Acute Neurological Emergencies: Headache. Brad Bunney, MD Associate Professor Dept of Emergency...

Acute Neurological Emergencies:Acute Neurological Emergencies:

HeadacheHeadache

Brad Bunney, MDBrad Bunney, MDAssociate ProfessorAssociate Professor

Dept of Emergency MedicineDept of Emergency Medicine

University of Illinois College of University of Illinois College of MedicineMedicine

Chicago, ILChicago, IL

Michael Gerardi, MD, FAAP, FACEPMichael Gerardi, MD, FAAP, FACEPVice-Chairman, Department of Emergency MedicineVice-Chairman, Department of Emergency Medicine

Morristown Memorial HospitalMorristown Memorial HospitalMorristown, New JerseyMorristown, New Jersey

Nina T. Gentile, MDNina T. Gentile, MDAssociate ProfessorAssociate Professor

Division of Emergency MedicineDivision of Emergency MedicineTemple University School of MedicineTemple University School of Medicine

Philadelphia, PAPhiladelphia, PA

Daniel G. Murphy, MD, FACEPDaniel G. Murphy, MD, FACEPVice Chair & Medical DirectorVice Chair & Medical DirectorMaimonides Medical CenterMaimonides Medical Center

Brooklyn, New YorkBrooklyn, New York

The CaseThe Case

One hour prior to ED presentation, a One hour prior to ED presentation, a 42 year old man was jogging and 42 year old man was jogging and “hit” by the worst headache of his “hit” by the worst headache of his life. It was associated with some life. It was associated with some nausea and the feeling as if he was nausea and the feeling as if he was going to pass out. He rested for 30 going to pass out. He rested for 30 minutes but the headache persisted minutes but the headache persisted as a diffuse, throbbing pain as a diffuse, throbbing pain radiating to the base of his skull. radiating to the base of his skull.

EMS was called. The patient felt as if he EMS was called. The patient felt as if he

could not concentrate, there was no could not concentrate, there was no

confusion, nor was there any other focal confusion, nor was there any other focal

neurologic complaint.neurologic complaint.

There was no past medical history, no There was no past medical history, no

medications, no family history, and no medications, no family history, and no

significant use of alcohol, tobacco or significant use of alcohol, tobacco or

other drugs.other drugs.

The Case The Case (Continued)(Continued)

If a patient presented with the worst If a patient presented with the worst headache of his life, what is the work-headache of his life, what is the work-up that should be initiated?up that should be initiated?

a. Non-contrast CTa. Non-contrast CT

b. LP after neg. CTb. LP after neg. CT

c. LP without CTc. LP without CT

d. CT, LP, and angiographyd. CT, LP, and angiography

What is the differential of a “thunderclap What is the differential of a “thunderclap headache”?headache”?

What is the sensitivity of neuroimaging in What is the sensitivity of neuroimaging in subarachnoid hemorrhage (SAH)?subarachnoid hemorrhage (SAH)?

What constitutes a “positive” lumbar What constitutes a “positive” lumbar puncture in SAH and when should it be puncture in SAH and when should it be performed?performed?

Do patients with suspected SAH who have a Do patients with suspected SAH who have a negative CT and lumbar puncture require negative CT and lumbar puncture require additional imaging to “rule-out” expanded additional imaging to “rule-out” expanded but unruptured aneurysm?but unruptured aneurysm?

ObjectivesObjectives

HeadacheHeadache

1 of 10 top presenting complaints1 of 10 top presenting complaints 1 to 2% of visits to ED1 to 2% of visits to ED 18 million outpatient visits18 million outpatient visits 638 million days of work lost per year638 million days of work lost per year 78% of women and 64% of men had 78% of women and 64% of men had experienced at least one in the prior yearexperienced at least one in the prior year 36% of women and 19% men suffer from 36% of women and 19% men suffer from recurrent headachesrecurrent headaches

HeadacheHeadache

Most have primary headache Most have primary headache disordersdisorders

migrainemigraine tensiontension

Only a few have treatable secondary Only a few have treatable secondary causes that threaten life, limb, brain causes that threaten life, limb, brain such as such as subarachnoid hemorrhagesubarachnoid hemorrhage

1 - 4 % of headache visits1 - 4 % of headache visits

““Worst” HeadacheWorst” Headache

Normal exam: 12- 33% SAHNormal exam: 12- 33% SAH Abnormal exam:Abnormal exam: 25% SAH 25% SAH Initial hemorrhage may be fatalInitial hemorrhage may be fatal Early definitive surgery improves Early definitive surgery improves

outcomesoutcomes

Patients with greatest likelihood of Patients with greatest likelihood of benefiting from surgery are most benefiting from surgery are most likely to receive incorrect diagnosislikely to receive incorrect diagnosis

Physicians Consistently Physicians Consistently Misdiagnose SAHMisdiagnose SAH

1. Failure to appreciate spectrum of clinical 1. Failure to appreciate spectrum of clinical presentationpresentation

2. Failure to understand limitations of CT2. Failure to understand limitations of CT

3. Failure to perform and correctly interpret 3. Failure to perform and correctly interpret the results of LPthe results of LP

ED Goals in Headache PatientsED Goals in Headache Patients

1. Differentiate life-threatening from benign1. Differentiate life-threatening from benign

2. Initiate prompt treatment2. Initiate prompt treatment

3. Provide prompt pain relief3. Provide prompt pain relief

4. Prevent drug seeking and refer4. Prevent drug seeking and refer

5. Minimize resource utilization in ED5. Minimize resource utilization in ED

6. Optimize patient use of ED6. Optimize patient use of ED

7. Increase pre-ED treatment and reduce ED 7. Increase pre-ED treatment and reduce ED useuse

Medical Conditions That Medical Conditions That Present With HeadachePresent With Headache

Medical Conditions That Medical Conditions That Present With HeadachePresent With Headache

PheochromocytomaPheochromocytoma HyperthyroidismHyperthyroidism SLESLE Giant Cell ArteritisGiant Cell Arteritis FibromyalgiaFibromyalgia

Types of Headaches in the EDTypes of Headaches in the EDFinal DiagnosisFinal Diagnosis Percentage PercentageInfection - not intracranialInfection - not intracranial 39.3 39.3Tension HATension HA 19.3 19.3MiscellaneousMiscellaneous 14.9 14.9Post-traumaticPost-traumatic 9.3 9.3Hypertension relatedHypertension related 4.8 4.8Vascular (Migraine)Vascular (Migraine) 4.5 4.5No diagnosisNo diagnosis 6.0 6.0SAHSAH 0.9 0.9MeningitisMeningitis 0.6 0.6

Causes of Headache That Causes of Headache That Require Specific TherapyRequire Specific Therapy

Subarachnoid hemorrhageSubarachnoid hemorrhage MeningitisMeningitis EncephalitisEncephalitis Cervicocranial-artery dissectionCervicocranial-artery dissection Temporal arteritisTemporal arteritis Acute angle-closure glaucomaAcute angle-closure glaucoma Hypertensive emergencyHypertensive emergency

Causes of Headache That Causes of Headache That Require Specific TherapyRequire Specific Therapy

Carbon Monoxide poisoningCarbon Monoxide poisoning Pseudotumor cerebriPseudotumor cerebri Cerebral venous and dural sinus thrombosisCerebral venous and dural sinus thrombosis Acute stroke (hemorrhagic or ischemic)Acute stroke (hemorrhagic or ischemic) Mass LesionMass Lesion

tumortumor abscess intracranialabscess intracranial hematomahematoma parameningeal infectionparameningeal infection

Headache Headache DangerDanger Signals SignalsHeadache Headache DangerDanger Signals Signals

Onset Onset after 40 yearsafter 40 years new or different headachenew or different headache subacute HA that worsenssubacute HA that worsens exertion, sex, coughing, strainingexertion, sex, coughing, straining

Worst ever experiencedWorst ever experienced

Headache Headache DangerDanger Signals: Signals: Associated With Neurologic ChangeAssociated With Neurologic Change


Memory impairmentMemory impairment AtaxiaAtaxia DrowsinessDrowsiness Sensory lossSensory loss Signs of meningeal irritationSigns of meningeal irritation



Progressive visual or neurologic Progressive visual or neurologic changechange

ConfusionConfusion WeaknessWeakness Loss of coordinationLoss of coordination Asymmetry of pupils, DTRsAsymmetry of pupils, DTRs

Headache Headache DangerDanger Signals: Signals: Abnormal Medical Evaluation Abnormal Medical Evaluation

Headache Headache DangerDanger Signals: Signals: Abnormal Medical Evaluation Abnormal Medical Evaluation

FeverFever Chronic malaiseChronic malaise ArthralgiaArthralgia HTNHTN MyalgiaMyalgia Wt lossWt loss Tender, poorly pulsatile temporal Tender, poorly pulsatile temporal

arteriesarteries

Subarachnoid HemorrhageSubarachnoid Hemorrhage

Incidence of 16 /100,000Incidence of 16 /100,000 about 33,600 cases per yearabout 33,600 cases per year 54% secondary to ruptured 54% secondary to ruptured

aneurysmaneurysm Without treatment, 40% of aneurysm Without treatment, 40% of aneurysm

pts. have recurrent bleedingpts. have recurrent bleeding Aneurysm pt who survives initial Aneurysm pt who survives initial

rupture and is treated conservatively: rupture and is treated conservatively: 50% survival at one year50% survival at one year

Time of Death Time of Death Following SAH by CauseFollowing SAH by Cause

0

5

10

15

20

25

0 0.25 0.5 1 1.5 2 2.5 3

Time from SAH (weeks)

Per

cen

tag

e

Direct Effect Rebleed Vasospasm Medical Complications

Current Problems in Management of Current Problems in Management of Subarachnoid HemorrhageSubarachnoid Hemorrhage

Errors and delays in diagnosisErrors and delays in diagnosis Treatment of acute effectsTreatment of acute effects Prevention of recurrent hemorrhagePrevention of recurrent hemorrhage Prevention or treatment of Prevention or treatment of

vasospasm or cerebral ischemiavasospasm or cerebral ischemia

Classic Symptoms of Subarachnoid Classic Symptoms of Subarachnoid HemorrhageHemorrhage

Sudden, unusually severe or Sudden, unusually severe or “thunderclap” headache “thunderclap” headache

Loss of consciousnessLoss of consciousness Pain in neck, back, eye or facePain in neck, back, eye or face Nausea, vomiting, photophobia, Nausea, vomiting, photophobia,

phonophobiaphonophobia

Classic Signs of Classic Signs of Subarachnoid HemorrhageSubarachnoid Hemorrhage

Abnormal vital signs Abnormal vital signs Respiratory changes, hypertension, Respiratory changes, hypertension,

cardiac arrhythmiascardiac arrhythmias MeningismusMeningismus Focal neurologic signs may be presentFocal neurologic signs may be present

III nerve palsy – IC/PCA aneurysmIII nerve palsy – IC/PCA aneurysm Paraparesis – ACA aneurysmParaparesis – ACA aneurysm Hemiparesis, aphasia – MCA Hemiparesis, aphasia – MCA

aneurysmaneurysm Ocular hemorrhagesOcular hemorrhages

Subarachnoid HemorrhageSubarachnoid HemorrhageSubarachnoid HemorrhageSubarachnoid Hemorrhage

Onset: Onset: AcuteAcute Location: Location: GlobalGlobal Ass Sx:Ass Sx: N,V, meningismus, focalN,V, meningismus, focal Pain: Pain: Worst everWorst ever Duration: Duration: BriefBrief Prior Hx: Prior Hx: NoNo Dx tests:Dx tests: CT 80-90%CT 80-90% Phys ex: Phys ex: Focal signs, LOC, meningismusFocal signs, LOC, meningismus


Warning leaks in 50%Warning leaks in 50% CT misses up to 10% small leaksCT misses up to 10% small leaks Suspect if:Suspect if:

> 35 years> 35 years no previous HAno previous HA no fading of HAno fading of HA came on with exertioncame on with exertion altered LOC or neuro deficitsaltered LOC or neuro deficits stiff neckstiff neck

Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Neurologic FindingsNeurologic Findings

Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Neurologic FindingsNeurologic Findings

Sudden HA without localizing findingsSudden HA without localizing findings Altered mentationAltered mentation

Confusion, lethargyConfusion, lethargy Bilateral extensor plantar reflexBilateral extensor plantar reflex Unusual to find focal deficitsUnusual to find focal deficits

Causes of Non-Traumatic Causes of Non-Traumatic Subarachnoid HemorrhageSubarachnoid HemorrhageCauses of Non-Traumatic Causes of Non-Traumatic

Subarachnoid HemorrhageSubarachnoid Hemorrhage “ “Berry” aneurysmsBerry” aneurysms AVMAVM Cerebral angiomasCerebral angiomas Mycotic aneurysmMycotic aneurysm Extension from parenchymatous Extension from parenchymatous

hemorrhagehemorrhage Anticoagulation therapyAnticoagulation therapy

Causes of Non-Traumatic Causes of Non-Traumatic Subarachnoid HemorrhageSubarachnoid HemorrhageCauses of Non-Traumatic Causes of Non-Traumatic


Systemic bleeding diathesisSystemic bleeding diathesis Hemorrhagic encephalitisHemorrhagic encephalitis Hemorrhagic cerebral vasculitisHemorrhagic cerebral vasculitis Hemorrhage into CNS tumors or Hemorrhage into CNS tumors or

metastasesmetastases UnknownUnknown

Warning HeadacheWarning Headache

20 - 50% patients with SAH have HA days or 20 - 50% patients with SAH have HA days or weeks before index episodeweeks before index episode unusually severeunusually severe distinctdistinct

“ “Thunderclap” headacheThunderclap” headache Day and Raskin 1996Day and Raskin 1996 intense, acute, peak intensity at onsetintense, acute, peak intensity at onset develop in secondsdevelop in seconds maximal intensity in minutesmaximal intensity in minutes lasts hours to dayslasts hours to days

““Thunderclap” HeadacheThunderclap” Headache

25% associated with SAH25% associated with SAH ““Warning” headacheWarning” headache

followed by SAH in 5% to 60%followed by SAH in 5% to 60% Expansion or dissection of unruptured Expansion or dissection of unruptured

aneurysmaneurysm Cerebral venous thrombosisCerebral venous thrombosis Exertional / coital headacheExertional / coital headache

217 patients from 4 institutions217 patients from 4 institutions 54 (25%) were initially misdiagnosed54 (25%) were initially misdiagnosed 121 patients initially presented in 121 patients initially presented in

good clinical conditiongood clinical condition 46 (38%) were initially misdiagnosed46 (38%) were initially misdiagnosed

StrokeStroke 1996;27:1558-63 1996;27:1558-63

Misdiagnosis of SAHMisdiagnosis of SAH

Outcome of Patients with Good Initial Outcome of Patients with Good Initial Presentation in Misdiagnosed and Presentation in Misdiagnosed and Correctly Diagnosed Patients With SAH Correctly Diagnosed Patients With SAH

OutcomeOutcome Misdiagnosis (n=45) Misdiagnosis (n=45) Correct Diagnosis (n=75) Correct Diagnosis (n=75)

Excellent/goodExcellent/good 24 (53)* 24 (53)* 68 (91)*68 (91)*

FairFair 5 (11) 5 (11) 4 ( 5) 4 ( 5)

Poor/vegetative/deadPoor/vegetative/dead 16 (36)* 16 (36)* 3 ( 4)* 3 ( 4)*

Values are number (%) in each clinical grade category.Values are number (%) in each clinical grade category.

P<.001P<.001StrokeStroke 1996;27:1558-63 1996;27:1558-63


Rebleeds and Deteriorations Before Treatment Rebleeds and Deteriorations Before Treatment in Misdiagnosed and Correctly Diagnosed in Misdiagnosed and Correctly Diagnosed Patients With SAH Patients With SAH

Misdiagnosis (n=54)Misdiagnosis (n=54) Correct Diagnosis (n=163)Correct Diagnosis (n=163)

RebleedsRebleeds 21* 21* 44

DeteriorationsDeteriorations 55 00

TotalTotal 2626 44

*12/21 of misdiagnosed and 3/4 of correctly diagnosed patients rebled within 5 *12/21 of misdiagnosed and 3/4 of correctly diagnosed patients rebled within 5 days of presentation. days of presentation.

StrokeStroke 1996;27:1558-63 1996;27:1558-63


SAH…But not “Classic”SAH…But not “Classic”

Roughly half have minor bleeding with atypical Roughly half have minor bleeding with atypical featuresfeatures

Nonstrenuous activities (34%)Nonstrenuous activities (34%) Sleep (12%)Sleep (12%) HA in any location (localized, generalized, mild)HA in any location (localized, generalized, mild) May be relieved by non-narcotic analgesicsMay be relieved by non-narcotic analgesics Diagnosed as migraine, tension-type, sinusitisDiagnosed as migraine, tension-type, sinusitis

SAH: Most patients have...SAH: Most patients have...

Abrupt onset of severe, unique Abrupt onset of severe, unique headache, or neck painheadache, or neck pain

Abnormal findings on neurologic Abnormal findings on neurologic examinationexamination

Subtle meningismus or ocular Subtle meningismus or ocular findingsfindings

International Headache SocietyInternational Headache Society

A first episode of severe headache A first episode of severe headache cannotcannot be classified as migraine:be classified as migraine: more than 4 episodesmore than 4 episodes

nornor as tension-type headache: as tension-type headache: more than 9 episodesmore than 9 episodes

First or worst headache requires First or worst headache requires evaluationevaluation as do qualitatively different headachesas do qualitatively different headaches

Can a CT Scan Safely Can a CT Scan Safely “Rule Out” SAH?“Rule Out” SAH?

First diagnostic studyFirst diagnostic study Thin cuts ( 3 mm) through base of brainThin cuts ( 3 mm) through base of brain Blood on CT function of HgbBlood on CT function of Hgb

Hgb < 10: blood isodenseHgb < 10: blood isodense Sensitivity decreases over time from Sensitivity decreases over time from

onset of symptomsonset of symptoms

SAH CT FindingsSAH CT Findings

High density hemorrhage High density hemorrhage injuryinjury (1) Interhemospheric (1) Interhemospheric

fissurefissure (2) Inferior frontal sulci(2) Inferior frontal sulci (3) Third ventricle (3) Third ventricle (4) Ambient cistern (4) Ambient cistern (5)Sylvian fissure(5)Sylvian fissure

SAH: CT SensitivitySAH: CT SensitivitySames: Sames: Acad Emerg Med Acad Emerg Med Jan 1996Jan 1996

SAH: CT SensitivitySAH: CT SensitivitySames: Sames: Acad Emerg Med Acad Emerg Med Jan 1996Jan 1996

181 patients; aged 13-86 with SAH181 patients; aged 13-86 with SAH Sensitivity Sensitivity 91.2% 91.2%

pain < 24 hrspain < 24 hrs 93.1% 93.1% pain > 24 hrspain > 24 hrs 83.8% 83.8%

LP 100% sensitive if neg CTLP 100% sensitive if neg CT ““A normal NGCT does not reliably A normal NGCT does not reliably

exclude the need for LP”exclude the need for LP”

SAH Diagnosis: LP NeededSAH Diagnosis: LP NeededSidman: Sidman: Acad Emerg Med Acad Emerg Med Sep 1996Sep 1996

SAH Diagnosis: LP NeededSAH Diagnosis: LP NeededSidman: Sidman: Acad Emerg Med Acad Emerg Med Sep 1996Sep 1996

140 patients; aged 10-88140 patients; aged 10-88 Sensitivity of CTSensitivity of CT

< 12 hrs< 12 hrs 80/8080/80 100%100% > 12 hrs> 12 hrs 49/6049/60 81.7%81.7%

Overall, 11/140 had (-) CT and (+) LPOverall, 11/140 had (-) CT and (+) LP overall sensitivityoverall sensitivity 92.1%92.1%

Morgenstern LB, et al:Morgenstern LB, et al: Worst headache and Worst headache and SAH: Prospective, modern CT and spinal SAH: Prospective, modern CT and spinal fluid analysis.fluid analysis. Ann Emerg MedAnn Emerg Med Sept 1998 Sept 1998..

38,730 patients over 16 months, 38,730 patients over 16 months, prospectively screened for “worst HA”prospectively screened for “worst HA”

Blinded neuroradiologistsBlinded neuroradiologists Neg CTNeg CT LPLP

cell count x 2cell count x 2visual and spectrophotometric visual and spectrophotometric

detection of xanthochromiadetection of xanthochromiaCSF D-dimer assayCSF D-dimer assay

Morgenstern, et al: Morgenstern, et al: Ann Emerg MedAnn Emerg Med 1998 1998

455 headaches & 107 “worst headache”455 headaches & 107 “worst headache” CT:CT: 18 of 107 (17%): (+) SAH 18 of 107 (17%): (+) SAH (-) CT/ (+) SAH:(-) CT/ (+) SAH: Only 2 (2.5%) Only 2 (2.5%)

(95% CI, 0.3%to 8.8%)(95% CI, 0.3%to 8.8%) Modern CT is sufficient to exclude 98% of Modern CT is sufficient to exclude 98% of

SAH in patients SAH in patients

Morgenstern, et al: Morgenstern, et al: Ann Emerg MedAnn Emerg Med 1998 (1998 (107107 “Worst HA’s) “Worst HA’s)

VariablesVariables CT-/LP- CT+ CT-/LP+ CT-/LP- CT+ CT-/LP+PhotophobiaPhotophobia 4545 2828 50 50Stiff neckStiff neck 2626 3737 100 100NauseaNausea 6565 3636 100 100LethargyLethargy 1717 4040 5050Time < 24 hTime < 24 h 5858 7575 5050MigraineMigraine 2020 1111 0 0HeadacheHeadache 4848 2727 0 0

CT is Normal: Do LP?CT is Normal: Do LP?

Yes!Yes!

What about LP First?What about LP First?

Duffy et al; 1982: 55 patients who underwent Duffy et al; 1982: 55 patients who underwent LP as initial w/uLP as initial w/u Condition deteriorated immediately in 7 Condition deteriorated immediately in 7

patientspatients Hillman et al; 1986: 4 alert patients with SAH Hillman et al; 1986: 4 alert patients with SAH

who deteriorated after lumbar puncturewho deteriorated after lumbar puncture Both studies:Both studies:

clots on CT or a dilated pupilclots on CT or a dilated pupil

Traumatic TapsTraumatic Taps

20% of LPs20% of LPs 0.5% and 6% has incidental intracranial 0.5% and 6% has incidental intracranial

aneurysmaneurysm Impression or “3-tube” method not reliable in Impression or “3-tube” method not reliable in

detecting traumatic tapdetecting traumatic tap Erythrocytes disseminate rapidlyErythrocytes disseminate rapidly Released Hgb Released Hgb oxyhemoglobin oxyhemoglobin

xanthochromiaxanthochromia bilirubinbilirubin

XanthochromiaXanthochromia

Bilirubin, enzyme-dependent process, Bilirubin, enzyme-dependent process, is diagnostically more reliable but:is diagnostically more reliable but: takes up to 12 hourstakes up to 12 hours

Timing is importantTiming is important CSF should be centrifuged and CSF should be centrifuged and

examined promptly so RBCs don’t examined promptly so RBCs don’t undergo lysis in vitro, causing undergo lysis in vitro, causing xanthochromia from oxyhemoglobinxanthochromia from oxyhemoglobin

Xanthochromia vs. ErythrocytesXanthochromia vs. Erythrocytes

XanthochromiaXanthochromia primary criterion for SAH if neg CTprimary criterion for SAH if neg CT advocates: spectrophotometryadvocates: spectrophotometry

ErythrocytesErythrocytes considered more accurate by someconsidered more accurate by some used visual inspection which can used visual inspection which can

miss discoloration in up to 50%miss discoloration in up to 50%

Timing the TapTiming the Tap

With spectrophotometry, and waiting With spectrophotometry, and waiting 12 hours after onset of headache: very 12 hours after onset of headache: very accurateaccurate traumatic tap done earlier does not traumatic tap done earlier does not

lead to xanthochromia and confusionlead to xanthochromia and confusion Waiting: Waiting:

prolongation of ED stayprolongation of ED stay risk “ultra-early” rebleedingrisk “ultra-early” rebleeding

Normal CT & Persistently Normal CT & Persistently Bloody CSF ???Bloody CSF ???

Not prudent to delay LPNot prudent to delay LP Without xanthochromia and clinical Without xanthochromia and clinical

suspicion is high?suspicion is high? Vascular imagingVascular imaging

Xanthochromia present and clinical Xanthochromia present and clinical suspicion is high?suspicion is high? Vascular imagingVascular imaging

Differentiate Between Differentiate Between Traumatic LP and SAHTraumatic LP and SAH

CSF characteristic Traumatic tap True SAH

Color gets lighter with subsequent tubes

yes no

RBC count in first & last tube

count decrease stay constant

Clotting of blood in CSF

yes no

Xanthochromia in supernatant

rare with RBC count less than 200,000

present withi4 hrs of SAH, max at 1 wk, persists for about 3 weeks

Thunderclap Headache: Thunderclap Headache: NL CT & NL LP Vascular Imaging?NL CT & NL LP Vascular Imaging?

Wijdicks et al; Lancet, 1988Wijdicks et al; Lancet, 1988 Retrospective evaluation 71 patientsRetrospective evaluation 71 patients no SAH in 3.3 years f/uno SAH in 3.3 years f/u Half dx’d with migraine or tension HAHalf dx’d with migraine or tension HA

Markus 1991; Linn 1994; Harling 1989Markus 1991; Linn 1994; Harling 1989 117 patients117 patients no SAH, no sudden deathsno SAH, no sudden deaths

VasospasmVasospasm

Occurs in 70% of patients with SAH Occurs in 70% of patients with SAH Appears after 3-4 days, peaks at 7-10 Appears after 3-4 days, peaks at 7-10

days, and resolves over 2-4 weeksdays, and resolves over 2-4 weeks Can be localized or involve several Can be localized or involve several

arteriesarteries Caused by factors released at time of Caused by factors released at time of

bleeding that induce vasoconstriction bleeding that induce vasoconstriction and reduced blood flowand reduced blood flow

Calcium Channel Blocking Calcium Channel Blocking DrugsDrugs

Drugs that limit transmembrane fluxesDrugs that limit transmembrane fluxes Vascular smooth muscle contractionVascular smooth muscle contraction Cell ischemiaCell ischemia Platelet aggregationPlatelet aggregation

Selective cerebrovascular effectsSelective cerebrovascular effects Cross blood-brain barrierCross blood-brain barrier Limited cardiovascular effectsLimited cardiovascular effects

Clinical Trials of NimodipineClinical Trials of Nimodipine Nimodipine improves survival and Nimodipine improves survival and

functional recovery after SAHfunctional recovery after SAH

Benefits are due to its Benefits are due to its antihypertensive and neuronal antihypertensive and neuronal protective effectsprotective effects

The patient had labs drawn, was given The patient had labs drawn, was given

5mg of morphine and sent off to CT 5mg of morphine and sent off to CT

scan.scan.

The CT scan revealed an acute SAH. The The CT scan revealed an acute SAH. The

neurosurgeon ordered an angiogram neurosurgeon ordered an angiogram

which revealed an aneurysm.which revealed an aneurysm.

The patient went to the OR that day and The patient went to the OR that day and

was release with a normal neurological was release with a normal neurological

status 4 days later.status 4 days later.

The Case The Case (Continued)(Continued)

Case #2Case #2

First ED Visit: Late Friday First ED Visit: Late Friday NightNight

24 yo female with headache for 2 weeks, 24 yo female with headache for 2 weeks, worse over the last 2 daysworse over the last 2 days

104/76, 80, 18, 98.1F104/76, 80, 18, 98.1F Right frontal forehead, sharp, non-radiating, Right frontal forehead, sharp, non-radiating,

constant but waxing/waning, worse when constant but waxing/waning, worse when she moved.she moved.

(+) nausea(+) nausea (-) fever, photophobia, neck pain or visual (-) fever, photophobia, neck pain or visual

changeschanges

Past Medical/Social HistoryPast Medical/Social History

No recent traumaNo recent trauma Smoker 1 PPDSmoker 1 PPD Social drinkerSocial drinker No hx of headaches, except for last 2 No hx of headaches, except for last 2

weeksweeks No allergiesNo allergies No meds except ibuprofen and No meds except ibuprofen and

acetaminophen recently – not helpfulacetaminophen recently – not helpful Worked as a part-time sales clerkWorked as a part-time sales clerk

Exam: First VisitExam: First Visit

Alert, oriented, looked well except Alert, oriented, looked well except for discomfort of headachefor discomfort of headache

Face normal, Perrl, EOMI, fundi Face normal, Perrl, EOMI, fundi normal, TMs normal, mastoids non-normal, TMs normal, mastoids non-tender, neck supple, motor neuro tender, neck supple, motor neuro exam normal, normal gait, mental exam normal, normal gait, mental status normalstatus normal

ED Therapy and Work UpED Therapy and Work Up

Prochlorperazine 10 mg, by vein Prochlorperazine 10 mg, by vein Acetaminophen 325/Oxycodone 5, Acetaminophen 325/Oxycodone 5, orallyorally

CBC, Chem 7, UCG, CT Head CBC, Chem 7, UCG, CT Head without contrastwithout contrast

ED Diagnostic Results: Visit 1ED Diagnostic Results: Visit 1

WBC count 12.4KWBC count 12.4K CT head reviewed by ED attending CT head reviewed by ED attending

and radiology resident as negativeand radiology resident as negative

ED Disposition: Visit 1ED Disposition: Visit 1

Patient’s pain responded to Patient’s pain responded to medicationsmedications

Patient discharged with prescription for Patient discharged with prescription for acetaminophen/butalbital/caffeine = acetaminophen/butalbital/caffeine = Fioricet Fioricet

Radiology Over-Read: Monday AMRadiology Over-Read: Monday AM(2.5 days since 1(2.5 days since 1stst ED visit) ED visit)

Opacification of the right ethmoid Opacification of the right ethmoid and right sphenoid sinuses with and right sphenoid sinuses with expansion of the sphenoid expansion of the sphenoid septations toward the left. septations toward the left.

No intracranial diseaseNo intracranial disease

ED Discrepancy ProcedureED Discrepancy Procedure

Patient was contacted by phone and Patient was contacted by phone and informed of sinus problem on CTinformed of sinus problem on CT

Patient went to her PMD that afternoonPatient went to her PMD that afternoon PMD discharged her with prescription PMD discharged her with prescription

for levofloxacinfor levofloxacin

22ndnd ED Visit: Tuesday Morning ED Visit: Tuesday Morning(3.5 days after 1(3.5 days after 1stst ED visit) ED visit)

New onset swelling and severe pain New onset swelling and severe pain around left eyearound left eye

Continued, worsening right-sided Continued, worsening right-sided headacheheadache

Slept poorly, confused, Slept poorly, confused, hallucinating?hallucinating?

100/80, 96, 18, 100/80, 96, 18, 101.9F101.9F

Morning Exam: 2Morning Exam: 2ndnd Visit Visit

Left peri-orbital edema, erythema, Left peri-orbital edema, erythema, proptosis, chemosis, severe pain with proptosis, chemosis, severe pain with EOMs. Left pupil reacted to light.EOMs. Left pupil reacted to light.

Ambulated in with normal gait. No Ambulated in with normal gait. No obvious motor deficits.obvious motor deficits.

Awake. Followed simple commands, Awake. Followed simple commands, but mildly confused, answering slowly but mildly confused, answering slowly or incorrectly, with difficulty or incorrectly, with difficulty concentrating.concentrating.

(+) Nuchal rigidity(+) Nuchal rigidity

ED Therapy & Work UpED Therapy & Work Up

2 grams ceftriaxone by vein after 2 grams ceftriaxone by vein after culturescultures

Repeat CT of brain and sinuses with Repeat CT of brain and sinuses with contrastcontrast

LPLP ID and ENT consults; vancomycin and ID and ENT consults; vancomycin and

metronidazole given by vein metronidazole given by vein Admitted to MICUAdmitted to MICU

Afternoon Exam: 2Afternoon Exam: 2ndnd Visit Visit

Deteriorating mental status.Deteriorating mental status. Mild left sided weakness left upper Mild left sided weakness left upper

and left lower extremities.and left lower extremities.

ED Admitting DiagnosesED Admitting Diagnoses

Orbital CellulitisOrbital Cellulitis MeningitisMeningitis Rule out Cavernous Sinus Rule out Cavernous Sinus

ThrombosisThrombosis

Septic Dural Sinus ThrombosisSeptic Dural Sinus ThrombosisSuppurative Intracranial ThrombophlebitisSuppurative Intracranial Thrombophlebitis

Infected venous thrombosis of cortical Infected venous thrombosis of cortical veins or sinusesveins or sinuses

From From meningitis, subdural empyema, meningitis, subdural empyema, epidural abscess, infection in the skin of epidural abscess, infection in the skin of the face, paranasal sinuses, middle ear, the face, paranasal sinuses, middle ear, mastoid, maxillary teeth or neck.mastoid, maxillary teeth or neck.

Iatrogenic cases have been associated Iatrogenic cases have been associated with rhinoplasty, hip surgery and with rhinoplasty, hip surgery and oral/dental surgery. oral/dental surgery.

Non-Septic Dural Sinus Non-Septic Dural Sinus ThrombosisThrombosis

Dehydration from vomitingDehydration from vomiting Hypercoagulable statesHypercoagulable states Immunologic abnormalities, Immunologic abnormalities,

including the presence of including the presence of circulating antiphospholipid circulating antiphospholipid antibodiesantibodies

Septic Dural Sinus ThrombosisSeptic Dural Sinus Thrombosis

Rare; 155 reported cases since 1940Rare; 155 reported cases since 1940 Cavernous Sinus Thrombosis (CST) Cavernous Sinus Thrombosis (CST)

is the predominant subset (62%?)is the predominant subset (62%?) Fulminant, aggressive disease: Fulminant, aggressive disease:

mortality CST =30%, superior mortality CST =30%, superior sagittal sinus thrombosis =78%sagittal sinus thrombosis =78%

Morbidity CST: 50% cranial nerve Morbidity CST: 50% cranial nerve deficit; 17% visually impaireddeficit; 17% visually impaired

Infected Thrombus PathogensInfected Thrombus Pathogens

CSTCST: Staphylococcus aureus, other gram-: Staphylococcus aureus, other gram-positive organisms, and anaerobes. positive organisms, and anaerobes.

Lateral SinusLateral Sinus (otitis media and/or mastoid (otitis media and/or mastoid infection) Proteus species, Escherichia coli, infection) Proteus species, Escherichia coli, S. aureus, and anaerobes. S. aureus, and anaerobes.

Superior Sagittal SinusSuperior Sagittal Sinus (meningitis or air (meningitis or air sinus infection) - Streptococcus pneumoniae, sinus infection) - Streptococcus pneumoniae, S. aureus, other streptococci, and Klebsiella.S. aureus, other streptococci, and Klebsiella.

ED Presentation: ED Presentation: Superior Sagittal Sinus ThrombosisSuperior Sagittal Sinus Thrombosis

Headache, nausea and vomiting, Headache, nausea and vomiting, confusion, and focal or generalized confusion, and focal or generalized seizures.seizures.

Rapid development of stupor and Rapid development of stupor and coma.coma.

Weakness of the lower extremities Weakness of the lower extremities with bilateral Babinski signs or with bilateral Babinski signs or hemiparesis is often present. hemiparesis is often present.

Headache and earache.Headache and earache. Gradinego's syndromeGradinego's syndrome: otitis media, : otitis media,

sixth nerve palsy, and retro-orbital sixth nerve palsy, and retro-orbital or facial pain.or facial pain.

Sigmoid sinus and internal jugular Sigmoid sinus and internal jugular vein thrombosis may present with vein thrombosis may present with neck pain.neck pain.

ED Presentation: ED Presentation: Transverse Transverse Sinus ThrombosisSinus Thrombosis

Sinusitis, midface infection for 5-10 days.Sinusitis, midface infection for 5-10 days. Fever, headache, malaise, retro-orbital pain and Fever, headache, malaise, retro-orbital pain and

diplopia, which generally precede…..diplopia, which generally precede….. Ptosis, proptosis, chemosis, eyelid edema, Ptosis, proptosis, chemosis, eyelid edema,

peri-orbital edema and extraocular dysmotility peri-orbital edema and extraocular dysmotility due to deficits of cranial nerves III, IV, and VI. due to deficits of cranial nerves III, IV, and VI.

Hypo- or hyperesthesia of the ophthalmic and Hypo- or hyperesthesia of the ophthalmic and maxillary divisions of V, decreased corneal maxillary divisions of V, decreased corneal reflex. dilated, tortuous retinal veins and reflex. dilated, tortuous retinal veins and papilledema.papilledema.

Meningeal signs: nuchal rigidity, Kernig and Meningeal signs: nuchal rigidity, Kernig and Brudzinski signs. Brudzinski signs.

ED Presentation: ED Presentation: Cavernous Cavernous Sinus ThrombosisSinus Thrombosis

Diagnostic StudiesDiagnostic Studies

CBC, diff, culturesCBC, diff, cultures Sinus Films, CT, MR, MR Venography, Sinus Films, CT, MR, MR Venography,

Venous phase cerebral angiogramVenous phase cerebral angiogram LPLP

ED ManagementED Management AntibioticsAntibiotics: : S aureusS aureus is the usual cause, broad- is the usual cause, broad-

spectrum coverage for gram-positive, gram-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms also, pending negative, and anaerobic organisms also, pending cultures. cultures.

Drain primary source of infection, if feasible Drain primary source of infection, if feasible (eg, sphenoid sinusitis, facial abscess).(eg, sphenoid sinusitis, facial abscess).

Anticoagulation in carefully selected cases of Anticoagulation in carefully selected cases of septic cavernous-sinus thrombosis, not other septic cavernous-sinus thrombosis, not other forms of septic dural-sinus thrombosis. forms of septic dural-sinus thrombosis.

Urokinase or rtPA?Urokinase or rtPA? Corticosteroids?Corticosteroids?

ConsultsConsults

ENTENT NeurologyNeurology IDID Intensive CareIntensive Care

Outcome of CaseOutcome of Case

Day 1Day 1: : Seizure, worsening deficit, Seizure, worsening deficit, intubatedintubated

Day 2Day 2: : Heparinized, transient neuro Heparinized, transient neuro improvement then relapse.improvement then relapse.

Day 5Day 5: : Sinuses drainedSinuses drained Day 6Day 6: : Brain deadBrain dead Day 19Day 19: Demise: Demise

Acute Neurological Emergencies: Headache. Brad Bunney, MD Associate Professor Dept of Emergency...

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Transcript of Acute Neurological Emergencies: Headache. Brad Bunney, MD Associate Professor Dept of Emergency...