Neurology Grand Rounds 1-17-14 (1) - kumc.edu Grand Rounds 1-17-14 (1).pdf · • LP – clear – RBC 0 – WBC1 – Glucose 140 – Protein 35 – No xanthrochromia. Red Flags •

Neurology Grand Rounds

Scott Belliston DO PGY 3

1/17/14

History

• Early 50’s female presented to KUMC with 6 days retro-orbital pain in right eye and intermittent horizontal binocular double vision when looking to the right.

• Associated symptoms

– Severe headache, vertigo, burning and abnormal sensation on right side of head, stiffness on right side of neck, worse with movement

• PMH of HTN and DM not currently treating due to lack of insurance

Headache History

• She is not a headache person but over last 6-8

months had new onset of throbbing

headaches on the right. Associated with

nausea, photo/phonophobia, and lasting up to

24 hours.

• Some relief with Tylenol and Ibuprofen or

laying down in a cool dark room.

• She has 2-3 per week.

Exam

• Vitals – temp 36.9, pulse 68, resp. 17, BP 135/81, O2 98%

• Mental status normal

• Cranial nerves normal

• Motor 5/5 proximal distal

• Sensory – decreased pinprick on right face and leg

• Reflexes 2/4 – toes down-going

• Coordination normal

• Gait normal

Where What

Differential Diagnosis

• Secondary headaches

• SAH

• RCVS

• Cavernous/sinus venous thrombosis

• Occipital AVM

• Carotid or vertebral artery dissection

• Chronic Subdural Hemorrhage

• Meningitis

• Mass

• Primary headaches

• Migraine

• Tension Type Headache

• Trigeminal Autonomic Cephalalgias

• Cluster headache

• Paroxysmal Hemicrania

• SUNCT/SUNA

Labs

• Hgb 14.7

• WBC 6.2

• Plt 190

• Sodium 134

• Potassium 3.9

• Chloride 102

• CO2 26

• BUN 22

• Creatinine 0.69

• Glucose 291

• Hgb A1c 13.6

• LP – clear

– RBC 0

– WBC1

– Glucose 140

– Protein 35

– No xanthrochromia

Red Flags

• Abnormal neurologic exam or symptoms that are atypical for aura, especially dizziness, lack of coordination, numbness or tingling, or worsening of headache with the Valsalva maneuver

• Increasing frequency of headaches or a change in headache quality or pattern

• Headaches that awaken patients from sleep

• New headaches in patients over 50

• First headache, worst headache, or abrupt-onset headache

• New headache in patients with cancer, immunosuppression, or pregnancy

• Headache associated with loss of consciousness

• Headache triggered by exertion

• Special consideration should be given to a person who is receiving anticoagulation.

Migraines and Aneurysms

• Migraines as the presenting signs of aneurysms have been reported in association with fusiform middle cerebral artery aneurysm and saccular intracranial aneurysms.

• Unruptured saccular intracranial aneurysm cause a marked increase in the prevalence of migraine without aura but not in the prevalence of other types of headache.

• Hypothesis that increased sensory input from the sensory nerve endings around the aneurysms may sensitize the CNS and decrease threshold for spontaneous migraine attacks

ls

28 yo with 15 years headaches that

resolved after sacrifice of carotid

Theory

• Many mechanisms of migraine have been

proposed

• Abnormal release of neuropeptides including

calcitonin gene-related peptide, Substance P

and neurokinin

• Leads to sensitization the trigeminal system to

the pulsatility of cranial vessels

Outcome in our patient

• To OR for right craniotomy and right MCA

aneurysm clipping

• She states headaches resolved, and she has

minimal pain from the incision. Immediately

after surgery she noted her headaches where

gone, as well as, her blurred/double vision

and dizziness

Questions?

References • Benndorf G, Naeini RM, Lehmann TN. Triple carotid aneurysms in a patient with migraine

attacks. Journal of neurology, neurosurgery, and psychiatry 2004;75:993.

• Bruyn GW, Intracranial Arteriovenous Malformation and Migraine Cephalalgia September 1984 4: 191-207, doi:10.1046/j.1468-2982.1984.0403191.x.

• Gentile S, Fontanella M, Giudice RL, Rainero I, Rubino E, Pinessi L. Resolution of cluster headache after closure of an anterior communicating artery aneurysm: the role of pericarotid sympathetic fibres. Clinical neurology and neurosurgery 2006;108:195-8.

• Goedee HS, Depauw PR, vd Zwam B, Temmink AH. Superficial temporal artery-middle cerebral artery bypass surgery in a pediatric giant intracranial aneurysm presenting as migraine-like episodes. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2009;25:257-61.

• Katzung BG. Chapter 16. Histamine, Serotonin, & the Ergot Alkaloids. In: Katzung BG, Masters SB, Trevor AJ. eds. Basic & Clinical Pharmacology, 12e. New York: McGraw-Hill; 2012.

• Lebedeva ER, Gurary NM, Sakovich VP, Olesen J. Migraine before rupture of intracranial aneurysms. The journal of headache and pain 2013;14:15

• Narbone MC, Rao R, Grugno R, Pellicano M. A late 'migraine': the only symptom of an intrasellar aneurysm. Headache 1997;37:527-8.

• Rahman NU, Jamjoom A, Jamjoom ZA. Unruptured posterior communicating artery aneurysm masquerading as migraine: report of two cases. JPMA The Journal of the Pakistan Medical Association 1997;47:172-4.

• Sinclair W. Dissecting Aneurysm of the Middle Cerebral Artery Associated with Migraine Syndrome. American Journal of Pathology. Dec 1953; 29(6): 1083-1091.

• Chapter 10. Headache and Other Craniofacial Pains. In: Ropper AH, Samuels MA. eds. Adams and Victor's Principles of Neurology, 9e. New York: McGraw-Hill; 2009.

• Chapter 18. I Have a Patient with Headache. How Do I Determine the Cause?.In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 2e. New York: McGraw-Hill;

• Zaorsky N, Intracranial Aneurysms – inferior view – heat map. Wikipedia Creative Commons: 2011. Available at: http://en.wikipedia.org/wiki/File:Wikipediaintracranialaneurysms-inferiorview-heatmap.jpg