Headache and Inability to Solve Quadratic Equations

1. Headache and Inability to Solve Quadratic Equations Jonathan A. Edlow, MD, FACEP Associate Chief, Department of Emergency Medicine Beth Israel Deaconess Medical Center Assistant Professor of Medicine Harvard Medical School Boston, MA

2. History • 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

3. History 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

4. History 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

5. Past 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%”

6. Social 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

7. Physical 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

8. Neurological 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

9. Venous pulsations

10. Differential Diagnosis • Tension HA • Migraine HA • Sinusitis-related HA • SAH • Meningitis • Mass lesion • Hematoma (SDH, EDH, parenchymal) • Tumor • Infection (brain abscess, subdural empyema)

11. ED 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?

14. Ring enhancing lesion: differential diagnosis • Bacterial brain abscess • Toxoplasmosis, cryptococcosis • Tumor (glioblastoma or metastatic) • Lymphoma • Infarction • Necrotizing encephalitis • Granuloma

15. Toxoplasmosis Glioblastoma vs. lymphoma

16. Key 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

17. Brain 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)

18. Emissary veins ddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd Emissary veins

19. Proximity of sinuses to brain

20. Brain abscess: Stages of development • Early cerebritis (1-3 days) • Late cerebritis (4-9 days) • Early capsule (10-14 days) • Late capsule (beyond 14 days)

21. Early cerebritis Early abscess

22. 8-days later: frank abscess in the same area Left temporal cerebritis in a diabetic patient with a facial infection

23. Brain 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)

24. Brain abscess: clinical clues (source) • Look for signs and symptoms of • Chronic ear infection • Sinusitis • Odontogenic infection • Endocarditis (or bacteremia of any cause) • Lung abscess • Recent body piercing

25. More clues • HIV infection • Other immune defects • History of cancer (especially lung, breast, melanoma)

26. Brain abscess: Imaging • CT (with and without contrast) • MR (superior when available)

27. 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

28. Brain 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)

30. Brain 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

31. Brain abscess: Disposition • Admit for further treatment • To neurosurgery • Consider transfer to a center that is able to perform stereotactic biopsy

32. Outcome 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