Brain Tumours
Triad |
Other S&S |
Headache |
Nausea |
Vomiting |
Worse first thing in the morning |
Convulsions |
Valsalva movements make it worse |
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new onset/change in HA |
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Seizures |
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Confusion |
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Dysphagia |
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Motor Weakness |
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Personality Changes |
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Memory Loss |
Triad in children
Dizziness |
Headache |
Vomiting |
Temporal Arteritis
S&S |
Persistant unilateral throbbing over temporal region + scalp tenderness |
Associated with PMR - look for bilateral inflammatory signs over shoulder/hip area |
>50y |
Severe burning - worse in morning & constant |
Malaise, vague aches, pains, weight loss |
ESR/CRP elevated |
Mangement
Urgent referral (same day) to GP - risk of blindness |
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Mild Traumatic Brain Injury
Common in teens and young adults |
Athletes more at risk - football, boxing, hockey, soccer, MMA, military personnel, victims of domestic abuse, motor accidents |
Concussion
- One type of brain injury |
- Subconcussive injury = traumatic impact to the head that does not result in immediate clinical symptoms |
- Simple concussion = progressively resolves after 7-10 days without complications |
- Complex concussion = persistent symptoms and Hx of loss of consciousness >1 minute, recurrence/exacerbation on exertion, prolonged impairment of cognitive function, seizure |
Mechanical insult - complex cascade of biochemical dysfunction - mitrochondrial dysfunction - disrupts brain's neuronal homeostasis |
Presentation
- Headache |
- Confusion, light-headedness/dizziness, visual disturbances, tinnitus, lethargy, insomnia, photophobia, irritability, mood changes, cognitive difficulties |
- Impaired memory & leaning, reduced planning, inability to switch mental tasks, attention deficits, slower information processing, slowed reaction times |
- Symptoms worse with physical exertion/stress |
On field assessment of injured athlete = ruling out emergent situations
Palpation of head, neck, face , nose and TMJ for f#/injuries
Move fingers and toes - upper and lower sensation, strength and function
Red flags
- GCS <15 |
- Deteriorating mental status |
- Potential spinal injury |
- Progressive neurological signs/symptoms |
- Persistent vomiting |
- Suspected skull f# |
- Seizures |
- Coagulopathy |
- Prior neurosurgery |
- Multiple injuries |
Questions (Maddocks)
What ground/field/rink are we playing at? |
What team are we playing today |
What half/quarter/period is it? |
How far into the game is it? |
Which side scored last? |
What team did we play last game? |
Did we win last game? |
- Sideline for evaluation if suspected concussion (motor, sensory, reflex tests, CN evaluation, coordination and balance assessment)
- Difficulty with these questions = out and not allowed to play
- SCAT3
- Ask about concussion S&S
What to do next
Once concussed patient is out of the game, an attendant should stay with them for 24 hours post concussion |
Attendant should observe patient every 4 hours |
Should be alert for: worsening ha, irritability, persistent nausea/vomiting, difficulting speaking, swallowing, tinnitus, SOB, light headiness, numbness, confusion, memory loss, clear CSF discharge from nose/ears, unequal pupils, fever, visual disturbances, seizures, LOC, easily aroused |
Drink only clear fluids for 8-12 hours |
No alcohol |
Diet should begin light and progress to normal over 24 hours |
Sedatives, sleeping pills, aspirin and ibuprofen should be avoided |
Avoid physical and mental activity for first 24 hours - school, work, texting, video games, driving, operation of dangerous tools or heavy equipment |
Should sleep with head elevated for 24 hours |
Follow up assessment - did you hit your head? Lose conciousness? experience amnesia, loss of memory, disorientation/confusion? Dizziness or unsteadiness? Memory problems/forgetfulness? Concentration/attention problems? |
Imaging
May be used to rule out Cx injury |
Canadian CT head rule - witnessed loss of conciousness,amnesia/disorietnation |
MRI for: GCS <15 at 2 hours post injury
>2 episodes of vomiting
>65 or older
Suspected skull f# (haemotympanum, raccoon eyes, CSF otorrhoea/rhinorrhoea, battles sign (bruising over mastoid)
Pre injury amnesia >30 mins
Dangerous mechanism of injury - struck by motor vehicle, MVA ejection, fall from >3 feet |
Management
- Recovery period = 100 days |
- Some patients have post concussion syndrome within 1-2 weeks up to 3 months |
- Delayed recovery factors = >4 symptoms
HA >60 hours
Pre-injury HA
Self reported fatigue/foginess
prior mTBI
Hx of PTSD, ADHD, learning disability
advancing age
no and proximity of concussions
Duration of concussion (>10 days)
prolonged loss of consciousness (>1 minute)
amnesia
convulsions
co-morbidities
Medication |
- Allowed to play when:
Complete clearing of symptoms at rest - no pain meds
No symptoms after provocative testing - cycling, running, cardio exercises
Full return of cognitive ability, memory and concentration |
- Can do light aerobic activity after symptoms resolve if it does not excaberate symptoms then progressive more demanding activity should be considered (70%) |
- Multiple concussed patients increased risk of Alzheimers, ALS , Suicide, Parkinsons and Dementia |
- Assess Paraspinals - suboccipitals |
- Patients who worsen/do not show improvement after 3-5 days should be referred to a specialist |
- EPA/DHA/Magnesium |
Thunderclap HA
S&S |
Causes |
Management |
Sudden, abrupt Headache - Reaches peak @ 1 hour |
SAH |
REFER IMMEDIATELY TO HOSPITAL |
"Worse Headache of their life" |
Intracranial haematoma |
DON'T LET THEM DRIVE |
"Feels as though they are being hit on the back of the head" |
Cerebral venous sinus thrombosis |
Very Different type of Headache |
Cervical Artery dissection |
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Ischaemic Stroke |
Meningitis
S&S |
Severe Headache |
Neck Stiffness |
High Fever |
Altered Mental State |
Photo/Phonophobia |
Management
Refer immediately to hospital - dial 999 |
CRP, FBC, blood cultures, lx puncture |
Serious Signs of HA in Children
Present in the morning |
Wakes Child at night |
No PMHx |
No Family Hx |
Associated Poor health |
Associated Neuro symptoms |
Presents unilaterally |
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