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

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YourPatient’sFollow-up:Annapresentedwithmigrainethathadtransformedfrom
episodictochronic,likelyduetoherbusyresident’shoursandunderstandablestress.You tailoryour“headachehygiene”talktoherunpredictableschedulebysuggestingshekeep granolabarsoralmondsinherwhitecoatpocketstoavoidlongperiodswithouteating,and regularlyspend5to10minutesbeforebedrelaxingwithoneofthemanysmartphone meditationapps.Youalsoprescribesumatriptantotakeattheonsetofherheadaches
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(althoughsheshoulddothisnomorethan2to3times/week),aswellasdailycandesartan prophylaxis.Onherfollow-upvisitseveralmonthslater,herheadachefrequencyhas improvedtoone,atmosttwo,headachesperweek.Notperfect,butbetter.Youwill continuetoseeherregularlytohelpasmuchaspossiblewithherlifestylehabitsandtitrate hermedicationsasneeded.
Younowknow:
1. Migraines areoneofthemostcommonreasonsforEDvisitsworldwide.Theyaredefinednot onlybytheircharacteristicpainbutby specificassociatedsymptoms,geneticrisk,andpredispositiontootherdisorders.
2. Whenpatients presentwith headache,early andaccurate diagnosis is crucial,both todistinguishprimaryfrom secondaryheadaches, andtoinitiateappropriatetreatment.Thelongeraheadachedisordergoeson,theharderitistotreat.
3. Triptans are commonly prescribed medications for acute migraine. Although evidence is limited, we avoid triptans in patients with significantcardiac andperipheral vascular disease. The newer smallmolecule CGRP antagonistsare another good option for acute migraine,especiallyinpatientswhocannottaketriptans.
4. Chronicmigraine is toughtotreat.Wehaveahostofpreventiveoptions,allofwhichworkonlysomeofthetime.Thebesttreatment approachisoftenamultifactorialone:medicationin conjunctionwithlifestyle modification,headachehygiene, andother interventions suchasbotox.
5. TheCGRPmonoclonalantibodiesarethefirstmigraine-specificpreventivemedications.Althoughrelativelynew,theythusfarseemto beatleastaseffective—andwithsignificantlyfewersideeffects—thantheoldertherapies.
6. The trigeminal autonomic cephalalgias are defined by unilateral trigeminal-distribution pain associated with ipsilateral autonomic features.Thedifferentsubtypesarebestdistinguishedbythedurationofpainandtheirresponsetoindomethacin.
7. Therearemany typesofsecondaryheadaches,someofwhichcanhaveseriousconsequencesiftheygounrecognized.Eachhas its ownuniquepresentation,and—when appropriate—promptimagingandCSFanalysis willusually getyoutheansweryouneed.Know yourSNOOP2mnemonic!
8. Anyheadache—andespeciallyanynewheadache—duringpregnancymustbetakenseriously.Thepotentialdifferentialforunderlying etiologiesisbroadbut,whenindicated,thecombinationofMRI,MRA,andMRVcanruleout(orin)justabouteverything.
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4Concussion(akaMildTraumaticBrain Injury)
Inthischapter,youwilllearn:
1. How todistinguishmild headtraumafrommoreserioustraumathatrequiresimagingand maynecessitateinpatientcare
2. Whataconcussionisandwhattoexpectregardingprognosis
3. Howtoguideyourpatientsbacktonormalactivity,withspecialemphasisonathletes
4. Whentosuspectpostconcussivesyndromeandwhattodoaboutit
5. About chronic traumatic encephalopathy, a devastating complication of repeated head traumaseenmostofteninathletesinvolvedincontactsportsandmilitarypersonnel
CASE4
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YourPatient:Paul,a22-year-oldcollegestudent,isdrilledinan(illegal)helmet-to-helmet
tackleduringhisfootballteam’sfull-contactpracticesession.Hedoesnotlose consciousnessbutisgroggyasheishelpedtothesideline.Hestatesthathe“sawstars”on impactandiscomplainingofasevereheadache.Withinafewminutes,heclaimstofeel backtonormalexceptforsomemildnauseaandaslightheadache,andheaskstoreturnto thegame.Yourneurologicassessment,usingastandardconcussionprotocol,isnormal. Whatisyourrecommendation?
Whatwedon’tknowaboutconcussionfarexceedswhatwedoknow.Wearenotsurehowbesttoprevent aconcussionorhowtomanageone,andwecan’tevenagreeonhowpreciselytodefineanddiagnoseit. Soundslikethismightbeashortchapter!Itwillbe,butwewon’tleaveyouinthelurch.Ourknowledge inthisfieldisgrowingrapidly,inlargepartbecauseofourbelatedrecognitionoftheneurologicissues thataretroublingmanyathleteswhoengageincontactsportsandmilitarypersonnelexposedtosevere blastinjuries.Andwearebeginningtoknowenoughtofeelsomeconfidenceinourabilitytoevaluate andmanagepatientswithmildtraumaticbraininjury.
IsItMildorSevere?
Thisisthefirstquestionyouneedtoaskwhenyouareconfrontedwithapatientwithheadtrauma.Severe traumacancauseanepiduralhematoma,subduralhematoma,parenchymalbleed,oracutelyincreased intracranialpressure,andthesepotentiallylife-threateningdiagnosesareonesyoudon’twanttomiss.
ThetestofchoiceinpatientswithsevereheadtraumaisaCTscan.MRIislesssensitiveforacute
bleedingandisalsomoreexpensiveandoftennotimmediatelyavailable.Butnoteveryonewithhead
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traumaneedsaCT.Fortunately,therearereliableguidelinestodifferentiatethosewhodofromthosewho canbemanagedmoreconservatively.Therearemanysuchguidelines,buttheytendtoconvergeonafew pointsthat,shouldyouanswer“yes”toanyofthem,necessitateanurgentheadCT:
Asubduralhematoma(labeled‘S’)withmasseffect(notethemidlineshift,indicatedbythewhitearrow)in apatientwhosufferedacuteheadtrauma.(ModifiedfromPoperTJJr,HarrisJHJr.Harris&Harris’the RadiologyofEmergencyMedicine.5thed.WoltersKluwer;2012.)
GlasgowComaScale(GCS)score<15(seeTable4.1).
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Table4.1 The Glasgow Coma Scale (GCS) is themost common scoring system used to help gauge the severity of traumaticbraininjury
Domain Response Score
Eyeopening Spontaneous 4
Tospeech 3 Topain 2 None 1
Bestverbalresponse Oriented 5
Confused 4 Inappropriate 3 Incomprehensible 2 None 1
Bestmotorresponse Obeying 6
Localizing 5 Withdrawal 4 Flexing 5 Extending 3 None 1
Totalscore Deepcomaordeath 3
Fullyalertandoriented 15
AdaptedfromIns tituteofNeurologicalSciences.GlasgowComaScale.https://www.glasgowcom as cale.org/
Anewneurologicdeficit(anymotor,sensoryorcranialnervedeficit,oranyalterationincognition, gaitorcoordination). Twoormoreepisodesofvomiting(thiscanbeasignofincreasedintracranialpressure). Thepatientisonanticoagulationorhasanunderlyingbleedingdisorder. The patient is age60 years or older (itis importantto notethat reliance solely onthe GCS may underestimatetheseverityofheadinjuryintheelderly). Any evidence of a basilar skull fracture (periorbital bleeding, retroauricular bleeding, hemotympanum(bloodinthemiddleearcavity),otorrheaorrhinorrhea). Evidence suggesting a possible open or depressed skull fracture (e.g., a scalp laceration or hematoma). Aseizureaccompanyingorfollowingthetrauma.
Otherfactorsarenotasabsolute,butifanyofthesearepresent,youshouldhavealowthresholdfor
scanning:
Retrogradeamnesia(forgettingmemoriesformedbeforethetraumaticevent)ofatleast30minutes. Anyhigh-impactinjury(suchasamotorvehicleaccidentoralongfall). Abnormalbehavior(agitation,unusualaffect,violentbehavior,etc.).
Theseguidelinesapplytoadultsonly;therearedifferentprotocolsforguidingtheevaluationof
children.
If,usingtheseguidelines,yourscreencomesupnegativebutyourclinicalinstinctstilltellsyouthat— forwhateverreason—theremaybemoreherethanmeetstheeye,gettheCT(anddon’tforgettogetanx­rayofthecervicalspineiftherehasbeentraumatotheneck;youdon’twanttomissafracture).
ThepresenceofafractureorbloodontheCTnecessitatesimmediatereferraltoneurosurgery.Ifthe CTisnormal,youshouldstillconsiderhospitaladmissionfor(1)patientswithalowGCSscore,(2) whopresentwithseizures,or(3)whoareonanticoagulationorhaveableedingdisorder.Anyoneelse
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youcangenerallyfeelcomfortablesendinghome.
Thecriticalcaremanagementofthepatientwithsevereheadtraumacausingintracranialhemorrhage andelevatedintracranialpressureisdiscussedinChapter14.Fortherestofthischapter,wearegoingto focussolelyonthosepatientswhocanbemanagedasoutpatients,thatis,thosewithmildtraumatichead injury.
SoWhatIsaConcussion?
Definition.Youwouldthinktherewouldbeasimpleanswertothisquestion,butthereisconsiderable disagreement.Probablythesimplestdefinitionistoviewconcussionasalteredmentalstatus,withor withoutlossofconsciousness,causedbyheadtrauma.Someexpertsaddtheterm“short-lived”before “alteredmentalstatus”;however,thereisadifferenceofopinionastowhat“short-lived”actuallymeans, plusthisdefinitionisonlyusefulinretrospect(howdoyouknowiftheeffectsofthetraumaareshort liveduntiltheyhaveresolvedorpersisted?)andthusofnorealutilityinpractice.
Twoimportantpoints:
1. Concussionisaclinicaldiagnosis,notonemadebyeitherimagingorlaboratorytesting(althoughnewresearchonbiomarkersthatare releasedbyaxonalandglialinjuryislookingpromising).
2. Thisdefinition—intentionally—doesnotspecifywhetherornotthereislossofconsciousnessaccompanyingthetrauma.
Box4.1BrainContusion
Thetermcontusionreferstotheruptureofbloodvesselscausedbytrauma,anditcan occurjustaboutanywhereinthebody.Abraincontusionisatypeofintracerebral hemorrhageandisbestthoughtofasabrainbruise.Justlikewhenyoubruiseyourarmor legandwindupwitha“blackandbluemark,”acerebralcontusionisassociatedwithsmall microbleeds.Theclinicalpresentationdependsonthelocationandseverityofthedamage andcanincludeconcussion.
Coup–contrecoupisapatternofinjuryoftenassociatedwithbraincontusions,inwhich damageoccursbothatthesiteofimpact(oftenminimal)andattheoppositesideofthe head(oftenmoresevere).Theinjuryattheoppositesideofthehead—theso-called contrecoupinjury—occurswhenastrongblowtotheheadcausesthebraintostriketheside oftheskulloppositefromthepointofimpact.
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Extensivebifrontalcontusions.(ReprintedfromSanelliP,SchaeferP,LoevnerL.Neuroimaging:The Essentials.WoltersKluwer;2015.)
Mechanism.Traumatothehead—fromwhiplash,forexample,ordirectinjuryfromafall,collision,ora blastinjury—causesrapidacceleration,deceleration,orrotationofthebrainwithinthecranialvault, resultinginshearstrainonthebrainparenchyma.Axonaldamageandthereleaseofexcitatory neurotransmittersappeartoplayanimportantroleincausingthesymptomsofconcussion.
https://t.me/med1917
Violenttraumatotheheadunderliesmostcasesofconcussion.
SymptomsandManagement.Concussivesymptomsmaydevelopimmediatelyoruptoseveraldays afterthetrauma.Symptomscanpersistfordaystoweeks.Whentheylastlonger,werefertothecondition aspostconcussionsyndrome(PCS),whichwediscussbelow.
Themostdramaticsymptomsofconcussionarelossofconsciousness,disorientation,andamnesia,
butthesearenotthemostcommonsymptoms.
Headacheisnumberone.Mostconcussion-relatedheadachesaremigraine-likeandcanbetreatedjust likeothermigraines,usuallybeginningwithanonsteroidalanti-inflammatorydrug(NSAID).Tension-type headachesarethesecondmostcommonheadachetype.Whenheadacheisaccompaniedbynausea, medicationssuchasprochlorperazineormetoclopramidecanbehelpful.Seethediscussiononpost­traumaticheadache(page118)formoredetails.
Dizzinessisthesecondmostcommonsymptom.Sometimesitpresentsasvertigo,butmoreoften patientscomplainofanill-definedsenseoflightheadednessanddisequilibrium.Thereisnospecific therapy,andthesesymptomsusuallyresolvewithtime.
Othersymptomsincludefatigue,inabilitytofocusorconcentrate,slowedreactiontimes,compromised executivefunction,emotionallability,sleepdisturbances,depression,anxiety,andirritability.These neuropsychiatricsymptomsmayoccurimmediately,hours,orevendaysaftertheheadtraumaandtendto lastforseveralweeksbeforegraduallyresolving.
Patientswhodonotrequireimaging(orwhohavehadanormalCTscan)anddonotrequireinpatient observationcanbemanagedconservatively.Earlierrecommendationsforaprolongedperiodofphysical andmentalresthavebeensupplantedbymorelenientguidelines,buttheidealdurationofrestisunknown andshouldbedeterminedonacase-by-casebasis.“Brainrest”isoftenrecommended:limitedscreens (thisincludestexting,playingvideogames,andusingacomputer)andlimitedreading.Afterashort period(typicallyontheorderof3to5days),patientscangraduallyresumelightcognitiveandphysical
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activityastolerated.
Itisimportanttorecognizethatitcantakeweeksforthebraintorecoverfrommildtrauma.Duringthis time,themetabolicdemandsoftherecoveringbrainexceedtheavailableenergysupply,andthebrain remainsatincreasedriskoffurtherinjury.
Sports-relatedConcussion
Athleteswhosustainheadtraumashouldbeimmediatelyremovedfromthesportsactivity.Athletesare oftenunderstandablyeagertoreturntothefield,butguidelinesstresstheimportanceofobjective assessmentofneurologiccompromisetodetermineifthereisaconcussionorsomethingevenmore serious.
ThemostcommonlyusedsidelinetestsaretheBalanceErrorScoringSystemandtheSports ConcussionAssessmentTool.Focusshouldbedirectedtowardidentifyingredflagsforseriousinjury, objectivesignsofneurologicdysfunction(especiallygaitandbalanceissues),memoryimpairment,the GCSscore,andacarefulcervicalspineassessment.However,theaccuracyofthesetoolsinpredicting seriouspathologyisstillupfordebate.Clinicaljudgmentalwaysprevails.
Athletesdiagnosedwithconcussionshouldnotreturntoplaythatdayandshouldbetotallyfreeof symptomsbeforebeginningastandardizedrehabilitationprogressionthatstartswithlightaerobic exerciseandcontinuesforseveraldays.1Nomatterhowfastathletesrecover,atleast10daysshouldbe allowedbeforetheyresumeacontactsport;theprolongedrecoveryofthebrainfollowingconcussion makesthebrainhighlysusceptibletoasecondinjury,theconsequencesofwhichcouldbemuchmore severethanthefirst.
Importantnote:Thehelmetsandotherprotectiveequipmentthatarecurrentlyavailablefor contactsportssuchasAmericanfootballandhockeydonotprotectagainstconcussion. Theydoprotectagainstfractureandotherheadandneckinjuries,butnotconcussion.
PostconcussionSyndrome
Patientswithmildheadtraumashouldgraduallyimproveoveracourseofdaystoafewweeks.However, somepatientswillhavepersistentsymptoms(i.e.,lastingbeyondtheusualrecoveryperiod),acondition referredtoaspostconcussionsyndrome.
ForpatientswithPCSwhohavealreadyhadanormalCT,thereisnothingtobegainedbyrepeated imagingunlesstheyhaveprogressivesymptoms,newfocalneurologicdeficitsortheirsymptomshave becomedisabling.Thedataareclearonthispoint:otherthanforthoseexceptionsjustmentioned,a repeatCTwillinalllikelihoodaddnothingtoyourmanagement(thechancesofdetectingableedor fracturearevirtuallynil).If,however,imagingwasnotdoneatthetimeofthetrauma,itisappropriateto orderitnow.
Neuropsychologicaltestingisoftenrecommendedforpatientswithpersistentsymptoms.However, whereasitmayhelppredictthecourseofrecovery,thereisnocompellingevidencethatitwillaffect management.
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