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Emergency Medicine > Tintinalli's - HA > Flashcards

Tintinalli's - HA Flashcards

1
Q

clinical red flags for HA onset

A
  • Sudden
  • trauma
  • exertion
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2
Q

clinical red flags for HA sx

A
  • Altered mental status
  • Seizure
  • Fever
  • Neuro sx
  • Visual changes
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3
Q

clinical red flags for HA meds

A
  • anticoag/antiplatelet
  • Recent abx use
  • immunosupp
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4
Q

clinical red flags of HA hx

A
  • No prior HA
  • Change in HA quality, or worsening over wks/mo
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5
Q

clinical red flags of HA associated conditions

A
  • Pregnancy or post pregnancy status
  • SLE
  • Behcet’s disease
  • Vasculitis
  • Sarcoidosis
  • Cancer
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6
Q

clinical red flags of HA PE findings

A
  • Altered mental status
  • Fever
  • Neck stiffness
  • Papilledema
  • Focal neurologic signs
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7
Q

what age group are considered high-risk pts?

A

> 50 y/o with new/worsening HA, “thunderclap HA”

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8
Q

CT noncontrast is useful for what other DDx?

A
  1. hemorrhage
  2. subdural hematoma
  3. space-occupying lesion
  4. elevated ICP
  5. SAH
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9
Q

MRI would be a good imaging choice for what DDx?

A

cerebral venous thrombosis

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10
Q

MR/CR angiography imaging would be a good choice for what other DDx?

A
  • arterial dissection
  • small SAH
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11
Q

lumbar puncture would be an important diagnostic work-up for what other DDx?

A
  1. meningitis
  2. encephalitis
  3. SAH
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12
Q

hemorrhagic causes of “thunderclap” HA

A
  1. Intracranial hemorrhage
  2. “Sentinel” aneurysmal hemorrhage
  3. Spontaneous intracerebral hemorrhage
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13
Q

vascular causes of “thunderclap HA”

A
  1. Carotid or vertebrobasilar dissection
  2. Reversible cerebral vasoconstriction syndrome (RCVS)
  3. Cerebral venous thrombosis
  4. Posterior reversible encephalopathy syndrome (PRES)
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14
Q

other causes (besides hemorrhage and vascular) of “thunderclap HA”

A
  1. Coital HA
  2. Valsalva-associated HA
  3. Spontaneous intracranial HoTN
  4. Acute hydrocephalus
  5. Pituitary apoplexy
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15
Q
  1. bilateral/unilateral
  2. Constant/intermittent
  3. Worse upon awakening, valsalva, positional
  4. N/V
  5. Cancer dx, seizures, or mental status change = primary or metastatic brain lesion
A

brain tumor

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16
Q
  1. Hypercoagulable state - OCP, postpartum or periop status, clotting factor def., polycythemia
  2. Papilledema
  3. Neuro findings - wax and wane
A

Cerebral venous thrombosis

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17
Q

diagnostics of Cerebral venous thrombosis

A
  1. LP - increased opening pressure
  2. DX: MR venography
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18
Q
  1. ≥50 y/o
  2. new HA
  3. temporal artery abnormality - tender, nonpulsatile, or diminished pulse
  4. ESR ≥50
  5. abnormal bx

other: Fatigue, F, jaw claudication, vision changes

A

temporal arteritis

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19
Q

diagnostics temporal arteritis

A

Labs - ESR/CRP
DX: temporal artery bx

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20
Q

tx temporal arteritis

A
  1. prednisone
  2. consult ophthalmologist or other specialist to arrange bx to confirm dx, f/u, and tx
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21
Q

MCC benign HA

A

migraine

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22
Q

Pt with HA describes it as:
Gradual onset, lasting 4-72h
Unilateral, pulsating
Worsening by physical activity
N/V, photophobia, phonophobia
W/ or w/o aura

what is the dx

A

migraine

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23
Q

tx migraine

A
  • DHE, sumatriptan, metoclopramide, chlorpromazine, or prochlorperazine
  • Dexamethasone IV - adjunctive to reduce migraine recurrence
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24
Q

Idiopathic intracranial HTN aka Pseudotumor cerebri is MC in what demographic

A

Obese women, 20-44 y/o

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25
Q
  • quick vision disturbances, back pain, pulsatile tinnitus
  • Permanent vision loss if left untreated
A

Idiopathic intracranial HTN

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26
Q

DX criteria for Idiopathic intracranial HTN

A
  1. Papilledema
  2. nml neuro exam
  3. increased LP opening pressure
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27
Q

HA after a procedure involving dura (LP, epidural anesthesia)

A

Intracranial HoTN

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27
Q
  • HA worsens w/ upright position; Alleviated: lying down
  • N/V, hearing/vision changes
A

Intracranial HoTN

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28
Q

tx Intracranial HoTN

A
  • acetazolamide
  • wt loss if obese
  • LP for therapeutic to reduce pressure to 15-20 cm H2O
  • consult neuro and/or ophthalmologist
  • If d/t LP or epidural anesthesia - symptomatic; most effective epidural blood patch by anesthesiologist
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29
Q
  • Uncommon
  • Daily for wks, periods of remission that may last for wks-yrs
  • Severe, unilateral, localized (orbital, supraorbital, or temporal)
  • Lacrimation, nasal congestion, rhinorrhea, conjunctival injection, pacing in room
A

cluster HA

30
Q

tx cluster HA

A
  • high-flow oxygen @ 12 L/min x 15 min via nonrebreathing face mask
  • sumitriptan SQ for pain if unresolved
31
Q

SAH onset of sx assoc w/ activities that affects BP how?

A

elevate BP - sex, wt lifting, defection, coughing

32
Q

s/s SAH

A
  • Loss of consciousness
  • seizure
  • diplopia
  • vomiting
  • photophobia
  • nuchal irritation
  • low-grade fever
  • altered mental status
  • +/- focal neuro findings - dependent on location of aneurysm
33
Q

major arteries and what region of brain it supplies

A
  • Ophthalmic - Optic nerve and retain
  • Anterior cerebral - Frontal pole; Anteromedial cerebral cortex; Anterior corpus callosum
  • Middle Cerebral - Frontoparietal lobe; Anterotemporal lobe
  • Vertebral - brainstem
  • Posteroinferior cerebellar - Cerebellum
  • Basilar - Thalamus
  • Posterior cerebral - Auditory/vestibular structures
  • Medial temporal lobe - Visual occipital cortex
34
Q

SAH RF

A
  1. Excessive alc
  2. Polycystic kidney disease
  3. FHx SAH
  4. Marfan’s syndrome
  5. Ehlers-Danlos syndrome
  6. Drug use hx, chiropractors, BP elevating activities
35
Q

Stroke RF

A
  1. Age
  2. Comorbidities
  • Afib
  • HTN
  • DM
  • Smoking
  • Coronary atherosclerosis
  • Valvular replacement
  • Recent MI
36
Q

SAH PE

A
  • Motor weakness
  • Sensory deficits
  • Cerebellar dysfunction
  • Other: meningismus, carotid bruits, signs of embolic disease, papilledema, preretinal hemorrhage
37
Q

diagnostics SAH

A
  1. CT noncontrast
    - If done earlier = better dx! (< 6hrs)
    - If negative but SAH still suspected → LP = RBC or xanthochromia
  2. Other tests - glucose, CBC, ECG, pulse ox, lytes, coags, cardiac enzymes, tox screen, blood alc, echo, carotid duplex scanning
  3. High suspicion for other DDX → MRI, MR angiogram, CT angiogram
38
Q

DDX for SAH

A
  1. Intracranial hemorrhage
  2. Drug toxicity
  3. Ischemic stroke
  4. Meningitis
  5. Encephalitis
  6. Intracranial tumor
  7. Venous sinus thrombosis
  8. Primary HA syndromes
39
Q

tx SAH

A
  • ABCs, IV access, glucose testing, cardiac monitoring and pulse ox (keep pulse ox >94%)
  • Once stabilized → noncontrast CT and labs, including coagulation studies.
  • BP control at a pt’s prehemorrhage BP or a MAP < 140 mm Hg if the baseline bp is unknown.
  • IV labetalol / nicardipine
  • Admit ICU in consultation with a neurosurgeon.
  • nimodipine PO - improvements by decreasing vasospasm
  • Seizure prophylaxis is controversial and should be discussed with the admitting specialist.
  • Reverse any coagulopathy with Vit K, FFP, and/or prothrombin concentrates.
40
Q

SAH risk of rebleeding is greatest in when?

A

the first 24 hrs

41
Q

indications for early neurosurgical consultation is appropriate for patients with SAH

A
  1. evidence of increased ICP
  2. location of bleeding
  3. other conditions suggest that surgical intervention may be indicated.
42
Q

inflammation of membranes surrounding brain and spinal cord

A

Meningitis

43
Q

causes of Meningitis

A
  1. bacterial
  2. aseptic - Drug reactions, rheumatologic, nonbacterial infections (fungi, virus)
    - MC - enteroviruses & echoviruses
44
Q

meningitis triad

A

1) F,
2) Neck stiffness
3) altered mental status

MC - HA + F

45
Q
  • Fever
  • Meningeal signs - nuchal rigidity, Kernig’s, Brudzinski’s
  • Skin - petechiae, splinter hemorrhages

these PE findings are for what dx?

A

Meningitis

46
Q

infection of brain parenchyma → inflammation within CNS

A

Encephalitis

47
Q

MCC viral infection of Encephalitis

A

HSV

48
Q

presentation of encephalitis

A

Same as meningitis
+ Altered mental status, cognitive deficits, psychiatric sx, seizures

49
Q

when to get CT before getting an LP for meningitis/encephalitis

A
  1. altered mental status
  2. new onset of seizures
  3. Immunocomp
  4. focal neuro signs
  5. papilledema

CI to LP - occult mass, signs of brain shift or herniation

50
Q

diagnostics for meningitis/encephalitis

A
  1. LP
    - CSF - cell count & diff, protein & glucose lvls, gram staining, bacterial cx
  2. CBC, glucose & lytes, BUN, Cr, blood cx
  3. MRI
51
Q

when would additional work-up needed on CSF with meningitis/encephalitis

A
  • immunocomp or specific CNS infections
  • Additional: HSV, enterovirus PCT, bacterial antigen, fungal
52
Q

MRI findings in medial temporal and inferior frontal lobes is indicative of

A

HSV

53
Q

tx meningitis

A

Empiric ASAP after LP/blood cx

  1. 1st: Dexamethasone - >3 mo
  2. < 50 y/o - ceftriaxone + vanc
    - Add Ampicillin - Listeria (>50 y/o, pregnant, alc, immunocomp)
54
Q

tx encephalitis

A
  • Acyclovir
  • CMV - ganciclovir
  • Other viral causes - supportive
55
Q

Bacterial infection of brain parenchyma - central purulent cavity ringed by layer of granulation tissue and outer fibrous capsule

A

brain abscess

56
Q
  • HA, neck stiffness, F, vomiting, confusion, changes in mental status
  • 1-8 wks
A

brain abscess
Neurosurgeon consult for surgery

57
Q

diagnostics brain abscess

A
  1. DX: CT WITH Contrast = rings
    - Alt: MRI
  2. AVOID LP
  3. Blood cx, cx of other infection sites
58
Q

DDx brain abscess

A
  1. Cerebrovascular disease
  2. Meningitis
  3. Brain neoplasm
  4. Subacute cerebral hemorrhage
  5. Focal brain infections - toxoplasmosis
59
Q

brain abscess penetrating trauma tx

A

cefotaxime/ceftriaxone + metronidazole +/- rifampin

60
Q

brain abscess post-neurosurgery tx

A
  • vanc/linezolid + ceftrazidime +/- rifampin
  • Alt: meropenem, pip/taz, cefepime for ceftrazidime
61
Q

Pyogenic material in epidural space

A

Epidural abscess

62
Q

MCC of Epidural abscess

A

from hematogenous spread of bacteria from tissue, urine, or rsp

63
Q

epidural abscess MC spread to where?

A

thoracic and lumbar spine

64
Q

RF epidural abscess

A
  1. immunocomp
  2. IVDU
  3. spinal surgery
  4. recent procedures of LP or epidural anesthesia
65
Q

triad s/s of epidural abscess

A

Back pain, F, neuro sx

rare

66
Q
  1. Back pain, F, localized spinal tenderness
  2. Spinal irritation w/ radicular pain, hyperreflexia, nuchal rigidity
  3. fecal/urinary incontinence + focal neuro deficits
  4. LE Motor paralysis
  5. PE: midline spine tenderness, cauda equina syndrome (decreased rectal tone and perineal sensation)
A

epidural abscess

67
Q

diagnostics for epidural abscess

A
  • CBC
  • ESR
  • CRP
  • Blood cx
  • Gadolinium MRI preferred, CT w/ myelography is ok
68
Q

tx epidural abscess

A
  1. Consult spine surgeon
  2. Debridement
  3. Empiric - vanc + ceftazidime/cefepime
    - Add gentamicin if recent neurosurgery
69
Q
  • Painless ischemic optic neuropathy
  • Women, >50 y/o, hx of polymyalgia rheumatica
A

Temporal Arteritis (Giant Cell Arteritis)

70
Q

s/s Temporal Arteritis (Giant Cell Arteritis)

A
  1. Vision changes, HA, jaw claudication, scalp/temporal artery tenderness, fatigue, F, sore throat. URI sx, anorexia
  2. Unilateral, BL possible
  3. ⅓ - neuro events (TIA)
  4. APD; fundoscopic exam - flame hemorrhage
  5. CNVI palsy
  6. Vision loss
71
Q

GCA - strong suspicion of TA or vision loss tx

A

Admit, methylprednisolone

72
Q
  1. Facial pain in distribution of 5th CN
    - Paroxysms of severe pain - lasting seconds
  2. Normal PE findings
A

trigeminal neuralgia presentation

73
Q

tx trigeminal neuralgia

A

Carbamazepine

Emergency Medicine (20 decks)

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