Neuro Exam III

small vessels extracellular space white

1) vasogenic cerebral edema: A) most common form of edema B) occurs due to increased permeability of small ______________ (disruption of the BBB) C) involves the escape of proteins, fluids into (extra/intra)cellular space, especially of _________ matter; because the fluid can flow along fiber tracts; the swelling may be greater in white matter than in gray matter

A. Streptococcus pneumoniae

1. A 62- year-old male with a history of heavy alcohol use presents to the emergency department with headache and fever. Lumbar puncture is consistent with meningitis. The MOST LIKELY pathogen to cause meningitis is this individual is: A. Streptococcus pneumoniae B. Haemophilus influenza type b C. Staphylococcus aureus D. Actinetobacter calcoaceticus E. Neisseria Meningitis

B. eosinophilic neurons

1. Following occlusion of a cerebral artery, which of the following changes would occur? A. chronic cell change B. eosinophilic neurons C. neurofibrillary tangles D. schwann cell proliferation

apoptosis

2) "simple" neuronal atrophy ("degeneration") there may be neuronal death resulting from a progressive disease process, with cell loss as a characteristic histologic feature, such as in degenerative diseases like amyotrophic lateral sclerosis (ALS) and Alzheimer disease; in many of these diseases, __________ appears to be the prominent mechanism of cell death

cell membranes intracellular gray matter

2) cytotoxic cerebral edema (cellular brain edema) A) increased permeability of cell _____________ secondary to cellular injury B) (extra/intra)cellular accumulation of excess fluid; may occur with ischemia or with other conditions such as metabolic poisons; because neurons are most vulnerable to cell injury, cytotoxic edema may be more severe in ________ matter

C. increased permeability of capillaries

2. Which of the following is associated with vasogenic cerebral edema? A. intracellular accumulation of excess fluid B. increased permeability of neuronal membranes C. increased permeability of capillaries D. greater swelling in gray matter than in white matter

central chromatolysis, or axonal reaction Nissl bodies nucleus

3) axonal reaction/central chromatolysis/Wallerian degeneration: Wallerian degeneration is when the axon of a neuron is cut or damaged, and the axon and its myelin sheath undergo degeneration distal to the lesion the sequence of events that takes place in the cell body is known as central __________lysis or axonal reaction a. the cell body swells b. disruption and dispersion of _______ bodies, which move peripherally c. the __________ is displaced peripherally in the cell d. this is a reparative process associated with increased protein synthesis to facilitate axon regeneration

B. neuronophagia

3. Which of the following is a reaction to injury involving microglia? A. central chromatolysis B. neuronophagia C. gemistocytic change D. inclusion bodies

Negri body Lewy bodies

4) subcellular alterations in organelles and cytoskeleton a wide range of subcellular alterations are recognized: a. neuronal inclusions may occur as a manifestation of aging; this can involve cytoplasmic accumulation of lipids, proteins and carbohydrates (lipofuscin is an example, containing lipids) b. in many cases of viral encephalitis, inclusion bodies composed of viral particles occur in the cytoplasm or nucleus of infected cells; one example is the ________ body, characteristic of rabies c. in some degenerative diseases, specific types of intraneuronal inclusions occur; for example, in Parkinson disease, large spherical, eosinophilic, intracytoplasmic inclusions called _________ bodies are found (arrow in image)

tau

4) subcellular alterations in organelles and cytoskeleton, continued: d. in Alzheimer disease, cytoplasmic accumulation of abnormal neurofilaments containing ______ protein, called neurofibrillary tangles (black inclusions) occur

C. gliosis

4. Which of the following is the usual reaction to injury in the CNS? A. neuronal inclusion body formation B. oligodendrocyte proliferation C. gliosis D. fibrosis

A. oligodendrocytes

5. Which of the following cell types would degenerate in a demyelinating disease affecting only the CNS? A. oligodendrocytes B. astrocytes C. neurons D. schwann cells E. ependymal cells

C. neurons

6. Which of the following cell types is most sensitive to decreased oxygen supply? A. oligodendrocytes B. astrocytes C. neurons D. microglia E. ependymal cells

D. central chromatolysis

7. Which of the following describes changes in the neuronal cell body when the peripheral axon of a motor neuron is cut or damaged? A. eosinophilic neuron B. neurofibrillary tangles C. gemistocytic change D. central chromatolysis

jaw blindness

giant cell arteritis (GCA); also known as temporal arteritis: GCA is a type of vasculitis, affecting the vessels of the head and neck; it occurs only in adults over the age of 50, women more commonly than men; the most common symptom of GCA is HA this is one of the secondary HA syndromes; there are often associated symptoms of scalp tenderness, ______ claudication (pain here with chewing), fatigue, loss of appetite, weight loss and flu-like symptoms GCA can cause ___________ and thus is considered an urgent issue when identified the cause of GCA is unknown; it is often associated with a syndrome called polymyalgia rheumatica

does NOT have rash

haemophilus influenzae meningitis: this is a gram(-) coccobacillus; also has encapsulated strains (type b used to predominate) peak incidence: ~2yo; range 3 months to 5 years incidence has declined greatly since the successful introduction of Hib vaccine more insidious onset, (does/does NOT) have rash, lower mortality diagnostic approach is same as for other causes of meningitis treatment: again, is 3rd-generation cephalosporins

carbonic anhydrase acetazolamide shunt

idiopathic intracranial hypertension (IIH); also known as pseudotumor cerebri, continued: risk factors for development include exposure to certain medications, Lyme's disease, endocrine and metabolic disorders the list of medications implicated is extensive, including vitamin A, antibiotics, oral contraceptives and many more treatment is aimed at preserving optic nerve function, while managing increased intracranial pressure; pharmacologic treatment includes _________________ inhibitors and ___________amide to lower the ICP surgical intervention may be necessary if there is not response to pharmacologic therapy; surgical therapy includes a lumbo-peritoneal ________ to drain CSF

obese women of childbearing age pulsatile tinitis MRI lumbar puncture

idiopathic intracranial hypertension (IIH); also known as pseudotumor cerebri: IIH is a disorder of unknown etiology; it predominantly affects _________ women of _____________ age; there is chronic elevation of intracranial pressure, leading to HA and papilledema; optic atrophy may develop if the increased pressure is not treated signs and symptoms are related to the elevation in intracranial pressure; these include HA, which is nonspecific in type and diffuse in nature, binocular horizontal diplopia secondary to CN VI dysfunction, and pulsatile ________ symptoms of papilledema may include transient visual obscurations (dimming of vision with bending or standing), progressive loss of peripheral vision in one or both eyes, blurring and distortion of central vision and sudden vision loss there is NO change in level of consciousness or cognition diagnosis is via _____ to rule out a space occupying lesion or venous thrombosis, and ______________ to document elevated opening pressure with normal CSF constituents

neutrophils (PMNs) lymphocytes

in bacterial: cloudy and turbid due to ____________ in aseptic: not as cloudy as bacterial; WBC cell count not as high as bacterial, and are mostly ________________

strep. pneumonia

in patients that don't survive meningitis, this is what you see on a gross specimen of the brain, with all of that purulent material image: purulent material from _______________ meningitis in the brain (acute bacterial meningitis)

chronic

just read: fungal meningitis: cryptococcus neoformans is the main cause HIV and immunosuppressed patients (cell-mediated immune defects) at risk, but note it does NOT cause cryptococcal meningitis in HIV patients; it does in AIDS have more (acute/subacute/chronic) presentation, but includes insidious onset of headache, fever, neck stiffness diagnosis made on CSF examination, which shows raised lymphocyte count and protein, low sugar, and encapsulated yeasts, and a positive fungal antigen treat with amphotericin B + fluctyosine

25%

medication overuse HA (MOH): MOH is characterized by a daily, constant dull HA; it is often associated with depression and found in patients taking abortive medications more than 3 days a week, on a chronic basis multiple medications have been implicated in the development of this type of HA, including: NSAIDs, acetaminophen, narcotics, opiates, barbiturates, triptans, ergotamine and caffeine treatment is aimed at withdrawal of the offending agent, tapering by _____% per week; patients require education about the appropriate frequency of use of abortive medications and consideration should be given to prophylactic agents

listeria monocytogenes

meningitis case: patient: 50yo that had non-Hodgkins lymphoma, treated with aggressive chemotherapy, and had a reccurence which was treated again with aggressive chemotherapy, with prolonged steroids they came in with a history of headache over last week and a half; got worse, then had a fever of 100, then 101, wasn't getting better; family said he wasn't totally oriented to time and place, so came to ER on exam, was able to answer a lot of questions, but still confused to time and place; didn't have a stiff neck per se, but did complain of severe headaches getting worse and temperature of 101, so had routine bloodwork done; this really didn't show much as far as CBC; CT of head was negative spinal tap (image) showed gram(+) bacilli and an immune response [~150 cells (lymphocytes mostly)], protein was slightly up, glucose slightly low (but not more than 50% down); was found to be a _____________________ infection, and was put on appropriate antibiotics this was someone with a cell-mediated immune defect due to being on steroids and had a Hodgkin's lymphoma, so his T-lymphocytes weren't functioning normally although was a bacterial infection, it presents itself a little differently than strep. pneumoniae or n. meningitidis

h. influenzae (when you hear coccobacilus, think h. influenzae)

meningitis case: patient is a younger individual (5yo), complaining about ear infection, wasn't given antibiotics initially (family thought to be non-infectious, so they thought it would clear on its own); infection got more and more severe, developed ruptured eardrum; started developing fevers, became irritable, non-communicable family brought to ER; at this point is non-responsive; temperature was 102-103; was tachycardic and tachypneic; CT didn't show anything abnormal; spinal tap showed numerous PMNs when you talk to the family more, you find out that they're "anti-vaxx" image: CSF WBCs and gram(-) coccobacilli: this is ________________

chocolate CO2

microbiological diagnosis: if possible, collect CSF fluid (may not be, if raised ICP) and blood culture both before antibiotic therapy sample from petechial skin may yield meningococcus CSF subjected to cell count, gram stain of deposit, and culture on _______________ agar in (O2/CO2) atmosphere

myelin

oligodendrocytes: pathological reactions: oligodendrocytes swell in response to almost any type of toxic or metabolic change; diseases with primary involvement of oligodendrocytes result in disorders of __________, with demyelination or abnormal myelin formation the two major groups of diseases affecting oligodendrocytes and myelin are leukodystrophies, which include inherited disorders of myelin metabolism, and acquired demyelinating diseases (e.g. multiple sclerosis)

abdominal migraine cyclical vomiting vertigo absent

pediatric HA, continued: concerning features of HA in children, suggesting secondary causes include: 1) escalating frequency and/or severity of HA over several weeks in a child under 12; even more important if the child is under 7 2) a change in the frequency or severity of HA patterns in young children 3) fever 4) HA accompanied by seizure children may experience periodic syndromes that are thought to be migraine equivalents; these include: 1) ____________ migraine (including episodic abdominal pain) 2) cyclical __________ 3) benign positional _________ of childhood HA is often (present/absent) in these syndromes; over time these often resolve and the more typical adult symptoms of migraine emerge

NONE

pediatric HA, continued: treatment of pediatric migraine is both non-pharmacologic and pharmacologic non-pharmacologic treatment includes avoidance of dietary triggers, avoidance of caffeine overuse, maintenance of normal BMI and proper sleep (none/some/all) of the typical migraine medications are FDA-approved for use in children; there are data to support the use of NSAIDS in children over 15 and triptans in children 12-17

migraine shorter duration (as short as one hour at times), and the presence of bilateral pain

pediatric HA: ____________ is the most common HA syndrome in children; 6% of adolescents experience migraine yearly; the diagnosis of pediatric migraine can be more difficult secondary to the variability of expression of the common associated symptoms key features that differentiate pediatric migraine from adult migraine include (shorter/longer) duration, and the presence of ________lateral pain children often have a difficult time explaining throbbing pain or describing the common associated symptoms, which often have to be inferred from behavior of the child children may also experience difficulty thinking, fatigue and lightheadedness

gram(+) diplococcus extremes of age

pneumococcal meningitis: strep. pneumoniae is the cause (a common one), a capsulate (encapsulated) gram(+) _________________ highest incidence in those at _____________ of age: infants (<3 years) and the elderly alcoholism, debilitation, malnutrition, hyposplenism are all predisposing factors (is also often a cause of post-splenectomy sepsis) may spread from middle ear or sinus infection, or following trauma that causes basal skull fracture

acute rash is NOT a feature

pneumococcal meningitis: clinical features: (acute/subacute/chronic) onset (headaches, fevers, stiff neck, etc.) with rapid development of loss of consciousness skin rash (is/is NOT) a feature may be a history of ear infection, splenectomy bacteremia is a feature higher mortality rate than other causes high incidence of post-meningitis complications in survivors

"draughtsmen"

pneumococcal meningitis: microbiological investigations: CSF and blood cultures should be taken gram stain of CSF deposit shows gram(+) cocci in short pairs culture on blood and chocolate agar in CO2 gives alpha-hemolytic (green) colonies; known as "________________" direct sensitivities for penicillin, cefotaxime/ceftriaxone (3rd-generation cephalosporins), and ampicillin

headache fever meningismus (nuchal rigidity) altered sensorium

presenting symptoms and signs in patients with bacterial meningitis: symptom or sign/relative frequency (%): going down this chart increases in ICP persistence and expansion ____________ (>85%) ____________ (>80%) ____________ (>80%) altered ___________ (>75%) vomiting (35%) seizures (30%) focal neurological findings (10-35%) papilledema (<5%)

72 hours

status migrainosus occurs when there is a severe persistent HA lasting >_____ hours this HA syndrome likely develops secondary to neurogenic sterile inflammation, mediated by the aforementioned pathways the management of this consists of insuring there is not a secondary cause present, and once eliminated, pain management effective therapies include hydration, DHE, IV valproic acid, ketorolac, metoclopramide and corticosteroids

less than 15 days a month band-like sensation

tension type HA (TTH): TTH may be episodic or chronic episodic TTH occurs less than _____ days a month, chronic more frequently than that; TTH has peak prevalence between the ages of 20 and 50; the location is typically bi-occipital, bi-frontal or holo-cranial the quality of a TTH may be a dull ache, pressure or a _________-like sensation around the head there is often tenderness to palpation of the areas involved; notably absent are nausea, vomiting, photophobia, phonophobia and lack of aggravation by physical activity precipitating factors include stress and sleep deprivation

cryptococcus m. tuberculosis lactic acid/procalcitonin tests PCR

tests available for diagnosis of infectious agents in CSF: A) conventional laboratory methods: 1) cellular, protein, and glucose content 2) gram stain (india ink for _______________ and acid-fast stain for _______________) 3) culture with isolation and identification of organisms: needed especially because some strains of pneumococcus are resistant, and you want to identify the sensitivitives of antibiotics so we give the right ones B) detection of specific bacterial antigens: not done as much now; were for when people may have previously been on antibiotics, so cultures may not be positive because of antibiotic suppression 1) latex agglutination test, coagglutination 2) counter immunoelectrophoresis, elisa C and D: these are done much more now; the only thing is that they can't give you the sensitivity of the organism, so you still need cultures if worred about reisstnace C) rapid and nonspecific methods 1) c-reactive protein test 2) lactic acid assay (___________ and/or __________ tests can differentiate between an aseptic cause of meningitis and vs. bacterial) 3) LDH enzyme assay D) _________ tests (sensitivity 90%, specificity 95%)

primary secondary

the International Headache Society (IHS) has developed criteria for the diagnosis of different HA types the most basic differentiation is between primary and secondary HA syndromes _______________ HA syndromes are those WITHOUT a specific cause ______________ HA syndromes have underlying structural or metabolic etiologies

dorsal raphe nucleus dilation

the pathophysiology of migraine is likely related to a central "migraine generator"; the ______________ nucleus of the midbrain is activated; this area has interaction with the trigemino-vascular system, leading to the presentation of migraine stimulation of the trigeminal nerve leads to release of substance P and calcitonin gene-related peptide (CGRP); release of these substances leads to vessel (dilation/constriction), the subsequent stretch on the vessel wall produces pain on functional imaging, there is evidence of spreading areas of excitation and depression across the cerebral cortex during the aura phase and during migraine

triptan medications or DHE

the treatment of migraine should begin AS SOON as an individual is aware of the HA abortive medications should NOT be used more than 3 days a week; if there is need for more than that, preventive medications should be considered abortive treatment options include migraine specific medications such as _________ medications or ______ general analgesics or NSAID may be considered as well DHE (dihydroergotamine) is a non-selective 5HT agonist; DHE contraindications are similar to the triptan medications

structural unilateral

trigeminal neuralgia (TN): TN is a facial pain syndrome; it is more common in females and typically presents in older adults; if a patient presents under the age of 50 with symptoms suggestive of TN, evaluation should be undertaken to identify __________ causes the pain is caused by irritation of the trigeminal nerve; it may be idiopathic, or secondary to structural lesions such as MS, aneurysms, arterial compression of the nerve, tumor or dental issues TN presents with electrical shooting pain in the distribution of the trigeminal nerve; the pain is typically _______lateral and may be provoked by wind, touch, talking, eating or brushing of the teeth

high opening pressure high WBC count; neutrophils (or PMNs) high proteins low glucose (~50%)

typical CSF findings in patients with bacterial meningitis: CSF parameter/typical finding: opening pressure: (high/low), 200-500 mmH2O WBC count: (high/low) (1000-5000 mm³, where normal is <100-10,000), with ______________ being the majority (>80%, where normally it's ≤5/mm³) protein: (high/low), 100-500 mg//dL (normally is 15-45 mg/dL) glucose: (high/low), usually by 50% (can be <40mg/dL, where normally is 50-75mg/dL); note: in aseptic meningitis, gluose will be low, but not as low (so if normal is 80, will be like 50-60, not 40) CSF to serum glucose ratio: <0.4 gram stain: positive in 60-90% culture: positive in 70-85%; these will be positive unless treated before with antibiotics PCR: promising, as it has a lot of sensitivity and specificity

liquefactive necrosis

A) necrosis: necrosis refers to a set of morphological changes that follow cell death; the histological appearance is primarily the result of two processes: enzymic digestion of the cell and denaturation of proteins in the brain, ____________ necrosis often occurs (rather than coagulative necrosis, in which general tissue architecture is preserved in hypoxic death of cells in all tissues except the brain) this type of necrosis describes dead tissue that appears semi-liquid as a result of dissolution of tissue by the action of hydrolytic enzymes released from lysosomes

gray nucleus Rosenthal fibers

B) Alzheimer's type II astrocytes: Alzheimer's type II astrocytes are found in the (gray/white) matter in patients with liver disease (e.g. hyperammonemia) or metabolic disorders involving the urea cycle these cells have a very large __________ and a prominent nuclear membrane; note: these cells have NO association with Alzheimer disease C) ____________ fibers: these fibers are elongated, eosinophilic structures that occur within astrocytic processes; they are found in regions of long-standing gliosis and in a few specific disorders

energy dependent

B) apoptosis: apoptosis, a form of programmed cell death, involves different cellular mechanisms than necrosis; apoptosis is an __________-dependent process designed to switch cells off and eliminate them although apoptosis is a physiological process occurring normally during development, it can also be induced by pathological conditions ranging from a lack of growth factor or hormone, to a positive ligand-receptor interaction, to specific injurious agents the process consists of 4 major components: (i) signaling pathways, (ii) control and integration mechanisms, in which the BCL-2 family is important, (iii) an execution phase often involving the caspase family of proteases, and (iv) removal of dead cells by phagocytosis

eosinophilia

C) basic histopathological reactions to injury: 1) acute neuronal injury/ischemic cell change (eosinophilic/red neurons) neurons are quickly injured by hypoxia (decreased oxygen supply) or ischemia (regional absence of blood supply); after 6-12 hours after insult, morphological changes to the cells include acute shrinkage, angularity, and homogeneous ___________philia of the cytoplasm the nucleus becomes shriveled, pyknotic and eventually karyorrhexis ensues; these changes are part of the process of cell death; affected cells are called ischemic neurons (aka red neurons or eosinophilic neurons)

erythrocyte sedimentation rate (ESR) temporal artery biopsy corticosteroids

GCA, continued: GCA cannot be diagnosed by clinical history and lab tests alone; the ___________________, a non-specific measure of inflammation, is elevated in GCA definitive diagnosis is made by ________ artery biopsy; in GCA there is evidence of inflammation within the vessel wall treatment of GCA should begin as soon as possible, often BEFORE the biopsy results are available, secondary to the risk of visual loss teatment consists of ________________, which often have to be continued for at least a year; patients are monitored by following their ESR

A) 1. Migraine; 3. Medication overuse HA B) 5. Anticonvulsants C) 5. It is treated by tapering the offending medication

HA case 1: HPI: A 45-year-old female has debilitating HA 2-6 times a month. She describes the pain as a constant dull pressure over the occiput, neck and forehead. The pain is moderate intensity, throbbing. She has associated vomiting. She typically feels better after sleep. Her HA are provoked by soy sauce, ice cream, chocolate and alcohol. She is currently taking Vicodin 4-6 tablets daily, Ibuprofen 400mg 3 times a week and a Triptan 3 times a week. Her family history showed that her mother had migraine. Her neurologic exam is normal. Musculoskeletal exam revealed pain to palpation of the trapezius, splenius capitus and temporalis. A) Which of the following is the most likely diagnosis for this patient? More than one may be correct. 1. Migraine 2. Tension type HA 3. Medication overuse HA 4. Headache due to substance withdrawal B) Which of the following medications is UNLIKELY to cause medication overuse HA? 1. Triptans 2. NSAIDs 3. Ergotamine 4. Acetaminophen 5. Anticonvulsants C) Which of the following is TRUE regarding medication overuse headache? 1. It does not occur in children or adolescents 2. It is not associated with depression 3. Prophylaxis is not effective in preventing it 4. It occurs in patients taking analgesics more than 1 time a week 5. It is treated by tapering the offending medication

2. CT scan of the head should be ordered

HA case 2: A 56-year-old male presents with a 15-year history of HA. Over the last 5 months he has noted a change in his HA pattern, including a metallic taste in his mouth lasting 20 minutes, followed by a visual disturbance. He describes the vision as "looking through water". He notes tingling of his left hand and the left side of his tongue, lasting 5-15 minutes. The HA typically occurs after the numbness and taste episodes. After 30 minutes all symptoms resolve. He notes the HA can worsen with coughing or straining. Review of systems is positive only for hearing loss on the left. His neurologic exam finds a left hemi-sensory deficit and brisk reflexes on the left vs. the right. It is otherwise non-focal. Which of the following is TRUE? 1. Migraine with aura is the most likely diagnosis 2. CT scan of the head should be ordered 3. Onset of HA after the age of 30 is concerning for secondary HA syndromes 4. HA that worsens with coughing is common in migraine 5. Focal neurologic deficits are common in migraine Worrisome features of HA: "Red Flags" SNOOP (Think Secondary HA!) 1. S - Systemic symptoms - fever, weight loss or secondary risk factors (HIV, systemic cancer 2. N - Neurologic symptoms or abnormal signs 3. O - Onset - sudden, abrupt or split second 4. O - Older - new onset and progressive HA, especially > 50 5. P - Previous HA history - first HA or different (change in attack frequency, severity or clinical features)

A) 2. Migraine B) 3. Topiramate C) 1. Vicodin

HA case 3: A 47-year-old woman presents with intermittent headache. She has a history of migraine without aura since the age of 16. The pain was worse with moving around. She described the pain as throbbing. The pain typically lasts 4-6 hours. In the past she has used NSAIDs or aspirin. 6 months ago her HA increased in frequency to 3x/wk. The HA is less severe, though associated with photophobia, phonophobia and nausea. She has not been sleeping well. She is currently only taking Vicodin as needed for her HA. She is using it less than 5 times a month. She has two cups of coffee daily A) What is the appropriate diagnosis? 1. Medication overuse HA 2. Migraine 3. Chronic tension type HA 4. Caffeine withdrawal HA 5. Trigeminal neuralgia B) What migraine prophylactic medication could be considered in this patient? 1. Triptan 2. DHE 3. Topiramate 4. NSAIDS 5. Corticosteroids C) Which of the following is NOT appropriate for the treatment of episodic migraine? 1. Vicodin 2. Triptans 3. DHE 4. NSAIDs 5. Acetaminophen

A) 5. Stroke B) 4. Carbamazepine is helpful in managing the pain

HA case 4: A 57-year-old male presents with sharp shooting pain occurring across his left cheek. He notes it is worse when he attempts to talk or eat. The pain occurs more than 20 times a day and lasts seconds to minutes. His neurologic examination is normal. A) Which of the following is NOT likely to be a cause of this type of pain? 1. Idiopathic 2. Aneurysm 3. Tumor 4. Dental abscess 5. Stroke B) Which of the following is TRUE of this pain syndrome? 1. It is more likely to occur in males 2. It is more common under the age of 40 3. Narcotics are helpful in managing the pain 4. Carbamazepine is helpful in managing the pain 5. There are no surgical options to treat this

supine patch

LP HA, continued: clinical presentation is the key to diagnosis; there is a characteristic postural component to the HA; the HA will occur within minutes of sitting or standing up and will have complete or near complete resolution with the patient being placed in a (supine/prone) position; it is typically diffuse and throbbing in nature diagnosis is based on the appropriate clinical history treatment depends on the severity of the HA; the HA may resolve on its own with rest and hydration; if necessary, an epidural blood _________ can be placed which typically results in near immediate resolution of the HA caffeine, oral or IV, can be effective for some patients as well

lumbar puncture CT scan

__________________: aspiration of spinal fluid: this is the clinical diagnostic test for meningitis normal CSF pressure: 80-180 mmH2O measure and record opening and closing CSF pressures remove CSF carefully, if opening pressure is >180mmH2O, to prevent cerebral herniation use small gauge needle (20-22 gauge); using a stylet is also helpful if papilledema is present or intracranial pressure is high, a few drops of CSF will suffice for analysis in lecture: "if a patient has any signs of increased ICP, such as papilledema, seizures, confusion, and disorientation, it's probably better to do an initial ______ scan to see if there's increased ICP, because if you do a spinal tap, you have to do it under extreme controlled conditions to prevent herniation of the brainstem otherwise collect 2 or 3 mL of fluid in each of 3 sterile tubes

transformed migraine (TM) analgesic overuse

_________________________: is seen in individuals who have experienced previous episodes of migraine that have increased in frequency to daily or near daily occurrence the common features of this are a history of episodic migraine, decreases in associated symptoms such as nausea, photophobia and phonophobia; the HA may take on a chronic TTH quality the increase in frequency often occurs in the setting of __________ overuse treatment is tailored to the presence or absence of medication overuse; if medication overuse is present, the offending agent must be withdrawn or tapered; prophylactic medications are often of benefit

astrocytes

astrocytes: pathological reactions: A) gliosis and gemistocytotic astrocytes: in the brain, repair and glial scar formation is mainly accomplished by gliosis (fibrosis and formation of fibrous scar tissue by fibroblasts does NOT occur in the brain) gliosis involves proliferation of ___________cytes with formation of many glial processes; some of these become gemistocytic (arrows in image), i.e. they appear plump or swollen, and the cytoplasm is eosinophilic

4

chronic daily headache (CDH): CDH is a group of HA disorders that occur most days of the month, lasting ___ hours or more these can include both primary and secondary HA syndromes primary HA syndromes include: transformed migraine, medication overuse HA, chronic TTH, hemicrania continua secondary HA syndromes include: cerebral venous thrombosis, increased intracranial pressure, low intracranial pressure, space occupying masses, sleep apnea and cervical spine disorders

absent fontanelle head

clinical features of neonatal meningitis: lethargy, hyperirritability signs of meningeal irritation, such as nuchal rigidity, usually (present/absent) respiratory distress poor feeding and regurgitation cyanosis jaundice bulging anterior _________ in about 40% of cases increases ________ circumference, may occur late in course because of the increased ICP

unilateral eye

cluster HA often wake individuals from sleep, though they may occur during wakefulness it is a sudden severe pain, ______lateral in nature; the pain is described as burning, sharp and typically steady; the pain is typically located in or around the ______, it may also be retro-orbital in location the pain reaches maximum in 5-10 minutes and may last up to 2 hours; the pain will often recur multiple times a day for several days in a row, and then leave the individual with a period of pain freedom; on occasion the HA may become chronic lasting for a year or more

men

cluster HA: cluster HA is a form of a chronic episodic HA disorder it is 4 times more common in (men/women); the HA may occur at any age, though it is most common in adolescence and middle age the etiology of cluster HA is unknown, but theories include abnormalities in histamine or serotonin release from the brain, or hypothalamic dysfunction; multiple triggers have been identified, including: alcohol and cigarette use, high altitudes, bright light, exertion, heat, foods high in nitrites

immunocompromised

etiologic agents in bacterial meningitia pathogen: (incidence/case fatality rate) streptococcus pneumonia (47%/21%) neisseria meningitidis (25%/3%) group B streptococcus (12%/7%) listeria monocytogenes (8%/15%): often seen in _______________ patients haemophilus influenzae (7%/6%); important to vaccinate! e. coli (9.6%/-%) note: the top 2 are the most common, and are adult related, while the bottom 4 are more in neonates

strep. agalactiae strep. agalactiae

etiology of bacterial meningitis according to age: (age: bacterial pathogens): <1 month: steptococcus ____________, e.coli, listeria monocytogenes, klebsiella species 1-23 months: _____________, e. coli, h. influenza, s. pneumoniae, n. meningitidis 2-50 years: s. pneumoniae, n. meningitidis >50 years: s. pneumoniae, n. meningitidis, l. monocytogenes, aerobic gram(-) bacillus note: image is for more specifics