0071643192.pdf

SYMPTOMS/EXAM

■ Shunt obstruction (most common): Headache, N/ V, altered mentation

■ Other findings may include fever, meningismus, and tenderness or warmth

along shunt tubing.

DIAGNOSIS/TREATMENT

■ Shunt tap is required to exclude diagnosis as a LP may miss the CNS

infection.

■ Immediate neurosurgical consultation and initiation of antibiotic therapy

(vancomycin + third-generation cephalosporin and aminoglycoside).

HEADACHE

Intracranially, only the arteries at the base of the brain, their main branches,

the periarterial dura mater, and the venous sinuses are pain sensitive. These

pain-sensitive intracranial structures are supplied by sensory axons of the

trigeminal ganglion (supratentorial structures) and by the upper cervical roots

(posterior fossa structures).

Headaches are classified as primary (vast majority of headaches) and sec-

ondary(see Table 15.7). Secondary headaches are considered “secondary” to

some underlying cause (eg, subarachnoid hemorrhage).

A 54-year-old female presents complaining of a severe headache. The

headache was sudden in onset while she was moving boxes of books at

work. The patient has neck stiffness and nausea but denies weakness or

numbness in arms or legs. Her VS and neurologic examination are normal. Head

CT confirms your suspicion for SAH. What is her likely prognosis? What pharma-

cologic agent has been shown to prevent secondary ischemic stroke in patients

with SAH?

Based on the Hunt and Hess classification, this patient has a Grade I hemor-

rhage and should have a good neurologic outcome. Nimodipine is used to pre-

vent vasospasm-induced ischemic stroke. Treatment is otherwise aimed toward

preventing further bleeding (eg, antiemetics, seizure prophylaxis).

Subarachnoid Hemorrhage

Subarachnoid hemorrhage is an acute bleed into the subarachnoid space.

CAUSES

The majority of patients with nontraumatic SAH have a ruptured berry

aneurysm.Other causes include mycotic aneurysms, arteriovenous malforma-

tions (AVMs), neoplasms, and trauma.

Conditions associated with increased incidence of berry aneurysms:

■ Family history of berry aneurysm

■ Coarctation of aorta

NEUROLOGY

Lumbar puncture is not useful

in diagnosing a shunt

infection. A shunt tap is

required.