Headache Answers 365the mainstays of treatment for many headache syndromes including tension
headaches, migraines, cluster headaches, and others. Their use should be
avoided when there is suspicion that the patient has an intracranial bleed
because they have antiplatelet effects and can exacerbate bleeding.
334.The answer is d.(Cohen and Powderly, pp 279-283.)Brain abscesses
are uncommon and their incidence has decreased over the past several
years as a result of better antibiotic treatment of the remote infections that
cause them. Today, the majority of brain abscesses in developed countries
are the result of contiguous spread from otitis media, mastoiditis, paranasal
sinusitis, or meningitis. They can also occur after trauma, classically after a
basilar skull fracture. Presentation is often nonspecific, with almost half
present with headache alone. Focal weakness, fevers, and nausea are other
common presenting complaints. Antibiotic choice should be guided by
suspected source and ability to penetrate the CNS. In general, MRI is more
sensitive at detecting CNS infection than CT. With contrast CT, the walls of
the abscess enhance and there is a central necrotic area of lower density. On
this CT with IV contrast, there are multiple ring-enhancing lesions with
surrounding edema in the left frontal lobe. The large extra-axial collections
with enhancing margins represent emphysemas. There is also midline shift
secondary to mass effect of the abscesses.
(a)CNS toxoplasmosis is uncommon in the developed world outside the
setting of advanced HIV or other immunocompromised states. Patients often
present with altered mental status, neurologic deficits, or seizures. On contrast
enhanced CT, there are often multiple, small, ring-enhancing lesions. (b)Sub-
dural hygromas are fluid-filled subdural pockets containing xanthochromic
fluid. They are often the result of trauma and present with signs and symp-
toms of increased ICP or with neurologic deficits. They are thought to result
from tears in the arachnoid with fluid accumulation. (c)Glioblastoma multi-
forme is the most common and most aggressive of the primary brain tumors.
On CT scans, glioblastomas usually appear as irregularly shaped hypodense
lesions with a peripheral ringlike zone of contrast enhancement and a penum-
bra of cerebral edema. (e)Spontaneous SAHs present as severe headaches
associated with nausea, vomiting, nuchal rigidity, and can have neurologic
deficits associated with them. It appears on noncontrast CT as hyperdense
fluid that may fill the cisterns and subarachnoid space.
335.The answer is d.(Tintinalli et al, pp 1434-1435.)Patients with CSF
analysis consistent with viral meningitis can be managed as outpatients