Acute Onset Of Severe Headache Research Articles

Opalski's syndrome: a rare variant of Wallenberg's syndrome

A 54-year-old, right-handed male presented with acute-onset severe headache, vertigo, and vomiting. Initial neurologic examination illustrated dysarthria (lingual), nystagmus (horizontal), left dysmetria on finger-to-nose testing, and weakness of the left upper and lower limb. Magnetic resonance imaging showed left lateral medullary infarction (Wallenberg syndrome). The patient was discharged 3 weeks later to an inpatient treatment with neurorehabilitation facility with gradual improvement of his symptoms.

AN UNUSUAL CASE OF SUBACUTE BACTERIAL ENDOCARDITIS PRESENTING WITH CATASTROPHIC SUBARACHNOID HEMORRHAGE

AN UNUSUAL CASE OF SUBACUTE BACTERIAL ENDOCARDITIS PRESENTING WITH CATASTROPHIC SUBARACHNOID HEMORRHAGE

Case Report: An Intracranial Complication of COVID-19 Nasopharyngeal Swab.

IntroductionCerebrospinal fluid (CSF) leaks are often the result of trauma or recent surgical procedures; however, a subset can develop from non-traumatic etiologies. Cerebrospinal fluid leaks from congenital and spontaneous encephaloceles can be clinically occult and have devastating consequences if undetected for prolonged periods of time. This report highlights a unique case of meningitis after CSF leak caused by ruptured congenital meningocele during a routine nasopharyngeal swab.Case ReportA 54-year-old female with diagnosed CSF leak presented to the emergency department (ED) with acute onset of severe headache, and neck and back pain. Prior to this presentation, the patient had experienced two months of persistent headache and rhinorrhea since her coronavirus disease 2019 (COVID-19) nasopharyngeal swab. As part of her outpatient workup, an otolaryngology consultation with subsequent beta-2 transferrin testing and magnetic resonance imaging was performed and she was diagnosed with a CSF leak from ruptured congenital meningocele. On ED presentation, she was afebrile, but with mild tachycardia, leukocytosis, and meningismus. Lumbar puncture revealed acute streptococcal meningitis. This patient’s meningitis developed due to prolonged occult CSF leak after her COVID-19 nasopharyngeal swab ruptured a pre-existing congenital meningocele.ConclusionNasopharyngeal swabs are being performed much more frequently due to the COVID-19 pandemic. All front-line providers should be aware of the potential presence and rupture of congenital meningoceles in patients who have undergone recent nasopharyngeal swab when risk-stratifying for potential CSF leak and meningitis.

Emergency endoscopic surgery for pituitary apoplexy presenting as cerebral infarction in a limited resources condition: A case report.

Introduction and importancePituitary apoplexy is defined as a sudden onset of neurologic deficit due to infarction or hemorrhage of the pituitary tumor. We report a case of emergency endoscopic surgery for pituitary apoplexy presenting as cerebral infarction due to ICA compression in a limited resources condition.Case presentationA 38-year-old female presented with acute onset of severe headache, decreased level of consciousness, decreased visual acuity bilaterally, aphasia, and right hemiparesis. Computed tomography angiography showed a hyperdense sellar mass with stenosis of the left ICA. The patient underwent emergent endoscopic transsphenoidal surgery for sellar decompression.Clinical discussionThe epidermiology, presentation and diagnosis and strategy of treatments as well as their outcomes were discussed.ConclusionPituitary apoplexy should be taken into consideration in a patient with increasing headache and neuro-ophthalmic symptoms. Pituitary apoplexy presenting as cerebral infarction is rare. The aim of surgery in emergency setting was sellar decompression. Endoscopic transsphenoidal surgery was an effective treatment.

Pituitary apoplexy induced by gonadotropin-releasing hormone agonist administration: a rare complication of prostate cancer treatment.

SummaryGonadotropin-releasing hormone (GnRH) agonists, currently used in the treatment of advanced prostate cancer, have been described as a rare cause of pituitary apoplexy, a potentially life-threatening clinical condition. We report the case of a 69-year-old man with a known pituitary macroadenoma who was diagnosed with prostate cancer and started treatment with GnRH agonist leuprorelin (other hormones were not tested before treatment). Few minutes after drug administration, the patient presented with acute-onset severe headache, followed by left eye ptosis, diplopia and vomiting. Pituitary MRI revealed tumor enlargement and T1-hyperintense signal, compatible with recent bleeding sellar content. Laboratory endocrine workup was significant for low total testosterone. The patient was managed conservatively with high-dose steroids, and symptoms significantly improved. This case describes a rare phenomenon, pituitary apoplexy induced by GnRH agonist. We review the literature regarding this condition: the pathophysiological mechanism involved is not clearly established and several hypotheses have been proposed. Although uncommon, healthcare professionals and patients should be aware of this complication and recognize the signs, preventing a delay in diagnosis and treatment.Learning points:Pituitary apoplexy (PA) is a potentially life-threatening complication that can be caused by gonadotropin-releasing hormone agonist (GnRHa) administration for the treatment of advanced prostate cancer.This complication is rare but should be taken into account when using GnRHa, particularly in the setting of a known pre-existing pituitary adenoma.PA presents with classic clinical signs and symptoms that should be promptly recognized.Patients should be instructed to seek medical care if suspicious symptoms occur.Healthcare professionals should be aware of this complication, enabling its early recognition, adequate treatment and favorable outcome.

MON-239 Pituitary Apoplexy Induced by Gonadotropin-Releasing Hormone Agonist Administration: A Rare Complication of Prostate Cancer Treatment

Background: Pituitary apoplexy is a potentially life-threatening clinical condition associated with bleeding and/or infarction into the pituitary gland, usually within a tumor. Gonadotropin-releasing hormone (GnRH) agonists, currently used in the treatment of advanced prostate cancer, have been described in the literature as a rare cause of pituitary apoplexy. Case: We report the case of a 69 year-old man with a known pituitary macroadenoma incidentally detected in 2016, without further investigation. He was diagnosed with prostate cancer in 2017 and underwent retropubic prostatectomy. Two years later there was evidence of histologic prostate tumor progression, so he started treatment with leuprorelin 45mg (GnRH agonist). Immediately after the first subcutaneous injection he presented with acute-onset severe headache, followed by left eye ptosis, diplopia and vomiting. Left cranial nerve III palsy was confirmed by examination in the emergency department. Head computed tomography showed a lesion in the sellar region; laboratory endocrine workup was significant for total testosterone 72.07 ng/dL (86.49 – 788.22), with no other abnormalities. Magnetic resonance imaging of the pituitary revealed tumor enlargement and a T1-hyperintense signal, compatible with recent haemorrhagic sellar content. The patient was managed conservatively with high dose steroids, and symptoms were significantly improved on discharge. Discussion: Pituitary apoplexy induced by GnRH agonist administration is a rare complication, described in only 20 documented cases to date. The pathophysiologic mechanism involved is not clearly established and several hypotheses have been proposed: a combination of metabolic hyperactivity, cell division/tumor growth and increased intrasellar pressure, inducing ischemia in a poorly perfused adenomatous tissue given the demand. Although uncommon, healthcare professionals should be aware of this serious consequence of GnRH agonist administration and recognize the signs, preventing a delay in diagnosis and treatment.

Confusional migraine in a young adult female: Is it a subtype of migraine with aura?

A 22-year-old female was admitted to our hospital due to acute onset of severe headache, confusion, and deterioration of consciousness. Results of initial examinations did not suggest cerebrovascular diseases, encephalitis, or nonconvulsive status epilepticus. Over the next several weeks, her level of consciousness fluctuated in parallel with the severity of headache. The electroencephalogram, recorded during a symptomatic episode, showed lack of posterior dominant rhythm, and the single-photon emission CT (SPECT) also revealed a decrease in cerebral blood flow predominantly in the occipital lobes. Administration of sodium valproate and topiramate, recommended as treatment for migraine, dramatically ameliorated her headache and consciousness. Although this was an adult-onset case, her symptoms and clinical course were similar with the diagnosis of ICHD-3-unlisted confusional migraine rather than other listed subtypes of migraine with aura. Further accumulation of similar adult-onset cases is necessary to clarify the nature of this illness.

CMET-09. A UNIQUE CASE OF PRIMARY GLIOSARCOMA WITH METASTASIS TO SACRUM ON BEVACIZUMAB

Abstract INTRODUCTION Gliosarcoma is a rare variant of glioblastoma that accounts for approximately 0.48% of all adult brain tumors. Although, metastatic potential of gliosarcoma via hematogenous route has been proposed in the past, we report the first case of metastasis to the sacrum while undergoing treatment on bevacizumab. CASE REPORT: A 40-year-old woman presented with acute onset severe headache with pertinent examination findings of left upper extremity pronator drift. Imaging revealed right frontal lobe enhancing mass measuring 4.5 x 3.7 cm associated with edema and 10 mm leftward midline shift. A right frontal craniotomy for tumor debulking showed gliosarcoma (IDH wild-type, WHO grade 4). She was initiated on radiotherapy with concomitant and adjuvant temozolomide via Stupp’s protocol after second debulking surgery. Chemotherapy regimen was changed to bevacizumab when tumor progression was identified. Within six months of initiation of bevacizumab, she developed left leg shooting pain. Imaging revealed heterogeneously enhancing mass in the left hemisacral region measuring 6.2 cm concerning for metastatic process. Sacral bone biopsy showed malignant cells which were negative for an extensive immunohistochemical panel (including GFAP and Olig2), suggesting metastasis of the sarcomatous element of gliosarcoma and arguing against a second malignancy. Next generation sequencing performed on both the intracranial and sacral tumor showed an identical molecular prolife (including PTEN, NF1, TERT and TP53 genomic alterations), confirming common origin. After completion of radiation therapy to sacral region, chemotherapy regimen included lomustine followed by pembrolizumab. The patient died at 14 months after initial presentation due to disease progression. DISCUSSION To the best of our knowledge, this is the first case primary of gliosarcoma with metastases to the sacrum while evolved on chemotherapy with bevacizumab. The aim of this report is to bring awareness to medical community in order to expedite the diagnosis and management.

Dual microcatheter technique for the treatment of a ruptured wide neck basilar tip aneurysm

Endovascular treatment is a safe and efficient therapy for intracranial aneurysms with lower complication and mortality rates compared to surgical clipping. Wide-neck aneurysms still represent a challenge to complete and safe aneurysm occlusion in spite of techniques such as stent-assisted or balloon-assisted coiling, developed in order to achieve better occlusion rates. These techniques themselves may lead to further complications, so alternative methods such as the dual microcatheter technique were developed. This technique assumes that, via two microcatheters inserted into an aneurysm, simultaneous deployment of two coils achieves a stable coil frame without the use of adjunctive devices. The aim of this paper is to present a successfully treated basilar tip wide-neck aneurysm treated with the dual microcatheter technique.Case report. A 46-year-old male patient with acute onset of severe headache presented in the emergency room with altered state of consciousness. Non-enhanced CT scan showed subarachnoid and intraventricular haemorrhage. CT angiography revealed a wide-neck basilar tip aneurysm. Digital subtraction angiography confirmed the presence of an aneurysm with a wide, 4.9 mm neck.Dual microcatheter technique was chosen as the first treatment option, while a hypercompliant balloon was kept as backup. Two microcatheters were placed inside de aneurysm and two coils were introduced in order to form a stable framing coil mass that served as a support for further coils deployed in an alternately manner through each microcatheter. No procedural complication occurred, and the patient’s evolution was uneventful with no neurological deficits at discharge.Conclusion. The dual microcatheter technique is a safe and effective therapeutic option for wide-neck ruptured or unruptured intracranial aneurysms. Periprocedural complication rates are similar to simple coiling or balloon-assisted coiling, but lower than for stent-assisted coiling.

Rituximab‐associated posterior reversible encephalopathy syndrome

Rituximab‐associated posterior reversible encephalopathy syndrome

Cerebrospinal fluid findings in reversible cerebral vasoconstriction syndrome: a way to differentiate from cerebral vasculitis?

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by an acute onset of severe headache and multi-focal segmental vasoconstriction of cerebral arteries resolving within 12weeks. Diagnostic criteria include normal or near-normal findings in cerebrospinal fluid (CSF) analysis, especially leucocyte levels<10/mm³. Distinguishing RCVS from primary angiitis of the central nervous system (PACNS) is essential to avoid unnecessary and sometimes unfavourable immunosuppressive treatment. We reviewed retrospectively the clinical and diagnostic data of 10 RCVS patients who presented in our neurological department from 1January 2013 to February 2017. The main purpose was to verify whether CSF leucocyte counts<10/mm³ serve to discriminate RCVS from PACNS. Five of six patients who underwent lumbar puncture presented with CSF leucocyte levels ≥10/mm³. Two patients had a history of misinterpretation of CSF pleocytosis as cerebral vasculitis and of immunosuppressive treatment. A complete restitution of cerebral vasoconstriction was evident in all. No patient had further cerebral strokes or bleedings without immunosuppressive treatment over more than 12weeks. Despite the established diagnostic criteria, RCVS can manifest with CSF leucocyte levels >10/mm³. Careful anamnesis and the response of 'vasculitis-like angiography' to nimodipine given as a test during angiography and as oral medication are key to differentiate RCVS from cerebral vasculitis.

Hypersomatotropism induced secondary polycythaemia leading to spontaneous pituitary apoplexy resulting in cure of acromegaly and remission of polycythaemia: ‘The virtuous circle’

A young man with subtle clinical features suggestive of hypersomatotropism presented with acute-onset severe headache. Relevant investigations confirmed polycythaemia and growth hormone (GH)-secreting pituitary macroadenoma with apoplexy. Secondary polycythaemia and...

Occipital Lobe Infarction due to Acute Hydrocephalus Secondary to Third Ventricle Colloid Cyst in a Child

An 11-year-old boy presented with sudden onset of altered consciousness following acute-onset severe headache and vomiting. Computed tomography showed hydrocephalus due to obstruction of the foramen of Monro by an isodense mass in the anterior third ventricle. Ventriculoperitoneal shunt was placed to relieve the hydrocephalus and the patient improved clinically. Magnetic resonance imaging of the brain revealed a well-defined lesion with isointense signal intensity on T1-weighted and hyperintense signal intensity on T2-weighted images. Acute, right occipital lobe and right thalamic infarction was revealed by diffusion-weighted imaging; smaller infarct was seen in the medial left occipital lobe. Imaging findings were compatible with third ventricle colloid cyst causing acute hydrocephalus and occipital lobe infarction due to central transtentorial herniation.

An Epidural Blood Patch for Spontaneous Intracranial Hypotension - A Case Report

Spontaneous Intracranial Hypotension (SIH) is a potentially serious, rare, pathophysiological entity of diverse origin. Orthostatic headache, low CSF pressure and diffuse meningeal enhancement on brain MRI are the major features. We report a 36 year old nun with an acute onset of severe headache over the vertex of the head becoming holo-cephalic, associated with neck pain, peaking in intensity in 15-on assuming the erect posture and relieved on assuming the recumbent position. Conventional treatment resulted in minimal improvement. MRI of the brain with gadolinium showed cerebellar tonsillar descent and diffuse meningeal enhancement. Lumbar puncture revealed an opening pressure of 60 mm of H2O and the CSF unremarkable on analysis. With the working diagnosis of SIH, she was posted for an epidural blood patch. After a pre-anaesthetic checkup and due consent, the patient was pre-medicated. In the operating room, the patient was positioned and draped in the left lateral position with a 15 degree trendelenburg tilt. At the L2-L3 intervertebral space, the primary anaesthesiologist identified the epidural space with an 18G Touhy needle adopting the loss of resistance to air technique. Simultaneously a 16G needle with extension was secured by the first assistant in the cephalic vein. Blood collected in 10 mL syringes was then introduced into the epidural space. After a volume of 26 mL, significant lower limb parasthesia and pain was complained of. The procedure was halted and the patient placed supine. She was discharged and noted to be symptom free at follow ups.

Headache presenting as cerebral venous thrombosis associated with heterozygous methylenetetrahydrofolate reductase gene mutation: A case report

Headache is among the most common pain problems encountered by the primary care physician. Cerebral venous thrombosis (CVT) is relatively rare in young adult males. Homocysteinemia is a significantly independent prothrombotic risk factor for atherogenic thrombotic cardiovascular, cerebrovascular, and peripheral vascular diseases. Methylenetetrahydrofolate reductase (MTHFR) gene mutation results in high serum homocysteine levels. Here, we report a 45-year-old male who presented with acute onset severe headache. Brain imaging showed thrombosis of superior sagittal sinus. The level of serum homocysteine was elevated and there was heterozygous CG677T polymorphism of the MTHFR gene.

Primary Central Nervous System Vasculitis Mimicking Brain Tumor

Primary central nervous system vasculitis (PCNSV) is a rare disease with a nonspecific and expansive spectrum of clinical manifestations. A 40-year-old woman presented with acute onset of severe headache associated with nausea. Computed tomography of the brain showed 1 solitary hypodense parenchymal lesion over the left temporal lobe with an internal fluid level. A brain magnetic resonance imaging showed the presence of 1 isointense parenchymal lesion on T1-weighted and T2-weighed images, with surrounding brain edema. The patient accepted craniotomy for excision of lesion under the preoperative impression of brain tumor with hemorrhagic transformation. The pathologic report was extensive vasculitis with hemorrhagic infarction. The diagnosis of PCNSV was made after exclusion of secondary causes–related vasculitis and hereditary hypercoagulant status. This report highlights that PCNSV could appear as a hemorrhagic tumor-like lesion on neuroimaging. Considering PCNSV in the differential diagnosis is important in patients suspected with cerebral hemorrhage, cerebral thrombosis, or brain tumor.

PP04.4 – 2897: SMART syndrome: A rare complication of cranial radiotherapy

Objective SMART syndrome (stroke-like migraine attacks after radiation therapy) is a rare complication of cranial radiotherapy characterized by migraine-like headache and transient neurological deficits with typical gyriform enhancement on magnetic resonance imaging (MRI). Little is known about the pathophysiology of this condition. Potential underlying mechanisms are endothelial damage or dysfunction, vascular instability, vasospasm and, neuronal dysfunction. Patients We report an 11-year-old girl with primary diagnosis of medulloblastoma presented with acute-onset severe headache and left sided weakness 20 months after completion of cranial radiotherapy. MRI demonstrated unilateral cortical swelling and concomitant leptomeningeal, gyral contrast enhancement, and increased cortical perfusion in the right temporoparietooccipital region. Her symptoms resolved spontaneously over several days. Conclusion SMART syndrome appears to be a reversible and long-term complication of cranial radiotherapy. Up to now, a limited number of pediatric patients with SMART syndrome have been reported. Awareness and recognition of clinical signs and radiological imaging of SMART syndrome is important for preventing unnecessary interventions, appropriate diagnostic workup and management.

Giant Supratentorial Acutely Hemorrhagic Enterogenous Cyst: Case Report and Literature Review

The authors report the first case of a giant supratentorial enterogenous cyst presenting with acute symptomatic hemorrhage within the cyst. We report the case of a 78-year-old Philipino female who was found to have a large right fronto-parietal mass after a minor fall. She had a small amount of hemorrhage within the cyst but was stable for discharge the following day. She was readmitted 5 days later with acute onset severe headache and leftside weakness. On repeat imaging, her cyst had grown in size and had large acute hemorrhage within it. She was taken to the operating room for craniotomy and cyst resection. She recovered well post-operatively. This is the first known case of a giant supratentorial enterogenous cyst presenting with symptomatic enlargement due to large hemorrhage within the cyst. Enterogenous cysts should be considered on the differential diagnosis of hemorrhagic supratentorial giant cysts.

SIRPIDS: An unusual EEG pattern in a critically ill patient

A 61-year-old woman presented with acute onset of severe headache and loss of consciousness. She had a history of hypertension and end-stage renal disease. Neuroimaging showed severe diffuse subarachnoid haemorrhage...

Spontaneous cerebellar hemorrhage associated with a novel Notch3 mutation

A 55-year-old woman with no significant medical history presented with an acute onset severe headache. A non-enhanced CT scan of the head revealed a right cerebellar hemorrhage. Investigation for etiology of the hemorrhage included an MRI showing extensive subcortical ischemic disease and also several previous microbleeds. The MRI appearance and absence of any other etiology for hemorrhage prompted work up for cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). She was found to have a guanosine to thymidine transversion at nucleotide position 1336, codon position 420, resulting in a glycine>cysteine substitution interpreted as “predicted CADASIL-associated mutation”. To our knowledge, this mutation has not yet been reported in association with CADASIL.