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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 Medical Center Assistant Professor of Medicine Harvard Medical School Boston, MA. History. 32 yo male with headache for 3 weeks.

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headache and inability to solve quadratic equations

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

history
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
history of present illness
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
history of present illness1
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
past history meds allergies
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%”
social history
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
physical examination
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
neurological examination
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
differential diagnosis
Differential Diagnosis
  • Tension HA
  • Migraine HA
  • Sinusitis-related HA
  • SAH
  • Meningitis
  • Mass lesion
      • Hematoma (SDH, EDH, parenchymal)
      • Tumor
      • Infection (brain abscess, subdural empyema)
ed work up
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?
ring enhancing lesion differential diagnosis
Ring enhancing lesion: differential diagnosis
  • Bacterial brain abscess
  • Toxoplasmosis, cryptococcosis
  • Tumor (glioblastoma or metastatic)
  • Lymphoma
  • Infarction
  • Necrotizing encephalitis
  • Granuloma
slide15

Toxoplasmosis

Glioblastoma vs. lymphoma

key teaching points
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

brain abscess pathophysiology
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)
emissary veins
Emissary veins

ddddddddddddddddddddddddddddddddddddddddddddddddd

dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd

Emissary veins

brain abscess stages of development
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)
slide21

Early cerebritis

Early abscess

slide22

8-days later: frank abscess in the same area

Left temporal cerebritis in a diabetic patient with a facial infection

brain abscess clinical presentation
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)
brain abscess clinical clues source
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
more clues
More clues
  • HIV infection
  • Other immune defects
  • History of cancer (especially lung, breast, melanoma)
brain abscess imaging
Brain abscess: Imaging
  • CT (with and without contrast)
  • MR (superior when available)
brain abscess lp
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
brain abscess initial steps
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)
brain abscess treatment
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
brain abscess disposition
Brain abscess: Disposition
  • Admit for further treatment
    • To neurosurgery
    • Consider transfer to a center that is able to perform stereotactic biopsy
outcome of case
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