- If you think CT will show a cause for the headache, do a CT
- If a CT is indicated for other reasons (depressed conscious level, focal neurology), do a CT
- If a GCS 15 patient is to undergo LP for suspected (or to rule out) meningitis, and they have a normal neurological exam (including fundi), and are not elderly or immunosuppressed, there is no need to do a CT first.
- If you’re seriously worried about meningitis and are intent on getting a CT prior to LP, don’t let the imaging delay antimicrobial therapy.
- CNS infection should be considered in all patients with a headache, neck stiffness, fever, altered sensorium, or diffuse or focal neurological findings.
- pneumoniae is one of the two leading causes of bacterial meningitis in adults. Mortality from S. pneumoniae is 30%.
- pay close attention to cranial nerves 2, 3, 4, and 6
- Altered mental status in a patient with suspected meningitis can be a sign of increased ICP or encephalitis.
- You’ve got to get the LP! Only true way to assess for meningitis
- Early initiation of empirical antimicrobial therapy is recommended in cases of suspected acute CNS infection. Antibiotic administration should not be delayed for CSF analysis or performance of neuroimaging studies.
- Antibiotic chemoprophylaxis should be assured for close contacts of patients with meningitis resulting from N. meningitidis or H. in uenza.
- Concomitant CNS infection should be strongly considered in any symptomatic patient with another severe systemic infection, such as urinary tract infection or pneumonia.
- First line treatment for bacterial meningitis is ceftriaxone plus vancomycin.
- Acyclovir is recommended for patients with suspected meningoencephalitis.
- Dexamethasone is recommended prior to treatment with antibiotics in adults (controversial)
A thunderclap headache (TCH) has been defined as a “headache that reaches 7 (out of 10) or more in intensity within less than one minute.”