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Headache and Inability to Solve Quadratic Equations

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

8 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 Differential Diagnosis
Tension HA Migraine HA Sinusitis-related HA SAH Meningitis Mass lesion Hematoma (SDH, EDH, parenchymal) Tumor Infection (brain abscess, subdural empyema)

11 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?



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 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 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
ddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd Emissary veins

19 Proximity of Sinuses to Brain

20 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 8-days later: frank abscess in the same area
Left temporal cerebritis in a diabetic patient with a facial infection

23 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 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 More Clues HIV infection Other immune defects
History of cancer (especially lung, breast, melanoma)

26 Brain Abscess: Imaging
CT (with and without contrast) MR (superior when available)

27 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 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 Source Location Microbes Therapy Sinuses Frontal Aerobic strep
Anaerobic strep Hemophilus, bacteroides Pen (or cefotaxime) + metronidazole Otogenic Temporal Cerebellum Strep, bacterioides Enterobacteraceae Pseudomonas Pen + ceftazidime + metronidazole Metastatic Multiple (usually MCA) Depends on source (IE, lung, abd, GU) Naf + metronidazole + cefotaxime Penet. trauma Variable Staph aureus, clostridia, Enterobacteraceae Naf + cefotaxime Post-op Same as above + Staph epi Vanc + ceftazidime

30 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 Brain Abscess: Disposition
Admit for further treatment To neurosurgery Consider transfer to a center that is able to perform stereotactic biopsy

32 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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