Headache Flashcards

1
Q

Sinister causes of headache

A

Vascular: SAH, sub/extradural, cerebral venous sinus thrombosis
Infection: meningitis, encephalitis
Vision threat: temporal arteritis, acute glaucoma, pituitary apoplexy, cavernous sinus thrombosis
Intracranial pressure: SOL, hydrocephalus, malignant hypertension
Dissection: carotid dissection

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2
Q

New onset headache

>50 yrs

A

Suspicious of temporal arteritis until proven otherwise

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3
Q

Headache

Decreased GCS

A

Sudden onset worst pain ever, recalls exact moment pain began
Must exclude SAH
+ Hx head injury:
Fluctuating consciousness = suggestive of subdural
Lucid interval -> fluctuating consciousness = possible extradural

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4
Q

Persistent headache
Worse lying down
Early AM nausea

A

Raised ICP

E.g. Infection/SOL

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5
Q

Progressive

Persistent headache

A

Expanding SOL possible

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6
Q

Headache

Constitutional sx

A

Malignancy
Chronic infection: TB
Chronic inflammation: temporal arteritis

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7
Q

Temporal arteritis: opthalmological emergency

A

Inflammatory granulomas form in tunica media of med/large arteries. Can block med arteries
Mandibular branch of ext carotid -> jaw claudication
Superficial temporal branch ECT carotid -> headache + tender scalp
Posterior ciliary arteries -> ischaemic retina(blurry/visual field loss) or optic motor muscles (diplopia)
CRP + ESR (temporal artery biopsy)
High dose corticosteroids

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8
Q

Management of suspected SAH

A

Urgent CT head: bright blood in sylvian fissures
LP for xanthochromia if CT -ve (12 hrs from onset to 12 days)
SAH confirmed -> neurosurgeons + nimodipine (CCB reduces spasm of ruptured cerebral artery, preventing ischaemia) + bed rest
Survive + improved Sx -> cerebral angiography - platinum coil to resolve ruptured aneurysm ISAT study
High risk of morbidity + mort: 50% die pre hosp, 17% die in hosp, 17% survive with neuro deficit, 17% survive without deficit

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9
Q

Main causes of SAH

A

Rupture of arterial aneurysm: 45% oft berry at junction betw arteries of circle of Willis
Trauma: 45%
AVMs: 10% haemangioma rupture or cerebral vein around brainstem

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10
Q

Intracranial tumour ddx

A

90% are secondary mets: most common sources of primary cancer = lung, kidney, breast, melanoma, colon
Primary tumours:
Axial/neuroepithelial-50%: astrocytomas, ependymomas, oligodendrogliomas, medulloblastomas
Extra-axial: meningioma-15%(neurofibromatosis T2), vestibular schwannoma (7th + 8th nerve palsy) pituitary adenoma, Prolactinoma, craniopharyngiomas

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11
Q

Performing an LP

A

SC ends at L1/L2
LP safe at or below L3/L4
Tuffier’s line betw post-sup-iliac-crests = L4/L5
Skin->subcutis->supraspinous lig->interspinous lig->ligamentum flavum->dura mater->arachnoid space

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12
Q

Indications for an LP

A
Diagnostic
Oligoclonal bands- MS
High protein- GBS
Blood/BR- SAH
Pathogens- bact meningitis, viral encephalitis
Malignant cells- CNS lymphoma
Improvement in gait/cog function after 30ml removed- normal P hydrocephalus
Therapeutic
Intrathecal drug admin
Temporary reduction in ICP
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13
Q

Relative CI to LP

A

Raised ICP
Increased bleeding risk: warfarin, DIC, deranged clotting
Infection at prospective puncture site
Cardiorespiratory compromise

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14
Q

Signs of raised ICP

A

Early AM headaches/nausea/vom worse on lying down/straining
Impaired GCS
Papilloedema
Focal neuro signs (6th nerve palsy) visual blurring
Cushing’s reflex paradoxical bradycardia + raised bp + irreg breathing
Cushing’s peptic ulcer-> epigastric pain
If any doubt image first!!

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15
Q

Risks of LP

A

Headache: 30% due to IC hypotension, minimise by lying flat for 2 hrs, smaller calibre needle
Nerve root pain: 10% pain in lumbosacral nerve root distribution due to irritation of a nerve in cauda equina, minimise by inserting and withdrawing needle slowly
Infection at site of puncture

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16
Q

Causes of raised ICP

A

SOL: tumour, haematoma, abscess, cyst
Cerebral oedema: 2 to trauma or other lesion
Hydrocephalus: CSF drainage obstruction/arachnoid granulation (resorption) dysfunction/choroid plexus dysfunction (production)
Increased BP in CNS: vasodilators e.g. GTN, sildenafil, malignant htn, hypercapnic vasodilat, venous sinus thrombosis, SVC obstruction