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

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

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

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

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%”

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

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

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

Venous Pulsations

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

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?

Ring Enhancing Lesion: Differential Diagnosis Bacterial brain abscess Toxoplasmosis, cryptococcosis Tumor (glioblastoma or metastatic) Lymphoma Infarction Necrotizing encephalitis Granuloma

Toxoplasmosis Glioblastoma vs. lymphoma

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

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)

Emissary Veins Emissary veins ddddddddddddddddddddddddddddddddddddddddddddddddd dddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd Emissary veins

Proximity of Sinuses to Brain

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)

Early cerebritis Early abscess

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

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)

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

More Clues HIV infection Other immune defects History of cancer (especially lung, breast, melanoma)

Brain Abscess: Imaging CT (with and without contrast) MR (superior when available)

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

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)

Source Location Microbes Therapy Sinuses 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 Same as above + Staph epi Vanc + ceftazidime

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

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

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

Questions?