Posts Tagged ‘Literatur’

Kopfschmerz/Neurologischer Notfall

Sonntag, 20. April 2008

CCT CMRT bei akuten u. subakuten Kopfschmerzen und neurologischen Notfällen

Kopfschmerz

Hirn_Gefäßerkrankungen

Kopfschmerzen_CCT_CMRT

neurolognotfaelle

shtradiologe

Imaging „Worst Headache of My Life“

Subarachnoid Hemorrhage
(78 % haben Blutung, ein Prozent Unselektiert unch. Headache.)
lumbar puncture is still recommended in cases of clinically suspected SAH with a negative CT.In 80% of cases, the etiology is a ruptured aneurysm.
CT angiography (CTA), or less commonly, magnetic resonance angiography (MRA) is mandatory for definitively localizing the aneurysm.
132 Patienten (6,2%) hatten eine SAH. Die Entscheidungsregel aus Alter ab 40 Jahren, Nackenschmerzen oder -steife und bezeugter Bewusstseinsverlust oder Symptombeginn bei Anstrengung hatte eine Sensitivität für eine SAH von 98% und eine Spezifität von 28%. Wurden zudem die Parameter „Donnerschlagkopfschmerz“ (plötzlicher, sehr starker Kopfschmerz) und „limitierte Nackenbeugung bei der Untersuchung“ berücksichtigt, so hatte diese als Ottawa SAH Rule bezeichnete Entscheidungsregel eine Sensitivität von 100% bei einer Spezifität von 15%.

Fazit: Bei nicht traumatischen Patienten mit starken, plötzlich entstandenen Kopfschmerzen ohne neurologische Ausfälle (vorläufig nur in diesem Setting!) werden mit der Ottawa SAH Rule nahezu alle Patienten mit SAH erfasst.

Parenchymal Hemorrhage

Hydrocephalus

distinguishing ex vacuo dilation of the ventricles (ie, dilation due to parenchymal volume loss) from true hydrocephalus.communicating or noncommunicating?
Communicating hydrocephalus, by contrast, shows dilation of the entire ventricular system.

Ischemia

Posterior reversible encephalopathy syndrome (PRES).

multifocal areas of edema usually involving the parieto-occipital white matter, seizures, visual disturbances, and alteration of consciousness.
commonly observed in conjunction with particular disease states, especially hypertension, eclampsia/preeclampsia, immunosuppression, chemotherapy, and autoimmune diseases

Brain Tumor

isolated headache was the clinical presentation in only 8% of patients.

Dural Sinus Thrombosis

Occasionally the headache is accompanied by altered mentation, decreased level of consciousness, and papilledema.On initial inspection, venous infarction may mimic the appearance of arterial infarction. Importantly, however, venous infarctions will not be confined to the usual arterial vascular territories, which may provide a clue to the correct diagnosis.

Arterial Dissection

Headache is present in approximately 70% of patients with dissection of the carotid or vertebral artery (co-called cervicocephalic arterial dissection).[possibility of dissection include the presence of neck or facial pain, orbital pain, or Horner syndrome.

Meningitis

diagnosis of meningitis is established by cerebrospinal fluid (CSF) analysis and clinical symptoms.When an abnormality is present, it usually takes the form of mild, transient hydrocephalus. Occasionally, leptomeningeal enhancement can be seen on postcontrast imaging , the absence of such enhancement does not exclude meningitis.Complications of severe meningitis can include ventriculitis, extra-axial fluid collections (empyemas and subdural effusions), parenchymal infection (cerebritis or abscess), and secondary infectious vasculitis.[7] Imaging with CT or MR may help to identify these complications.

Pituitary Apoplexy

Pituitary apoplexy is an uncommon cause of worst headache of life, and denotes symptomatic hemorrhage within the pituitary gland,usually into a pituitary adenoma.

Disorders of CSF Pressure

In some patients with headache, CSF pressure may be too high, as in the case of idiopathic intracranial hypertension (IIH, aka, pseudotumor cerebri), or too low, as in the case of intracranial hypotension.IIH They most commonly are young, obese women.On physical exam, these patients may have papilledema as a result of the increased intracranial pressure
Once thrombosis is excluded, one sign suggesting the presence of IIH that may be visible on venous sinus imaging is narrowing at the junction of the transverse and sigmoid sinuses.
On MRI, other potentially subtle findings associated with IIH include flattening of the posterior globe, dilation, and tortuosity of the optic nerve sheath, and an empty sella.
ultimately the diagnosis is established by lumbar puncture with measurement of opening pressure.
Bilateral subdural hygromas or hematomas may also accompany intracranial hypotension, and can be identified on the initial scan.Diffuse smooth dural enhancement is the most suggestive MR imaging feature.  Other variably present findings include crowding of the basilar cisterns due to brain sagging, pituitary enlargement, cerebellar tonsillar ectopia, and distension of the venous sinuses.


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