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Acute Neurological Emergencies: Headache

Acute Neurological Emergencies: Headache. Brad Bunney, MD Associate Professor Dept of Emergency Medicine. University of Illinois College of Medicine Chicago, IL.

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Acute Neurological Emergencies: Headache

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  1. Acute Neurological Emergencies:Headache

  2. Brad Bunney, MDAssociate ProfessorDept of Emergency Medicine University of Illinois College of Medicine Chicago, IL

  3. Michael Gerardi, MD, FAAP, FACEPVice-Chairman, Department of Emergency MedicineMorristown Memorial HospitalMorristown, New JerseyNina T. Gentile, MDAssociate ProfessorDivision of Emergency MedicineTemple University School of MedicinePhiladelphia, PADaniel G. Murphy, MD, FACEPVice Chair & Medical DirectorMaimonides Medical CenterBrooklyn, New York

  4. The Case One hour prior to ED presentation, a 42 year old man was jogging and “hit” by the worst headache of his life. It was associated with some nausea and the feeling as if he was going to pass out. He rested for 30 minutes but the headache persisted as a diffuse, throbbing pain radiating to the base of his skull.

  5. The Case (Continued) EMS was called. The patient felt as if he could not concentrate, there was no confusion, nor was there any other focal neurologic complaint. There was no past medical history, no medications, no family history, and no significant use of alcohol, tobacco or other drugs.

  6. If a patient presented with the worst headache of his life, what is the work-up that should be initiated? a. Non-contrast CT b. LP after neg. CT c. LP without CT d. CT, LP, and angiography

  7. Objectives • What is the differential of a “thunderclap headache”? • What is the sensitivity of neuroimaging in subarachnoid hemorrhage (SAH)? • What constitutes a “positive” lumbar puncture in SAH and when should it be performed? • Do patients with suspected SAH who have a negative CT and lumbar puncture require additional imaging to “rule-out” expanded but unruptured aneurysm?

  8. Headache • 1 of 10 top presenting complaints • 1 to 2% of visits to ED • 18 million outpatient visits • 638 million days of work lost per year • 78% of women and 64% of men had experienced at least one in the prior year • 36% of women and 19% men suffer from recurrent headaches

  9. Headache • Most have primary headache disorders • migraine • tension • Only a few have treatable secondary causes that threaten life, limb, brain such as subarachnoid hemorrhage • 1 - 4 % of headache visits

  10. “Worst” Headache • Normal exam: 12- 33% SAH • Abnormal exam: 25% SAH • Initial hemorrhage may be fatal • Early definitive surgery improves outcomes • Patients with greatest likelihood of benefiting from surgery are most likely to receive incorrect diagnosis

  11. Physicians Consistently Misdiagnose SAH 1. Failure to appreciate spectrum of clinical presentation 2. Failure to understand limitations of CT 3. Failure to perform and correctly interpret the results of LP

  12. ED Goals in Headache Patients 1. Differentiate life-threatening from benign 2. Initiate prompt treatment 3. Provide prompt pain relief 4. Prevent drug seeking and refer 5. Minimize resource utilization in ED 6. Optimize patient use of ED 7. Increase pre-ED treatment and reduce ED use

  13. Medical Conditions That Present With Headache • Pheochromocytoma • Hyperthyroidism • SLE • Giant Cell Arteritis • Fibromyalgia

  14. Types of Headaches in the ED Final Diagnosis Percentage Infection - not intracranial 39.3 Tension HA 19.3 Miscellaneous 14.9 Post-traumatic 9.3 Hypertension related 4.8 Vascular (Migraine) 4.5 No diagnosis 6.0 SAH 0.9 Meningitis 0.6

  15. Causes of Headache That Require Specific Therapy • Subarachnoid hemorrhage • Meningitis • Encephalitis • Cervicocranial-artery dissection • Temporal arteritis • Acute angle-closure glaucoma • Hypertensive emergency

  16. Causes of Headache That Require Specific Therapy • Carbon Monoxide poisoning • Pseudotumor cerebri • Cerebral venous and dural sinus thrombosis • Acute stroke (hemorrhagic or ischemic) • Mass Lesion • tumor • abscess intracranial • hematoma • parameningeal infection

  17. Headache Danger Signals • Onset • after 40 years • new or different headache • subacute HA that worsens • exertion, sex, coughing, straining • Worst ever experienced

  18. Headache Danger Signals: Associated With Neurologic Change • Memory impairment • Ataxia • Drowsiness • Sensory loss • Signs of meningeal irritation

  19. Headache Danger Signals: Associated With Neurologic Change • Progressive visual or neurologic change • Confusion • Weakness • Loss of coordination • Asymmetry of pupils, DTRs

  20. Headache Danger Signals: Abnormal Medical Evaluation • Fever • Chronic malaise • Arthralgia • HTN • Myalgia • Wt loss • Tender, poorly pulsatile temporal arteries

  21. Subarachnoid Hemorrhage • Incidence of 16 /100,000 • about 33,600 cases per year • 54% secondary to ruptured aneurysm • Without treatment, 40% of aneurysm pts. have recurrent bleeding • Aneurysm pt who survives initial rupture and is treated conservatively: • 50% survival at one year

  22. Time of Death Following SAH by Cause

  23. Current Problems in Management of Subarachnoid Hemorrhage • Errors and delays in diagnosis • Treatment of acute effects • Prevention of recurrent hemorrhage • Prevention or treatment of vasospasm or cerebral ischemia

  24. Classic Symptoms of Subarachnoid Hemorrhage • Sudden, unusually severe or “thunderclap” headache • Loss of consciousness • Pain in neck, back, eye or face • Nausea, vomiting, photophobia, phonophobia

  25. Classic Signs of Subarachnoid Hemorrhage • Abnormal vital signs • Respiratory changes, hypertension, cardiac arrhythmias • Meningismus • Focal neurologic signs may be present • III nerve palsy – IC/PCA aneurysm • Paraparesis – ACA aneurysm • Hemiparesis, aphasia – MCA aneurysm • Ocular hemorrhages

  26. Subarachnoid Hemorrhage • Onset: Acute • Location: Global • Ass Sx: N,V, meningismus, focal • Pain: Worst ever • Duration: Brief • Prior Hx: No • Dx tests: CT 80-90% • Phys ex: Focal signs, LOC, meningismus

  27. Subarachnoid Hemorrhage • Warning leaks in 50% • CT misses up to 10% small leaks • Suspect if: • > 35 years • no previous HA • no fading of HA • came on with exertion • altered LOC or neuro deficits • stiff neck

  28. Subarachnoid Hemorrhage: Neurologic Findings • Sudden HA without localizing findings • Altered mentation • Confusion, lethargy • Bilateral extensor plantar reflex • Unusual to find focal deficits

  29. Causes of Non-Traumatic Subarachnoid Hemorrhage • “Berry” aneurysms • AVM • Cerebral angiomas • Mycotic aneurysm • Extension from parenchymatous hemorrhage • Anticoagulation therapy

  30. Causes of Non-Traumatic Subarachnoid Hemorrhage • Systemic bleeding diathesis • Hemorrhagic encephalitis • Hemorrhagic cerebral vasculitis • Hemorrhage into CNS tumors or metastases • Unknown

  31. Warning Headache • 20 - 50% patients with SAH have HA days or weeks before index episode • unusually severe • distinct • “Thunderclap” headache • Day and Raskin 1996 • intense, acute, peak intensity at onset • develop in seconds • maximal intensity in minutes • lasts hours to days

  32. “Thunderclap” Headache • 25% associated with SAH • “Warning” headache • followed by SAH in 5% to 60% • Expansion or dissection of unruptured aneurysm • Cerebral venous thrombosis • Exertional / coital headache

  33. Misdiagnosis of SAH • 217 patients from 4 institutions • 54 (25%) were initially misdiagnosed • 121 patients initially presented in good clinical condition • 46 (38%) were initially misdiagnosed Stroke 1996;27:1558-63

  34. Misdiagnosis of SAH Outcome of Patients with Good Initial Presentation in Misdiagnosed and Correctly Diagnosed Patients With SAH Outcome Misdiagnosis (n=45) Correct Diagnosis (n=75) Excellent/good 24 (53)* 68 (91)* Fair 5 (11) 4 ( 5) Poor/vegetative/dead 16 (36)* 3 ( 4)* Values are number (%) in each clinical grade category. • P<.001 Stroke 1996;27:1558-63

  35. Misdiagnosis of SAH Rebleeds and Deteriorations Before Treatment in Misdiagnosed and Correctly Diagnosed Patients With SAH Misdiagnosis (n=54) Correct Diagnosis (n=163) Rebleeds 21* 4 Deteriorations 5 0 Total 26 4 *12/21 of misdiagnosed and 3/4 of correctly diagnosed patients rebled within 5 days of presentation. Stroke 1996;27:1558-63

  36. SAH…But not “Classic” • Roughly half have minor bleeding with atypical features • Nonstrenuous activities (34%) • Sleep (12%) • HA in any location (localized, generalized, mild) • May be relieved by non-narcotic analgesics • Diagnosed as migraine, tension-type, sinusitis

  37. SAH: Most patients have... • Abrupt onset of severe, unique headache, or neck pain • Abnormal findings on neurologic examination • Subtle meningismus or ocular findings

  38. International Headache Society • A first episode of severe headache cannot be classified as migraine: • more than 4 episodes • nor as tension-type headache: • more than 9 episodes • First or worst headache requires evaluation • as do qualitatively different headaches

  39. Can a CT Scan Safely “Rule Out” SAH? • First diagnostic study • Thin cuts ( 3 mm) through base of brain • Blood on CT function of Hgb • Hgb < 10: blood isodense • Sensitivity decreases over time from onset of symptoms

  40. SAH CT Findings • High density hemorrhage injury • (1) Interhemospheric fissure • (2) Inferior frontal sulci • (3) Third ventricle • (4) Ambient cistern • (5)Sylvian fissure

  41. SAH: CT SensitivitySames: Acad Emerg Med Jan 1996 • 181 patients; aged 13-86 with SAH • Sensitivity 91.2% • pain < 24 hrs 93.1% • pain > 24 hrs 83.8% • LP 100% sensitive if neg CT • “A normal NGCT does not reliably exclude the need for LP”

  42. SAH Diagnosis: LP NeededSidman: Acad Emerg Med Sep 1996 • 140 patients; aged 10-88 • Sensitivity of CT • < 12 hrs 80/80 100% • > 12 hrs 49/60 81.7% • Overall, 11/140 had (-) CT and (+) LP • overall sensitivity 92.1%

  43. Morgenstern LB, et al:Worst headache and SAH: Prospective, modern CT and spinal fluid analysis.Ann Emerg Med Sept 1998. • 38,730 patients over 16 months, prospectively screened for “worst HA” • Blinded neuroradiologists • Neg CT LP • cell count x 2 • visual and spectrophotometric detection of xanthochromia • CSF D-dimer assay

  44. Morgenstern, et al: Ann Emerg Med 1998 • 455 headaches & 107 “worst headache” • CT: 18 of 107 (17%): (+) SAH • (-) CT/ (+) SAH: Only 2 (2.5%) • (95% CI, 0.3%to 8.8%) • Modern CT is sufficient to exclude 98% of SAH in patients

  45. Morgenstern, et al: Ann Emerg Med 1998 (107 “Worst HA’s) Variables CT-/LP- CT+ CT-/LP+ Photophobia 45 28 50 Stiff neck 26 37 100 Nausea 65 36 100 Lethargy 17 40 50 Time < 24 h 58 75 50 Migraine 20 11 0 Headache 48 27 0

  46. CT is Normal: Do LP? Yes!

  47. What about LP First? • Duffy et al; 1982: 55 patients who underwent LP as initial w/u • Condition deteriorated immediately in 7 patients • Hillman et al; 1986: 4 alert patients with SAH who deteriorated after lumbar puncture • Both studies: • clots on CT or a dilated pupil

  48. Traumatic Taps • 20% of LPs • 0.5% and 6% has incidental intracranial aneurysm • Impression or “3-tube” method not reliable in detecting traumatic tap • Erythrocytes disseminate rapidly • Released Hgb oxyhemoglobin xanthochromia bilirubin

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