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Headache and Inability to Solve Quadratic Equations Jonathan A. Edlow, MD, FACEP Associate Chief, Department of Emergency Medicine Beth Israel Deaconess.

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Presentation on theme: "Headache and Inability to Solve Quadratic Equations Jonathan A. Edlow, MD, FACEP Associate Chief, Department of Emergency Medicine Beth Israel Deaconess."— Presentation transcript:

1 Headache and Inability to Solve Quadratic Equations Jonathan A. Edlow, MD, FACEP Associate Chief, Department of Emergency Medicine Beth Israel Deaconess Medical Center Assistant Professor of Medicine Harvard Medical School Boston, MA

2 Jonathan A. Edlow, MD History 32 yo male with headache for 3 weeks. A mathematics grad student at MIT, he has noticed increasing problems at work, such as his ability to solve complex differential calculus problems and quadratic equations Both the HA and the math difficulty have increased gradually over the 3 weeks

3 Jonathan A. Edlow, MD History of Present Illness Severity: gradually progressing to 7/10 Quality: waxing, waning, pressure-like, unfamiliar (he rarely gets HA) Onset: gradual Location: left sided front-parietal, non- radiating

4 Jonathan A. Edlow, MD History of Present Illness ROS and associated symptoms: + nausea & vomiting (once, yesterday) - fever, photophobia, neck pain, visual changes, focal weakness or sensory changes. No ear or sinus pain, respiratory or GI symptoms No head trauma

5 Jonathan A. Edlow, MD Past History, Meds, Allergies Asthma (mild, never hospitalized) No allergies No medications except for Tylenol which he has been taking for the present HA, and which helped “about 66.67%”

6 Jonathan A. Edlow, MD Social History He is at the point of defending his PhD thesis and has been having problems with his advisor Non-smoker Drinks socially He is homosexual, monogamous for 4 years. He has been HIV tested 1 years ago and was negative

7 Jonathan A. Edlow, MD Physical Examination Alert, oriented, looks well Vital signs: Temp: 99.4 P: 72BP: 128/72R: 14 General physical exam, including a careful HEENT exam, is entirely normal; neck is supple No rash, lymphadenopathy or murmur

8 Jonathan A. Edlow, MD Neurological Examination MS normal (I was unable to test his math abilities) CN 2-12 normal, including good venous pulsations Motor: 5/5 strength with no pronator drift Sensory, gait and cerebellar all normal Reflexes: normal, toes down-going

9 Venous Pulsations

10 Jonathan A. Edlow, MD Differential Diagnosis Tension HA Migraine HA Sinusitis-related HA SAH Meningitis Mass lesion Hematoma (SDH, EDH, parenchymal) Tumor Infection (brain abscess, subdural empyema)

11 Jonathan A. Edlow, MD ED Work Up Treat him with analgesics and discharge him with follow-up with his PCP in 2-3 days? Send a ESR and WBC count? Perform a spinal tap? Order a brain CT scan?

12 Jonathan A. Edlow, MD

13

14 Ring Enhancing Lesion: Differential Diagnosis Bacterial brain abscess Toxoplasmosis, cryptococcosis Tumor (glioblastoma or metastatic) Lymphoma Infarction Necrotizing encephalitis Granuloma

15 Toxoplasmosis Glioblastoma vs. lymphoma

16 Jonathan A. Edlow, MD Key Teaching Points Work-up patients with new, unusual HA, esp. if severe and/or abrupt in onset. Is there another likely diagnosis? Patients with brain abscess often have no fever nor  WBC count Patients with frontal lobe processes often have normal exams The likely organisms and location asst. with brain abscess are a function of the underlying pathophysiology Bacterial brain abscess is a neurosurgical disease, although some may be cured with needle aspiration and IV antibiotics

17 Jonathan A. Edlow, MD Brain Abscess - Pathophysiology Extension from contiguous infection (direct or via emissary veins) Paranasal sinus: frontal lobe Otogenic infection: temporal lobe Hematogenous dissemination Often multiple abscesses (often MCA territory) Penetrating trauma and surgery Depends on location of trauma/surgery In 20-30%, no reason is identified (cryptogenic)

18 Emissary Veins Emissary veins ddddddd ddddddd ddddddd ddddddd ddddddd ddddddd ddddddd ddddddd ddddddd ddd dddddd dddddd dddddd dddddd dddddd dddddd dddddd dddddd d

19 Jonathan A. Edlow, MD Proximity of Sinuses to Brain

20 Jonathan A. Edlow, MD Brain Abscess: Stages of Development Early cerebritis (1-3 days) Late cerebritis (4-9 days) Early capsule (10-14 days) Late capsule (beyond 14 days)

21 Early cerebritis Early abscess

22 Left temporal cerebritis in a diabetic patient with a facial infection 8-days later: frank abscess in the same area

23 Jonathan A. Edlow, MD Brain Abscess: Clinical Presentation Quite variable, HA being the most common (~ 80-90%) Seizure (~ 50%) Fever < 50% in some series Papilledema < 25% Signs of Mass (depends on location) Increased ICP (n/v,  MS)

24 Jonathan A. Edlow, MD Brain Abscess: Clinical Clues (source) Look for signs and symptoms of Chronic ear infection Sinusitis Odontogenic infection Endocarditis (or bacteremia of any cause) Lung abscess Recent body piercing

25 Jonathan A. Edlow, MD More Clues HIV infection Other immune defects History of cancer (especially lung, breast, melanoma)

26 Jonathan A. Edlow, MD Brain Abscess: Imaging CT (with and without contrast) MR (superior when available)

27 Jonathan A. Edlow, MD Brain Abscess – LP? While the risk is quite low, transtentorial herniation may occur More importantly, an LP in brain abscess rarely is diagnostically useful Cultures are almost always negative The CSF formula is non-specific Pressure is usually elevated

28 Jonathan A. Edlow, MD Brain Abscess: Initial Steps ABC’s (if applicable) Blood cultures (usually negative) IV antibiotics Selected based on mechanism May be delayed in well-appearing patients in consultation with surgeon Consultation with neurosurgeon Steroids (for symptomatic cerebral vasogenic edema) Anticonvulsants (if patient has seized)

29 SourceLocationMicrobesTherapy SinusesFrontalAerobic strep Anaerobic strep Hemophilus, bacteroides Pen (or cefotaxime) + metronidazole OtogenicTemporal Cerebellum Strep, bacterioides Enterobacteraceae Pseudomonas Pen + ceftazidime + metronidazole MetastaticMultiple (usually MCA) Depends on source (IE, lung, abd, GU) Naf + metronidazole + cefotaxime Penet. trauma VariableStaph aureus, clostridia, Enterobacteraceae Naf + cefotaxime Post-opVariableSame as above + Staph epi Vanc + ceftazidime

30 Jonathan A. Edlow, MD Brain Abscess: Treatment IV antibiotics for long duration Surgical drainage In some early-diagnosed cases (in cerebritis stage), prolonged IV antibiotics may be curative Follow imaging studies Treat underlying disease if necessary

31 Jonathan A. Edlow, MD Brain Abscess: Disposition Admit for further treatment To neurosurgery Consider transfer to a center that is able to perform stereotactic biopsy

32 Jonathan A. Edlow, MD Outcome of Case Patient transferred to a center with neurosurgical expertise Stereotactic needle drainage was done yielding pus that cultured out mixed bacterial flora Open craniotomy was not needed He received 6 weeks of IV penicillin and metronidazole; HIV testing was negative He regained his ability to solve quadratic equations

33 Questions?


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