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is created the moment of guys. Yeah, we have. Uh uh, You can start. Can he's joined the this order ten's engagement that form at If you go to your brother is the most or tap and But use this deep, we will have will be able to proceed. I would give you a couple of, uh, having me to please join. Right. So today I'm going to talk to him. Approach to acute headache. And what we will be able to go over today is about talking about today in your science. Authentic common cause is behind it and approach to bomb on paper to to patients with such headaches. What we will not be able to cover is two specific a man and off all the specific headaches. Because it's it's between this which won't be able to cover, uh, primary headaches, uh, like, migrant and, uh, uh, tried to another comic fl change it up. Headache. And these and these stuff because I food need a and they're different him station for to cover these stuff. Let us a star. Well, when we're talking about her that we need to know that this is the headache is the one probably commonest one of the commonest complain of phased by the neurologist team. It is around 4% of the portability idiot. And then, according to some studies, patient can come with wide variety. Of course, is from her life threatening into very benign causes. Which is important is to identify the life threatening causes because failure to get recognized, the serious headaches can cause very serious complications, including permanent. You look good deficient. Yeah, but so, like first, I'm sorry, this Redflex science or then your science is going to be a very big long exam testing boring list. But we will go through this one in. So these the red flag points, Uh, when a history section we're going to and we're going to take the cough, they and a good patient presents with headache. We need to focus on Go through this one by one. Oh, first lead with her with her thing is under club headache. So before the Thunder Club, can I you ask how you feel That what you are idea, But when we call a headache, it 100 headache with how much time you should take before well before breach it's within my duty to speak. So, uh, let us stop it. A lean, Uh, the pool is open kindly. Registry responses. We can move forward now if that anybody is interest stood. Get your closing it Now the closing the pole. Now let's see. Well, absolutely right. I'll go with the majority of the definition. Wise 100 club pick is that kind of sudden onset headache which should reach it, speak minutes off. So, uh, it should be a sudden I said a persistent headache. And as we have already said, we should reach it in the PM What, Within one minute subarachnoid hemorrhage deserve is definitely the one of the most important cause is there are some other causes as well, which which could include our CVS county of a possible to the dissection, venous venous thrombosis, pituitary apoplexy and some other less common causes as well. Oh, well, if the patient tells us that this is the fast or fast of a headache off my life or lost headache or ever in my life, we should take it very seriously and investigated. Investigated it totally. Because these kind off complaints can lead us to causes like internal hemorrhage, Ciena's infection and and a lot of other things this boring. It might be helpful to to help us, to differentiate between migraines, a savior addicts off my man. Because migraine attack patients usually have similar headaches in the bus, and by definition you need, at least well, definition as you need it is five bucks off my went to to give five attacks off. Like to give a diagnosis off my mental patient extra if the patient, if there isn't a sign off extracranial infection like a sinusitis, barrels off and ascites Mr Center Cities Fair. Inject these inner ear infections. They might serve as a source of infections and need us off development off meningitis or intracranial abscess. So this is also very important. Any patient with change, mental status, personality or fluctuation off a fracturing of GCS is it needs to be investigated very sincerely. For example, syncope your person could be at the adduct at the onset of headache. Could could be related to subject, not hemorrhage. Any headache with Caesar can be related to an intricate in any intracranial pathology, its best local population to press etcetera. It is very important, uh, in a patient with well with altered mental status. Lordy CS with headache at that, we need to see the look of blood because level that is one of the common mistakes we do in our e d. Um, if the headache is sitting with exertion like exercise, sexual intercourse or even sometimes a minor about movement of that of the neck, that raises the possibility off vaginal artery dissection or interventional hemorrhage. Any severe headache in a patient it was eighties over 15 needs to be taken seriously, and most of the cases next story investigations because this much li, it might be related to interventional internal space occupying lesion or gentle arthritis patients. If a patient with HIV cancer or immunosuppressive do any reason, comes with saviors. Headache. That's also falls into a red flag side because it the's people are are vulnerable to infections like toxoplasmosis, meningitis, brain abscess and even the chances off uh, med stuff is is high. And, uh, in a patient who is already diagnosed to have cancer, Visual disturbance is probably one of the most important. Uh, thing to explore in a patient with coming home comes with severe headache, quite a lot off serious headaches could be related with Can be can be related with video. This time it's like for a diabetic interferon. You'll hypertension. The patient can complain of Diplopia alone with occasional blurring of vision. Giant cell arthritis Visual complaint is not usually the first thing to present. They're present initially with headache, and at some point visual equipped visual equity can be compromised to do to optic neuritis. And unfortunately, in the prognosis in off the prognosis off a headache with gentle arthritis with visual uh, disturbance is not too good. Um, it's huge angle closure. Glaucoma can definitely present with Headache Camp A long wait hurried I, uh, hallow around eyes are Helen, life source is and loss of visual equity put press that is, postural reversal in careful about the syndrome can present with white verge of visual complaints like a visual field defects, a visual equity problem, even even vegetarian jewel hallucinations and a lot off Well, it's quite very, very variable for most to reverse it and developed the same room pregnancy and post partum estate. But it breaking a patient ah, with headache is again Ah, red flag. We which, because these specials are vulnerable to preeclampsia or press venous and a strong dose, especially apoplexy. Supposed to do a lumbar puncture headache if the patient had has spinal anesthesia or if you do really well, I'm not sure sure about your beautiful but yes, definitely with the spinal anesthesia here. The patient, uh, if those patients who are on anticoagulant or any states are vulnerable to develop a serious headaches like intracranial hemorrhages since they're on anticoagulant about is already 18 and chances off a hemorrhage inside the brain is high since they were on anticoagulant. That indicates probably the patient had some somebody given in the past, which makes the patient a high risk patient for David developing thrombotic even as well. Other than hemorrhage illicit drugs like cocaine amphetamine, I can increase risk of both ischemic and hemorrhagic stroke. There are different expression for that toxin exposure, like carbon monoxide poisoning I, and it's to be explored extraordinary. Well, these were the least off things Redflex in history wise. Now, if we look into examination, there are again a few lists. A few a few red flag lists, fastly abnormal, vital size patient with coming, a headache with fever can definitely low related to CNN's infection or inflammation. See, your hypertension can itself mean if it's just hit, it gets sometimes toxic appearance. Like if the patient looks liturgical, poor profusion, Palo Civics Severe severe headache, fever, sweating that can give us also a clue that that might be something serious, uh, condition going on. But most of the times it can be loaded with systemic illness or infection. Yeah, if you're patient with headache show shows altered consciousness level that is very unlikely, very less likely to be related to be any benign headache at all. The possibilities off meningitis and then even careful. It is a subarachnoid hemorrhage. A special population. Toxins and metabolic causes should be considered focal. Neurological signs might be a very important for you to think off any any different gel cause any serious cause behind the headache. Sometimes the phone these focus and serve very obvious, like loss of vision. Heavy purse is that extra? See there etcetera. Sometimes they may be very subtle, like slight people are es asymmetry. Front of my different aggrieved visual field problems, which is not going not sometimes missed in the examination in the e. T. Uh, extra supplanted to plant a response and etcetera focal neurological cause. This focal neurological deficit, alone with headache, can be related to a wide bridge off for this, including issue mix. Stroke hemorrhage Brianti Married teamer Ah, acute angle, possibly looking blue. Commercial is not my ability with visual problem good, I go to doctor dissection. This needs to be noted that low migraine headache, benign headaches like migraine headache could also be related to Focalin urological deficient, which is commonly known as hemiplegic migraine or some other Magan with other organ damage or feature, but a focal neurological deficits never be as, um, related to migraine at the at the first presentation, we can only only consider it if there is in previous history off, uh, similar. Uh, even is there, uh, patient with the meninges most? I mean the sense of manageability a shin could be related to many judges and subject, not hemorrhage off. More logic off ability finding, as is there is a very important part of our tricks. I mean, in a patient with headache, Papilledema definitely can be released with related to increase the CT reading on sabbatical, retina or stop 100 hemorrhages can be related to subarachnoid hemorrhage, though I have never seen it yet in in the beginning off my training figured the A loss of vision can be related to dance. A lot right is scattered through that section and ankle closer glaucoma. This is a list off a list off the same, then you reflect signs, but some people prefer to use the Nasonex snoop just imputed slight if include this light. If anybody is interested with the knee, Monix the's is now more or less about the headache up about the red flags. Now, let us discuss about two a few cases where depending on just a short discussion. I have I have. We have just just don't, uh so imagine have 45 year old male with previous history of recurrent migraine. Uh, this time presented with new see the Nazi be a headache in the whole of the left side of the head for two days, persistently there, according to him, into your steady ever helped his baby acidics off my previous headaches off. Migraine was nowhere as serious as it is. He has a bit of photophobias. Some, uh, photophobia bit is the same as it was before with other My Benedicts GCS is 14 because he's has his having occasional fluctuation of confusions. Examination is otherwise normal. There is no one make rigidity. So if you could go to the pool again, happily fiction again What it want you to consider the first possibility off Top possibility. Very getting the diagnosis. The police up in the bones. Oh, uh, well, needles are coming. All right, let me close the pool. Let's see the results. Well, there is message. Majority will for him severe my plan. It has gone out of my, uh, uh, screen. So the exact percentage's is not very about nostril feasible. We'll let us review some off the things in the case for, for example, this patient had one important feature that is occasional confusion. The C is 14. Definitely migraine seizure migrant could be one of the one off the different shells. But for some, for some reasons like this, occasional confusion and on austerity ever are huge. Probably put CNs infection, asthma, cough differential. But definitely it was even more again is going to be one of the defense. Yes, I understand that No neck region it is, It might be a distracting a factor that just to let you know there's some. Sometimes the rigidities are not very obvious, especially if it is vital viral meningitis. And, uh, Onda gets a while. When it gets you need to have, ah, very regional need to be very vigilant to pick up many neck rigidity. And sometimes it's not present just at all. So good. Let's go to the next Skase. So now it's 20 to Europe or female who has ah, seasonal section six days back because she developed a clumsy A while pregnant. Say, for example, she was 32 weeks pregnant and it waas terminated by inference is a low section six years back. Uh, for two days, she had seen your headache. No visual complaint at all. Ah, headaches. She feels. She says that headache is relieved significantly if she lies down Officer and telling normal neurological examination is entirely normal. No papilledema urine dipstick taste. Ah, you don't Dipstick test is normal, so I mean, no protein area is there. So if we have to go for look for, uh uh the diagnosis What? How would you What should be that your top different shell. Let us see Pool is open. Okay. Right to let me close the pole. So right. Okay. So opposed to a bunch of headache, but it goes them go custom. Good. Imaginative. Oh, did I would go with the majority? I would say that Yes, because one off the characteristic future, though it was not disgusting in risk factor sex Redflex section That a postcoital headache is is ah, catastrophic Chertoff low CSF pressure headache And it can be related to a patient who had intrinsic Ah, civilization six days back. Probably had a spinal in a station. It could be that. All right, get cold. Just move on. So now let us discuss about few cases. Few, uh, approach to help approach to execute headache. We will discuss this with with going to the presentation so fast. Letters discussed with approach to patient with a club headache. Well, Communist called. Well, not patients. Ecommerce. One of the important cause. This subject not hemorrhage and definitely can present with hundreds of headache. Stevia neck pain can also be there. Transient loss of conscious consciousness, especially in the beginning of headache. And it could be it could be there. Negligee could be present and very commonly the patient is nauseous, and vomiting is also Come on. Uh, so there are some other people other causes off the subject of hemorrhage A Z well, and we can give get some clues from the from the history, Like a recurrent. I'll turn the club headache for over a few days. Two weeks can be related to reversible terrible vessel constriction syndrome. Uh, patient with the post partum postpartum A step stage with the club and they could be could be related to our CVS. And being a Sinus troubles is, uh, the recent history of trauma could be related to the dissection order syndrome and can lead us to county dissection tablet tomorrow could be allergic to several. You know, Sinus troubles is well now. So if we need to see if we need to consider what should be the first line of investigation innovation with your, uh, with 100 lap headache like we have got a history of the patient who is the criteria of teleplay 100 club headache. So what should be the first step? Work faster. Investigation wise, all is open. They just see what you think. Greater that me close the pole. If there is, though, the reporting, right? Let's see. Yeah, absolutely, absolutely serious. A CD head is definitely the faster step off investigation. Let so there are few examples of CT Head. I'm not sure that you can see my most pointer. The fasting pictures, always who shows quite extensive subject and hemorrhage, which is not. Usually most of the patient will do not have that senior homes that extensive damage. But it Yeah, I have given this picture just to you show your easy example. Second picture is summer from hemorrhage around the mid brain, which is more popular clique or perimesencephalic hemorrhage. The third one, if you can see that there is, if you can see my most part of the reason. It was a second hemorrhage here. But there is a lot off but a lot of significant soft tissue swelling here with this at and and it shows some bit of confusion here as well. So it's more like it. It's it's definitely looks like a traumatic cervical and hemorrhage getting, uh, so if the CT scan showed hemorrhage, then it's the diagnosis obvious. If it is negative, lumbar puncture is the next step, and the llama can share. Uh, definitely needs to be done after two hours off 12 hours after the onset of the pain. The the lumbar puncture because the lumbar puncture can be negative despite being it a subject and hemorrhage if the liver puncture is done before 12 hours, because the, uh with the usual usual lab test we identify people came across like breakdown for us, which is which will not be there before two hours. So it will be a false negative sample. If the sample well it's been sent to the lab is exposed to light. It is very likely to be a false negative one. So the common practices to send the patients and the sample in a light What will you do? We do is we pack it in there, brown envelope and send it to the left. Prolonged delay in CSF analysis scan again be related to false negative cases. But there are some interesting, really interesting cases. Have interesting examples off false positive cases. Repeat lumbar puncture. What? What happens? A little number cruncher can carry. The sample can carry a breakdown product from the from the blood from which came from the previous level. Bunch of maybe so. That could be a false positive if the patient has a high, very high CSF protein. I don't I'm not sure about That's my explanation, but patient with Hae see us if protein can, the result can can be positive at, uh, if the patient has has joined these with hyperbilirubinemia again, it can be positive. Full supposed to five. Okay, so after after lumbar puncture have after the diagnoses and and the stuff that messed up saquinavir evolution in cures CT angiogram mostly to an ent. If I the calls off the off non traumatic aneurysm like non traumatic cervical hemorrhage, like if there is an aneurysm or malformation us there in this picture, you get in the left and the picture A. There is a suburb, not hemorrhage in both sides. And the picture beat the CT angiogram shows on and you're on any reason in the left? A. C or a Come eight comes I, uh So now, uh, two approaches sabellica to approach and meningitis or encephalitis. Suspected meningitis. Encephalitis patient. It is suspected when patient with headache, fever, fever, altered level of consciousness. We don't without her neck rigidity is there? So say, for example, you think you got a patient with her with these symptoms? Headache. Ultra consciousness fever on you definitely were suspecting bacterial meningitis. So what? Huge. What do you think? The first thing to do in this patient? I do send the patient to see the scan. And it's lumbar puncture sent blood culture or starting triple antibiotic. Right? Joey, fall is open. Yeah, right. Let me close the bull. Well, uh, two drops. Choices are start empirical antibiotic consent. Blood culture. Well, both are important, but I would probably go for sending the blood culture first and then start them their antibody. Definitely. Both are important, but But you need to send the blood culture first before starting the antibody. So So start sending blood culture, I would say, would be the first step and then definitely antibiotics, but it is preferable to do the lumbar puncture if possible, even before starting the antibiotics and about it. But in I understand in most of the times it's not not practically possible in most of the eating, my justice sit ups in the UK, but that's the That's the ideal. That's the guideline. That's the ideal in ideal world. We should do that. Empirical antibiotic plus minus dexamethasone. Empirical antibiotic choice of antibiotic is is variable from guideline to guidelines. So she should follow the local protocol. Uh, dexamethasone, uh, is, uh, according to the guidelines, if you feel it, so if you're clinically suspect it is a bacterial meningitis, We actually should need to start exam. It's, um, in in those cases, unless unless that until the lumbar puncture results are available. And we should, uh, it's actually, it's it's indicated only case off pneumococcal meningitis up. In other cases, it's in. If lover Party shows other organisms, we need many to stop it. Uh, but if we start to take some of that, some dexamethasone again needs to be given just before the antibiotic is it started. But we definitely should not. Uh uh, Well, I wear about some people some in some cases, it is might be important to do a CT scan before going for a lumbar puncture, but definitely we should not delay or lumbar puncture, uh, because we just couldn't do the CT scan. But in those patients where CT scan might be meant might be very important to to an important thing to do before going for a lumbar puncture is if the patient says, um, history off any any CNS disease immunocompromised to state nuance of Caesar. Happily, them are focal, neurological, deficient, deficient or abnormal, level of cautious. That's basically if there is any sign which can keep, uh, secured that something out in the angel cranial Ishan is there other than infection. But we may need to do a CT scan first to exclude the country in the issue. It's off love. A bunch of, uh Okay, So next situation is if a patient with sub acute focal neurological deficit or PAPILLEDEMA is there with new headaches. So we're going to see where we're seeing a patient headaches, either headache Ellen with focal neurological deficit or peppery well, which develops sub acutely. Because if it is acute onset, it would actually go for going to the stroke of turn off, uh, stroke pathway. So that's why I've had it the world sub acute. So what should be the investigation off choices, uh, in these situations. Right. Okay. And you're also coming. Okay, let me close the pool game. Well, city hit MRI CD being the measured it. Well, most of the cases, actually, yes, we That's what we do in city head. But if we Because that's more, that's a more practical way to do it. But if we see if you think off what should be the, uh what what? We just can't will carry most of the information. Uh, it would probably be the MRI and where I should be the investigation of choice. But in most cases, we are practical. It's not possible to do it right away. So, yes, if America is not available, right, arrested, just kind of head is it will be the answer. So the in this patient with headache, half sub acute or focal neurological deficit or puppet amount The thing is we're looking for if there is an internalist so condition there, there may be, uh, eso the papilloma could be related with that also with the obstructive hydrocephalus as well. Cerebral edema from ischemia. Infection. If Yeah, after a few days off a stroke. Yes, it can cause in from the focal neurological science. Or, uh, let me get him up. Has say the memory is the is usually the first choice, but if not if not immediately available, CT scan off It could be is definitely the option if in such patient with mostly for depression, if any patient with headache papilledema scan didn't show it, show anything significant to explain the symptoms that we need to plan for lumbar puncture, mostly to measure the pressure and just answer any to the lab for tests. Um, because I have to excuse the diagnosis like like I I h okay, so the next set of symptoms is if a patient with headache comes with neck pain plus minus on a syndrome with with new headache. I have a just a picture off wholeness syndrome. Here we can see that the patient has a the left side, the people is constricted and there is partial toesies. These are the features of understandable away turkey. Sometimes we can also have, and Hydro sees in having it's a little part of the face. Ah, in these cases, that clue it could be related to, uh uh, carotids, I should say, and I counted artery dissection, and the pews here from the history is good. But sometimes way have already discussed. Sometimes there could be a history of trauma even minor symptoms off a round 60% of cases off dissection Patient has features off. Ah, stroke issue next drug as well. So at this is also this also used to be thank you and just be kept in mind. Investigation of choices CT hit ideally along with CT angiogram in in these cases, and there is a picture here which shows in the right internal right internal carotid artery the reason we can see science off dissection there. The management of that section is actually focused on a managing stroke if there is any and prevention of further strokes down the line for the estimate on the line. So that was more That was all from my said today. Today I were not able to discuss management part, uh, for for management section for the headaches, because I I thought it would it would be too exhausting and and it would be difficult recovery in one session. And I didn't touch migrant part, which I think the migraine itself would need a different section. So if we could manage time, uh, time it manages schedule, I'll be able to, um, discuss it in future. Eso any questions that will come. And meanwhile, please provide your feedback of scanning that you were called Alex. Julia, we have any question? Thanks very much comment on that. This is That was pretty. And if it was any questions, feel free to the chart. Apologize. The technical issues that they ever did My computer is probably not quite up to the job of trying to broadcast from a major web platform. Um, if they're going to access slides on recording, So, yeah, this will be uploaded to be to you about, say, the YouTube, like someone really old there. It will be uploaded to YouTube afterwards. Um, and you'll be able Teo access the recording. I think if you want to send if you can send me the slides, I think there is a way we concerned. That's everyone who gave feedback. Yeah, I think I've just put something in the chart about the street. The infamous disaster, A stroke session. Uh, we did on, I think, essentially medal of food. A shame for GTP are reasons doesn't save people's emails on their account, which I thought it would. So if you want that you want the slice specifically, if you send an email to see urology at my calm. I looks like the host is just kind of sitting in there. Uh, I can see their test. Some people are not being able to camp use. Ah, the feedback. Let me copy the copy. Paste it in the comments section. I'm not sure whether you have excess. See that some off. You are not being able to put us go for the feedback. So if you could follow the link here just provided I'm not sure whether you have excess to this judge. Mm. Can you write the evening for the smile? Well, I have to. Someone else for if I could email that's lives into the chair. Well, our, uh I believe how it works is I have to email it to Alex, and you can contact him. I will definitely be the sliced rallies. And you can contact him to get no to get this lines. Well, yeah, it looks like Alex has, but what did the main Yeah, I will send the mail slice to this email a crucifix. Any more question, kids? Well, well, any clinical question on let me check the chart history in the policy they missed any clinical question. I'll thank you. Thank you for your positive common guys. Uh huh. Pushes well. Oh, if there is. Thank you. Thanks for your for your big guy. So if I'm not sure whether Alex you can hear me or not If, uh uh, yeah, if there's no more question, can we stop the session here? Someone else for my decision? Definitely. Migraine actually needs to be discussed her. When we're talking about neurology, my feeling is probably the common special. We can we see. But, uh, yes, definitely. We need our will. Think I will try to a schedule fit if I tried to feed it into my schedule at some point. All right. Thank you. Thank you. Nice. Uh, relaxes it. Okay. If I leave, I don't share with you. Can't hear me a lot. Right. Thank you, guys.