Lesson. The most important aspect in the assessment of headache is a careful history

Transcription

1 Lesson The most important aspect in the assessment of headache is a careful history

2 Investigation of? SAH

3 Summary A CT scan within 12 hours of presentation is 98% sensitive for SAH CSF >12 hours with spectrophotometric detection of bilirubin is 96% sensitive for a SAH. Visual analysis of CSF is not acceptable

4 CSF spectrophotometry Confirmed SAH evident by CT also had a confirmed bilirubin peak on spectrophotometry 100% of cases, 12 hours to two weeks 70% after 3weeks 40% after 4 weeks

5 CT scans positive for SAH 98% within 12 hours 95% within 24 hours 73% on day three

6 71 patients with thunderclap headache and negative CT and CSF examinations were followed up for a mean of 3.3 years. None of these patients had a subarachnoid haemorrhage during the follow up period Wijdicks EFM, Kerkhoff H, Van Gijn. Long term follow up of 71 patients with thunderclap headache mimicking subarachnoid hemorrhage. Lancet 1988;ii:68 70

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8 1 67 year old nurse awoke two weeks prior with a constant right parietal headache unrelieved by simple analgesia -8/10 day1 Still continue in her work as a Nurse day Eased after 24 hours remained persistent Fluctuating severity from 2 to 6/10 with slight nausea Worse for bouncing on a trampoline and with other Valsalva manoeuvres.

9 Two days after onset she had developed a number of episodes which she thought she could smell gas, associated with feeling shaky and weak lasting for seconds Had hit her head two weeks prior running into a netball hoop. Associated with bilateral periorbital black eyes.

10 PH of 2monthly migraine with a visual aura for 30 minutes and subsequent global nonthrobbing headache with nausea. Effectively treated with Paracetamol. Current headache different to normal migraine headache. PH hypertension.

11 On examination, longstanding reduced hearing left ear. Air conduction greater than bone conduction. Weber referred to the left. Remaining examination normal.?diagnosis and what do you want to do

12 in rysm

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14 Clinical Pointers Headache was new onset, different character to previous headache. Worse with Valsalva manoeuvre Associated symptoms - suggesting focal seizures. Headache was not apparently of sudden onset. It did not cause waking from sleep, but was consistent with intracranial mass.

15 2 A 36 year old Maori women complained of headache and dizziness while refereeing touch rugby but was still able to run on for a period before suddenly collapsing to the ground with a severe headache and loss of consciousness for about 5 minutes. There were episodes of body stiffening.

16 Repeated neurological examination over 3 days was normal though there were episodes of apparently severe headache associated with thrashing around during which she remained responsive.

17 What diagnosis/diagnoses would you consider important? What investigation(s) would you consider important?

18 Days 1-2 CT scan - normal CSF 800 RBC in the first bottle 194 RBC in the 3rd bottle. Xanthochromia -ve EEG - normal

19 Day 10 MRI 10 days after the ictus - normal Repeat CSF 10 days after the ictus 92 lymphocytes, 51 RBC. Protein 0.71 Normal CSF glucose.

20 Day 14 Patient collapsed with sudden headache with dysconjugate eye movements and developed a locked in state with the only means of communication being vertical eye movement. Horizontal VOR was absent; bilateral facial palsies, a depressed corneal reflex, quadraparesis and bilateral extensor plantars.

21 Because of her previously inflammatory CSF she was treated for meningitis though a repeat CSF was normal. The patient deteriorated with a depressed level of consciousness with a CT head scan showing acute hydrocephalus improving with an intraventricular drain.

22 Repeat MRI showed an abnormal cerebellar hemisphere.

23 T2 MRI Infarct of Cerebellar Hemisphere

24 What investigation would you have liked to do on the day of her presentation?

25 Poorly filling basilar

26 Dissection of vertebral vessel wall

27 Lessons The essence is in the history An inflammatory CSF may represent infection inflammation malignancy blood Neck stiffness may be absent in up to 16% of known subarachnoid haemorrhages - even when examined by experts (J Edmeads 1995)

28 Dissection The mode of onset of headache is instantaneous and severe in about 13% of cases. Unless accompanied by stroke or SAH, CT and lumbar puncture may be unrevealing MR angiography is fast becoming the imaging modality of choice in demonstrating the arterial dissection

29 A 24 year old woman has the sudden onset of a severe hemicranial headache while sitting on a bus. The headache reached its maximal intensity at onset and persisted as a constant headache for the next 2 weeks. There was associated dizziness and intermittent vomiting occurring every second day? 3

30 Neurological examination was normal. What is your differential diagnosis Does the history warrant any investigations?

31 Head CT scan was normal. A CSF performed to look for xanthochromia from a possiible subarachnoid bleed showed 200 WBC, predominantly lymphocytes with a mildly raised protein and a normal glucose. Xanthochromia -ve

32 An EEG was abnormal with bilateral increase in slow wave activity. The patient was well and to try and seek further information as to the cause of her clinical condition an MRI with Gadolinium was performed. This was normal.

33 The patient had an episode of dysphasia on the 2nd hospital day? Want to do

34 The patient was treated for herpes simplex encephalitis and for TB. Three days later a polymerase chain reaction for HSV encephalitis was positive. TB treatment was discontinued

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36 4 A 22 year old pregnant woman at 25 weeks gestation developed throbbing occipital headaches with exacebation by postural change. What is your diagnosis?

37 Two days later she was diagnosed as having an intrauterine death. Half an hour following this diagnosis, one hand went out in front of her and there was shaking of the fingers with heavy breathing. She bit her tongue.

38 A few days later a generalised seizure occurred Subsequent episodes of generalised limb shaking, of a different character to the initial event, were associated with preserved consciousness

39 On day 10 the patient complained of difficulty moving her left hand side. Her blood pressure had been elevated post delivery to levels of 180/120 requiring a Nitroprusside drip in coronary care.

40 O/E mixture of functional and organic signs. Swollen optic discs Left leg pyramidal signs

41 What is the diagnosis now?

42 Puerperal sagittal sinus thrombosis

43 What investigation is needed to confirm this?

44 Normal CT

45 Filling defect

46 Absent venous filling

47 CT may be normal. MRI / MRA is the investigation of choice. MRI may be normal < 5 days or > 30 days and an angiogram may be needed Repeat MRI at 3 months to ensure that the CVT has resolved as in some patients the CVT may persist and could give a false diagnosis in subsequent pregnancies.

48 What treatment is indicated and why?

49 Rx Heparin in all cases - even if associated with venous haemorrhage. Thrombolysis not used by this group but advocated if Rx fails. Give low molecular weight heparin at time of further pregnancy to prevent recurrence. Anticonvulsants stopped after 6/12.

50 Differential pueperal related SST headache: Boussay France Can present with migraine with or without aura. Menstrual migraine may improve in pregnancy and often recurr post partum. Can be thunderclap with blood in CSF simulating an aneurysmal bleed (10%). May simulate low pressure post epidural headache with improvement on lying down. However, improvement is not as dramatic as occurs with true low pressure headache.

51 CVST The CSF pressure should always be measured as high intracranial pressure may be an important clue to the presence of CVST where about 25% of CT scans will be negative.

52 CSVT - onset is usually subacute over several days, Thunderclap headache may be the presenting feature in up to 10% CT is interpreted as normal in about 25% of patients with CVST.

53 Eclampsia can occur up to 2 wks post delivery and cause headaches and seizures. Pituitary necrosis may cause sudden severe headache and mimic SAH

54 5 53 year old woman, PH Bipolar Depression Sudden onset of headache with shooting pains to her shoulders and hips, lasting for 10 mins. Simultaneously hit by a grey light Subsequent vomiting O/E CNS NAD ECG sinus Bradycardia 38/min, Inverted T waves V2-V6 and 1st degree heart block

55 Day 2 dehydration 2nd to vomiting but complaining of headache and restless Patient concerned that she was unwell and attributed this to withdrawal from smoking and requested to see a social worker Day 3 febrile Day 4 Incontinent overnight Day 5 cognitive deterioration. L hand weakness

56 What investigation would you like to do?

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58 CT scan Haemorraghic infarction of right temporal parietal region. CSF 54 WBC 74 RBC, Protein 0.56, glucose CSF/serum : 2.5/6.0

59 Neurologist did not find any neck stiffness Patient was confused with bilateral grasp reflexes with spasticity and bilateral upgoing plantars

60 What possible diagnoses would you consider in light of the CSF?

61 Considered - cortical venous sinus thrombosis, vasculitis with haemorraghic infarct Day 7 Positive sciatic nerve stretch test, spiking fevers, depressed level of consciousness. Day 15 Rapid deterioration.

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63 Progressive cerebral oedema and death What abnormality do you expect to find at postmortem?

64 Ruptured berry aneurysm of the right middle cerebral artery, containing thrombus with extensive intracerebral and subarachnoid haemorraghe

65 An inflammatroy response can be seen in the CSF from subarachnoid blood. The presentation was complex with sidetracking symptoms but there was a history of sudden onset headache with radiation to the spine, consistent with subarachnoid bleeding. The history is the most important item. Without an accurate history and correct intepretation the direction of investigation is random and inappropriate.

66 An increased opening pressure may also help distinguish between a traumatic lumbar puncture and a subarachnoid haemorrhage. NB 20% of lumbar punctures are traumatic

67 Where the CSF or clinical findings are difficult to interpret or the index of suspicion is unusually high (family or personal history of subarachnoid haemorrhage), MRA is an appropriate procedure for detecting a saccular aneurysm in most patients.

68 Thunderclap headaches with normal neurological examinations can be the presenting feature of cerebral venous sinus thrombosis pituitary apoplexy, cervicocephalic arterial disection, acute hypertensive crisis -pheochromcytoma spontaneous intracranial hypotension orgasmic headache - may often evade detection by CT and lumbar puncture.

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70 Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study BMJ 2011;343:d4277 doi: /bmj.d4277

71 100% sensitivity and specificity in 121 patients with SAH but criticisms: LPs only done in ½ Spectrophotometric analysis of CSF not done No strong evidence to demonstrate the superiority of xanthochromia by spectrophotometer versus visual detection of xanthochromia?? CT sensitivity drops too 85% after 8hrs AE physicians and radiology trainees misinterpreted scan in 4 subjects 2% of patients were lost to follow-up at six months.