A First Class Emergency: Headache in Flight

1
A First Class EmergencyHeadache in Flight

• David Bordo, MD
• Department of Emergency Medicine
• Resurrection Medical Center
• Chicago, Illinois

2
Objectives

• Previous cases demonstrated importance of LP
• This case discusses a complication of LP
• 1. Who is at risk for complications?
• 2. What are the CT findings that may help predict
  who is at risk?
• 3. When should an LP be avoided?

3
Case Presentation

• 41 y/o flight attendant, boards a plane in
  London, with c/o her typical migraine, takes an
  Imitrex
• 4 hours later, patient is in severe pain
• RN on board opens medical kit, administers 10mg
  diazepam IM and phenergan, lies pt down in first
  class seating
• 4 hours later, upon landing in Chicago, patient
  is unresponsive
• Paramedics find pt responsive only to painful
  stimuli, transport patient to our ED

4
PMHx

• Only significant for migraines
• Unclear what workup patient has had for headaches
  in the past
• Unknown SHx, FHx, Meds, Allergies

5
Physical Exam

• VS 96.9, 149/77, 63, 16
• Pupils reactive L 3mm R4mm
• Lungs, Heart, Abdomen Normal
• No Skin Findings
• Toes downgoing, localized to painful stimuli, no
  spontaneous eye opening
• Occasional moaning

6
Differential Diagnosis

• Neurologic
• Subarachnoid Hemorrhage vs Meningitis
• Toxicologic
• Metabolic
• Endocrine
• Other infectious etiologies
• Encephalitis, Sepsis

7
ED Course

• Patient immediately had a noncontrast CT of the
  brain
• Upon returning from CT, patient intubated without
  difficulty for airway protection

8
Lab Results

• WBC 15.3, 95 Segs
• Hgb 12.4 Hct 36.2
• Platelets 250
• Chemistry wnl

9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12

• What is the next step in this patients
  management?

13
CT Prelim

• Hydrocephalus with early cerebral edema. Subtle
  increased density in the circle of Willis may
  represent a rather low density subarachnoid
  hemorrhage. CT with contrast or MRI would be
  helpful.

14
Case Course

• Patient given acyclovir, ceftriaxone, and
  methylprednisolone
• LP performed successfully with an opening
  pressure of 20 cmH2O
• Patient returned for a CT Brain with contrast,
  read the same as the previous study
• Patient became completely unresponsive to all
  stimuli with fixed pupils bilaterally

15
Lumbar Puncture

• LP first developed by Henry Quincke in 1890
• Complications well documented as early as 1896
• Complications include infection, bleeding, post
  dural puncture headache, and herniation

16
Tentorial and Tonsillar Herniation

• Two common types
• Tentorial medial portion of the temporal lobe
  herniates into the tentorial notch and compresses
  the midbrain, peduncle, and third nerve
• Tonsillar herniation of the cerebellar tonsils
  through the foramen magnum
• Etiology can include cerebral edema, space
  occupying lesions (abscesses, tumors, blood),
  hydrocephalus

17
(No Transcript)
18
Tentorial Herniation

• Clinical features of tentorial (uncal)
  herniation
• Dilated, unreactive pupil due to compression of
  CN III, begins unilateral and can become
  bilateral
• Contralateral hemiparesis from the ipsilateral
  peduncle compressing against the tentorium
• In up to 25 of patients, contralateral peduncle
  is forced against the opposite edge of the
  tentorial hiatus, hemiparesis on the same side of
  the dilated pupil A false localizing sign termed
  Kernohans notch syndrome

19
Tonsillar Herniation

• Clinical features of tonsillar herniation
• Neck stiffness and head tilt from impaction of
  the foramen magnum
• Bradycardia and wide pulse pressure
• Respiratory irregularities and arrest

20
Herniation after LP in patients with brain masses

• Marotta in 1954 looked at 447 LPs done in pts
  with neoplasms, 32 had papilledema, only one
  patient had a complication
• Lubic LG, Marotta JT Brain tumor and lumbar
  puncture. Arch Neurol Psychiatry 1954. 72
  568-572.

21
Herniation after LPin patients with brain masses

• Korein in 1954 looked at LPs done in 129 patients
  with papilledema or intracranial HTN, again only
  noted one complication
• Korein J, Cravioto H, Leicach M Reevaluation of
  lumbar puncture A study of 129 patients with
  papilledema or intracranial hypertension.
  Neurology 1959 9290-297.

22
Herniation after LPin patients with brain masses

• Conclusion
• CT has eliminated this concern
• In acutely raised ICP, papilledema is absent in
  50 of children and at least 15 of adults
• The foregone assumption that papilledema always
  meant a patient would herniate is not necessarily
  true, and papilledema is not always (rarely?)
  present in patients with increased intracranial
  pressure

23
Opening pressurescompared to CT diagnosis

• 42 LPs
• 13 with elevated pressure 29 Normal OP
• 6 normal CT 4 mass lesions
• 1 mass with midline shift No complications
• No complications 48 hours later
• 6/13 with inc OP, had normal CT a normal CT
  cannot r/o increased ICP, and pts with mass
  effect on CT may have normal OPs
• Baker N. The efficacy of routine head computed
  tomography prior to lumbar puncture in the
  emergency department. The Journal of Emergency
  Medicine. 12 597-601, 1994.

24
Meningitis and Herniation

• Objective was to determine if the incidence of
  herniation is increased in children with
  bacterial meningitis, and whether children with
  herniation have normal CTs
• 445 children with bacterial meningitis
• 19/445 herniated (4.3)
• CT performed at time of herniation in 14 of the
  cases 5 had normal CTs
• Rennick G. Cerebral herniation during bacterial
  meningitis in children. British Medical Journal.
  306 953-955, 1993.

25
Meningitis and Herniation

• 493 episodes of bacterial meningitis in adults
• 5 developed signs consistent with herniation
  minutes to hours after LP
• Durando ML. Acute bacterial meningitis A review
  of 493 episodes. N Engl J Med 32821-28, 1993.

26
Meningitis and Herniation

• LP can cause herniation in bacterial meningitis
  and that normal results on CT do not mean it is
  safe to do an LP. If meningitis is suspected in a
  child with decorticate or decerebrate posturing,
  focal neurological signs or no response to pain,
  give abx and do not do an LP, even if the CT is
  normal.

27
Who is at risk for herniation?

• Previous studies proven that it is impossible to
  tell who will have increased ICP on CT
• Papilledema is not reliable
• Although CT findings are not always reliable,
  there are findings that suggest who is at risk
  for herniation

28
CT findings that suggest risk for herniation

• Journal of Neurology 2002
• LP may cause herniation if brain shift exists
  with or without papilledema
• Perform CT before LP if clinical suspicion exists
  for brain shift and look for
• Loss of differentiation of gray and white matter
• Effacement of CSF spaces, sulci, fissures,
  ventricles
• Displacement of brain structures
• Crevel H. Lumbar puncture and the Risk of
  Herniation When Should We First Perform CT?
  Journal of Neurology. 2002 249129-137.

29
Who should we CT prior to LP

• Decreased mental status
• Papilledema
• Focal neurological deficits
• Minimal or absent fever
• Head trauma
• Recent seizure

30
CT findings that contraindicate LP

• Lateral shift of midline structures
• Loss of basilar cisterns
• Obliteration of the fourth ventricle
• Obliteration of superior cerebellar/quadrigeminal
  cisterns with sparing of the ambient cisterns
• Holdgate et al. Perils and pitfalls of lumbar
  puncture in the emergency department. Emergency
  Medicine. 200113 351-358.

31
Herpes encephalitis Loss of differentiation
of grey and white matter Loss of sulci
and gyri
32
Large right-sided subdural hematoma producing
right to left midline shift and right uncal
(arrow) herniation
33
Normal Third Ventricle
34
Normal Fourth Ventricle
35
Abnormally large 4th ventricle
36
Treatment of Cerebral Herniation

• 20 mannitol IV 1g/kg over 15 minutes
• Effects last 4-6 hours.
• Corticosteroid dexamethasone IV 12-24 mg IVP
  (Rosen states no benefit proven.)
• Intubate and hyperventilate

37
Case course, contd

• Patient admitted to ICU, ventriculostomy was
  done, CSF pressure noted to be 40.
• Patient was pronounced dead the next morning.
• MRI/MRA done noted a colloid cyst in the third
  ventricle.

38
Teaching Points

• CT is not 100 reliable in identifying who will
  herniate from lumbar puncture
• CT findings that should be excluded include loss
  of differentiation of gray and white matter,
  effacement of CSF spaces, sulci, fissures, and
  ventricles, and displacement of brain structures
• Consider deferring LP in patients with focal
  neurological signs, papilledema, and
  unconsciousness

39
Questions?