Acute Onset Of Headache Research Articles

Guidance for the management of adult patients with coronavirus disease 2019.

In December 2019, a novel coronavirus was identified in Wuhan City, Hubei Province, China and later the disease was named coronavirus disease 2019 (COVID-19). On March 11, 2020, the World Health Organization (WHO) officially announced that COVID-19 had reached global pandemic status. This article summarized the understanding of the etiology, pathogenesis, epidemiology, clinical characteristics, diagnosis, treatment, rehabilitation, and prevention and control measures of COVID-19 based on the available data and anti-epidemic experience in China.

Sudden onset headache, dizziness, unilateral facial numbness, and speech disturbance

A 48-year-old woman presented to the emergency department with acute onset of headache, dizziness, right facial numbness, and difficulty of swallowing and speech. She was not a smoker and consumed alcohol occasionally, and there was no surgical or other medical history. On admission, her blood pressure was 114/78 mm Hg, pulse rate was 72 beats per minute, and room air arterial oxygen saturation by pulse oximetry was 100%. Laboratory tests showed no abnormalities. Physical examination revealed paresthesia of right side of face and left lower extremity and paralysis of right vocal cord, but with no other neurological findings such as consciousness disturbance, cerebellar ataxia, double vision, and hemiparesis.

Hemorrhagic Presentation of Rathke Cleft Cysts: A Surgical Case Series.

Rathke cleft cysts (RCCs) are benign sellar and suprasellar lesions commonly presenting as asymptomatic incidental findings. Rarely, RCCs hemorrhage and mimic pituitary apoplexy on presentation. To review a series of hemorrhagic RCCs for physicians encountering this rare presentation. A database review of>1700 transsphenoidal pituitary operations was performed at the USC Pituitary Center to identify patients with pathologically confirmed RCCs presenting with acute symptoms and evidence of hemorrhage at the time of surgery. Surgical treatment involved transsphenoidal RCC fenestration and drainage. Clinical, endocrine, and imaging outcomes were reviewed. A total of 119 RCCs were identified, and 6 (5.0%) presented with hemorrhage mimicking pituitary apoplexy. Presenting symptoms included acute onset headaches (5/6), vision loss (2/6), and oculomotor nerve palsy (n=1). Endocrine disturbances at presentation included pre-existing amenorrhea in all female patients (3/3), hypothyroidism (n=2), panhypopituitarism (n=2), and one with profound hyponatremia (Na 116 meq/L). All patients underwent endonasal transsphenoidal fenestration and drainage with no major complications. Over mean follow-up of 38.4 mo, 2/2 patients with vision loss reported improvement, and 2/5 patients with headaches reported improvement. Although all women resumed menses, patients with preoperative hypopituitarism did not experience pituitary axis improvement. Follow-up magnetic resonance imaging showed no instances of RCC recurrence with a mean imaging follow-up of 38.6 mo. RCCs occasionally present with hemorrhage and clinical symptoms that may be confused with apoplexy. Outcomes following hemorrhagic RCC treatment are excellent when treated at tertiary pituitary centers. Although hyperprolactinemia often improves following surgery, other pituitary axis deficits typically do not.

The role of D-dimer in diagnosis of cerebral sinus venous thrombosis

Background: Cerebral sinus venous thrombosis (CSVT) is a fatal condition and should be considered in all patients with acute new onset headache. D-dimer has been shown to be a sensitive diagnostic tool in deep vein thrombosis and pulmonary thromboembolism. The purpose of this study was to investigate whether this test could be useful in the diagnosis of CSVT. Methods : In this prospective study, we reviewed patients referring to Nemazee hospital with presentations suggestive of CSVT. Diagnosis was established, using MRI and MRV. Serum D-dimer level was checked among 24 hours after hospital admission. Results: From 117 enrolled patients, 37 (31.6%) patients had CSVT. The reported D-dimer levels showed negative (< 500 ng/ml) in 21 (56.76%) and positive level in 16 (43.24 %) patients who had CSVT. Also, D-dimer was negative in 66 (82.5%) and positive in 14 (17.5%) patients who did not have CSVT. These results demonstrated a sensitivity of 43.24%, specificity of 82.5%, positive predictive value of 53.3%, and negative predictive value of 75.86%. Conclusion: Normal D-dimer levels make the presence of CSVT very unlikely; our study suggests that D-dimer test may guide us to approach patients who are suspected with CSVT in emergency situations with limited access to MRI/MRV. However, every patient with D-dimer level more than 500 ng/mL and high clinical suspicion of CSVT should undergo MRI/MRV. In addition, our results showed a negative D-dimer test was not a reliable assay to completely rule out CSVT. However, we recommend further studies to confirm our results.

Epidemiology of spontaneous subarachnoid hemorrhage in the state of Qatar.

Background: Spontaneous subarachnoid hemorrhage (SAH) is one of the significant etiologies for stroke. SAH causes higher morbidity and mortality with loss of productivity, resulting in increased disease burden. Only few studies in Qatar have reported on SAH, and the epidemiological features of SAH and aneurysmal SAH (aSAH) have not been comprehensively studied before in Qatar. Our study aimed to describe the epidemiological profile of patients with SAH and aSAH in the State of Qatar.Methods: We reviewed the medical records of all patients with SAH and/or ruptured aneurysm who were consecutively admitted to Hamad General Hospital (600-bed tertiary care facility) from January 1, 2007 to December 31, 2016. We performed a quantitative analysis of demographics, clinical characteristics, diagnostic findings, interventions, and overall mortality. We used SPSS version 18 for data entry. We used chi-square and student t tests to compare the groups. We considered p < 0.05 as statistically significant.Results: The study included 323 patients with aneurysmal and non-aneurysmal SAH. The mean age at presentation was 47.4 ± 12.2 years. Men comprised 68.7% of the cases. Further, 86.6% of the patients presented with acute-onset headache. Additionally, 217 patients had 1 aneurysm, and 32 patients had multiple aneurysms. Anterior communicating artery aneurysm has been found to be the most common aneurysm. Non-aneurysmal SAH occurred in 74 patients (22.9%), with male predominance. Moreover, 23.7% and 52.6% of the patients underwent microsurgical clipping and coiling of the aneurysm, respectively. The overall mortality in World Federation of Neurosurgeon Score (WFNS) grades 1 and 2 SAH was lesser than that in higher grades (28.6% vs 71.4%). Of 323 patients, 69 died within 1 month post-ictus, accounting for an overall mortality rate of 21.2% in our study.Conclusions: The annual incidence of aneurysmal SAH in Qatar has been increasing. Men had a higher incidence of aSAH. Internal carotid aneurysms have been found to be more common in Qatari women, which may have a genetic basis. Lower WFNS grades of aSAH have been associated with better prognosis. The overall mortality associated with aSAH in Qatar has declined over the last 3 years.

Fast effective treatment of spontaenous CSF leak causing intracranial hypotension and debilitating orthostatic headache

We are reporting a case series describing clinical, laboratory, MRI and CT myelogram imaging and treatment results for 4 patients with spontaneous cerebral spinal fluid (CSF) leak with subsequent intracranial hypotension; all of which resolved via blood patches. A 33-year-old woman (case 1) presented abrupt onset severe pain in the back and head; without preceding trauma or procedure. MRI brain revealed leptomeningeal enhancement, after CT myelogram identifying a CSF leak she received a 20ml epidural blood patch in the lumbar area. By the next day her symptoms had completely resolved. A 36year old woman (case 2) with 1 year-long history of positional headaches. Her CT Myelogram showed frequent multilevel Tarlov Cysts; one of which displayed leakage. Her orthostatic headaches disappeared after repeated EBP. A middle aged male (case 3) had an acute onset headache which persisted with orthostatic features since 6 weeks. He had complete remission after one epidural patching. A 47 year old man (case 4) presented with 5 days of typical orthostatic headaches, CT Myelogramm demonstrated a leaking thoracolumbar cyst. He required 2 EBP within 3 days to completely recover. Our cases support the notion that blood patching is a fast, effective and safe treatment for an increasingly recognized diagnosis of orthostatic headache caused by spontaneous intracranial hypotension.

Resection of a Neuroenteric Cyst Using a Far Lateral Approach.

This operative video highlights a rare case of a neuroenteric cyst at the ventral craniocervical junction. The case involved a 30-year-old man who initially presented 13 years earlier with acute onset of headache and visual changes. At that time, he was found to have a small, enhancing ventral intradural extramedullary mass at the rostral aspect of C1 thought to be a meningioma. The lesion was managed conservatively, and surveillance imaging tracked its slow progressive enlargement to a size of 1.4 cm ( Fig. 1A, B ). Although he remained asymptomatic, nonurgent elective resection was recommended because of his age and mass progression. The patient underwent a left far lateral approach to the craniocervical junction for resection of the mass. This involved dissection of the suboccipital musculature to expose the C1 transverse process in the suboccipital triangle and ultimately the vertebral artery. After a small craniectomy and C1 hemilaminectomy, the dura was opened and a cystic lesion encountered ( Fig. 2 ). The cystic contents were debulked and the capsule resected. Histopathologic examination revealed abundant goblet cells consistent with a neuroenteric cyst. Dural closure was bolstered with fascia lata and autologous fat graft. Postoperative magnetic resonance imaging (MRI) was consistent with gross total resection ( Fig. 1C, D ). The patient tolerated the procedure well with no new postoperative neurological deficits and was discharged home on postoperative day 2. On completing a 3-day decadron taper, he developed steroid-responsive symptoms consistent with aseptic meningitis, possibly related to cerebrospinal fluid contamination with the cyst contents during resection. The link to the video can be found at: https://youtu.be/SskETPe5PXQ .

Surgical Resection of a Cavernous Malformation of the Anterior Perforated Substance: 2-Dimensional Operative Video.

Cavernous malformations (CMs) are intracranial vascular anomalies of the brain blood vessels which are usually asymptomatic but sometimes may cause headache, seizures, or focal neurologic symptoms.1 The latter may be attributed to either hemorrhage of the lesion or due to associated mass effect.2 Here, we describe the case of a 27-yr-old woman who had an acute onset of headache and occasional left sided peripheral visual disturbances. A brain computed tomography scan revealed intraparenchymal hemorrhage near the right hypothalamus and a brain magnetic resonance imaging (MRI) was consistent with an anterior perforated substance CM. Medical management was pursued but severe headache persisted for several weeks to the point of interfering with normal daily function. Given the evidence of past hemorrhage and the persistence of symptoms, a microsurgical resection was indicated. She was scheduled for an elective resection through a right frontotemporal craniotomy. The lesion was found in the right anterior perforated substance, just above the optic tract and was resected without complications. The patient was neurologically stable at discharge. At 4-mo follow-up, the patient had a significantly decreased intensity of headache and an adequate resection cavity on MRI. Otherwise, she was neurologically intact. Cavernous malformations of deep brain structures, such as the anterior perforated substance can be surgically treated but carry a challenging procedure with a risk of visual deficits. In the following video illustration, we narrate this operative case and highlight the nuances of this approach. Patient consent was obtained for the submission of the video to this journal.

Liver function assessment using indocyanine green plasma disappearance rate in a young male with icteric leptospirosis: a case report

BackgroundLeptospirosis is one of the leading global zoonotic causes of morbidity and mortality. It is induced by a pathogenic spirochete of the genus Leptospira. The icteric form of leptospirosis is characterized by pronounced hyperbilirubinemia and associated with significantly increased mortality. Conventional static liver function tests insufficiently assess hepatic damage and have limited prognostic value. Dynamic tests, such as indocyanine green plasma (ICG) clearance, more adequately reflect hepatic functional status. In this case report we describe the ICG plasma disappearance rates (ICG-PDR) in a patient with leptospirosis and massive hyperbilirubinemia, expanding our knowledge of liver dysfunction in icteric leptospirosis.Case presentationA 21-year-old Caucasian man presented with acute-onset jaundice, myalgia, fever and headaches. Laboratory tests upon admission revealed, most notably, acute kidney failure and hyperbilirubinemia of 17 mg/dl with mild elevation of aminotransferases. In the course of the following 4 days, total serum bilirubin increased to 54 mg/dl. The clinical outcome was favorable with intravenous ceftriaxone and doxycycline. Presumptive diagnosis of leptospirosis was later confirmed by PCR-based amplification of leptospiral DNA in the blood. ICG-PDR values, bilirubin as well as aminotransferases were recorded throughout hospitalization and a 3-month follow-up period. Initially dramatically reduced ICG-PDR (2.0%/min, normal range: 18–25%/min) rapidly normalized within 10 days, while bilirubin remained elevated up to week 7. Mild elevation of serum alanine aminotransferase was at its peak of 124 U/l by day 12 and reached close to normal levels by week 7 upon admission.ConclusionsMarkedly diminished ICG-PDR values presented in this case report suggest severe liver function impairment in the acute phase of icteric leptospirosis. Prolonged elevation of serum bilirubin may not adequately reflect recovery of liver injury in this disease. ICG clearance appears to be a promising marker for the detection of hepatic dysfunction and recovery in icteric leptospirosis in addition to the static tests.

Non-traumatic pneumocephalus caused by increased depth of olfactory fossa

We report a case of unilateral Keros type III variant of the cribriform plate (olfactory fossa >7 mm deep) that caused non-traumatic pneumocephalus. A 61-year-old male patient presented to the emergency room complaining of acute-onset headache after blowing his nose. Computed tomographic (CT) examination showed a massive pneumocephalus; a CT scan from three months before showed a Keros type III variant. The defect was repaired endoscopically with mucoperichondrial and mucoperiostal grafts. Pneumocephalus that has developed in a Keros type III variant has been theorised about, but never reported to our knowledge. Radiologists should be familiar with the Keros classification so that they can identify patients who are at increased risk of fractures of the cribriform plate.

SUN-420 Pituitary Apoplexy Associated With Apixaban

Background: Pituitary apoplexy (PA) is a relatively rare condition associated with sudden hemorrhagic pituitary infarction, and usually occurs in the setting of a pituitary adenoma. Patients typically present with the acute onset of headache, visual changes and pituitary hormonal deficiencies. Oral anticoagulation therapy is a known risk factor for PA and has recently been described in association with the newer anticoagulants, including both thrombin and Factor Xa inhibitors. Clinical Case: An 82 year-old woman with a history of renal cell carcinoma and recent post-operative pulmonary embolism treated with apixiban, presented with acute-onset headache, diplopia, and vomiting. Mental status remained intact. Vital signs were normal. Her physical exam was significant for a left superior temporal quandrantanopsia and was otherwise normal. Brain imaging revealed an 8 x 11 x 12 mm hyperdense mass within the sella representing hemorrhage. She had no known history of pituitary disease. The patient was admitted to the neurosurgical service for close monitoring of her neurologic and hemodynamic status. She was treated with conservative management and empiric glucocorticoids. Pituitary hormone assessment on admission was significant for inappropriately low LH of 0.5 mIU/mL (reference range 10-60) and FSH of 8.6 mIU/mL (reference range 17-114) in a postmenopausal woman. TSH was <0.03 mIU/L (reference range 0.4-5), and free T4 was elevated at 3.31 ng/dL (reference range 0.6-1.2). IGF-1 was within normal limits at 85ng/mL (reference range 31-208). Serum prolactin level was 13.7 ng/mL (normal <20). Cortisol and ACTH were measured after the patient had received empiric stress dose steroids and were thus unreliable. Of note, the patient did not exhibit signs or symptoms of adrenal insufficiency, such as hypotension or electrolyte derangements. Her headache and visual field deficit resolved with conservative treatment and she was discharged on physiologic glucocorticoid replacement therapy. Approximately two months after her initial presentation, the patient generally felt well except mild tremor and insomnia. Repeat endocrine evaluation confirmed central hypogonadism and primary hyperthyroidism. She was diagnosed with Graves’ disease and treated with methimazole. An ACTH stimulation test was normal and hydrocortisone replacement was discontinued. A repeat pituitary MRI demonstrated resolution of the hemorrhage and no evidence of a pituitary adenoma. Conclusion: Anticoagulation therapy, including the newer anticoagulants, is a risk factor for PA and is typically associated with an underlying pituitary tumor. To our knowledge, this is the first case of pituitary hemorrhage in a patient treated with apixaban without evidence of a pituitary tumor.

A case of acute onset headache and visual loss

Granulomatosis with polyangiitis (GPA) is a multisystem autoimmune disorder. Typically,GPA presents with upper airway, pulmonary, and renal symptoms; an initial presentation limitedto central system involvement (CNS) is rare. This case report describes a 54-year-old womanwho presented with persistent daily headaches and a visual defect. Investigation revealedmeningeal inflammation and optic neuritis demonstrated by magnetic resonance imaging andpositive serine proteinase-3 ANCA serology diagnostic of GPA. She had a dramatic clinicalresponse to corticosteroids. This case highlights a rare initial presentation of GPA with CNSmanifestations.

Acute Onset Headache With Neurologic Impairment

Patients with acute neurologic conditions presenting to the emergency department, urgent care, or medical outpatient clinic can be a challenge to the medical provider. Many neurologic disorders warrant decisive action and collaboration with appropriate higher levels of specialty care for optimal patient outcomes. Initial management is made by exclusion, warranted by a complete history and physical examination, so as not to miss any key findings with this elusive disorder. Understanding the most significant presenting signs and symptoms of neurologic presentations led the provider to the appropriate questions in order to identify the differential diagnoses.

Retrosigmoid Approach for Resection of Cerebellar Peduncle Cavernoma.

The case described in this video involved a 38-year-old man, who presented with a 4-week history of worsening acute-onset headache, nausea, double vision, and vertigo. On examination, he had impaired tandem gait and diplopia on right horizontal gaze. A computed tomography (CT) scan revealed a hyperdense lesion of the right cerebellopontine angle. Magnetic resonance imaging (MRI) revealed a nonenhancing middle cerebellar peduncle lesion that was isointense on T2-weighed imaging and hypointense on FLAIR imaging ( Fig. 1A – B ). The differential diagnoses for this lesion included cavernous malformation, thrombosed aneurysm, and neurocysticercosis. CT angiography was done preoperatively to rule out cerebral aneurysm. Surgical resection of the lesion was recommended to relieve his symptoms, to prevent further deterioration/bleeding, and to obtain a pathological diagnosis. The patient underwent a right retrosigmoid craniotomy for resection of the right middle cerebellar peduncle cavernoma ( Fig. 2 ). The patient tolerated the procedure well with no new postoperative neurological deficit. Postoperative MRI depicted gross total resection of the lesion and expected residual blood in the resection cavity ( Fig. 1C – D ). The patient was discharged home on postoperative day 4. At his last follow-up appointment, 1 month after surgery, he reported complete resolution of his preoperative symptoms, including diplopia. The patient gave consent for publication. The link to the video can be found at: https://youtu.be/TRieS9DXbV4 .

Does This Adult Patient With Jolt Accentuation of Headache Have Acute Meningitis?

In order to identify appropriate candidates with suspected meningitis for lumbar puncture (LP), study designs and diagnostic values of jolt accentuation of headache (JA) were reviewed. Acute meningitis is a life-threatening disease that requires LP for accurate diagnosis. JA was reported the most sensitive indicator of cerebrospinal fluid pleocytosis; however, subsequent studies have failed to confirm this claim. We reviewed articles concerning JA, published prior to December 2017, using MEDLINE and Japanese medical databases. Seven original articles based on independent cohorts were eligible for inclusion and articles citing these 7 were thoroughly searched (11 in total). Additionally, all medical records of our previously reported cohort were reviewed again to explore how the patients' background influenced diagnostic values of JA. We hypothesized that an oversimplified dichotomy of JA findings, pleocytosis, and meningitis created a misconception that JA is a universal indicator of meningitis. We clarify the difference between them and present altered mental status (AMS) as a key to decrease the sensitivity of JA. Notably, the sensitivity and specificity of JA were relatively low in unselected groups, while they tended to be high in the selected sub-groups with acute onset of headache and fever, without AMS or neurological deficits. Unselected populations included etiologies of pleocytosis other than acute meningitis, which might weaken the association between JA and pleocytosis. JA is not a universal, stand-alone, indicator of meningitis in febrile patients with headache. Therefore, we propose a stepwise approach for patients with suspected acute meningitis. AMS or neurological deficits suggest an intracranial pathology, which may necessitate a lumbar puncture. JA seems a useful tool for distinguishing acute aseptic meningitis from upper respiratory infection when used in the selected cohort of febrile patients (≥37°C) with recent-onset headache (within 2 weeks before presentation) and normal mental status. This approach and diagnostic values of JA should be further investigated by prospective studies using operationally sorted candidates.

A Hospital Based Retrospective Study of Acute Postpartum Headache.

To describe acute headache diagnoses in women presenting emergently in the postpartum period and to determine which factors may be associated with secondary vs primary headache. Hormonal, vascular, and procedural factors elevate the risk for both secondary and primary headache disorders in the postpartum period. Differentiating between these can be a diagnostic challenge, particularly among the most severe patients referred for urgent neurological consultation. A single-center retrospective study of consecutive postpartum women age ≥18 years presenting with acute headache to a large urban tertiary-care hospital and receiving neurological consultation. Of 63 women who presented with acute postpartum headache, 17 (27.0%) were diagnosed with a primary headache disorder and 46 (73.0%) were diagnosed with a secondary headache disorder. Migraine comprised the majority of primary headache diagnoses (76.5%). Secondary headache most commonly featured postdural puncture headache (PDPH) (45.7%), postpartum preeclampsia (PEC) (26.1%), and a diverse group of cerebrovascular headache disorders (21.7%). Presentation within 24 hours and lack of side predominance helped to differentiate PDPH from migraine. However, abnormal diagnostic testing was more prevalent in the patients with headache secondary to cerebrovascular disorders/PEC. Nearly three-quarters of postpartum women who present with acute onset headache and receiving neurological consultation are found to have a secondary headache - with nearly half of the secondary headaches attributed to PEC or cerebrovascular headache disorders. The absence of a headache history and a clear PDPH description should prompt strong consideration for neuroimaging to rule out cerebrovascular etiologies of headache as well as close monitoring for signs and symptoms of preeclampsia in women presenting with acute severe postpartum headache.

Endovascular strategies for management of intradural vertebral artery dissecting aneurysms.

Endovascular treatment of vertebral intradural dissecting aneurysms is complex and requires different strategies for each case. The current study aims to classify these aneurysms for an easy selection of optimal strategies for endovascular therapy. This study is a retrospective evaluation of 10 patients harbouring a vertebral intradural dissecting aneurysm (including 6 female and 4 male patients). The clinical, procedural, and angiographic data were evaluated. Nine patients presented with acute subarachnoid hemorrhage and 1 with acute-onset headache. The aneurysms were classified into two types, depending on the developmental state of the contralateral vertebral artery: Dominant (A) and hypoplastic (B). Type A (n = 7) group was further divided into three subtypes on the basis of location of the aneurysm in relation to the posterior inferior cerebellar artery (PICA): aneurysm proximal to the PICA, Type I (n = 3); involving the PICA, Type II (n = 2); and, distal to the PICA, Type III (n = 2). Internal trapping was done for 4 patients in this group, 2 patients with aneurysm involving the PICA underwent proximal occlusion and 1 patient underwent stent-assisted coiling since he refused to undergo vertebral artery sacrifice. B Type patients (n = 3) were treated with reconstructive endovascular management. No symptomatic complication was seen in the patients with trapping. Antiplatelet medication-related complication was seen in 2 patients who underwent stent-assisted coiling. Clinical outcome at the time of discharge was good [modified Rankin score (mRS) 0-2] in 8 and poor (mRs >2) in 2 patients. At follow-up visit, one patient had developed severe cognitive impairment but was independent in activities of daily living. The classification of vertebral artery aneurysms based on their location and on the status of the contralateral vertebral artery appears to be an effective method for the selection of safe and appropriate endovascular therapy.

Racemose neurocysticercosis

Racemose neurocysticercosis refers to the 'aberrant proliferating cestode larvae" presenting as multiple, non-capsulated cystic membranes that bud exogenously giving a multilocular cystic appearance resembling a 'bunch of grapes'. These are typically located in non-confining areas of brain such as cisterns and lack scolex, contrast-enhancement or edema. We describe a 12-year-old boy with acute-onset headache, vomiting, drowsiness and irrelevant speech, irritability, meningismus, brisk muscle-stretch-reflexes and Babinski's sign. Magnetic resonance imaging brain revealed racemose neurocysticercosis. He received ventriculo-peritoneal shunt, oral corticosteroids and albendazole for 4 weeks. Racemose cysts in neurocysticercosis are a rare presentation in children. Treatment is difficult.Racemose neurocysticercosis refers to the 'aberrant proliferating cestode larvae" presenting as multiple, non-capsulated cystic membranes that bud exogenously giving a multilocular cystic appearance resembling a 'bunch of grapes'. These are typically located in non-confining areas of brain such as cisterns and lack scolex, contrast-enhancement or edema. We describe a 12-year-old boy with acute-onset headache, vomiting, drowsiness and irrelevant speech, irritability, meningismus, brisk muscle-stretch-reflexes and Babinski's sign. Magnetic resonance imaging brain revealed racemose neurocysticercosis. He received ventriculo-peritoneal shunt, oral corticosteroids and albendazole for 4 weeks. Racemose cysts in neurocysticercosis are a rare presentation in children. Treatment is difficult.

Subarachnoid Hemorrhage Associated with Intratumoral Aneurysm Rupture within a Posterior Fossa Hemangioblastoma: The Importance of Continued Surveillance for Cerebral Vasospasm

Cerebellar hemangioblastomas are rare tumors of the neuraxis. Only seven cases of hemangioblastoma associated with a cerebral aneurysm have been reported. We report a case of a patient who presented with acute onset headache as a result of subarachnoid hemorrhage (SAH) and hydrocephalus. Radiographic workup revealed a hemangioblastoma with an intratumoral aneurysm. Preoperative cerebral angiography was performed for both embolization as well as characterization of the aneurysm. The patient underwent a suboccipital craniotomy for tumor resection. The patient’s postoperative course was unexpectedly complicated by delayed ischemic neurologic deficit secondary to flow-limiting left internal carotid artery vasospasm. We present a case report, review of the literature, and management considerations for patients who present with tumors and an associated ruptured aneurysm.

Accidental hydroxychloroquine overdose resulting in neurotoxic vestibulopathy

Hydroxychloroquine is an oral antimalarial medication commonly used off-label for a variety of rheumatological conditions, including systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome and dermatomyositis. We present a case of...