sign in sign up
<<
Home , Intracranial pressure

pg 327-329 7/13/05 6:25 AM Page 327

NEUROSURGICAL OF NEUROSURGICAL IMPORTANCE

Headache is a banal symptom with many causes, organic and otherwise. It is probably the commonest symptom about which patients consult their doctors, or for which they are referred to neurological clinics.

To the public, tumour is a sinister condition and the person with a may have the unspoken fear that his/her headache could be due to a tumour, providing emotional overtones to a painful condition. So, it is hardly sur- prising that patients want reassurance that headache is not due to an expanding intracranial mass. It cannot be overemphasised that the history given by the patient is of cardinal importance in determining whether or not headache is due to a serious intracranial cause. Headache that has been present to the same degree day in and day out for months or years is very unlikely to be due to increasing intracranial pressure (ICP). It is headache of recent onset in a previously well individual, or in a per- son in whom longstanding headache changes in character, that alerts the neuro- surgeon to the possibility of intracranial pathology. We have access to highly sophisticated radiological imaging that reveals intracranial anatomy and patholo- gy in exquisite detail. However, the temptation to refer patients for costly radio-

V J R FARRELL logical investigation should be resisted unless the history strongly suggests a seri- ous cause of headaches. MB BCh, FRCS (Eng) Formerly Professor and Chief Neurosurgeon HEADACHE IN ADULTS

Johannesburg and Baragwanath Hospitals and University of the Witwatersrand Johannesburg Raised intracranial pressure

The common causes of raised ICP are: Professor Farrell was President of the • cerebral tumour, intracranial haemorrhage, Society of Neurosurgeons of SA from 1992 • to 1994. He was appointed Hunterian • benign intracranial (pseudotumour cerebri). Professor at the Royal College of Surgeons Whatever the cause, an enlarging mass reduces intracranial capacity; hence the of England in 1987, and was elected clinical terms, a ‘space-occupying’ or ‘space-taking’ lesion. Fellow of the College of Neurosurgeons of

SA by peer review in 2002. The major features of raised ICP are: • headache • • papilloedema • drowsiness and mental change.

Headache

Headache is the commonest symptom of intracranial hypertension and has dis- tinctive features. It may waken the patient at an early hour, or occur directly the patient wakens. At first it subsides within an hour or so. It is usually frontal or temporal and bilateral. It is often described as throbbing in nature. The headache is always intensified by any activities which raise ICP, such as exer- tion, coughing, sneezing, stooping, and straining at stool. It is often worse when

July 2005 Vol.23 No.7 CME 327 pg 327-329 7/13/05 6:25 AM Page 328

NEUROSURGICAL

It cannot be overempha- may also be due to diplopia, the com- Vomiting monest cause of which is abducens sised that the history given Repeated vomiting is common shortly nerve paresis that is usually unilateral by the patient is of cardi- after the haemorrhage. nal importance in determin- but occasionally bilateral. ing whether or not headache is due to a seri- Drowsiness and mental change Meningeal irritation ous intracranial cause. Drowsiness is the most important clini- This is evident by photophobia, neck Headache is the common- cal feature of raised ICP. It may stiffness and a positive Kernig’s sign. est symptom of intracranial presage rapid neurological deteriora- hypertension and has dis- tion and must never be dismissed as Aneurysmal subarachnoid haemor- tinctive features. ‘sleepiness’. rhage is a neurosurgical emergency. The diagnosis is confirmed by CT A variety of mental symptoms may brain scan. should The presence of papilloede- occur with raised ICP including intel- not be done as there is evidence in ma confirms raised ICP; lectual deterioration, apathy, personal the literature that release of CSF by neglect and incontinence. Mental lumbar puncture may precipitate fur- absence of papilloedema change occurs most commonly with ther haemorrhage. does not exclude it. tumours situated in the frontal lobe or corpus callosum; they may be pro- Head and neck trauma duced by an expanding intracranial the patient is lying down and may be mass in any situation which causes A common observation is that a blow relieved when upright. Severity gradu- increased ICP. Mental symptoms that to the head will cause generalised ally increases as the ICP rises – the result from increased ICP occur more headache after the immediate pain recognition of progression is an impor- often in elderly than in younger from the blow has subsided. Why this tant point in distinguishing it from patients. occurs is not clear. A concussive head headache due to other causes. injury is apt to be followed by more Acute intracranial prolonged headache; when Vomiting haemorrhage uncomplicated by other factors this rapidly subsides. Injuries sustained Vomiting, caused by increased ICP It might be thought that of all the caus- playing rugby do not produce chronic usually occurs during the night or in es of headache, aneurysmal subarach- headache! the early morning, but may occur at noid haemorrhage would be the least any time of the day, not necessarily liable to diagnostic error; sadly not so. When the injury occurs in the work- coincidental with headache; it is often The ‘sentinel haemorrhage’ is often place or follows a traffic accident, it is sudden, violent and without prelimi- unrecognised, leaving the patient at common to find that daily severe nary . risk of further and possibly catastroph- headache, preventing work, persists ic recurrent . for 3 or more years after a minor Papilloedema blow. Usually the symptoms are indis- Premonitory symptoms It is important to note that swelling of tinguishable from those of ; when any question of com- the optic discs does not invariably These can be elicited in a minority of pensation arises they are intractable. occur in all patients with raised ICP. patients. Unilateral ptosis, particularly Because of anatomical variation, it is associated with orbital or supra-orbital Symptomatic cervical spondylosis, absent in up to about one-third of pain, is highly suggestive of the rapid even when advanced, is rarely associ- patients with significant intracranial expansion of an aneurysmal sac and ated with chronic headache. hypertension. rupture is likely within days. Headache, other than from C2 entrap- The presence of papilloedema con- ment, rarely accompanies lower root Headache firms raised ICP; absence of papil- involvement. Irritation of the greater loedema does not exclude it. The oft This is a constant symptom of sub- and lesser occipital nerves causes sub- heard injunction that lumbar puncture arachnoid haemorrhage. It is usually occiptal, not generalised, pain unless is safe ‘because there is no papil- of such sudden onset and severity that accompanied by tension headache. loedema’ is incorrect and highly dan- the patient can recall the time it gerous! Lumbar puncture may precipi- occurred, or his/her activity at the Radiological imaging, particularly MRI tate catastrophic and irreversible moment. Brief loss of consciousness is scans, frequently shows the presence transtentorial . frequent shortly after the onset of of cervical abnormalities in asympto- headache. matic individuals, emphasising the If present, papilloedema may cause dangers of predicating operative blurring of vision. Blurring of vision decisions on diagnostic tests without

328 CME July 2005 Vol.23 No.7 pg 327-329 7/13/05 6:25 AM Page 329

NEUROSURGICAL

precisely matching those findings with Opportunistic intracranial is a significance. Separation of the sutures clinical . common complication, is difficult to may provide temporary relief. diagnose on clinical grounds alone, ‘Whiplash injury’, better designated and is readily overlooked unless one is Focal signs are frequently present. ‘neck sprain’, is a modern, world-wide alerted to this possible cause of persist- Truncal and gait ataxia indicate mid- epidemic that results most commonly ent headache of recent onset. When line cerebellar involvement; horizontal from compensable road traffic acci- the suspicion arises that HIV infection gaze nystagmus is frequently observed dents. It is correctly defined as a mus- is present a complaint of headache in tumours around the fourth ventricle. culoligamental strain of the cervical demands hospitalisation, appropriate Bulbar dysfunction, cranial nerve spine due to hyperextension or hyper- investigation and treatment without palsies and long tract signs arise from flexion. Patients suffering from an delay. brain stem involvement. acute traumatic lesion of cervical nerve roots or are excluded by Mental disturbances or psychiatric dis- definition; so too should be patients HEADACHE IN CHILDREN orders are rarely observed in children. with an acute annular disc tear, frac- Drowsiness, personality change and ture or dislocation. Raised intracranial pressure behavioural disorder suggest hypothal- amic or thalamic involvement. Neck pain and stiffness are the com- The common causes of elevated ICP in Changes in pattern or in appetite mon presenting symptoms within hours, children are tumours and hydro- are relatively common in frontal or at most a day or two, after the acci- cephalus. Intracranial tumours are the tumours. dent. Outlook is good in the great most common form of solid tumour in majority of patients, unless contaminat- children. Subtentorial tumours consti- ed by medico-legal issues. One of the tute 60 - 70% of all intracranial space- most contentious issues relates to the occupying lesions, the commonest of IN A NUTSHELL so-called ‘chronic whiplash syndrome’ which are cerebellar and in which generalised headache, day in . Headache is a common complaint and day out, is a major component. but in only a minority is it of neuro- Some of the differences in presentation surgical import. in these between adults and children will be Headache that has been present to patients is invariably normal. There is highlighted. Headache is less common the same degree day in and day no demonstrable abnormality on plain in children than in adults. Most com- out for months is very unlikely to be X-ray, CT and MRI scan, radionuclide monly the headache is transitory, due to raised ICP. studies and clinical electrophysiologi- occurs in the morning or may awake cal studies. the child at night. In children under Persistent headache of recent onset 10 - 12 years headache may cease may indicate the presence of In the debate regarding cause and temporarily with separation of the cra- intracranial pathology. long-term effect, the protagonists con- nial sutures, only to recur with further The history given by the patient is sider that ‘as yet undetectable physical growth of the tumour. of the greatest importance in deter- injury of the cervical spine’ may trig- mining whether or not headache is ger the initial symptoms of whiplash Posterior fossa tumours may cause irri- due to serious cause. (pain) but concede that ‘psychological tation of the upper cervical posterior Raised ICP causes headache with factors may contribute to persistence of nerve roots or tonsillar herniation distinguishing characteristics. symptoms in the long term’. resulting in pain in the back of the Early morning vomiting is common head and neck. Neck stiffness and a with raised ICP, but vomiting may In acute pain, the linkage between tis- persistent torticollis, which may be occur at any time of the day and is sue damage and pain behaviour is adopted to avoid diplopia, also point not coincidental with meals. fairly constant. In chronic pain it is to a posterior fossa tumour. In children with open sutures non-existent. Vomiting is one of the most constant headache of raised ICP may cease temporarily, only to recur with fur- HIV infection signs of raised ICP in children. In tumours arising within the fourth ventri- ther tumour growth. HIV infection has reached epidemic cle vomiting may be an initial symp- Headache other than from entrap- proportions and is protean in its clini- tom, due to irritation of the vomiting ment of C2 rarely accompanies cal presentation. In South Africa it is centre in the medulla in close proximity lower cervical nerve root involve- one of the most important causes of to the tumour. Vomiting as an early ment. persistent headache. symptom has an important localising

July 2005 Vol.23 No.7 CME 329