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

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

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

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

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%”

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

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

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

Venous PulsationsVenous Pulsations

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)

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?

Jonathan A. Edlow, MD

Jonathan A. Edlow, MD

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

Toxoplasmosis

Glioblastoma vs. lymphoma

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

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)

Emissary VeinsEmissary Veins

Emissary veins

dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd

ddddddddddddddddddddddddddddddddddddddddddddddddd

Jonathan A. Edlow, MD

Proximity of Sinuses to BrainProximity of Sinuses to Brain

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)

Early cerebritis Early abscess

Left temporal cerebritis in a diabetic patient with a facial infection

8-days later: frank abscess in the same area

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)

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

Jonathan A. Edlow, MD

More CluesMore Clues

• HIV infection• Other immune

defects• History of cancer

(especially lung, breast, melanoma)

Jonathan A. Edlow, MD

Brain Abscess: ImagingBrain Abscess: Imaging

• CT (with and without contrast)

• MR (superior when available)

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

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)

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

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

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

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

Questions?Questions?