Tintinalli's - HA Flashcards
clinical red flags for HA onset
- Sudden
- trauma
- exertion
clinical red flags for HA sx
- Altered mental status
- Seizure
- Fever
- Neuro sx
- Visual changes
clinical red flags for HA meds
- anticoag/antiplatelet
- Recent abx use
- immunosupp
clinical red flags of HA hx
- No prior HA
- Change in HA quality, or worsening over wks/mo
clinical red flags of HA associated conditions
- Pregnancy or post pregnancy status
- SLE
- Behcet’s disease
- Vasculitis
- Sarcoidosis
- Cancer
clinical red flags of HA PE findings
- Altered mental status
- Fever
- Neck stiffness
- Papilledema
- Focal neurologic signs
what age group are considered high-risk pts?
> 50 y/o with new/worsening HA, “thunderclap HA”
CT noncontrast is useful for what other DDx?
- hemorrhage
- subdural hematoma
- space-occupying lesion
- elevated ICP
- SAH
MRI would be a good imaging choice for what DDx?
cerebral venous thrombosis
MR/CR angiography imaging would be a good choice for what other DDx?
- arterial dissection
- small SAH
lumbar puncture would be an important diagnostic work-up for what other DDx?
- meningitis
- encephalitis
- SAH
hemorrhagic causes of “thunderclap” HA
- Intracranial hemorrhage
- “Sentinel” aneurysmal hemorrhage
- Spontaneous intracerebral hemorrhage
vascular causes of “thunderclap HA”
- Carotid or vertebrobasilar dissection
- Reversible cerebral vasoconstriction syndrome (RCVS)
- Cerebral venous thrombosis
- Posterior reversible encephalopathy syndrome (PRES)
other causes (besides hemorrhage and vascular) of “thunderclap HA”
- Coital HA
- Valsalva-associated HA
- Spontaneous intracranial HoTN
- Acute hydrocephalus
- Pituitary apoplexy
- bilateral/unilateral
- Constant/intermittent
- Worse upon awakening, valsalva, positional
- N/V
- Cancer dx, seizures, or mental status change = primary or metastatic brain lesion
brain tumor
- Hypercoagulable state - OCP, postpartum or periop status, clotting factor def., polycythemia
- Papilledema
- Neuro findings - wax and wane
Cerebral venous thrombosis
diagnostics of Cerebral venous thrombosis
- LP - increased opening pressure
- DX: MR venography
- ≥50 y/o
- new HA
- temporal artery abnormality - tender, nonpulsatile, or diminished pulse
- ESR ≥50
- abnormal bx
other: Fatigue, F, jaw claudication, vision changes
temporal arteritis
diagnostics temporal arteritis
Labs - ESR/CRP
DX: temporal artery bx
tx temporal arteritis
- prednisone
- consult ophthalmologist or other specialist to arrange bx to confirm dx, f/u, and tx
MCC benign HA
migraine
Pt with HA describes it as:
Gradual onset, lasting 4-72h
Unilateral, pulsating
Worsening by physical activity
N/V, photophobia, phonophobia
W/ or w/o aura
what is the dx
migraine
tx migraine
- DHE, sumatriptan, metoclopramide, chlorpromazine, or prochlorperazine
- Dexamethasone IV - adjunctive to reduce migraine recurrence
Idiopathic intracranial HTN aka Pseudotumor cerebri is MC in what demographic
Obese women, 20-44 y/o
- quick vision disturbances, back pain, pulsatile tinnitus
- Permanent vision loss if left untreated
Idiopathic intracranial HTN
DX criteria for Idiopathic intracranial HTN
- Papilledema
- nml neuro exam
- increased LP opening pressure
HA after a procedure involving dura (LP, epidural anesthesia)
Intracranial HoTN
- HA worsens w/ upright position; Alleviated: lying down
- N/V, hearing/vision changes
Intracranial HoTN
tx Intracranial HoTN
- acetazolamide
- wt loss if obese
- LP for therapeutic to reduce pressure to 15-20 cm H2O
- consult neuro and/or ophthalmologist
- If d/t LP or epidural anesthesia - symptomatic; most effective epidural blood patch by anesthesiologist
- Uncommon
- Daily for wks, periods of remission that may last for wks-yrs
- Severe, unilateral, localized (orbital, supraorbital, or temporal)
- Lacrimation, nasal congestion, rhinorrhea, conjunctival injection, pacing in room
cluster HA
tx cluster HA
- high-flow oxygen @ 12 L/min x 15 min via nonrebreathing face mask
- sumitriptan SQ for pain if unresolved
SAH onset of sx assoc w/ activities that affects BP how?
elevate BP - sex, wt lifting, defection, coughing
s/s SAH
- Loss of consciousness
- seizure
- diplopia
- vomiting
- photophobia
- nuchal irritation
- low-grade fever
- altered mental status
- +/- focal neuro findings - dependent on location of aneurysm
major arteries and what region of brain it supplies
- Ophthalmic - Optic nerve and retain
- Anterior cerebral - Frontal pole; Anteromedial cerebral cortex; Anterior corpus callosum
- Middle Cerebral - Frontoparietal lobe; Anterotemporal lobe
- Vertebral - brainstem
- Posteroinferior cerebellar - Cerebellum
- Basilar - Thalamus
- Posterior cerebral - Auditory/vestibular structures
- Medial temporal lobe - Visual occipital cortex
SAH RF
- Excessive alc
- Polycystic kidney disease
- FHx SAH
- Marfan’s syndrome
- Ehlers-Danlos syndrome
- Drug use hx, chiropractors, BP elevating activities
Stroke RF
- Age
- Comorbidities
- Afib
- HTN
- DM
- Smoking
- Coronary atherosclerosis
- Valvular replacement
- Recent MI
SAH PE
- Motor weakness
- Sensory deficits
- Cerebellar dysfunction
- Other: meningismus, carotid bruits, signs of embolic disease, papilledema, preretinal hemorrhage
diagnostics SAH
-
CT noncontrast
- If done earlier = better dx! (< 6hrs)
- If negative but SAH still suspected → LP = RBC or xanthochromia - Other tests - glucose, CBC, ECG, pulse ox, lytes, coags, cardiac enzymes, tox screen, blood alc, echo, carotid duplex scanning
- High suspicion for other DDX → MRI, MR angiogram, CT angiogram
DDX for SAH
- Intracranial hemorrhage
- Drug toxicity
- Ischemic stroke
- Meningitis
- Encephalitis
- Intracranial tumor
- Venous sinus thrombosis
- Primary HA syndromes
tx SAH
- ABCs, IV access, glucose testing, cardiac monitoring and pulse ox (keep pulse ox >94%)
- Once stabilized → noncontrast CT and labs, including coagulation studies.
- BP control at a pt’s prehemorrhage BP or a MAP < 140 mm Hg if the baseline bp is unknown.
- IV labetalol / nicardipine
- Admit ICU in consultation with a neurosurgeon.
- nimodipine PO - improvements by decreasing vasospasm
- Seizure prophylaxis is controversial and should be discussed with the admitting specialist.
- Reverse any coagulopathy with Vit K, FFP, and/or prothrombin concentrates.
SAH risk of rebleeding is greatest in when?
the first 24 hrs
indications for early neurosurgical consultation is appropriate for patients with SAH
- evidence of increased ICP
- location of bleeding
- other conditions suggest that surgical intervention may be indicated.
inflammation of membranes surrounding brain and spinal cord
Meningitis
causes of Meningitis
- bacterial
- aseptic - Drug reactions, rheumatologic, nonbacterial infections (fungi, virus)
- MC - enteroviruses & echoviruses
meningitis triad
1) F,
2) Neck stiffness
3) altered mental status
MC - HA + F
- Fever
- Meningeal signs - nuchal rigidity, Kernig’s, Brudzinski’s
- Skin - petechiae, splinter hemorrhages
these PE findings are for what dx?
Meningitis
infection of brain parenchyma → inflammation within CNS
Encephalitis
MCC viral infection of Encephalitis
HSV
presentation of encephalitis
Same as meningitis
+ Altered mental status, cognitive deficits, psychiatric sx, seizures
when to get CT before getting an LP for meningitis/encephalitis
- altered mental status
- new onset of seizures
- Immunocomp
- focal neuro signs
- papilledema
CI to LP - occult mass, signs of brain shift or herniation
diagnostics for meningitis/encephalitis
-
LP
- CSF - cell count & diff, protein & glucose lvls, gram staining, bacterial cx - CBC, glucose & lytes, BUN, Cr, blood cx
- MRI
when would additional work-up needed on CSF with meningitis/encephalitis
- immunocomp or specific CNS infections
- Additional: HSV, enterovirus PCT, bacterial antigen, fungal
MRI findings in medial temporal and inferior frontal lobes is indicative of
HSV
tx meningitis
Empiric ASAP after LP/blood cx
- 1st: Dexamethasone - >3 mo
- < 50 y/o - ceftriaxone + vanc
- Add Ampicillin - Listeria (>50 y/o, pregnant, alc, immunocomp)
tx encephalitis
- Acyclovir
- CMV - ganciclovir
- Other viral causes - supportive
Bacterial infection of brain parenchyma - central purulent cavity ringed by layer of granulation tissue and outer fibrous capsule
brain abscess
- HA, neck stiffness, F, vomiting, confusion, changes in mental status
- 1-8 wks
brain abscess
Neurosurgeon consult for surgery
diagnostics brain abscess
- DX: CT WITH Contrast = rings
- Alt: MRI - AVOID LP
- Blood cx, cx of other infection sites
DDx brain abscess
- Cerebrovascular disease
- Meningitis
- Brain neoplasm
- Subacute cerebral hemorrhage
- Focal brain infections - toxoplasmosis
brain abscess penetrating trauma tx
cefotaxime/ceftriaxone + metronidazole +/- rifampin
brain abscess post-neurosurgery tx
- vanc/linezolid + ceftrazidime +/- rifampin
- Alt: meropenem, pip/taz, cefepime for ceftrazidime
Pyogenic material in epidural space
Epidural abscess
MCC of Epidural abscess
from hematogenous spread of bacteria from tissue, urine, or rsp
epidural abscess MC spread to where?
thoracic and lumbar spine
RF epidural abscess
- immunocomp
- IVDU
- spinal surgery
- recent procedures of LP or epidural anesthesia
triad s/s of epidural abscess
Back pain, F, neuro sx
rare
- Back pain, F, localized spinal tenderness
- Spinal irritation w/ radicular pain, hyperreflexia, nuchal rigidity
- fecal/urinary incontinence + focal neuro deficits
- LE Motor paralysis
- PE: midline spine tenderness, cauda equina syndrome (decreased rectal tone and perineal sensation)
epidural abscess
diagnostics for epidural abscess
- CBC
- ESR
- CRP
- Blood cx
- Gadolinium MRI preferred, CT w/ myelography is ok
tx epidural abscess
- Consult spine surgeon
- Debridement
- Empiric - vanc + ceftazidime/cefepime
- Add gentamicin if recent neurosurgery
- Painless ischemic optic neuropathy
- Women, >50 y/o, hx of polymyalgia rheumatica
Temporal Arteritis (Giant Cell Arteritis)
s/s Temporal Arteritis (Giant Cell Arteritis)
- Vision changes, HA, jaw claudication, scalp/temporal artery tenderness, fatigue, F, sore throat. URI sx, anorexia
- Unilateral, BL possible
- ⅓ - neuro events (TIA)
- APD; fundoscopic exam - flame hemorrhage
- CNVI palsy
- Vision loss
GCA - strong suspicion of TA or vision loss tx
Admit, methylprednisolone
- Facial pain in distribution of 5th CN
- Paroxysms of severe pain - lasting seconds - Normal PE findings
trigeminal neuralgia presentation
tx trigeminal neuralgia
Carbamazepine
