Transient Global Amnesia – Late middle age – Anterograde and retrograde amnesia – Resolves within hours – Recurrences in 20% of patients – Postulated causes: migraine, temporal lobe seizures, and TIA in the posterior cerebrum Hauser, S, et al (2006) Harrison’s Neurology in Clinical Medicine. USA: McGraw Hill.

Headache PrimarySecondary Tension Migraine Cluster

Red flags: – Neurologic symptoms or signs – Immunosuppression or cancer – Meningismus – Onset of headache after age 50 – Thunderclap headache – Symptoms of giant cell arteritis – Systemic symptoms – Progressively worsening headache – Red eye and halos around lights Altered mental status 67 years old

Headache symptoms that suggest a serious underlying disorder – “Worst” headache ever – First severe headache – Subacute worsening over days or weeks – Abnormal neurologic examination – Fever or unexplained systemic signs – Vomiting precedes headache – Induced by bending, lifting, cough – Disturbs sleep or presents immediately upon awakening – Known systemic illness – Onset after age 55 Hauser, S, et al (2006) Harrison’s Neurology in Clinical Medicine. USA: McGraw Hill.

Symptoms of Serious Underlying Cause of Headache Nuchal rigidity, headache, photophobia, and prostration; may not be febrile. Lumbar tap is diagnostic Meningitis Nuchal rigidity and headache; may not have clouded consciousness or seizures. Lumbar puncture shows ‘bloody tap’ that does not clear by the last tube Intracranial hemorrhage May present with a unilateral pounding headache. Onset is generally in older patients (>50 years old) and frequently with visual changes ESR is elevated; definitive diagnosis by arterial biopsy Temporal arteritis May present with prostrating pounding headaches that are associated with nausea and vomiting. Should be suspected in progressively severe new ‘migraine’ that is invariably unilateral Brain tumor Hauser, S, et al (2006) Harrison’s Neurology in Clinical Medicine. USA: McGraw Hill.

Tumors of the CNSPrimarySecondary

Compression of neurons and white matter tracts by the expanding tumor and surrounding edema High grade gliomas and metastatic melanoma, and choriocarcinoma Sub acute progression of a focal neurologic deficit Disruption of cortical circuits. Tumors that invade or compress the cerebral cortex, even small meningiomas Seizure Increased ICP, Hydrocephalus,or Diffuse tumor spread Frontal lobe tumors - behavioral change Non focal neurologic disorder Approach to a patient with Brain tumor Hauser, S, et al (2006) Harrison’s Neurology in Clinical Medicine. USA: McGraw Hill.

Ropper, A, et al (2005) Adams and Victor’s Principles of Neurology. USA: McGraw Hill.

Modes of Clinical Presentation 1.Patients who present with focal cerebral signs and general impairment of cerebral function, headaches, or seizures 2.Patients who present with evidence of increased intracranial pressure 3.Patients who present with specific intracranial tumor syndromes Ropper, A, et al (2005) Adams and Victor’s Principles of Neurology. USA: McGraw Hill.

Patients who present with focal cerebral signs and general impairment of cerebral function, headaches, or seizures Astrocytoma (Well- differentiated) Oligodendroglioma Glioblastoma multiforme and Anaplastic Astrocytoma (High grade gliomas) Meningioma Ropper, A, et al (2005) Adams and Victor’s Principles of Neurology. USA: McGraw Hill.

Astrocytoma (Well- differentiated) tumor that forms from neoplastic transformation of the supporting cells of the brain, neuroglia. 20- to 40-y/o age group Headache or subtle neurobehavioral changes Seizures can occur and may be either focal or generalized Very gradual onset Ropper, A, et al (2005). Adams and Victor’s Principles of Neurology. USA: McGraw Hill. Goetz, C. (2003). Textbook of Clinical Neurology. USA: Elsevier

Oligodendroglioma arise within the cortex and further extend into the white matter of the cerebral hemispheres in rough proportion to the mass of each lobe (frontal, parietal, temporal, and occipital) 30- to 50-y/o age group Headache, hydrocephalus, focal neurological findings Seizures are the most common presenting symptom Grows very slowly Ropper, A, et al (2005). Adams and Victor’s Principles of Neurology. USA: McGraw Hill. Goetz, C. (2003). Textbook of Clinical Neurology. USA: Elsevier

Glioblastoma multiforme and Anaplastic Astrocytoma (High grade gliomas) heterogenous mixture of poorly differentiated neoplastic astrocytes, primarily affect adults, and located preferentially in the cerebral hemispheres. Most arise in the deep white matter and quickly infiltrate the brain extensively Occurs after 50 yrs old Clinical history is usually short, less than 3 months in >50% of patients Ropper, A, et al (2005). Adams and Victor’s Principles of Neurology. USA: McGraw Hill. Goetz, C. (2003). Textbook of Clinical Neurology. USA: Elsevier

Glioblastoma multiforme and Anaplastic Astrocytoma (High grade gliomas) General symptoms are headaches, nausea and vomiting, personality changes, and slowing of cognitive function. inc. ICP - headaches, nausea and vomiting, and cognitive impairment. Headaches can vary in intensity and quality, and more severe in the early morning or upon first awakening. Focal signs include hemiparesis, sensory loss, visual loss, aphasia, and others. Seizures Ropper, A, et al (2005). Adams and Victor’s Principles of Neurology. USA: McGraw Hill. Goetz, C. (2003). Textbook of Clinical Neurology. USA: Elsevier

Meningioma arise from arachnoidal cap cells, which reside in the arachnoid layer covering the surface of the brain. Increase incidence with age, 60- to 70-y/o age group Benign but may enlarge and cause compression of neural elements and can behave aggressively Subtle signs and symptoms such as progressive headache, memory loss, or cognitive changes Seizures Focal or more generalized cerebral dysfunction, like focal weakness, dysphasia, apathy, and/or somnolence. Ropper, A, et al (2005). Adams and Victor’s Principles of Neurology. USA: McGraw Hill. Goetz, C. (2003). Textbook of Clinical Neurology. USA: Elsevier

Meningioma Meningiomas in specific locations may give rise to the stereotyped symptoms – Parasagittal frontoparietal maningioma may cause a slowly progressive spastic weakness or numbness of one leg and later of both legs, and incontinence in the late stages. Ropper, A, et al (2005). Adams and Victor’s Principles of Neurology. USA: McGraw Hill. Goetz, C. (2003). Textbook of Clinical Neurology. USA: Elsevier