncture:
The only means of making a definitive diagnosis.
230
EBD of meningitis - Contraindications to LP:
```
Whenever there is suspicion of increased ICP.
Perform CNS imaging first.
1. CNS mass.
2. Elevated ICP.
3. Bleeding diathesis.
```
231
EBD of meningitis - Findings associated with mass effect on CT scan are:
1. Age >60.
2. Immunocompromise.
3. Pre-existing CNS disease.
4. Seizures within the previous week.
5. Abnormal level of consciousness.
6. Inability to answer 2 consecutive questions or follow 2 consecutive commands correctly.
7. Gaze palsy, abnormal visual fields, facial palsy, arm or leg drift, aphasia.
232
Less than ...% of all headaches are life-threatening.
1%.
