EMQs in Clinical Medicine.pdf - Peshawar Medical College

90 Neurology
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Initial investigation of choice is a CT brain scan. However, findings can be
negative in 10–15 per cent of subarachnoid haemorrhage. In patients in
whom clinical suspicion is high and CT scan is negative, lumbar puncture
(LP) should be performed.
Subarachnoid haemorrhage is confirmed by presence of xanthochromia
resulting from denatured red blood cells within the cerebrospinal fluid
(CSF). This can take up to 12 h to form and, therefore, LP should be
delayed for at least 12 h after onset of headache. Discoloration of the
CSF should be uniform, unlike a bloody tap where more red blood cells
are present in the initial sample.
Some patients may present with a small sentinel bleed with minimal
symptoms. It is important to make this diagnosis because timely intervention
may prevent a more catastrophic later event.
A 40-year-old businesswoman complains of a headache that feels like
a tight band around her head.
Tension headaches are common and the ‘band-like’ headache is a classic
description. Diagnosis requires the absence of symptoms and signs of
other types of headache. Treatment is rarely effective and avoidance of
the precipitants, e.g. stress, is the best remedy. Chronic use of analgesics
can lead to ‘rebound headache’ on withdrawal. Antidepressants are
sometimes prescribed, although benefit is uncertain.
A 55-year-old woman presents with a headache that has lasted a few
weeks. She gets pain in her jaw during meals and her scalp is tender
on palpation.
Giant cell arteritis is a medium-sized vessel vasculitis. Classically it
affects the temporal vessels giving symptoms of headache, scalp tenderness
and jaw claudication. There is a risk of blindness if the disease is
left untreated and treatment should be commenced empirically with oral
corticosteroids.
Diagnosis can be confirmed with a temporal artery biopsy and the condition
is usually associated with a high erythrocyte sedimentation rate
(ESR)/C-reactive protein (CRP). CRP is always elevated, although ESR is
very occasionally normal. As disease may not affect the part of the
artery that has been biopsied, treatment should be continued even
though the biopsy is negative if the clinical suspicion is high. Giant cell
arteritis is recognized to overlap with polymyalgia rheumatica.
A 30-year-old man complains of rapid-onset pain around his left eye
every night for the last 2 weeks, associated with lid swelling, watery
eye and flushing. He suffers from these bouts every 3 months.
Cluster headache typically presents with recurrent brief attacks of
headache around the eye. The hallmark of cluster headache is the association
with autonomic symptoms and signs, e.g. nasal stuffiness, conjunctival
hyperaemia, Horner’s syndrome.