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Headache and CNS infections
Neuro Assessment 9
152
Anatomy
Graduate
11/10/2011

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Cards

Term
What type of headache has no identifiable structural cause?
Definition
Primary
Term
What are the 3 types of Primary headaches?
Definition
migraine
cluster
tension
Term
What type of headaches have an underlying structural or metabolic cause?
Definition
Secondary
Term
What are the characteristics of an acute onset headache?
Definition
sudden onset
rapidly worsen
Term
What are the characteristics of a subacute onset headache?
Definition
gradual onset and progression
Term
What type of temporal mode classification do the primary headaches have?
Definition
Subacute onset
Term
What are the Pain sensitive structures of the Head?
Definition
Dura and Meninges at base of brain
Large arteries at base of brain
meningeal arteries
venous sinuses
scalp muscles
upper cervical muscles
periosteum of the skull
facial & head structures/organs
Term
What Brain structure is insensitive to pain?
Definition
Brain parenchyma
(has no sensory receptors)
Term
What will a mechanical or electrical stimulation of the thalamus or trigeminal nucleus caudalis trigger?
Definition
pain response
Term
What nerves transmit headache pain centrally?
Definition
CNs V, VII, IX, X
nerve roots C2-C3
Term
What nerve innervates pain in the anterior/middle fossa and scalp?
Definition
CN V1
(Ophthalmic branch of V)
Term
What nerve innervates pain in the posterior fossa?
Definition
CN IX
Term
Where do the pain sensitive fibers first synapse?
Definition
trigeminal nucleus caudalis and dorsal horn of the upper cervical spinal cord
Term
What is the pathway for pain transmitted centrally?
Definition
CNs and roots-> synapse in trigeminal nucleuscaudalis and dorsal horn-> synapse in VPL and VPM of thalamus-> sensory cortex
Term
What carries pain from the cervical muscles and posterior scalp?
Definition
C2-C3
Term
What are Red Flags that a headache has a secondary origin?
Definition
Abrupt onset, trauma, fever, immunosuppression, focal neurological symptoms, "Worst headache of my life"
Term
What are unique characteristics of a migraine?
Definition
Often unilatera, pulsating, nausea, photo/phonophobia, aura
Term
T/F A Migraine is just a headache.
Definition
False
It can have symptoms that start long before the headache
Term
How does a migraine typically progress?
Definition
Prodrome-> aura-> headache-> postdrome
Term
What is a prodrome and how frequent is it?
Definition
A vague constellation of symptoms seen in 40% of migraine patients
(mood swings, odd food cravings, malaise, fatigue)
Term
What is an aura and how frequent is it?
Definition
More symptoms, like visual disturbance, within 60 minutes of the headache (Scintillations->Scotoma)
May resemble a TIA
Seen in 20% of migraine pts
Term
T/F A migraine is strictly a spontaneous phenomenon.
Definition
False
there can be a trigger, such as menses, no breakfast, late hours, oversleeping, weather, altitude, smoking, emotions....
Term
What is a frequent dietary trigger of migraines?
Definition
Monosodium glutamate
Term
How common are migraines?
Definition
10-15% of women
5-10% of men
usually begin <20y/o
Term
What is Familial hemiplegic migraine?
Definition
Rare form of migraine linked to an AD gene on chromosome 10
Term
What is "the anatomical substrate for all migraines"?
Definition
The Trigeminovascular system involving CNV1 innervation of pain receptors in the dura, meninges, and medium/large vessels
Term
What nucleus are parasympathetic fibers & CN VII associated with?
Definition
Superior salivatory nucleus
PS innervation-> vasodilation-> pain
Term
What is the mechanism responsible for the vascular changes associated with migraine?
Definition
Vessel innervation-> Cell body in the trigeminal ganglion-> synapse at the superior salivatory nucleus-> synapse in the pterygopalatine ganglion-> synapse on the blood vessels
Term
What is the current theory concerning migraine pathogenesis?
Definition
1. Peripheral stimulation intiates a signal that releases glutamate & peptides in CNS
2. Antidromic activation (retrograde signalling) down the same sensory nerve intitiates release of sensitizing neuropeptides back in the periphery (peripheral sensitization)
3. This causes more central stimuli, which decreases inhibition at the nucleus caudalis and dorsal horn (central sensitization)
Term
How is the aura thought to arise?
Definition
A wave of depolarization spreads across the brain at a speed of 2-5 mm/min and renders the neurons in the area nonfunctional while leading to vasodilation (hyperemia)
Term
What does the existance of an aura depend on?
Definition
the cortical site of depolarization
Term
In the majority of migraineurs who do not experience an aura, what activates neurogenic inflammation?
Definition
Central Generator or Triggers
Term
What region of the brain is stimulated in auras?
Definition
Cortex
Term
What accounts for an auras bright multicolored scintillations changing to scotoma?
Definition
Cortical Spreading Depression
Wave of excitation briefely increases blood flow, as wave pass a point of cortex excitation changes to prolonge depolarization and decreased blood flow. Depolarized tissue is non-functional-> transient loss of vision (scotoma) until neurons recover
Term
What are the 2 main neurotransmitters involved in the cerebral vasodilation during migraines/headaches?
Definition
Calcitonin Gene Related Peptide (CGRP)
Substance P
Term
What are the 3 functions of CGRP?
Definition
1. Vasodilation
2. Mast cell degranulation
3. Direct stimulation of the central brain stem neuron
Term
What evidence is there to confirm CGRP's role in migraines?
Definition
IV CGRP-> headache
Triptans Tx (Block CGRP)
Term
How do Triptans work?
Definition
Agonize 5HT1 receptors, which are found throughout cerebral vasculature and nerve fibers that release CGRP
Term
How do Gepants work?
Definition
Direct CGRP antagonists
(block the CRL receptors on blood vessels, mast cells, and pain transmitting nerves)
Term
What are unique characteristics of a cluster headache?
Definition
Pain always unilateral, frontal, retro-orbital
Constant, severe, nonpulsating pain for wks/months
remission for yrs
Term
How are cluster headaches treated?
Definition
Acute: Nasal oxygen, triptans
Prevention: CCB (verapamil), lithium, valproic acid, prednisone
Term
What is the male to female ratio for cluster headaches?
Definition
4:1 (male:female)
Term
What are unique characteristics of a tension headache?
Definition
Usually bilateral and bandlike
typical headache everyone gets
Term
How do episodic tension headaches differ from the chronic persuasion?
Definition
Episodic - Daily attacks <15 days/month
Chronic - Daily attacks >15 days/month
Term
Tx of tension headaches?
Definition
Episodic - Pts self-medicate with analgesics
Chronic - Refer pt to neurologist and let them figure it out
Term
What type of headache can cause tears, stuffy or runny nose?
Definition
Cluster headache
Term
What is idiopathic intracranial hypertension (IIH)?
Definition
CSF pressure >250 mm H2O in the presence of a normal MRI
Term
What are the Clinical Features of IIH?
Definition
Headache of varying character Papilledema Transient visual obscurations Diplopia secondary to CN VI paresis Tinnitus Constriction of visual fields
Term
What is another name for IIH?
Definition
pseudotumor cerebri
Term
What should IIH be considered and why?
Definition
Neurologic emergency, since failure to diagnose and treat in a timely manner my lead to loss of vision
Term
What are the Risk Factors for IIH?
Definition
9:1, Female:Male
Ages 20-45
Obesity by 20% overweight
Term
Causes of IIH?
Definition
Most idiopathic
CSF production > CSF reabsorption
Primary - Metobolic abnormality
Secondary - physical block
Term
What is the pathogenesis of primary IIH?
Definition
Hypervitaminosis A
Antibiotics
Steroid withdrawal
Term
What is the pathogenesis of Secondary IIH?
Definition
Venous Sinus thrombosis
Chronic meningitis
Chiari Malformation
Term
How is IIH (pseudotumor cerebri) Diagnosed?
Definition
Clinical Presentation
MRI and MRV - Normal
LP - opening pressure > 250 mmH2O
Visual Fields
Term
How do you assess whether IIH treatment is success or disease progression?
Definition
Visual fields over time for imporvement/decay
Term
How is IIH treated?
Definition
WEIGHT LOSS
Lower CSF production (Rx or LP)
Surgery
Term
What is Giant Cell Arteritis (GCA)?
Definition
Autoimmune, systemic vasculitis causing granulomatous infiltration and occlusion of medium/small elastic arteries
Term
What are the symptoms of GCA?
Definition
Headache (usually unilatera and the CC in 70% of cases)
scalp tenderness over temporal artery
visual symptoms
Stroke
Term
How is GCA diagnosed?
Definition
No single test
ESR is usually High
C-reactive protein elevated
Biopsy may be negative
Should be considered in pts >55 with new unilateral headache
Term
How is GCA treated?
Definition
Corticosteroids
Term
What are the complications of GCA?
Definition
can progress to acute onset monocular blindness
Term
What does a depressed level of consciousness indicate?
Definition
Disruption of ascending arousal system in the upper brainstem
Term
What does a stiff neck indicate?
Definition
Meningeal irritation
Term
What does hypotension with a fever indicate?
Definition
Sepsis
Term
Is Meningococcus a clinical concern?
Definition
A little bit... Can kill patients in 6-12 hrs. Yikes
Term
How can death from Meningococcus be prevented?
Definition
Treating empirically even before the bacteria has been isolated
Term
How do bacteria get into the CSF?
Definition
Bacteremia
Nearby infection (otitis, sinusitis)
Direct CSF communication with the outside (trauma, surgery)
Term
How do bacteria cause damage once in the CSF?
Definition
Immune Response-> Damage
TNF and IL-1 released-> meningeal inflammation, vasculitis, thrombophlebitis
Term
What allows bacteria to flourish in CSF?
Definition
Few immune cells (initially), lots of glucose
Term
What is the result of IL-1 and TNF release in CSF?
Definition
Vigorous inflammatory response-> small vessel vasculitis and thrombophlebitis -> ischemia
Decreased BBB
Term
What happens if the infection leads to SIADH?
Definition
Decreased [Na]-> hypo-osmolar blood-> worsened edema-> septic shock
Term
What should be given before antibiotics to Tx bacterial meningitis and why?
Definition
Corticosteroids to mildly suppress immunity
Antibiotics tear bacterial cell walls apart-> Increases host immune response
Term
Name 2 most common causes of bacterial meningitis in adults.
Definition
Pneumococcus and Menigococcus
Term
Name 3 most common causes of bacterial meningitis in neonates.
Definition
Group B strep, E. coli, Listeria
Term
What are immunosuppressed, elderly, and pregos at risk for?
Definition
Listeria monocytogenes
Term
What's the leading cause of community-acquired meningitis?
Definition
Pneumococcus (S. pneumoniae)
Term
Why has Meningococcus been less of a threat lately?
Definition
Vaccine
Term
What had Meningococcus outbreaks been associated with?
Definition
Outbreaks in Military Barracks, Schools
(Found in nares of 5% of the population and require less than 3 ft to transmit)
Term
What is Waterhouse-Friderichsen Syndrome?
Definition
Depletion of corticosteroids following hemorrhagic necrosis of adrenal glands from a Meningococcus infection - causes Addison's crisis (Give Steroids)
Term
What are the risk factors for Pheumococcus?
Definition
EtOH
Chronic Otitis/sinusitis
CSF leaks
Asplenia
Sickle Cell
Term
Who is at risk for Listeria meningitis?
Definition
Immunosuppressed
Older Pts
Chronic illness (renal/hepatic)
Found on meat counters, hot dogs, unpasteurized dairy products
Term
What symptoms of bacterial meningitis are seen in infants?
Definition
Nonspecific
Fever, irritability, vomiting, high-pitched cry, lethargy
Convulsions and bulging fontanae if advanced
Term
What symptoms of bacterial meningitis are seen in adults?
Definition
URI, sore throat, fever, headache, stiff neck, vomiting, seizures
Term
What would show up on Physical exam for bacterial meningitis?
Definition
High fever
Low BP
petechiae
purpura
stiff neck
signs of other infection
Term
How is Kerning's sign used to test for meningismus?
Definition
Patient lays supine with hip flexed at 90 degrees
+ if can't straighten leg
Term
What is Brudzinski sign?
Definition
Passive flexion of neck causes flexion of the knees
Term
What causes meningismus?
Definition
Inflammation of meningis -> neck pain-> involuntary contraction of agonist and antagonist muscles to make a splint
Term
What 2 test are especially useful to distinguish septic & aseptic?
Definition
Serum procalcitonin and CRP are much higher in septic meningitis
Term
T/F Opiates should be given to treat neck stiffness.
Definition
False
will fix it, but are sedating -> coma/stupor
Term
What tests are used to Dx bacterial meningitis?
Definition
CBC (increased PMNs)
electrolytes (correct SIADH)
INR
culture
Term
What should be done before EVERY lumbar puncture?
Definition
CT scan
If there's a cerebral mass, LP could cause herniation
Term
What special tests use CSF to identify the cause of meningitis?
Definition
PCR-16S ribosome = bacterial
Specific Ags for herpes/TB - IgM for acute infection, IgG for chronic
Term
Describe the WBC, glucose, & protein make-up in bacterial CSF.
Definition
Increased neutrophils
Decreased glucose
Increased protein (BBB breakdown)
Term
What causes high lymphocytes, low/normal glucose, and high/normal protein in CSF?
Definition
Partially treated bacterial meningitis, chronic meningitis, aseptic meningitis, brain abscess, and parameningeal inflammation
Term
What does CSF grossly look like in Meningococcus meningitis?
Definition
Cloudy and turbid
Term
Tx of bacterial meningitis?
Definition
Steroids First!
antibiotics after 15 minutes
drain CSF if needed to reduce ICP
Term
Should you give antibiotics/steroids to every case of meningitis?
Definition
Unless you're positive that it's not bacterial, then Yes.  Risks of giving them for one day are negliible compared to benefits
Term
What precautions should be taken by any care-takers?
Definition
Isolate patient and take prophylactic rifampin
Term
What do splinter hemorrhage and distal pupura suggest?
Definition
Septic embolism
(septic endocarditis)
Term
What are four ways in which infectious endocarditis affects the brain?
Definition
1. Sepsis - Metabolic encephalopathy-> confusion, delirium, coma
2. Large cerebral vessel occlusion-> Acute ischemic stroke
3. Focal brain ischemia and inflammation-> abscess fromation
4. Septic embolism of a distal cerebral artery-> focal inflammatory erosion of vessel wall-> aneurysm-> hemorrhage
Term
What's the leading cause of bacterial endocarditis?
Definition
Strep. viridans
(followed by Staph. aureus and Enterococcus)
Term
Why would headaches from ruptured brain abscess hurt more laying down? (Tumor headaches)
Definition
Cerebral veins are valveless, so laying down counteracts gravity-> increased blood in veins while supine, which causes an exponential increase in pain when ICP is already high
Term
What are some non-neurologic signs of bacterial endocarditis?
Definition
Splinter hemorrhages
Osler's nodes
Janeway lesions
Roth's spots
Term
Tx of bacterial endocarditis?
Definition
Antibiotics and maybe a new heart valve
Term
What should make you think of brain abscess so you know to order a CT scan?
Definition
Headache, worse lying down
papilledema
seizures
focal neuro deficits (CT/MRI shows mass with surrounding edema)
Term
Tx of brain abscess?
Definition
Drain large abscesses and treat with antibiotics
Term
Symptoms of spinal epidural abscess (SEA)?
Definition
Pint tenderness, fever, high WBC &ESR, urinary incontinence, lower weakness and sensory loss, Babinski signs, severe pain
Term
What part of the spinal column is usually affected by maetastasis?
Definition
Bone
(Spares Disks)
Term
What part of the spinal column is usually affected by infection?
Definition
Disc
(spares Bone)
Term
What causes 90% of spinal epidural abscesses?
Definition
Staph. aureus
Term
Risk factors for SEA?
Definition
Trauma/surgery
osteomyelitis
Sepsis
Dental Work
Term
Treatment for SEA?
Definition
High dose steroids
antibiotics
drainage
Term
Symptoms of Rocky Mountain Spotted Fever (RMSF)?
Definition
Rickettsia attacks vascular endothelial cells-> systemic vasculitis attacks brain parenchyma-> confusion, seizures, focal deficits, petechial rash in extremities, fever, headach, flu-like
Term
Dx of RMSF?
Definition
Normal CSF/mild increase in lymphocytes
IgG/IgM tests
Tick bite Hx
Term
Tx of RMSF?
Definition
IV doxycycline
Term
Sypmtoms of Lyme disease after days, weeks, months?
Definition
Days: Erythema migrans (targetoid rash)
Weeks: Flu-like SS, malaise, arthritis, aseptic meningitis, meningoradiculitis=electric shock sensations in bands
Months: Cognitive declin, encephalopathy, radiculopathy
Term
Dx of Lyme disease?
Definition
ELISA (confirm with Western blot)
caused by a spirochete
Term
Tx of Lyme disease?
Definition
IV ceftriaxone or oral doxycycline
Term
What is a common reservoir of Lyme disase and RMSF?
Definition
Ticks
Term
Symptoms of Syphilis in each of the three stages?
Definition
Primary: Painless genital chancre (3 wks post infection)
Secondary: Maculopapular rash on palms/soles, meningitis, arthritis
Tertiary: Severe skin, bone, heart, and brain complications
Term
What are immunocompromised pts with syphilis at risk for?
Definition
Greater risk of meningitis and stroke
Term
Dx of neurosyphilis?
Definition
Serum/CSF VDRL
fluorescent treponemal Ab
RPR
Term
Tx of syphilis?
Definition
High dose IV penicillin
Term
Symptoms of chronic meningitis?
Definition
Fever, headache, lethargy, poor appetite/weight loss, cranial neuropathy, personality change, cognitive impairment
Term
What produces granulomatous meningitis worst at brain base and how is diagnosed?
Definition
Mycobacterium tuberculosis
Spinal tap and check CSF for acid fast bacilli
Term
What is a consequence of inflammation at the base of the brain?
Definition
CN entrapment and block of CSF flow-> hydrocephalus
Term
How does TB cause meningitis?
Definition
Primary lung infection-> miliary TB goes to brain and reactivates years later-> meningitis
Term
Dx of TB meningitis?
Definition
Cultrue bug (for drug sensitivities)
RNA PCR
CXR
PPD
CSF
Term
Risk factors for TB?
Definition
third world country
HIV
homeless
Alcoholic
Term
Tx of TB meningitis?
Definition
Isoniazid, Rifampin, Pyrazinamide, and streptomycin or ethambutol
Also Corticosteroids
Term
What causes stiff neck, fever, and headache with no rash, high lymphocytes in CSF, and fairly normal glucose and protein?
Definition
Viral meningitis
Term
T/F Viral meningitis is more common than bacterial.
Definition
True
Term
What are some common causes of viral meningitis?
Definition
Enteroviruses (Echo, Coxsackie, enterovirus) - 80%
Term
Symptoms of viral meningitis?
Definition

Not as ill as bacterial meningitis

Fever, malaise, headache, stiff neck, low back pain for 10-14 days

Term
What causes recurrent viral meningitis?
Definition
Herpes simplex virus II
Term
Dx of viral meningitis?
Definition
increased CSF opening pressure and lymphocytes, negative gram stain
Term
Tx of viral meningitis?
Definition
Just treat symptoms
Term
What can cause increased ICP, lymphocytes, and temperature without any CT masses or abnormal cells in CSF?
Definition
viral encephalitis
Term
at test would asist in the Dx of viral encephalitis?
Definition
MRI, helps rule out abscess, thrombosis, or hemorrhage
Term
If you suspect viral encehalitis, what should be done?
Definition
Immediately give acyclovir, if pt goes into coma first, the prognosis is very poor
Term
What are common causes of viral encephalitis?
Definition

Arborvirus (mosquitoes) - 30%

Enteroviruses - 23%

HSV-1 - 27%

Term
What is the clinical course of viral encephalitis?
Definition
URI-> fever-> headache (mild stiff neck)-> lethargy-> confusion-> seizures-> coma/stupor-> death
Term
Tx for viral encephalitis?
Definition
Prognosis depends on prompt acyclovir/ganciclovir
Term
What are some important things to remember about herpes encephalitis?
Definition

Curable if Tx early - devastaing if Tx late

Tx should be empirical (acyclovir) before Dx

MRI gives immediate Dx, PCR has many false negatives may resemble bacterial meningitis

Term
Where does Herpes Zoster virus live and lay dormant?
Definition
In sensory ganglia-> shingles
Term
what's unique about the distribution of shingles?
Definition
across one or two dermatomes
Term
Symptoms of Shingles?
Definition
Pain starting days before and persisting weeks after the rash
Term
what happens if HSV sets up camp in CN V1?
Definition
It can lead to ulceration of the cornea
Term
What are tow ways HIV can cause neurologic disease?
Definition
Directly cause meningitis (acute of chronic)-> Dementia, myelopathy, neuropathy, and myopathy
Indirectly by decreasing immunity and increase risk for other infections
Term
What's the most common opportunist that causes neurologic disease in AIDS patients?
Definition
Toxoplasmosis - parasite that preferentially invades the basal ganglia
Term
What hope is there for HIV patients?
Definition
HAART therapy greatly increase prognosis
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