302 ț Congenital: myelomeningocele; dermoid sinus with midline cranial or spinal dermal sinus; petrous fistula; neurenteric cysts – Parameningeal infec- tion ț Paranasal sinusitis ț Pyogenic otitis media with chronic mastoid osteomyelitis ț Cranial or spinal epidural abscess – Idiopathic recurrent bacterial meningitis – Defective immune mechanisms ț Hypoimmunoglobulinemia ț Postsplenectomy susceptibility in children Special bacterial meningitis – Organisms ț Mycobacterium tuberculosis ț Borrelia burgdorferi ț Brucella melitensis ț Leptospira species Fungal meningitis – Cryptococcus neoformans – Coccidiodes immitis – Histoplasma capsulatum – Blastomyces dermatitides – Candida species – Sporothrix schenckii Parasitic meningitis – Cysticercus cellulosae, C. racemosus – Toxoplasma gondii – Angiostrongylus cantonensis, A. costaricensis – Schistosomiasis Viral meningitis – HIV – Echovirus Noninfectious causes Sarcoidosis Rheumatological diseases and vasculitis affecting the CNS – Systemic lupus erythematosus – Polyarteritis nodosa – Behçet’s syndrome – Sjögren’s syndrome – Vogt–Koyanagi–Harada syndrome – Mollaret’s meningitis Intracranial and intraspinal neoplasms – Craniopharyngioma – Ependymoma – Cerebral hemangioma CNS: central nervous system; HIV: human immunodeficiency virus. Infections of the Central Nervous System Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 303 Conditions Predisposing to Recurrent Bacterial Meningitis – Anatomical communication with the nasopharynx, middle ear, paranasal sinuses, skin (e.g., congenital dermal sinus tracts), or prostheses (e.g., ven- triculoperitoneal or lumboperitoneal shunts) – Parameningeal inflammatory foci, which can drain to the meninges or cause repeated inflammatory meningeal reactions, leading to clinical meningitis – Immunodepression (e.g., hypogammaglobulinemia, splenectomy, leukemia, lymphoma, hemoglobinopathies such as sickle-cell anemia, or complement deficiencies) Conditions Predisposing to Polymicrobial Meningitis – Fistulous communications – Tumors neighboring the central nervous system – Infections at contiguous foci – Disseminated strongyloidiasis Spinal Epidural Bacterial Abscess Organism Frequency (%) Staphylococcus aureus 62 Gram-negative rods (aerobic) 18 – (Escherichia coli, Klebsiella, Enterobacter, Serratia, Pr oteus, Providencia, Arizona, etc.) Aerobic streptococci 8 Staphylococcus epidermidis 2 Anaerobes 2 – Gram-positive (e.g., peptococci, peptostreptococci, Clostridia), Bacteroides fragilis – Gram-negative, other than B. fragilis Other organisms 2 Unknown 6 Spinal Epidural Bacterial Abscess Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 304 Neurological Complications of Meningitis Acute Complications These occur within the first one or two days of admission, and result from the intense disruption of normal brain function. This is most likely to be produced by synergistic effects between the infecting organism or bacterial products, the host inflammatory response, and alterations of normal brain physiology that result in brain injury. The pathophysiologi- cal changes that accompany acute meningitis are: a) brain edema, b) in- tracranial hypertension, and c) abnormalities of cerebral blood flow, loss of cerebrovascular autoregulation and decreased cerebral perfusion pressure. Type of complication Associated organisms Associated conditions Seizures – Occur in 15– 25% of patients. May be generalized (due to increased ICP or irri- tative effects of infection), or focal due to increased ICP or venous or arterial infarcts ț Streptococcus pneumoniae ț Haemophilus influenzae ț Group B streptococci ț Herpes simplex virus ț Sarcoidosis ț Mass lesions ț Cortical vein thrombosis Syndrome of inappropriate re- lease of antidiuretic hormone (SIADH) – Occurs in 30% of children with purulent meningitis within the first 24 h of admis- sion to hospital ț Neisseria meningitides ț S. pneumoniae Ventriculitis – Occurs in about 30% of patients and up to 50% of neonates with Gram-nega- tive enteric organism infec- tion ICP: intracranial pressure. Infections of the Central Nervous System Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 305 Intermediate Complications These complications become manifest during hospitalization, and may persist after discharge. In some cases, the problems are present earlier in the course of the meningitis but are not recognized until the patient has been in the hospital for a few days, or they do not develop until the dis- ease process has gone on for several days. Type of complication Associated organisms Hydrocephalus Haemophilus influenzae – Two types: a) obstructive, due to obstruction of CSF resorption from postinflammatory adhesions of arachnoid granulations; and b) ex vacuo, due to diffuse brain injury and loss and resultant brain atrophy Mycobacterium tuber- culosis Group B streptococci Subdural effusions H. influenzae – Common in children; up 25%. Almost all sterile effusions resolve spontaneously, except for a small minority, which may cause pressure phenomena, requiring serial subdural taps Streptococcus pneu- moniae Fever – In cases of purulent meningitis, fever resolves within 3– 4 days of drug therapy. About 10% of children with H. influenzae meningitis have a delayed defervescence over 7– 8 days. After a week of therapy, drug fever may occur, although this is most typical after 10– 14 days Brain abscess Citrobacter species – Unusual complication of common bacterial menin- gitis, except with disease attributable to Citrobacter species, where abscesses develop in approx. 50% of cases, and, rarely, Listeria Listeria monocytogenes CSF: cerebrospinal fluid. Neurological Complications of Meningitis Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 306 Long-Term Complications Type of complication Associated organisms Associated conditions Cranial nerve abnor- malities ț Neisseria meningitidis (nerves VI, VII, VIII) ț Mycobacterium tuberculo- sis (nerve VI) ț Borrelia burgdorferi (Lyme disease, nerve VII) ț Sarcoidosis (nerve VII; also VIII, IX, X) ț Meningeal carcino- matosis (variable) Motor handicaps – Range from isolated paresis to global in- jury, leading to tetra- plegia. Only 20% of motor handicaps present at discharge persist at one-year follow-up ț Streptococcus pneumoniae Deafness, hearing loss – The most common long-term injury in meningitis, with 5– 25% of survivors suffering some form of hearing impair- ment. It is age-specific and pathogen- specific, with neonates and children with S. pneumoniae meningitis having the highest incidence ț Haemophilus influenzae ț N. meningitidis ț M. tuberculosis ț Mumps ț S. pneumoniae Impairment of cogni- tive function – May range from milder forms of “learning disability” in approx. 25% to more serious forms of injury, in approx. 2% of children with meningitis Infections of the Central Nervous System Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 307 Pain Myofascial Pain Syndrome Myofascial pain syndrome is a regional musculoskeletal pain disorder which stems from the lack of obvious organic findings and characterized by tender trigger points in taut bands of muscle that produce pain in a characteristic reference zone. Diagnostic Clinical Criteria Major criteria – Regional pain complaint – Pain complaint or altered sensation in the expected distribution of referred pain from a myofascial trigger point – Taut band palpable in an accessible muscle – Exquisite spot tenderness at one point along the length of the taut band – Some degree of restricted range of motion, when measurable Minor criteria – Reproduction of clinical pain complaint, or altered sensation, when pressure is applied at the tender spot – Elicitation of a local twitch response by transverse snapping – Palpation at the tender spot or by needle insertion into the tender spot in the taut band – Pain alleviated by stretching the muscle or by injecting the tender spot From: Simons DG. Muscle pain syndromes. J Man Med 1991; 6: 3– 23. Associated Neurological Disorders Neuropathies – Radiculopathy – Entrapment neuropathies – Peripheral neuropathy – Plexopathy Multiple sclerosis Rheumatological disorders – Osteoarthritis – Rheumatoid arthritis – Systemic lupus erythematosus Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 308 Psychosocial factors – Psychosomatic or somatoform disorders – Secondary gain issues – Adjustment disorders with depression and anxiety Differential Diagnosis Mixed tension–vascular headaches Associated with trigger points in the sternomastoid, suboccipital, temporalis, posterior cervical, and scalene muscles Thoracic outlet syn- drome Associated with trigger points in the scalene and pectoralis minor muscles Temporomandibular joint (TMJ) dysfunction TMJ conditions are often primarily myofascial in origin, with particular trigger point involvement of the tem- poralis, masseter, and pterygoid muscles Piriformis muscle syn- drome Pseudosciatica, with entrapment of the sciatic nerve by the involvement of the piriformis muscle and the trigger points identified in this muscle Postherpetic Neuralgia This is a common and severe form of neuropathic pain in the elderly, caused by reactivation of the varicella zoster virus, usually a childhood infection. The incidence of postherpetic neuralgia (PHN) after herpes zoster varies between 9% and 15%, with 35 –55% of patients continuing to have pain three months later, and 30% having intractable pain for one year. The dermatomal distribution and frequencies of PHN are as fol- lows. Thoracic dermatome 55% Trigeminal distribution 20% Cervical dermatomes 10% Lumbar dermatomes 10% Sacral dermatomes 5% Pain Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 309 Atypical Facial Pain The pain usually starts in the upper jaw. Early spread is to the other side, and back to below and behind the ear. Finally, spread onto the neck and the entire half head can occur. Postherpetic neuralgia This occurs mainly with first-division herpes; although the whole zone hurts, pain in the eyebrow and around the eye is especially severe. Pain is continual and burn- ing, with severe pain added by touching the eyebrow or brushing the hair. The condition shows a tendency to spontaneous remission Temporal arteritis Swelling, redness and tenderness of the temporal artery and a headache in the distribution of the arter y are the classic hallmarks of the disease. Diffuse head- ache can occur Cluster headache Migrainous neuralgia. Nocturnal attacks of pain in and around the eye, which may become bloodshot with the nose “stuffed up,” with lacrimation and nasal wa- tering. Bouts last 6–12 weeks and may recur at the same time each year Temporomandibular joint (TMJ) dysfunction, or Costen’s syndrome Pain is mainly in the TMJ, spreading forward onto the face and up into the temporalis muscle. The joint is tender to the touch, and pain is provoked by chewing or just opening the mouth. The pain ceases almost entirely if the mouth is held shut and still Odontalgia A dull, aching, throbbing, or burning pain that is more or less continuous and is triggered by mechanical stimulation of one of the teeth. It is relieved by sympathetic blockade Myofascial pain syndrome Aching pain lasting from days to months, elicited by palpation of trigger points in the affected muscle Atypical facial neuralgia Chronic aching pain involving the whole side of the face, or even the head beyond the distribution of the trigeminal nerve. This condition is much more com- mon in women than in men, and is often associated with significant depression Atypical Facial Pain Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 310 Cephalic Pain Migraine headache – Classical migraine (hemicrania) A pulsatile headache that starts in the temple on one side and spreads to involve the whole side of the head. Usually self-limiting, lasting from 30 minutes to several hours – Cluster headache (migrainous neural- gia) Nocturnal attacks of pain in and around the eye, which may become bloodshot and with the nose “stuffed up,” with lacrimation and nasal watering. Bouts last 6– 12 weeks and may recur at the same time each year – Chronic paroxysmal hemicrania Unilateral, shooting, drilling headache, associated with lacrimation, facial flushing and lid swelling and lasting 5– 30 minutes day or night, without remissions Temporomandibular joint (TMJ) dysfunction, or Costen’s syndrome Pain is mainly in the TMJ, spreading forward onto the face and up into the temporalis muscle. The joint is tender to the touch, and pain is provoked by chewing or just opening the mouth. The pain ceases almost en- tirely if the mouth is held shut and still Odontalgia A dull, aching, throbbing, or burning pain that is more or less continuous and is triggered by mechanical stimulation of one of the teeth. It is relieved by sym- pathetic blockade Tension headache Pain is believed to be due to spasm in the scalp and suboccipital muscles, which are tender and knotted. Descriptions such as experiencing tightness like a “band” or the scalp being “too tight” are a frequent clue Temporal arteritis Swelling, redness, and tenderness of the temporal artery and a headache in the distribution of the arter y are the classic hallmarks of the disease. Diffuse head- ache can occur Psychotic headaches A specific spot on the head is isolated, and bizarre complaints such as “bone going bad,” “worms crawl- ing under the skin,” quickly followed by an invitation to feel the increasingly large lump. Usually nothing other than a normal bulge in the skull is palpable. This condition should always be suspected if the patient offers to locate the headache with one finger. A re- lentless sense of pressure over the vertex is typical of simple depression headache Pressure headache Occurs on waking, is aggravated by bending or cough- ing, produces a “bursting” sensation in the head, and does not respond well to analgesics Pain Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. 311 Posttraumatic head- aches Pain occurs as a persistent and occasionally progres- sive and localized symptom following head trauma, with an onset often many months after the accident. It may relate to an entrapped cutaneous nerve neu- roma, extensive base of skull fractures associated with injuries to the middle third of the face, or stripping of the dura from the floor of the middle fossa, after dia- static linear fractures, etc. Occipital neuralgia This is commonly a secondary manifestation of a benign process affecting the second cervical dorsal roots of the occipital nerves Carcinoma of the head and neck Often a deep, drilling, heavy ache, debilitating in its progressive persistence, regional or diffuse, and in- duced by carcinoma of the face, sinuses, nasopharynx, cervical lymph nodes, scalp, or cranium Headaches related to brain tumors or mass lesions A “cough” or “exertional” headache may be the sole sign of an intracranial mass lesion. Patients often wake up early in the morning with the headaches, which may be more frequent daily, in contrast to the epi- sodic occurrence in migraine. Neural examination may reveal focal abnormalities, as well as papilledema on funduscopic examination Headaches related to ruptured aneurysms and arteriovenous anomalies The pain is usually sudden in onset, severe or disabling in intensity, and with a bioccipital, frontal and orbito- frontal location Carotid artery dissection May present as an acute unilateral headache as- sociated with face or neck pain, Horner’s syndrome, bruit, pulsatile tinnitus, and focal fluctuation neuro- logical deficits due to transient ischemic attacks. Dis- sections occur in trauma, migraine, cystic medial necrosis, Marfan’s syndrome, fibromuscular dysplasia, arteritis, atherosclerosis, or congenital anomalies of the arterial wall Spinal tap headaches These occur in approximately 20– 25% of patients who undergo lumbar puncture, irrespective of whether or not there was a traumatic tap and regard- less of the amount of CSF removed. Characteristically, the headache is much worse when the patient is upright, it is often associated with disabling nausea and vomiting, and it improves dramatically when the patient lies flat in bed Cephalic Pain Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Usage subject to terms and conditions of license. [...]... (HLD) The incidence of HDL is one in 10 000 The back pain may be worse when the patient is sitting and standing, and may be relieved when she lies down Symphysiolysis pubis Pain in the groin, symphysis pubis and thigh, which may be increased while rising from sitting to standing, and during walking Transient osteoporosis of the hip Pain in the hip and groin areas, increasing when carrying weight, and with... sitting up in bed) 5 – 10 15 Performing personal toilet (washing face, combing hair, shaving, cleaning teeth) 0 5 Transferring on and off toilet (handling clothes, wiping, flushing) 5 10 Bathing self 0 5 Walking on level surface (or, if unable to walk, propelling wheelchair) 10 15 * Score only when unable to walk Ascending and descending stairs 0* 5* 5 10 Dressing 5 10 Controlling bowel 5 10 Controlling bladder... reproductive age (10% ) – Cyclic pelvic pain (25 – 67%) – Back pain (25 – 31%) Pelvic inflammatory dis- – Young, sexually active women ease – Ascending infection: endocervix to upper urogenital tract and symptoms of fever and chills, and leukocytosis – Lower abdominal, back and/ or pelvic pain – Vaginal discharge, leukorrhea – Dysuria, urgency, frequency Tsementzis, Differential Diagnosis in Neurology and Neurosurgery. .. bed-ridden, incontinent, needs constant nursing care 3 4 5 Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved Usage subject to terms and conditions of license Measures (Scales) of Disability 327 Barthel Index* The Barthel index is a weighted scale of 10 activities, with maximum independence equal to a score of 100 Patients who score 100 on the Barthel index... paravertebral muscle prominence Metabolic disorders Osteoporosis – Women over 60 years – Vertebral compression fractures; progressive loss of height and increasing thoracic kyphosis – Pelvic stress fracture: weight-bearing parasacral or groin pain – Chronic mechanical spine pain: increased with prolonged standing, relieved rapidly in supine position Osteomalacia – Diffuse skeletal pain: back pain (90%), ribs,... aberrations, and multiple sclerosis Trigeminal neuralgia is the most frequent of all forms of neuralgia Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved Usage subject to terms and conditions of license Face and Head Neuralgias 313 Glossopharyngeal neuralgia Attacks, lasting for seconds or minutes, of paroxysmal pains, which are burning or stabbing in nature, and. .. bladder 5 10 * Mahoney F., Barthel D Functional evaluation: The Barthel index Maryland State Med J 1965; 14: 61 – 65 Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved Usage subject to terms and conditions of license 328 Neurorehabilitation Mini-Mental State Examination The mini-mental examination is the most frequently used cognitive screening test,... 54 retinal disease 101 retinal vein occlusion 109 retrobulbar neuritis, acute 100 rheumatological disorders 318 – 20 Rickettsia 294 rigidity 233 ring enhancing lesions 47 – 9 RNA virus infections 285 – 6 Rocky Mountain spotted fever 294 Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme GTV/Tsementsis All rights reserved Usage subject to terms336 conditions of license and. .. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved Usage subject to terms and conditions of license 322 Pain Back Pain in Children and Adolescents Younger children (under the age of 10) develop back pain caused by medical problems (e.g., infections, tumors), whereas older children and adolescents tend to have a greater proportion of traumatic and mechanical... limited sensitivity in detecting language dysfunction and in determining the cognitive basis for disability in the neurorehabilitation population Scoring must be considered within educational and age-adjusted norms Maximum score Patient’s score 5 ( ) 5 ( ) 3 ( ) 5 ( ) 3 ( ) 2 ( ) Language Name a pencil and watch 1 ( ) Repeat the following: “No ifs, ands, or buts” 3 ( Follow a three-stage command: “Take a . occurring prior to orgasm, and located in the posterior cervical and occipital regions – Explosive type: the pain is excruciating and throb- bing, and is thought to be of vascular origin, occur- ring. weight-bearing parasacral or groin pain – Chronic mechanical spine pain: increased with pro- longed standing, relieved rapidly in supine position Osteomalacia – Diffuse skeletal pain: back pain (90%),. fever and chills, and leukocytosis – Lower abdominal, back and/ or pelvic pain – Vaginal discharge, leukorrhea – Dysuria, urgency, frequency Pain Tsementzis, Differential Diagnosis in Neurology and