2025 – PAGE 409 – 410 – NEUROLOGY

SUBARACHNOID HEMORRHAGE

Patients with a subarachnoid hemorrhage present with a sudden and extremely painful headache. This is the one described as being the “worst headache of my life.” It can occur from head trauma, spontaneously, or due to a ruptured cerebral aneurysm. Think of it as a stroke + headache. It can lead to death. Diagnose with noncontrast CT head. If that is negative, do a lumbar puncture or CT angiography.

PEARL: CT head can be falsely negative especially beyond more than a couple of hours beyond the hemorrhage. Look for a lumbar puncture showing RBCs in an equal proportion within ALL of the tubes collected. (A traumatic tap, in contrast, tends to have fewer RBCs in each tube in sequence.)

MENINGITIS PEARLS

If meningitis is suspected, do not do a pre-LP CT scan of the head unless there are focal deficits on exam. Do the lumbar puncture before the antibiotics if the patient is extremely stable or if the diagnosis is in question. Give the antibiotics before you do anything if there is a history of a coagulopathy, nuchal rigidity, or any sign of increased intracranial pressure (ICP), including systemic hypertension, bradycardia, fast/irregular breathing, or seizures.

SPINA BIFIDA

There are many types of spina bifida (occulta, with meningocele, with meningomyelocele—all discussed below), but the term “spina bifida” basically means the vertebrae didn’t form correctly. The danger is that the spinal cord and its coverings could protrude out of the protective vertebral column. Each of the related conditions may have a skin finding or cyst at the lower back. If you see any of those, or are concerned about a neural tube defect, get a spinal ultrasound (or MRI). If the condition is mild, patients can be asymptomatic.

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• SPINA BIFIDA OCCULTA: Vertebrae are so minimally split that there is no opening on the back. There may be a dimple or a tuft of hair at the site. The nerves are all intact. Many people are actually walking around right now and have no idea they have it. Symptoms are absent or relatively mild (incontinence or mild sensory problems).
  • MNEMONIC: OCCULTA means HIDDEN. The problem is hidden from the eye, and for many people it’s hidden from their brain. It’s so benign that they don’t even know they have it.
• SPINA BIFIDA WITH MENINGOCELE: Vertebrae are slightly more split and open enough to let the meninges herniate out of the spinal column. A visible cyst is created which contains the meninges and CSF, but no nerves. Again, the nerves are essentially intact. Children may have mild symptoms, but the prognosis is generally good.
  • MNEMONIC: MENINGO-CELE = MENINGES ARE SEALED in a cyst.
• SPINA BIFIDA WITH MENINGOMYELOCELE: Vertebrae are more widely split. Both the meninges and the spinal cord herniate through the vertebral column. All patients have at least some paralysis, but the degree varies. Patients are a setup for urologic issues (incontinence, retention, infections) and orthopedic problems. The neurosurgery, urology, and orthopedic consultants should all be called. The patients also require a CT of the head to rule out a Chiari II malformation, in which the cerebellar tonsils are displaced downward through the foramen magnum, and a non-communicating hydrocephalus exists. The Chiari II malformation with associated hydrocephalus is very common in these children, and the prognosis is poor. Most patients die within 2 years.

CHIARI MALFORMATION (ARNOLD-CHIARI MALFORMATION)

There are multiple types (I–IV) of Chiari malformation, but basically this refers to a downward displacement of the cerebellar tonsils below the foramen magnum. This can be asymptomatic, in which case no surgeries are needed. If, however, there is evidence of brainstem dysfunction, the patient will need surgical decompression. Symptoms may include headaches, ataxia, apnea, spasticity, or bladder dysfunction. Diagnosis is by MRI imaging of the brain and spinal cord.