Hey, guys - I once heard that there used to be a disease called "Pseudotumor Cerebri" - undoubtedly has a new terminology in ICD 10. Doesn't that cause headaches? And, shouldn't we consider that in the - usually young - person with ongoing, daily, unremitting headache - perhaps who has been thrown out of several other ER's because of return visits (true story). I'd argue that ongoing, relatively longstanding headaches should all have an LP if the CT is negative (yes, a funduscopic exam may be diagnostic but we can't do those in the new age of high efficiency medicine, God forbid if a resident takes time to do a funduscopic exam or ocular ultrasound). Although high csf pressure is the most frequent diagnostic finding, you periodically stumble into the chronic meningitis, such as TB. And, then there is the other extreme of intracranial hypotension - I suspect that an LP, with pressure measurement, is a good idea in all headaches that are relieved by lying down. (For reasons that escape me, I made this diagnosis as many times in my 4 months in Tasmania as in the other 45 years of my career).
Idiopathic Intracranial Hypertension. Caught one in our walk in care service after discharge from the ED. IR did the LP - opening pressure of 29. Young, obese, ongoing headache x 5 days, wooshing auditory sounds, occasional black specs left eye, back stiffness. CT normal.
C-3 is great...HOW MUCH IS IT GOING TO COST US?? JUST SAYING: TEMPORAL ARTERY BIOPSY IN GCA NOT THAT GREAT A TEST , 10-25% FALSE NEGATIVES, AND STEROIDS CREATE FALSE NEGATIVES "AFTER 14 DAYS" ALSO SED RATE MAY BE FALSLY NEGATIVE . FUNDOSCOPIC EXAMS NOT IN THIS ALGORITHM MOSTLY BECAUSE THEY ARE NOT EASY TO DO (AND CANT BE DONE WITH AN ULTRASOUND PROBE) THEY DONT MAKE THE PROVIDER INEFFICIENT ESPECIALLY IF THERE IS SOMETHING TO SEE.
I once heard you could still have a normal ESR and wind up having a positive biopsy for Temporal arteritis. I suppose if your suspicion is high you would still start them on steroids.
I was looking in the area where you put summaries for the other episodes and missed the big "Summary" tab initially. It does not appear downloadable however, can you put this into a pdf and allow downloads for paid subscribers?
LOVE the information I'm getting here! However, I noticed that the written summary seems to stop after GC Arteritis and doesn't cover the rest of the podcast. Will the summary be updated to include everything from pregnancy to the end?
Another DDX for headache, I consider in back of my head is cavernous sinus thrombosis, outside of pregnancy. I consider it more on anyone with hypercoagulable disorder, CN 3-6 deficit. I have not seen a case myself but wanted your wisdom on existing cases and how to augment my clinical suspicion. Is CT head venogram sufficient to rule it out or MRI must be done for moderate to high suspicion?
What's your guys thougts on CT head being negative within first few hours of headache suspicious for SAH ? Sensitivity for SAH is very high in first few hours ( I wanna say 95+%). Are LPs still standard practice even with neg head CT within first few hours of symptom onset? So basically, If I have a patient with red flag SAH symptoms starting 3 hours ago and CT head negative am I still telling this patient " Hey, I still have to stick this long needle into your spinal column"?
I will never forget a recent brain abscess I missed in a mid 20s male presenting mid winter 'flu like symptoms and frontal headache, along w a high percentage of pts that same shift. Next morning, lethargic unable to walk, ambulance to hospital - workup revealed a brain abscess. Seized for 45mins in hospital, L hemiplegia....still in ICU. Brain abscess will always be on my differential, but I still fail to see how I could prevent missing another similar initial presentation - so general and common the initial presentation! Headache and 'flu like symptoms.
James M. - January 3, 2016 3:35 PM
Did you mean eclampsia as a cause of postpartum headache or preeclampsia or both. I believe you said preeclampsia which confused me a little.
Paul G. G. - January 10, 2016 6:59 PM
WONDERFUL GREAT REVIEW HOPE YOU WILL CONTINUE IT
Rabbott - January 16, 2016 9:54 AM
Hey, guys - I once heard that there used to be a disease called "Pseudotumor Cerebri" - undoubtedly has a new terminology in ICD 10. Doesn't that cause headaches? And, shouldn't we consider that in the - usually young - person with ongoing, daily, unremitting headache - perhaps who has been thrown out of several other ER's because of return visits (true story). I'd argue that ongoing, relatively longstanding headaches should all have an LP if the CT is negative (yes, a funduscopic exam may be diagnostic but we can't do those in the new age of high efficiency medicine, God forbid if a resident takes time to do a funduscopic exam or ocular ultrasound). Although high csf pressure is the most frequent diagnostic finding, you periodically stumble into the chronic meningitis, such as TB. And, then there is the other extreme of intracranial hypotension - I suspect that an LP, with pressure measurement, is a good idea in all headaches that are relieved by lying down. (For reasons that escape me, I made this diagnosis as many times in my 4 months in Tasmania as in the other 45 years of my career).
Greggae - January 22, 2016 2:41 PM
As a relatively newly-graduated resident I had the fundoscopic exam/ technique drilled into me I am happy to say.
D-Wade MS, PA-C - December 11, 2020 9:52 AM
Idiopathic Intracranial Hypertension. Caught one in our walk in care service after discharge from the ED. IR did the LP - opening pressure of 29. Young, obese, ongoing headache x 5 days, wooshing auditory sounds, occasional black specs left eye, back stiffness. CT normal.
Cristina L. - January 21, 2016 10:46 AM
I'm loving C3 project. Please submit more of these!
Angelika U. - January 23, 2016 1:28 PM
What a great review of headaches! thank you so much
John M., M.D. - January 24, 2016 4:09 PM
C-3 is great...HOW MUCH IS IT GOING TO COST US??
JUST SAYING:
TEMPORAL ARTERY BIOPSY IN GCA NOT THAT GREAT A TEST , 10-25% FALSE NEGATIVES, AND STEROIDS CREATE FALSE NEGATIVES "AFTER 14 DAYS" ALSO SED RATE MAY BE FALSLY NEGATIVE .
FUNDOSCOPIC EXAMS NOT IN THIS ALGORITHM MOSTLY BECAUSE THEY ARE NOT EASY TO DO (AND CANT BE DONE WITH AN ULTRASOUND PROBE) THEY DONT MAKE THE PROVIDER INEFFICIENT ESPECIALLY IF THERE IS SOMETHING TO SEE.
Jessica H. - January 25, 2016 1:32 PM
thanks so much for starting the C3 back up again, please keep them going!
django - January 29, 2016 7:33 AM
I once heard you could still have a normal ESR and wind up having a positive biopsy for Temporal arteritis. I suppose if your suspicion is high you would still start them on steroids.
Brian B. - February 21, 2016 10:23 AM
Is there a written summary of the C3's that I am missing?
Brian B. - February 21, 2016 10:26 AM
I was looking in the area where you put summaries for the other episodes and missed the big "Summary" tab initially. It does not appear downloadable however, can you put this into a pdf and allow downloads for paid subscribers?
Mel H. - February 24, 2016 2:47 PM
It is downloadable - under the download tabs there is a PDF.
Erin M. - March 7, 2016 8:18 PM
LOVE the information I'm getting here! However, I noticed that the written summary seems to stop after GC Arteritis and doesn't cover the rest of the podcast. Will the summary be updated to include everything from pregnancy to the end?
Sharmin K. - April 10, 2016 8:11 AM
Another DDX for headache, I consider in back of my head is cavernous sinus thrombosis, outside of pregnancy. I consider it more on anyone with hypercoagulable disorder, CN 3-6 deficit. I have not seen a case myself but wanted your wisdom on existing cases and how to augment my clinical suspicion. Is CT head venogram sufficient to rule it out or MRI must be done for moderate to high suspicion?
Roderick F. - June 28, 2016 5:41 PM
In cases where there is high suspicion (i. e. postpartum female with altered mental status) a CTV is sufficient.
Adam N. PA-C MS - September 28, 2016 12:39 PM
What's your guys thougts on CT head being negative within first few hours of headache suspicious for SAH ? Sensitivity for SAH is very high in first few hours ( I wanna say 95+%). Are LPs still standard practice even with neg head CT within first few hours of symptom onset? So basically, If I have a patient with red flag SAH symptoms starting 3 hours ago and CT head negative am I still telling this patient " Hey, I still have to stick this long needle into your spinal column"?
Adam N. PA-C MS - October 3, 2016 10:41 AM
I just listened to the January short on this subject so question answered. Thanks!
RAM D. - June 25, 2018 7:00 PM
Thank you Dr Mel & Stewart.
Great C3 which is real.
Sharon M., Dr. - July 22, 2018 6:36 PM
I will never forget a recent brain abscess I missed in a mid 20s male presenting mid winter 'flu like symptoms and frontal headache, along w a high percentage of pts that same shift. Next morning, lethargic unable to walk, ambulance to hospital - workup revealed a brain abscess. Seized for 45mins in hospital, L hemiplegia....still in ICU.
Brain abscess will always be on my differential, but I still fail to see how I could prevent missing another similar initial presentation - so general and common the initial presentation! Headache and 'flu like symptoms.
Brad L. - November 5, 2018 10:36 AM
What about syncope related to headache as a red flag???