Red flag headaches II part

Red Flag Headache - Part 2

• Employability skills developed and enhanced within the clinical neurology module include problem-solving, communication, practice and patient awareness, team working, and professional knowledge/skills.

Lecture Outcomes

• Understanding causes and hallmark symptoms and signs of raised ICP
• Understanding common conditions leading to raised ICP and their presentation
• Understanding principles of intracranial tumours, with examples of pituitary adenomas and acoustic neuromas.
• Understanding principles of brain infection, with examples of meningitis and abscesses.

Space Occupying Lesion

• A blanket term for a mass within a specific area of the brain.
• The mass may be a tumor, cyst, aneurysm, abscess, or other.
• These lesions can cause neurological deficits by compressing brain structures.
• They also commonly lead to raised intracranial pressure (ICP).

What is ICP?

• The cranium is an enclosed space divided into three physiological compartments.

• Cerebral parenchyma comprises 80% of the intracranial volume.

• Cerebrospinal fluid (CSF) accounts for 10%.

• Blood makes up the remaining 10%.

• ICP is the interaction between brain, CSF, and cerebral blood.

• Cerebral blood flow volume/amount typically remains constant.

• CSF can displace into the lumbar cistern, enlarging the subarachnoid space.

• Normal effectors include position changes (standing/lying down), systemic arterial pressure, and Valsalva manoeuvres.

Normal Effectors to ICP

• Positional changes (standing versus lying down).
• Systemic arterial pressure.
• Breathing/Valsalva manoeuvres.
• These manoeuvres increase intrathoracic and intra-abdominal pressure, causing an increase in pressure within the jugular veins or epidural venous plexus.
• Since cerebral veins lack valves, the increased pressure is transmitted to the intracranial space, raising ICP.

Pathophysiology of Raised ICP

• If a growth occurs (tumor or hematoma), a fourth compartment is created.
• For prolonged or severe changes, other compartments must reduce in size to avoid an increase in ICP.
• A slow-growing lesion can cause the parenchyma to deform or remodel to adjust.
• Brain structures may shift (herniate) as a compensation.
• Many raised ICP symptoms result from herniation, not just the absolute ICP level itself.

Brain Herniations

• Diagrams of brain herniations are provided in slide 9.

Hallmark Symptoms of Raised ICP

• Headaches described as throbbing or bursting, aggravated by Valsalva maneuvers (straining, coughing, sneezing) and prolonged supine or prone positions.
• Headaches often worsen in the morning and lessen during the day.
• New pulsatile tinnitus, worsened by bending over or lying down, and visual changes (blurred vision, double vision, or "greyed-out" vision) are common.
• Nausea and vomiting can be a later symptom.

Hallmark Testing for Raised ICP

• Physical exam includes Valsalva maneuvers to assess headache aggravation.
• Neurological examination includes Cranial nerve assessment (CN II – vision, CN III – pupillary dilation/ptosis, CN VI – double vision), mental state, balance, and evaluation for papilledema (via fundoscopy, referred to an ophthalmologist).

Raised ICP - Diagnosis and Management

• Diagnosis includes CSF pressure monitoring, CT scan, and MRI.
• Management requires immediate referral to address the cause.
• Treatment options depend on the cause, and might include surgery, shunts, pharmaceuticals (diuretics, anti-seizure meds, etc.), and potentially hypothermia.

Benign Intracranial Hypertension

• Idiopathic raised intracranial pressure, often in young, obese women.
• Symptoms include brief visual changes ("greying out") that vary with position, a whooshing sound in the ears, and positional symptoms.
• Immediate referral is advised due to risk of partial blindness.
• Treatment includes removing CSF, diuretics, and weight loss.

Arterial Hypertension Headache

• Secondary headache stemming from elevated arterial blood pressure.
• Potentially linked to very high blood pressure readings or very rapid increases in blood pressure.
• Urgent referral and medical care are necessary.
• A definitive diagnosis requires elevated blood pressure readings (systolic blood pressure (SBP) above 180 mmHg or diastolic blood pressure (DBP) above 120 mmHg).
• A specific example is pre-eclampsia or eclampsia (conditions related to pregnancy)

Intracranial Tumors

• Primary tumors originate from neural elements within the brain (incidence approximately 6 per 100,000).
• Secondary tumors are malignant spreads of distant cancers.
• Gliomas, metastases, meningiomas, pituitary adenomas, and acoustic neuromas account for 95% of all brain tumors.
• Benign tumors are often space-occupying lesions (SOLs), potentially infiltrating the surrounding brain tissue.

Intracranial Tumors - General Principles

• Headaches, possibly unilaterally but often diffuse, are common, with slow progression over weeks or months.
• Progression to increased ICP symptoms (headache worsened in the morning and with recumbency) can occur as the tumor grows.
• Focal neurological symptoms (depending on the compression site) and potential seizure involvement are hallmarks.
• Classification is often based on location relative to the tentorium cerebelli and surrounding dura mater.

Intracranial Tumours - Posterior Fossa

• Posterior fossa tumors are more prevalent in children.
• They account for about 54% or 70% of childhood brain tumors.
• Hydrocephalus frequently is associated with posterior fossa tumors.

Hydrocephalus

• Excess cerebrospinal fluid (CSF) in the brain.
• Often, this is associated with tumor growths.

Intracranial Tumors

• Insidious onset of nonspecific headaches; raised intracranial pressure symptoms (visual changes, loss of vision, tunnel vision, ptosis, diplopia, etc.)
• The visual changes and ptosis can be characteristic signs
• Also, endocrine dysfunction (acromegaly, Cushing's)
• Tumors can develop over decades, causing progressive loss of hearing and dizziness.

Tumor Physical Exam

• Assess for Valsalva maneuver-induced headache exacerbation.
• Scrutinize for nystagmus and ptosis.
• Evaluate cranial nerves (CNs 2, 3, 4, 6, 8, 12).
• Observe for abnormal pupillary light responses.
• Assess balance and possible cerebellar dysfunction.
• Look for other abnormalities related to the suspected compression site.

Brain Infection

• Viral and bacterial meningitis are common categories of brain infections.
• Encephalitis, abscesses, and other infections result from various causes like herpes zoster virus, cytomegalovirus, ear infections, chronic sinusitis, mastoiditis, head trauma, and surgical procedures.

Hallmark Signs of Brain Infection

• Symptoms usually develop over hours or 2 days.
• Headaches, progressive in severity, and typically constant.
• Fever frequently accompanies the infection and may be high.
• Stiff neck is a significant indicator of meningitis.
• Photophobia, fatigue, and lethargy are also associated symptoms.
• Neurologic signs include alterations in mental status (confusion, irritability, altered consciousness) and focal neurological deficits (weakness on one side of the body, speech problems, seizures).

Meningitis

• Inflammation of the meninges (protective membranes surrounding the brain and spinal cord).
• Usually caused by viral or bacterial infection.
• Bacterial meningitis is more serious than viral meningitis and often necessitates immediate medical attention.
• Bacterial meningitis can show symptoms such as a rash but this is a late sign (not always present)
• Also common causes include - collection of blood around meninges (e.g., subarachnoid haemorrhage) and infection( e.g., abscess, encephalitis)

Meningitis - Physical Exam

• Temperature.
• Mental status (ranging from mild irritability to confusion).
• Nuchal rigidity (stiffness in the neck).
• Reduced neck flexion (flexion causing pain and exacerbation of headache).
• Bruzinski's sign (pain increase in flexion), and Kernig's sign (pain in leg extension).
• Potential signs of raised ICP.
• Non-blanching rash (a late, serious sign).

Intracranial Abscess

• A localized collection of pus within the brain.
• Originating from sources like hematogenous spread from chronic otitis media/mastoiditis, dental infections/sinus infections or head fractures.
• Symptoms develop over 2–3 weeks, characteristically presenting as pyrexia (fever), malaise (general discomfort), raised ICP headache, meningismus (symptoms related to inflammation of the meninges), and focal neurological deficits.

Acromegaly

• Growth hormone (GH) hypersecretion in adults.
• If hypersecretion occurs before puberty, it results in gigantism.
• Typically caused by a pituitary tumor (usually a macroadenoma), causing increased GH secretion.

Acromegaly / Gigantism

• Images of acromegaly/gigantism patients, illustrating various features, are included in the slides .

Acromegaly - Symptoms

• General increase in body size (hands, feet, face).
• Enlargement of facial bones (supraorbital ridges, jaw), soft tissues (lips, tongue, nose).
• Progressive headache.
• Increased sweating.

Acromegaly - Clinical Features

• Illustrative images showcasing acromegaly features, such as enlarged hands, facial changes, and general body build.

Cushing's Syndrome

• Excessive activation of glucocorticoid receptors, leading to elevated cortisol levels.
• Can be iatrogenic (caused by prolonged use of synthetic glucocorticoids like prednisolone).
• Endogenous Cushing's can result from adrenal or pituitary tumors or ectopic ACTH production by another tumor.
• Also, pseudo-Cushing's occurs with cortisol excess due to various other medical conditions (e.g., alcohol excess, certain illnesses, obesity, major depression).
• Prevalence is approximately 4:1 female-to-male.

Cushing's Syndrome - Hallmark Symptoms

• Truncal obesity (especially the midsection).
• Stria (stretch marks), especially on the abdomen.
• Buffalo hump (fat deposition at the back of the neck).
• Moon-shaped face.
• Muscle wasting, predominantly in the extremities.
• Proximal muscle weakness.
• Easy bruising, poor wound healing.
• Emotional fluctuations (e.g., mood swings, depression).
• Diffuse, progressive headaches may occur if caused by a pituitary adenoma.

Cushing's Syndrome - Clinical Features

• Specific images displaying characteristic physical features of Cushing's syndrome (e.g., moon face, buffalo hump, truncal obesity).

Test your knowledge on Intracranial Pressure (ICP) with this informative quiz. Explore symptoms, diagnostic standards, and conditions associated with raised ICP. Perfect for medical students and healthcare professionals alike.