headache and inability to solve quadratic equations jonathan a. edlow, md, facep associate chief,...
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Headache and Inability to Solve Headache and Inability to Solve Quadratic EquationsQuadratic Equations
Jonathan A. Edlow, MD, FACEPAssociate Chief, Department of Emergency Medicine
Beth Israel Deaconess Medical Center
Assistant Professor of Medicine
Harvard Medical School
Boston, MA
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Jonathan A. Edlow, MD
HistoryHistory
• 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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Jonathan A. Edlow, MD
History of Present IllnessHistory 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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Jonathan A. Edlow, MD
History of Present IllnessHistory 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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Jonathan A. Edlow, MD
Past History, Meds, AllergiesPast 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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Jonathan A. Edlow, MD
Social HistorySocial 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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Jonathan A. Edlow, MD
Physical ExaminationPhysical 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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Jonathan A. Edlow, MD
Neurological ExaminationNeurological 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 PulsationsVenous Pulsations
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Jonathan A. Edlow, MD
Differential DiagnosisDifferential 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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Jonathan A. Edlow, MD
ED Work UpED 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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Jonathan A. Edlow, MD
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Jonathan A. Edlow, MD
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Jonathan A. Edlow, MD
Ring Enhancing Lesion: Ring Enhancing Lesion: Differential DiagnosisDifferential 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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Jonathan A. Edlow, MD
Key Teaching PointsKey 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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Jonathan A. Edlow, MD
Brain Abscess - PathophysiologyBrain 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 VeinsEmissary Veins
Emissary veins
dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd
ddddddddddddddddddddddddddddddddddddddddddddddddd
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Jonathan A. Edlow, MD
Proximity of Sinuses to BrainProximity of Sinuses to Brain
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Jonathan A. Edlow, MD
Brain Abscess: Stages of Brain Abscess: Stages of DevelopmentDevelopment
• 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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Left temporal cerebritis in a diabetic patient with a facial infection
8-days later: frank abscess in the same area
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Jonathan A. Edlow, MD
Brain Abscess: Clinical PresentationBrain 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)
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Jonathan A. Edlow, MD
Brain Abscess: Clinical Clues Brain Abscess: Clinical Clues (source)(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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Jonathan A. Edlow, MD
More CluesMore Clues
• HIV infection• Other immune
defects• History of cancer
(especially lung, breast, melanoma)
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Jonathan A. Edlow, MD
Brain Abscess: ImagingBrain Abscess: Imaging
• CT (with and without contrast)
• MR (superior when available)
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Jonathan A. Edlow, MD
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
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Jonathan A. Edlow, MD
Brain Abscess: Initial StepsBrain 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)
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Source Location Microbes TherapySinuses 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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Jonathan A. Edlow, MD
Brain Abscess: TreatmentBrain 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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Jonathan A. Edlow, MD
Brain Abscess: DispositionBrain Abscess: Disposition
• Admit for further treatment• To neurosurgery• Consider transfer to a center that is able to
perform stereotactic biopsy
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Jonathan A. Edlow, MD
Outcome of CaseOutcome 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?Questions?