Headache
Answers
320.The answer is a.(Rosen, pp 1527-1541.)This patient presents
with symptoms consistent with meningitis. Antibioticsare administered
empiricallyas diagnostic workup proceeds. The best choice in this patient
isceftriaxone,which has good CNS penetration. In order to avoid transten-
torial herniation in this patient with a neurologic deficit (confusion),a
noncontrast head CTshould be performed prior to LP.It is controversial
whether or not a head CT needs to be performed prior to all LPs. However,
if there is papilledema or a neurologic deficit, then head CT is mandatory.
(b)It is not prudent to wait for results from a head CT. This will only
delay treatment of a potentially fatal disease. (c)Although this patient can
benefit from acetaminophen and hydration, starting antibiotics empirically
is more important. In addition, this patient requires a head CT prior to LP.
(d and e)As previously stated, antibiotics should be started early in man-
agement and not be delayed while waiting for results.
321.The answer is e.(Rosen, pp 1463-1464.)The patient most likely has
IIH (pseudotumor cerebri),a neurologic disease seen primarily in young
obese womenofchildbearing age.Clinically, patients complain of a gen-
eralized headache of gradual onset and moderate severity. It may worsen
with eye movements or with the Valsalva maneuver. Visual complaints are
common and may occur several times a day and can become permanent in
10% of patients. Patients typically have papilledema and visual field defects
on physical examination. Diagnosis is made by a normal neuroimaging scan
(eg, head CT scan) and an elevated intracerebral pressure (> 200 mm H 2 O)
measured by the opening pressure from an LP. This is also therapeutic.
This patient does not require immediate surgery (a), but may require a
ventricular shunt in the future if she exhibits impending vision loss. Neuro-
surgery consultation can wait until after the diagnosis is made. Two grams of
ceftriaxone(b)is therapy for meningitis, which this patient does not have.
She is afebrile with no other constitutional symptoms. A carotid artery dis-
section(c)presents classically with the triad of unilateral headache, ipsi-
lateral partial Horner syndrome, and contralateral hemispheric findings,
357