3.18 Secondary Headaches/Ocular Neurology II

TBI's will be what type of brain hemorrhages ?

- epidural or subdural hematomas

Epidural hematoma definition

- blood between skull and dura mater - not as common

- convex shaped

Subdural hematomas - description

- blood under dura mater

- concave shaped

Epidural hematomas

- likely to report to OD?

- most often from ...

- no

- break in temporal bone & bleeding of middle meningeal artery

Epidural hematoma signs/symptoms

- compression of CN III

- ipsilateral ptosis, fixed/dilated pupil, down & out eye

- contralateral vision deficits

Subdural hematoma signs/symptoms

- midline anatomical shifts

- homonymous hemianopia (same side of VF impacted)

2 types of acquired brain injury

- subarachnoid hemorrhage/ruptured aneurysm

- intracerebral hemorrhage

Subarachnoid hemorrhage/ruptured aneurysm headache

- pain severity ?

- quality

- can happen in what demographic ?

- sudden and severe

- worst headache of life

- young healthy adults

Posterior communicating artery (PComA) Aneurysm

- located near what CN?

- associations

- III

- nausea, vomiting, stiff neck, diplopia, photophobia, seizure, confusion, loss of consciousness, sudden death

Posterior communicating artery aneurysm

- visual symptoms are ...

- if pupil involvement with CN III palsy presents, what to do?

- if it involves CN III - leads to dilated, unresponsive pupil, ptosis, and eye position down and out

- medical emergency and requires immediate ER referral for potential life saving surgery

Intracranial hemorrhage = what?

stroke

Meningitis

- what is this?

- inflammation (swelling) of protective membranes covering the brain and spinal cord

Meningitis

- demographics

- babies/young children, immune compromised

What does meningococcal vaccine protect against ?

just bacterial, not viral or other ones

Meningitis headache characteristics

associations

- throughout head, can radiate down back and other parts of body

- fever, stiff neck, nausea, vomiting, photophobia, confusion

What is Giant Cell Arteritis?

Vasculitis of medium and large arteries in body,

especially around the scalp, temples, head, neck, upper body and arms (but can be anywhere)

Ocular Sx of GCA

Ophthalmic artery or tributaries can be affected

High risk for partial or complete vision loss

VF defects typically altitudinal or complete

Systemic Sx of GCA

Increased risk of stroke, other ischemia

High systemic morbidity and/or mortality risk

Constitutes a true ocular and systemic urgency

Tests for GCA

Eye tests: VA, pupils, EOMs, visual fields, dilated

fundus exam, OCT

Labs: erythrocyte sedimentation rate (ESR) and

C-reactive protein (CRP)

Possible: ultrasound of temporal artery

Definitive test: biopsy of temporal artery

GCA management

Urgent testing- same day by PCP or send to ER

High dose IV or oral steroids

In 2017, FDA approved tx tocilizumab injection

for steroid failure cases

Systemic Hypertension Headache Features

Tests for Systemic Hypertension

Papilledema definition

- term only used when optic nerve swelling is caused by raised intracranial pressure (ICP) usually bilateral

Papilledema

- most common demographic?

- women child bearing age

Papilledema

- symptoms

- HA

- nausea/vomiting

- shoulder/neck pain

- tinnitus

2 types of anterior ischemic optic neuropathy (AION)

these both cause what?

- arteritic ischemic optic neuropathy (AAION)

- non-arteritic ischemic optic neuropathy (NAION)

optic nerve edema

AAION

- caused by ...

- what percent of cases?

- cause ?

GCA, temporal cell arteritis

10%

acute ischemia of posterior ciliary arteries or ophthalmic artery due to inflammation

AAION ocular findings

- sudden, painless loss of vision

- amaurosis fugax can happen before

- optic nerve edema

- CWS

- VF defects

- + RAPD in affected eye

AAION systemic findings (GCA)

- HAs, fatigue, fever, scalp tenderness, jaw pain, pain/stiffness in neck

Non-arteritic ischemic optic neuropathy (NAION)

- demographics?

- ocular findings

- 95% men

- painless altitudinal VF defect upon waking, 25% have central vision loss

- optic nerve edema obviously

- RAPD affected eye

NAION

- risk factors

- small, crowded nerve w/disc at risk (C/D <0.20)

- diabetes, HTN

how to rule out AAION ?

- ESR/CRP

Optic neuritis

-cause ?

- acute demyelinating or idiopathic optic neuropathy most often secondary to MS

optic neuritis symptoms ocular

- swollen nerve

- retrobulbar optic neuritis

- macular star shaped exudates

- pallor

- pain on eye movement

- unilateral vision loss

- reduced contrast

Optic neuritis treatment

- usually self resolving

- treat underlying MS

- IV steroids sometimes considered

Horner's Syndrome

- primary symptoms

- secondary symptoms

- ptosis, miosis, anhidrosis, anisocoria greater in dark

disrupts sympathetic pupil pathway

- conjunctival hyperemia

Myasthenia Gravis

- cause

- ocular signs

- antibodies inhibit ACh released from nerve endings leading to muscle weakness

- EOM weakness

- ptosis one or both eyes

- blurry or double vision

Myasthenia Gravis systemic signs

- difficulty swallowing

- impaired speech (dysarthria)

- shortness of breath

Myasthenia gravis extra tests to perform

- prolonged upgaze test

- ice pack test (measure palpebral aperture size before and after ice pack) - if more than 2 mm change it's positive

Sympathetic system problem with pupils and anisocoria

greater anisocoria in dark

Parasympathetic system problem with pupils and anisocoria

greater anisocoria in light

Exam techniques to distinguish small crowded optic nerve from early optic nerve edema (swelling)

- + SVP is good sign which disappears with disc swelling

- observe smallest arteries as they cross into disc

- OCT

- B scan