Headache and Inability to Solve Quadratic Equations

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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

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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

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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

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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

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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

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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

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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

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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

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Venous Pulsations
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Differential Diagnosis

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

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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?

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Ring Enhancing Lesion Differential Diagnosis

• Bacterial brain abscess
• Toxoplasmosis, cryptococcosis
• Tumor (glioblastoma or metastatic)
• Lymphoma
• Infarction
• Necrotizing encephalitis
• Granuloma

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Toxoplasmosis
Glioblastoma vs. lymphoma
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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

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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)

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Emissary Veins
dddddddddddddddddddddddddddddddddddddddddddddddddd
dddddddddddddddd
ddddddddddddddddddddddddddddddddddddddddddddddddd
Emissary veins
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Proximity of Sinuses to Brain
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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)

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Early cerebritis
Early abscess
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8-days later frank abscess in the same area
Left temporal cerebritis in a diabetic patient
with a facial infection
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Brain Abscess Clinical Presentation

• Quite variable, HA being the most common (
  80-90)
• Seizure ( 50)
• Fever lt 50 in some series
• Papilledema lt 25
• Signs of
• Mass (depends on location)
• Increased ICP (n/v, ?MS)

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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

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More Clues

• HIV infection
• Other immune defects
• History of cancer (especially lung, breast,
  melanoma)

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Brain Abscess Imaging

• CT (with and without contrast)
• MR (superior when available)

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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

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Brain Abscess Initial Steps

• ABCs (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)

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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 Variable Same as above Staph epi Vanc ceftazidime
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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

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Brain Abscess Disposition

• Admit for further treatment
• To neurosurgery
• Consider transfer to a center that is able to
  perform stereotactic biopsy

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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

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Questions?