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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_186_библиотеки_им_акад_М_И_Перельмана

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☆
MRIofapatientwithintracranialidiopathichypertension;notetheemptysella(arrow).(Source:Dr.Daniel T.Ginat,MD.)
Withoutanyintervention,thenaturalhistoryofpseudotumorcerebriisoneofslowsymptomatic progression.Treatmentisthereforerecommended.Conservativemanagementwithcloseobservation, weightloss,andotherriskfactormodificationsarefirst-linetreatmentsinpatientswithoutevidenceof visionloss.Iftheheadachedoesnotimproveorifthereisevidenceofearlyvisionloss,carbonic­anhydraseinhibitorssuchasacetazolamideortopiramateareused(thesedrugsdecreaseCSF production).Ifthereisprogressivevisionloss,proceduraloptionsincludeopticnervesheathfenestration (torelievepressureonthenerve)andplacementofaventriculoperitonealshunt(todivertCSFfromthe brainintotheabdomenforbetterabsorption).Thereisnoindicationforseriallumbarpunctures,which cancausesignificantdiscomfortandofferonlytemporaryrelief;theymay,however,beappropriateasa temporizingmeasurepriortosurgeryorinpregnantwomenwhowishtoavoidmedicationsduring pregnancy.
https://t.me/med1917
PosteriorReversibleEncephalopathySyndrome(PRES)
Althoughthepreciseincidenceofposteriorreversibleencephalopathysyndrome(PRES)isunknown,itis beingincreasinglyreportedinthemedicalliterature.Thisisonesyndromeyoureallyneedtoknowabout.
TheeasiestwaytothinkaboutPRESisasaconstellationofclinicalandradiographicfeaturesresulting fromacutevasogenicedema(i.e.,fromtheextracellularaccumulationofintravascularfluiddueto disruptionoftheblood-brainbarrier).Thenameisn’tthebest,becausePRESisnotexclusivelyposterior (i.e.,involvingtheparieto-occipitalregion),maynotbereversible,anddoesnotalwayscause encephalopathy.Solet’sgothroughitcarefully.
PREScanbecausedbytwothings:
Thefirstisarapidriseinbloodpressure.Thebrainisnormallyabletoautoregulateitselfsuchthat cerebralbloodflowremainsstableoverabroadrangeofmeanarterialbloodpressures.Thereisan upperlimittothisprocess, however,andwhenitisexceeded,cerebral bloodflowincreases.The resultingelevatedpressurescancausefluidtoextravasatefromthecerebralbloodvesselsintothe brainparenchyma,resultinginvasogenicedema. Thesecondisimmunosuppressivemedication,suchascyclosporineandtacrolimus.Thepostulated mechanismhereisdirectendothelial toxicitycausedbythemedicationitself,resultingincapillary leakageanddisruptionoftheblood-brainbarrier,whichcanoccurevenaftermonthsofexposureto theoffendingmedication.ToxiclevelsofthesemedicationsarenotrequiredtocausePRES.
https://t.me/med1917
MRIwithclassicPRESfeatures(symmetric,confluentwhitematteredema;whitearrows).(Modifiedfrom PulaJH,EggenbergerE.Posteriorreversibleencephalopathysyndrome.CurrOpinOphthalmol. 2008;19:479-484.)
Symptomsincludeheadache(oftenconstantandunresponsivetopainmedication),visualdisturbances (duetopreferentialposteriorcerebralinvolvementcausingvisualfieldcuts,hallucinations,cortical blindness,andsoforth),seizures,andencephalopathy(mostoftenlethargyandconfusion).
https://t.me/med1917
Imagingshowssymmetric,confluentwhitematteredemathatoften(butnotexclusively)involvesthe posteriorparieto-occipitalregions.ThisisbestseenonMRIbutcanbepickeduponCTinseverecases. Imagingisessential,becausetherearenoreliableclinicalguidelinesfordiagnosis,andasyoumight imaginethedifferentialdiagnosisofthissymptomcomplexisbroad(includingstrokesyndromes, malignancies,andencephalopathies).AnMRIconsistentwithPRESintherightclinicalsetting(elevated bloodpressureortheuseofimmunosuppressants)shouldmakeyoufeelconfidentinthediagnosis.
Treatmentissymptomatic,withbloodpressurecontrol,seizurecontrol,and,ifindicatedandfeasible, withdrawalordosereductionoftheoffendingmedication.Mostpatientsrecoverwell,butneurologic sequelae(suchasmotordeficitsandepilepsy)anddeathcanoccur.
CardiacCephalalgia
Cardiaccephalalgiareferstoheadacheduetomyocardialischemia.Theheadacheitselfcanclosely resembleamigrainebutisvariableinlocation,intensity,andduration.Itcanbe—butdoesnothavetobe —associatedwithchestpain,butisalwaysexacerbatedbyexertionandrelievedwithnitroglycerinor withcardiacstentingandcoronaryarterybypassgraft(CABG)whentheseinterventionsareappropriate.
https://t.me/med1917
Donotmissthediagnosisofcardiaccephalgia.
ThisisanuncommonbutDONOTMISSdiagnosisandshouldbeconsideredinolderpatientswith new-onsetheadacheandsignificantcardiovascularriskfactors.Itiswisetoobtainaresting electrocardiogram(ECG)andastresstestinsuchpatients,particularlypriortoprescribinganytriptans.
Post-traumaticHeadache
Ifheadacheonsetoccurswithin7daysofaheadinjury,orwithin7daysofregainingconsciousness followingaheadinjury,theheadacheisconsideredtobepost-traumatic.Riskfactorsincludeyounger age,priorheadachehistory,and,paradoxically,milderdegreesofheadtrauma(i.e.,traumaassociated withonlytransientamnesiaandbriefifanylossofconsciousness).Theheadachecharacteristicsare variableandcanresemblebothmigraineandtensiontype.Thekeytodiagnosis,therefore,istoelicita historyofantecedenttrauma.Lightheadedness,mildcognitiveslowing,andinsomniaarecommon. Considerationshouldbegiventoimagingthesepatientstoruleoutanunderlyingsubduralbleedor hemorrhagiccontusion.
https://t.me/med1917
Treatmentissymptomatic.Iftheheadachesoundslikeamigraine,treatthemigraine;ifitsoundslikea tension-typeheadache,treatthetension-typeheadache.Amitriptylineprophylaxisworkswellforbothand isthedrugthat’sbeenbeststudiedinthispatientpopulation.Mostpatientswillfullyrecoverwithinafew months,althoughtherarepatientmayhavesymptomsthatneverresolve.
Ahistoryoftraumaisthekeytodiagnosingpost-traumaticheadache.
Box3.12HeadacheinPregnancy
Headacheinpregnancyisawholedifferentballgame.Pregnancyputswomenatriskfora plethoraofconditionsthatcanpresentwithheadache,somelife-threatening,andthusany neworworseningheadachethatoccursduringpregnancymustbetakenseriously.Itcan seemlikethediagnosticpossibilitiesareendless,butlet’sbreakthemdowninto5 categories.ThesearetheDONOTMISSpotentialcausesofheadacheinpregnantwomen.
https://t.me/med1917
https://t.me/med1917
Therearemanycausesofheadacheinpregnancyandyouneedtoknowthemall.
1. CerebrovascularDisorders:Pregnancyisa hypercoagulable stateandthusincreasestheriskofvascular disorders suchas venoussinusthrombosis andacuteischemicorhemorrhagicstroke.Theriskofsubarachnoidhemorrhage, PRES, and reversible cerebral vasoconstriction syndrome (see Chapter 2) are also increased during pregnancy, especiallyinthethirdtrimesterandpostpartumperiod.
2.  Space-OccupyingLesions: Previously unrecognized Chiari malformations (see Box 3.11), colloid cysts (see page
400), and other tumors canmake themselves knownduring labor due to increased pressure caused bysustained Valsalvamaneuvers.Meningiomasalsohaveatendencytogrowrapidlyduringpregnancy.Themechanismbehindthis is unclear, but changes in blood flow dynamics, as well as hormone-mediated cellular proliferation, have been hypothesized.
3.  Disorders Relatedto HighBloodPressure: Gestational hypertension can cause both preeclampsia/eclampsiaand PRES.
4. DisordersRelatedtoChangesinIntracranialPressure:Idiopathicintracranialhypertensionoftenworsensinpregnancy due to relatively rapid weight gain. Epidural anesthesia also creates a risk for post-dural puncture (low-pressure) headache,aswellaspneumocephalus(entryofairintothebrain).
5. PituitaryApoplexy:Thiscanpresentasasuddenandsevereheadacheduetohemorrhageintoapreexistingpituitary lesionorenlargedpituitarygland.
Thegoodnewsisthatwecanscreenfornearlyallofthesewiththreeimagingstudies(none ofwhichrequiregadolinium,andallofwhichcanbedoneinjustonetripdowntothe scanner):
MRI (to lookat thebrain parenchyma,to ruleoutPRES,ischemicstroke, bleeds, and underlyingstructurallesions) MRA (to lookat theintracranial arteries, to rule out dissection and reversiblecerebral vasoconstrictionsyndrome) MRV(tolookatthevenoussinuses,toruleoutvenoussinusthrombosis)
Allofthissaid,notallpregnantpatientswithheadacheneedtobeimaged.Forinstance,ifa pregnantpatientwithahistoryofmigrainepresentswithaslightlymoresevereheadache thanisnormalforher,butonewhichisotherwiseidenticaltohernormalmigraines,you’re probablyoknotorderinganyimagingstudies.Butthebartoscanpregnantpatientsis,for obviousreasons,significantlylowerthannon-pregnantpatients,andifyou’reatallunsure, scan.
Assumingthescansarenegativeandyouhaveruledoutanypotentialsecondaryor dangerousetiologies,optionsforfirst-linetreatmentforheadacheinpregnancyinclude acetaminophenandmetoclopramide.
Interestingly,patientswithmigrainetendtohavefewerheadachesduringpregnancy, particularlyduringthesecondandthirdtrimesters,thancomparedtotheirpre-pregnancy baseline.Itisalsonotuncommontodevelopnewmigraineorevennewaurasymptoms duringpregnancy.
https://t.me/med1917
TheGeneralApproachtotheHeadachePatient
We’vejustgonethroughapanoplyofheadachetypesanditallmayseemmorethanalittleoverwhelming. Butinmanyinstances,thediagnosiswillbeobviouswithinminutesoflisteningtoyourpatientdescribe hisorhersymptoms.
Nomatterwhat,however,don’tbetooquicktojumptoadiagnosis.Inparticular,knowyourredflags —SNOOP2—cold.Thesearethediagnosesyoudon’teverwanttomiss.Inadditiontoyourhistoryand examination,thereareonlyafewtoolsyouwillneed—imaging,CSFanalysis,andsomelaboratory studies.Don’tordertheseindiscriminately.Theyareexpensive,time-consuming,andanxiety-provoking, andwithyournewfoundclinicalacumen,frequentlyunnecessary.
Herearesomequickexamplesthatwillillustratethegeneralapproachtothepatientwithheadache:
PatientApresentstoyourofficeforthefirsttimetoestablishcare.Onyourreviewofsystems,she reportsthatshegets“normalheadaches”onceinawhilewhenshe’stired,dehydrated,orstressedout. Sheusuallydoesn’thavetotakeanymedicationbutoccasionallyshe’lltakeanibuprofenandthepain goesaway.Herexaminationisnormal,andyoutellherthatshehastensionheadaches.Ibuprofenisan appropriatetreatment,aslongassherestrictsitsusetolessthantwiceperweek.
Aquickclinicalpearl:ifaheadachebringsapatienttoyourofficeor,especially,totheED,itisinall likelihoodnotatensionheadache.Theseareconsidered“normal”bymostpatientswhogetthemand,by definition,arenotdebilitating.PatientAlikelywouldnothavecometoseeyouforherheadache;shejust happenedtomentionit(sinceyouasked).
PatientBpresentswithinfrequentbutsevereheadachesforwhichshe’shadtomissadayortwoof work.Herheadachesareusually,butnotalways,left-sidedandassociatedwithnauseaandlight sensitivity.Hermothergetssimilarheadaches.Shefeelsbetterwhensheliesdowninadarkroom,and ibuprofenoracetaminophenhelpbutoftendonotfullyresolvethepain.Herexaminationisnormal,and youdiagnoseherwithepisodicmigrainewithoutaura.Givenhernormalexamination,familyhistory, andclassicmigrainehistory,thereisnoneedforimaging.Youprescribesumatriptantotakeatheadache onsetandtellhershecantakeitincombinationwithanNSAIDformaximaleffect.Youaskhertokeepa headachediaryforyoutoassessatyournextvisitanddiscusstheimportanceofregularexerciseand maintainingaregularsleepschedule.
PatientCcomestotheEDafter5daysofexcruciatingheadaches.Hetellsyouthathe’shad“normal” headachesinthepast,butnothinglikethis.Theseheadachesareright-sided,sharp,andsoseverethathe tellsyouhewouldratherdiethancontinuetoexperiencethem.Theyseemtoalwayscomeonjustafterhe eatsdinner,lastaboutanhour,andareassociatedwithrighteyetearingandadroopyeyelid(ptosis).He feelsfinerightnowandhisexaminationisnormal.Althoughhishistoryisconsistentwithcluster headache,obtaininganMRIwithoutcontrastwhileintheEDisreasonable,giventhesuddenchangein headachecharacteristicsandreportedfocaldeficit.Hisscanisnormal,andyoudischargehimona steroidtaper,withaprescriptionforsubcutaneoussumatriptanandclosefollow-upinyouroffice.
PatientDcomestoyourofficewithathrobbing,right-sidedheadachethat’sbeengoingonfor5days. Thepainisnoticeablyworseatnightbutneverfullygoesaway.Shehasn’thadmuchofanappetitebut doesreportthatforthepast2weeksshehasfeltadeepacheinherjawwhenshechews.Sheisill­appearing,butherexamination,includinghervision,isnormal,withtheexceptionofmoderatetenderness topalpationoverherrighttemporalartery.YousendoffanESRandCRP,bothofwhichreturnelevated.
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YoutellheryoususpectshehasGCA,startheronempiricsteroidsandreferherforurgenttemporal arterybiopsy.
PatientEpresentstotheEDwithasudden-onsetheadachethatbeganabout12hoursearlier.Shegets headachesfrequentlybutsaysthisoneistheworstheadacheshe’severhadandthatshe’snowseeing doublewhenevershelookstotheleft.Onexamination,youimmediatelynoteptosisofherrighteye,then discoverthatherrightpupilisdilatedandshecannotadductherrighteyeacrossmidline.HerheadCT, doneonarrivaltotheED,showsnoblood,butthisdoesnotreassureyou:asyounowknow(seeChapter
2),thesensitivityofCTforasubarachnoidbleeddramaticallydecreasesmorethan6hoursaftersymptom onset.YoutelltheEDthatsheneedsanurgentlumbarpuncture,whichdemonstratessignificantlyelevated redbloodcellsthatdon’tdilute.HerCTangiogramshowsarupturedposteriorcommunicatingartery aneurysm(likelycompressingherthirdcranialnerve,causingthefocaldeficitsyoufoundon examination),andsheiswhiskedofftotheoperatingroomforendovascularcoilingofheraneurysm.
https://t.me/med1917
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