Frontal Headache Research Articles

A Rare Case of P63-Negative Sinonasal Nut Midline Carcinoma in the Elderly.

Molecular analysis of a NUT carcinoma and age at diagnosis may serve as a potential means for predicting patient prognosis in cases of midline NCC.Each patient should receive careful monitoring and a personalised treatment strategy based on their molecular studies. Surgical resection, along with a combination of radiotherapy and chemotherapy, has the potential to improve overall survival rates.In line with the commonly observed relationship between increased p63 mutation and poorer survival rates, a negative p63 expression in squamous cell carcinomas may indicate a more favorable prognosis. This hypothesis highlights the importance of further research to validate these findings.

Gastric cancer of unusual presentation, the importance of differential diagnosis.

We present the case of a 67-year-old male smoker with no medical history of interest. Admitted to Neurology for frontal headache, unsteady gait, temporospatial disorientation and vomiting. Laboratory tests (including vitamin B12, folic acid, lues) and cranial CT scan were normal, encephalogram compatible with diffuse encephalopathy and lumbar puncture with a finding of leptomeningeal carcinomatosis. In light of these findings, it was decided to look for occult tumor by thoracoabdominal-pelvic CT, which was negative for malignancy. In view of the results of the previous tests, it was decided to perform an endoscopic study. Colonoscopy reveals six 0-IIa Paris polyps in the left colon measuring 7-10 cm, which are removed. Gastroduodenoscopy shows a poorly distensible stomach, with erythematous gastric body mucosa and hard on biopsy. In addition, in the duodenum, three raised lesions with an excavated center (Fig. 1) of about 5 mm were identified and biopsied. Histology findings report mucosal and submucosal infiltration by poorly differentiated carcinoma. Immunohistochemistry positive for CK19, Glipican-3, weak positivity for CK7, conserved expression of MUC5AC and SMAD, negative for SF-1, inhibin, synaptophysin, INSM1, chromogramin, Gata-3 and S-100. The findings were suggestive of infiltration by poorly differentiated carcinoma of probable gastric origin. Unfortunately, during hospital admission the patient presented a progressive clinical deterioration and died two weeks later.

SURG-15. RIGHT FRONTAL-PARIETAL PILOCYTIC ASTROCYTOMA WHO GRADE I ASSOCIATED WITH HEMORRHAGIC COMPONENT AND ESSENTIAL HYPERTENSION IN AN ADULT

Abstract Pilocytic astrocytoma (PA) is a primary glial neoplasm and low-grade tumor. After total resection, the prognosis is very good. A poor prognosis results from leptomeningeal spreading and bleeding, both of which are extremely uncommon in Pilocytic Astrocytoma patients. Case presentation We report the case of a 43-year-old male that presented with a 4 days’ history of right sided frontal headache, non-radiating and mostly felt in the morning. Not associated with vomiting and fever. In addition, there was a sudden decline in level of consciousness with no associated stool or urine incontinence. The patient also developed three episodes of tonic clonic convulsions, lasting less than 3 minutes associated with urine incontinence and frothing from the mouth. Two days later, there was a sudden onset of left sided weakness involving upper and lower limbs. However, there is no history of trauma or hypertension. He was identified as having a hemorrhagic right frontal-parietal PA evidence on MRI associated with essential hypertension. The patient had an intervention combination of medical treatment and craniotomy via fronto-temporal approach plus excision of lesion. Histopathological examination of specimen determined that it was PA WHO grade I. He was treated with oral anti-epileptic therapy (Phenytoin 300 mg once a day), folic acid supplementation (400 mcg once a day), anti-hypertensive therapy (Amlodipine 10 mg and Losartan 50 mg once daily) and he showed marked improvement and was discharged home after 1 month and followed up by primary neurosurgeon, oncologist and physician. CONCLUSION: This case report raises awareness of Pilocytic Astrocytoma among adults and emphasizes the value of early diagnosis and management of patients with Pilocytic Astrocytoma associated with essential hypertension can prevent complications, reduce morbidity and mortality.

Abstract 099: Reversible Cerebral Vasoconstriction Syndrome Secondary to Weight Loss Patch: A Case Report​

Introduction Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a clinico‐radiographical syndrome characterized by severe thunderclap headache and reversible multifocal arterial vasoconstriction1. RCVS can be spontaneous or related to a trigger such as vasoactive medication/supplements. There is no previous data on the association of weight loss patch formulation in the genesis of unexplained RCVS. Methods A woman in her 40s presented with five days of recurrent acute onset severe right frontal headaches after starting Thrive weight loss patch supplementation. Head CT showed right frontal lobe hemorrhage with bilateral SAHs (Figure1). Brain MRI redemonstrated hemorrhages, numerous scattered foci of restricted diffusion, and a large area of restricted diffusion in the left insular cortex (Figure 2). Cerebral angiogram showed diffuse multifocal narrowing with a ‘beads‐on‐a‐string’ appearance of the cerebral vasculature and no aneurysms (Figure 3). Thrive patch contains undisclosed amounts of sympathomimetics and vasoactive compounds. Given the history, clinical symptoms of recurrent thunderclap headaches, and angiographic findings, the diagnosis of RCVS was made. Brain MRA 3 months after discharge showed no areas of cerebrovascular focal stenosis (Figure 4). At 4 month follow up, she reported 90% improvement of her symptoms. Results We report a temporal relationship between RCVS in a woman in her 40s and usage of a Thrive weight loss patch, which contains green tea extract, L‐arginine, 5‐hydroxytryptophan (5‐HTP), and Yerba Mate. We believe this report represents the first case of RCVS triggered by a weight loss patch. Multiple compounds within the Thrive patch have vasoactive properties that may contribute to RCVS genesis. Epigallocatechin (component of green tea extract) and 5‐HTP are metabolic compounds with potent vasoactive properties. They are components of weight loss and SSRI/SNRI medications respectively. Numerous studies have documented a temporal relationship between their use and subsequent development of RCVS2,3. Resolution of RCVS is reported after their discontinuation. Only one other case in our literature review investigated a patch modality in a temporal relationship with RCVS. It reported development and resolution of RCVS six days after nicotine patch use and discontinuation4. While Thrive patch does not contain nicotine, this case provides a further avenue for exploration as to whether pharmacokinetics of a patch modality influences a patient’s presentation with RCVS, as all prior reports document oral ingestion of substances. Conclusion Clinicians should be aware of the role of weight loss patches in RCVS, and their use should be assessed in large RCVS cohorts to clarify the association described in this report.

GLIOMA-13 RIGHT FRONTO-PARIETAL PILOCYTIC ASTROCYTOMA WHO GRADE I ASSOCIATED WITH HEMORRHAGIC COMPONENT AND ESSENTIAL HYPERTENSION IN AN ADULT: A CASE REPORT

Abstract Pilocytic astrocytoma (PA) is a primary glial neoplasm and low-grade tumor. After total resection, the prognosis is very good. A poor prognosis results from leptomeningeal spreading and bleeding, both of which are extremely uncommon in Pilocytic Astrocytoma patients. CASE PRESENTATION: We report the case of a 43-year-old male that presented with a 4 days’ history of right sided frontal headache, non-radiating and mostly felt in the morning. Not associated with vomiting and fever. In addition, there was a sudden decline in level of consciousness with no associated stool or urine incontinence. The patient also developed three episodes of tonic clonic convulsions, lasting less than 3 minutes associated with urine incontinence and frothing from the mouth. Two days later, there was a sudden onset of left sided weakness involving upper and lower limbs. However, there is no history of trauma or hypertension. He was identified as having a hemorrhagic right fronto-parietal PA evidence on MRI associated with essential hypertension. The patient had an intervention combination of medical treatment and craniotomy via fronto-temporal approach plus excision of lesion. Histopathological examination of specimen determined that it was PA WHO grade I. He was treated with oral anti-epileptic therapy (Phenytoin 300 mg once a day), folic acid supplementation (400 mcg once a day), anti-hypertensive therapy (Amlodipine 10 mg and Losartan 50 mg once daily) and he showed marked improvement and was discharged home after 1 month and followed up by primary neurosurgeon, oncologist and physician. CONCLUSION: This case report raises awareness of Pilocytic Astrocytoma among adults and emphasizes the value of early diagnosis and management of patients with Pilocytic Astrocytoma associated with essential hypertension can prevent complications, reduce morbidity and mortality.

A comparison of comorbid headache between patients with temporal lobe epilepsy and juvenile myoclonic epilepsy

Headache is one of the most common symptoms of epilepsy comorbidities. However, the relationship between the epilepsy and headache still needs clarification. Previous studies mostly investigated the overall incidence and clinical features of the headache in patients with the epilepsy. Temporal lobe epilepsy (TLE) and juvenile myoclonic epilepsy (JME) are the common types of focal epilepsy and generalized epilepsy, respectively. Nevertheless, there was no study comparing the clinical features of headache between TLE and JME. This study aimed to analyze the headache features of these two types of epilepsy. Patients with either TLE or JME diagnosed with headache and referred to the West China Hospital of Sichuan University were consecutively recruited from June 2021 to June 2022. The duration of epilepsy was longer than 6 months in these patients. Data on headache and epilepsy were obtained through face-to-face questionnaires. The headache was classified according to the International Classification Headache Disorders-3rd edition (ICHD-III) criteria. χ2-test, t-test, rank-sum test, logistic regression modeling and Mann Whitney test were used to compare the clinical differences of the headache in TLE and JME. A total of 151 TLE patients and 30 JME patients were enrolled in this study. There was no significant difference in the family history of headache, epilepsy durations, headache types, proportion receiving analgesic therapy, the frequency of inter-ictal headache (inter-IH), and the quality of life in epilepsy -10 inventory (QOLIE-10) between the TLE and JME patients. Patients in the TLE group were significantly older (p = 0.004), and a lower percentage of them had a family history of epilepsy (p = 0.007) compared with the JME patients. The proportion of cases with refractory epilepsy was higher in the TLE group than that in the JME group (p < 0.001). The types of seizures in the TLE group varied from those in the JME group (p < 0.001). The composition of the antiseizure medications (ASM) applied in the TLE group differed from that in the JME group (p = 0.047), and the usage of oxcarbazepine was more frequently in the TLE group than in the JME group (p = 0.003). There was no difference in the headache types among patients with TLE or JME. Specifically, 67 (44.37%), 12 (7.95%), and 118 (7.95%) patients were found with inter-IH, pre-ictal headache (Pre-IH) and post-ictal headache (Post-IH) in the TLE group; while 8 (26.67%), 4 (13.33%) and 26 (86.67%) patients had inter-IH, Pre-IH and Post-IH in the JME group. Thirty-nine patients in the TLE group and 4 patients in the JME group were identified with more than one type of headaches, respectively. Tension-type headache (TTH) were found in 38 patients (25.17%) in the TLE group and 3 patients (10.00%) in the JME group, respectively; migraines were found in 10 patients (6.62%) in the TLE group and in 2 patients (6.67%) in the JME group. Patients in the TLE group had a higher headache-attributed lost time-90 days (HLT-90) score than those in the JME group (p = 0.019). The proportion of patients with inter-IH accompanied by nausea in the TLE group was higher than that in the JME group (p = 0.029), while the proportion of patients with frontal headache was lower than that in the JME group (p < 0.05). There was no significant difference in headache severity, quality, headache nature, unilateral/bilateral, and headache duration either in inter-IH or peri-ictal headache (Peri-IH) between the two groups. The logistic regression analysis suggested that except for HLT-90 (AUC = 0.622, p = 0.027), other factors were not found to be correlated with refractory epilepsy. The clinical features of headache differed between TLE and JME patients. TLE patients had a higher ratio of refractory epilepsy, more headache time loss compared with JME patients. HLT-90 was associated with the occurrence of refractory epilepsy in TLE patients. Taken together, we suggested that the comorbid headache may essentially be different between TLE and JME patients.

SAT189 Giant Parathyroid Adenoma

Abstract Disclosure: S. Shah: None. P. Fujikawa: None. Parathyroid adenomas rarely weigh more than 4 grams. Our patient had a 5.3gram adenoma causing bilateral knee pain limiting mobility, constipation, low back pain, and frontal headache. Presenting with calcium of greater than 17 mg/dL, patient was treated with 2 rounds of hemodialysis, calcitonin, Zoledronate, and aggressive IV hydration to decrease calcium levels prior to parathyroidectomy. Patient then went onto develop Hungry bone syndrome which was treated with calcium carbonate and calcitriol. This rare giant parathyroid adenoma presents a unique opportunity to learn about pathogenesis and treatment of longstanding hyperparathyroidism causing hypercalcemia associated symptoms and hungry bone syndrome after parathyroidectomy. Presentation: Saturday, June 17, 2023

FRI339 Hypophysitis Secondary To Small Vessel Anca Vasculitistreated With Rituximab

Abstract Disclosure: A. Rivadeneira: None. N. Kumar: None. S. Banerjee: None. M. Gubbiotti: None. D. Yoshor: None. J. Kharlip: None. C.A. White: None. Introduction: Granulomatosis with polyangiitis (GPA) is an autoimmune small-vessel vasculitis associated with anti-neutrophil cytoplasmic antibodies (ANCAs) that rarely involves the pituitary. Conventional treatment of GPA includes high dose glucocorticoids with cyclophosphamide. Rituximab has been used in refractory cases with high rates of remission. We present a case of pituitary GPA treated with and excellent response to rituximab. Case: 51-year-old woman with hypothyroidism, post I-131 treatment for Graves’ disease. Patient presented with 1 year of worsening fatigue, myalgias, frontal headaches, sinus congestion and epistaxis. CT sinus showed pituitary enlargement and chronic mucosal disease. MRI pituitary showed diffusely enlarged pituitary with non-visualized posterior pituitary bright spot and thickened stalk. CT chest showed 18x11 mm nodular opacity and peribronchial fibrosis. Laboratory evaluation showed ACTH 26.7 pg/mL, cortisol 13.4 mcg/dL, TSH 1.1, T4 9.7, prolactin 53 ng/dL, estradiol &amp;lt;20, LH 4, FSH 23. Sodium 140 and urine osm 488. There was positive p-ANCA staining and elevated serum anti-proteinase 3 antibody (PR3), 74 units (0-20). Myeloperoxidase antibody was not elevated. ESR 73 mm/h (0 - 30) and CRP 7.9 (&amp;lt;7.4). Due to atypical ANCA pattern (p ANCA typically is associated with MPO not PR3), pituitary biopsy was performed and showed adenohypophysis with dense lymphoplasmacytic infiltration with nodularity of the inflammatory infiltrates, some arranged peri vascularly, compatible with involvement of the pituitary gland by GPA. She began rituximab 375 mg/m2 weekly for four weeks with plan to continue every 6 months. After treatment, the patient experienced resolution of daily frontal headaches, congestion, cough and epistaxis. CT chest showed improvement of prior lung findings, and ESR/CRP normalized. Repeat pituitary MRI is pending. Discussion: Pituitary involvement is uncommon in GPA, occurring in only 3.9% of cases. It may lead to partial or complete pituitary dysfunction, particularly central diabetes insipidus (87.5%) and hypogonadism (75%). Typical MRI abnormalities include diffusely enlarged pituitary gland, thickened pituitary stalk and absence of posterior bright spot. Treatment of GPA includes a combination of corticosteroids, Cyclophosphamide, Azathioprine and Rituximab. Remission is achieved in up to two thirds of patients. Treatment of lymphocytic hypophysitis, another common cause of diffuse pituitary enlargement, relies on high dose glucocorticoids, leading to many side effects and taper is limited by worsening symptoms. This case highlights the critical role in serologic evaluation and targeted pituitary biopsy to identify the specific etiology of pituitary infiltration to help guide alternate treatment options, and the emerging role of Rituximab as a steroid sparing agent for treatment of pituitary inflammation. Presentation: Friday, June 16, 2023

FRI321 Aggressive Prolactinoma Empirically Treated With Cabergoline Leading To Rapid CSF Leak

Abstract Disclosure: A. Yau: None. T. Reisman: None. Over two-thirds of pituitary tumors are prolactinomas. These are discovered as a result of symptoms of hypogonadism, menstrual irregularities, infertility or galactorrhea, as well as symptoms of mass effects including visual field deficit or acute severe headaches.1 A more rare subgroup, aggressive prolactinomas, in which the tumors are radiographically invasive and show resistance to dopamine agonist treatment as well as surgery, account for 10% of all hypophyseal neoplasia. 2 During medical treatment of prolactinomas, there is a known rare complication of CSF rhinorrhea; recorded time of onset of leak following treatment ranges from 14 days to 5 years.3 We present a case in which a patient with an aggressive prolactinoma rapidly developed a CSF leak within 48 hours of starting cabergoline treatment. Case: A 36-year-old male with type 2 diabetes, erectile dysfunction and infertility presents to Endocrine clinic after initial evaluation by Urology revealed elevated prolactin. He reported headaches, gynecomastia associated with liquid discharge from nipples, and minor issues with peripheral vision. He was started empirically on cabergoline for probable prolactinoma and within 48 hours developed worsening frontal headache, cough and clear fluid leakage from his right nostril. Labs revealed prolactin over 2600 ng/ml. MRI pituitary showed evidence of pituitary adenoma as well as likely CSF leak. Cabergoline was stopped and the patient was sent to the emergency room. The patient was underwent urgent neurosurgical transsphenoidal endoscopic surgery and CSF leak repair with resolution of rhinorrhea and cough. Post-operative MRI was consistent with minimal residual tumor. He was monitored in the NICU with no obvious post-operative pituitary hormone imbalance, diabetes insipidus, adrenal insufficiency or syndrome of inappropriate ADH. Months after discharge, the patient’s prolactin remained elevated to the 600’s ng/ml and repeat MRI showed a mass occupying the entire sella and suprasellar cistern, compressing the optic chiasm. Conclusion: In this case of a patient with the subtype of aggressive prolactinoma, there seems to be a more rapid presentation of complications. When treating these rare subtypes, physicians need to stay vigilant of developing complications or even consider nonstandard therapies as first-line management. 1. Molitch ME, Drummond J, Korbonits M. Prolactinoma Management. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc.; January 6, 2022.2. Lasolle H, Ilie MD, Raverot G. Aggressive prolactinomas: how to manage?. Pituitary. 2020;23(1):70-77. doi:10.1007/s11102-019-01000-73. Arimappamagan A, Sadashiva N, Kandregula S, Shukla D, Somanna S. CSF Rhinorrhea Following Medical Treatment for Prolactinoma: Management and Challenges. J Neurol Surg B Skull Base. 2019;80(6):620-625. doi:10.1055/s-0039-1677686 Presentation: Friday, June 16, 2023

Toxic optic neuropathy and acute angle closure secondary to divalproex sodium – A rare case report

This study aims to report the side effects of oral divalproex sodium in a 55-year-old woman presented with a bilateral sudden painless decrease of vision and frontal headache and nausea, causing unique development of optic neuropathy and secondary acute angle closure (AAC). She gave a history of taking oral divalproex sodium for her migraine headache for 2 weeks. On examination, the patient was found to have secondary AAC, optic neuropathy with high intraocular pressure, and optic disc edema in both eyes (BE). The patient was treated with topical medications. The best-corrected distance visual acuity revealed an improvement of 20/30 from hand movement in BE within 2 weeks from the initial presentation. The ocular side effect, induced by divalproex sodium and possibly even after withdrawal from the drug, on time early detection of secondary AAC, and optic neuropathy will improve the management and give optimal results.

Kondisi Psikologis Primigravida dengan Preeklampsia Berat dan Future Direction Strategi Komunikasi Perawat: A Case Report

Background. Preeclampsia is a pregnancy complication with a high risk of maternal and fetal morbidity and mortality. This case report aimed to describe primigravid pregnancies with severe preeclampsia and physical-psychological problems that impact patient-family’s decision-making for the health of the mother and fetus.&#x0D; Research Methods. This case report was conducted to improve understanding of a case primigravida pregnancies with severe preeclampsia. The stages of a case report included: defining the case; choosing a case; collecting and analyzing data; interpreting data; and reporting results. Data was collected through interviews, physical examinations, examination of health documents, discussions with patients and families, and information from other health workers—anxiety assessment using the Hamilton Rating Scale for Anxiety. Data analysis was done by reading the collected data, coding the primary data, comparing it, and summarizing it as a case presentation.&#x0D; Results. Primigravida, 33 weeks, severe preeclampsia and requires hourly monitoring. Complaints of frontal headaches, blurred vision and conveyed the results of high blood pressure examination at a clinic near the house. General condition: composmentis, blood pressure: 160/112 mmHg, N;118 x/min, R;24x/min, Temperature; 36.50 C, dry lips, oedema in the left lower extremity, MEWS score 4-5, fetal heart rate 134x/minute. Anxiety assessment with the Hamilton Rating Scale for Anxiety resulted in moderate-severe anxiety category. Husbands expressed the wishes of the mother and baby to be safe and to be born immediately with surgery.&#x0D; Conclusion. Severe preeclampsia with uncontrolled blood pressure requires appropriate treatment and intensive observation by health workers, especially nurses. Pregnancy with severe preeclampsia raises anxiety for patients and families, which risks further increasing blood pressure and threatening the fetus's well-being. Anxiety impacts interaction situations between patients, families, and caregivers, as well as family decision-making. A therapeutic communication approach by paying attention to comprehensive needs and holistic patient conditions is an effective nurse strategy for families to make maternal and fetal health decisions.

Concurrent Cerebral Thrombophlebitis and Nonfunctioning Pituitary Adenoma in a Postpartum Woman: A Rare Coexistence and Diagnostic Challenges

This case report presents a rare occurrence of concurrent cerebral thrombophlebitis and nonfunctioning pituitary adenoma in a postpartum woman. Cerebral thrombophlebitis is a rare condition that can manifest with diverse clinical presentations, posing diagnostic challenges. The patient, a 30-year-old primipara, presented with progressive vision loss, diplopia, and intense frontal headaches shortly after childbirth. Magnetic resonance angiography revealed thrombophlebitis in the right lateral sinus extending into the ipsilateral internal jugular vein, along with a large suprasellar lesion suggestive of a pituitary macroadenoma. Ophthalmological examination revealed papilledema and ptosis. Laboratory analyses ruled out hormonal abnormalities associated with pituitary adenomas. The patient received intravenous methylprednisolone and therapeutic anticoagulation, resulting in neurological and ophthalmological improvements. Subsequently, the patient underwent transsphenoidal resection. This case highlights the diagnostic and management challenges associated with rare postpartum conditions and emphasizes the importance of comprehensive evaluation and multidisciplinary care in such cases.

OA01 A case report of a patient with Type 1 diabetes mellitus and systemic lupus erythematosus: a management dilemma

Abstract Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organs. Up to 30% of patients with SLE will develop other autoimmune conditions. A few cases of SLE and Type 1 Diabetes Mellitus (T1DM) have been reported in literature. Corticosteroids which is key in induction therapy increases the risk of hyperglycemia and hypertension. Other immunosuppressive agents such as mycophenolate mofetil used in management of lupus nephritis increase the risk of hyperglycemia. This poses a challenge in the management of SLE in a patient with T1DM. Aim To describe a management dilemma in caring for a child with T1DM and SLE at a tertiary referral teaching hospital in Nairobi, Kenya. Method Retrospective chart review of a child with T1DM and SLE at Aga Khan University Medical College East Africa, Nairobi, Kenya. Results We discuss a 16-year-old male patient with T1DM since nine years of age on insulin and on follow up in the endocrine clinic. He presented with complaints of facial and lower limb swelling of three days and severe frontal headache associated with nausea for one day. He was also noted to have a strong family history of Sjogren’s disease and diabetes. His initial examination revealed hypertension with a blood pressure of 184/118 mmHg, facial and lower limb oedema. He was commenced on labetalol infusion and amlodipine for blood pressure control, and was to continue with his insulin regimen. Initial urinalysis showed proteinuria and hematuria. An impression of hypertensive emergency with nephropathy was made. Rheumatology review was requested. Investigations revealed an ANA titer of &amp;gt; 1:1280; anti-smith and anti dsDNA antibodies were positive; low C3 and low C4. Echo showed pleural effusion. The kidney biopsy showed features of proliferative lupus nephritis class IV with no features of diabetic nephropathy. A diagnosis of SLE was made and management initiated with hydroxychloroquine, methylprednisolone for three days then oral prednisolone and mycophenolate mofetil. During methylprednisolone therapy, the patient was noted to have unrecordably high blood glucose necessitating an insulin infusion for six days and close adjustment of insulin doses by the endocrinologist. Initially, after the 1st dose of methylprednisolone, his blood pressure seemed to improve. During the course of treatment, his blood pressure was elevated and difficult to control despite being on labetalol infusion, amlodipine, enalapril and carvedilol. Adjustment of antihypertensive drug doses and addition of hydralazine were made by the nephrologist, cardiologist and critical care specialist. He was eventually discharged with controlled blood glucose and blood pressure. He is currently doing well and is on follow up in the nephrology, rheumatology and endocrinology clinics. Conclusion Our case report highlights the challenges that arise while managing patients with SLE and other illnesses such as T1DM. It also points out the necessity of multi-disciplinary care. This may be a challenge in many African health facilities due to a low number of specialized doctors.

Impact of functional endoscopic sinus surgery on otologic symptoms associated with chronic rhinosinusitis

Background: The study was aimed at observing the impact of FESS on otologic symptoms associated with Chronic rhinosinusitis. Otitis media and other otologic symptoms develop frequently during the evolution of CRS. The evolution of middle ear disease in the setting of chronic rhino-snusitis possibly reflects the role of a dynamic conduit, eustachian tube, normal functioning of which, is crucial to keep the middle ear functions within physiologic limits. Methods: The study was conducted in the Department of Otorhinolaryngology, Jhalawar Medical College and SRG hospital, Jhalawar (Rajasthan) between August 2021 and November 2022. 53 patients of CRS with associated otologic symptoms were included in the study. Patients were subjected to functional endoscopic sinus surgery and septoplasty where relevant. Results: The majority of the study patients presented with ear discharge (72%), earache (41%) and ear fullness (41%). The most common sinusitis related symptoms were Nasal blockage (77%), frontal headache (53%) and nasal discharge (49%) with relatively lower proportion of post nasal drip (23%), facial pain (21%) and halitosis (15%). All participants were subjected to FESS which was combined with septoplasty and sub-mucous diathermy of the inferior turbinate where it was relevant. Patients were followed at 1st, 3rd and 6th week post-operatively. Conclusions: Majority of the patients (89%) shown a statistically significant subjective improvement in the otologic symptoms following the initial optimum medical therapy for the CRS. Endoscopic sinus surgery was found to improve symptoms on a statistically significant scale.

Mucocele of the Paranasal Sinuses: Retrospective Analysis of a Series of Eight Cases.

Paranasal sinus mucoceles are epithelium-lined cystic masses usually resulting from obstruction of sinus ostia. They most frequently occur in the frontal and ethmoid sinuses. The etiology is not clarified, but the most common identifiable cause of mucoceles following functional endoscopic sinus surgery (FESS), trauma, neoplasms, and allergy. The clinical symptoms of mucocele vary and are not specific, the most common being ophthalmic symptoms and headache, impinging on adjacent orbital structures, and causing ophthalmic sequelae such as double vision, commonly followed by orbital swelling, epiphora, proptosis, and ptosis. All patients in this study had frontal and frontoethmoidal mucocele and initially complained of frontal headache and ophthalmic symptoms. Definitive treatment options for paranasal sinus mucoceles include external approaches and endoscopic marsupialization. Objective:The study aimed to identify the etiology, clinical presentation, most common para nasal sinus affected by mucocele, management, and the rate of recurrence in eight cases with mucocele of the paranasal sinuses. Eight patients diagnosed with mucocele of the paranasal sinuses were admitted to our institution between 2014 and 2021. There were two females and six males aged between 14 and 67. Initial symptoms, duration, clinical presentation upon admission, location of the mucocele, type of surgical intervention, and outcome have all been studied. Results: The most common symptoms at diagnosis were orbital involvement, retrobulbar, and frontal headache. Most patients were diagnosed with frontal mucocele (40%), and three were frontoethmoidal mucocele at the time of presentation. The rest of the cases were diagnosed with ethmoidal mucocele (25%). The etiology was identified in four patients and was unclear in the rest. All patients underwent endoscopic sinus surgery. The most identifiable postoperative complication was a headache. The endonasal endoscopic approach is a safe and effective treatment for paranasal sinus mucocele and provides adequate drainage with a low recurrent rate.

De novo formation of a giant dural arteriovenous fistula after cerebral venous sinus thrombosis

A 45-year-old male patient with past medical history of obesity and diabetes presented with complaints of pulsatile, frontal headache evolving in the past two days. His vital signs were normal and he had no meningeal signs or neurologic deficits. Magnetic resonance angiography (MRA) revealed cerebral venous sinus thrombosis (CVST) with intraluminal thrombus in galen's vein, and right rectum and transverse sinuses

The Case Files

Figure: CT scan of the head illustrating possible cribriform penetration.FigureFigureInitial symptoms of cerebritis are nonspecific, making it difficult to diagnose A 34-year-old man presented with a frontal headache and two syncopal episodes over 24 hours. The patient had had URI symptoms—sore throat, rhinorrhea, and mild shortness of breath—for three weeks. He had no history of headaches or fevers, he hadn't traveled recently, and he didn't use drugs or take any medications. The patient's first syncopal episode occurred a day earlier while at work. It happened suddenly, without any prodromal symptoms. He did not seek medical care, and he finished his shift. The second episode occurred at home suddenly, without any prodromal symptoms, and prompted him to go to the ED. The patient had normal vitals and was alert. His physical exam showed no abnormalities. Lab work was ordered, including CBC, CMP, ECG, chest x-ray, and head CT. The CT identified extensive paranasal sinus disease with penetration of the cribriform plate and a small epidural collection, raising concern for an epidural abscess or cerebritis. The patient was treated in the ED with IV fluids and broad-spectrum antibiotics, including vancomycin and piperacillin-tazobactam, and he was made NPO. ENT recommended the patient be transferred to a tertiary care center for ENT and neurosurgery consultation. An MRI showed extensive sinus disease without a frank intracranial abscess. The patient underwent nasal septoplasty, inferior turbinate submucous resection, left maxillary antrostomy with tissue removal, left frontal sinusotomy, and left total ethmoidectomy. The patient's headache improved significantly following the procedures, and he had no more episodes of syncope. Blood cultures revealed Bacillus species. He was transitioned off IV antibiotics and discharged with a seven-day course of amoxicillin and clavulanate at home after a four-day hospital course. This was a rare form of syncope brought on by extensive sinus disease with early penetration into the CNS. Cerebritis is inflammation of the cerebrum with nonspecific findings on CT scan. It develops in response to pyogenic bacteria, most commonly Staphylococcus and Streptococcus. This infection develops typically from otogenic and odontogenic sources, recent procedures, penetrating head trauma, or via hematogenous spread. It's difficult to diagnose cerebritis early because initial symptoms are nonspecific and patients do not present until late findings such as headache, altered mental status, syncope, and seizures are present. Labs may show leukocytosis, but that is also not specific. Diagnosis is made by imaging with CT or MRI. Acute treatment in the ED includes managing the patient's symptoms, NPO status, broad-spectrum antibiotics, and admission with ENT and neurosurgery consults. Syncope is a common presentation in the ED, but cerebritis as a cause is rarely seen. Prompt evaluation and management likely prevented further complications and progression of the disease.

Girl with a frontal headache and fever.

Girl with a frontal headache and fever.

Pneumocephalus secondary to epidural analgesia: a case report

IntroductionEpidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a rare and potentially serious complication of epidural anesthesia, which is most often caused by accidental puncture of the dura with the introduction of air into intrathecal space.Case presentationWe present the case of a 19-year-old Hispanic female who developed a severe frontal headache and neck pain eight hours following epidural catheter placement to deliver analgesia during labor. Physical examination was within normal limits without any neurological deficits. Computed tomography of the head and neck would later demonstrate small to moderate amounts of pneumocephalus, predominantly within the frontal horn of the lateral ventricles, and a moderate amount of air within the spinal canal. She was treated conservatively with analgesia. Though headache recurred after discharge, repeat imaging showed improvement in the volume of pneumocephalus and conservative management was continued.ConclusionsAlthough a rare complication and an uncommon cause of headache following epidural anesthesia, a high index of suspicion must remain for pneumocephalus as it may cause significant morbidity and, in some cases, be potentially life-threatening.

Teaching Neuro Images : Morgagni-Stewart-Morel

A 30-year-old woman presented with a 4-year history of slowly progressive memory loss, frontal headache, vertigo, depression, and seizures (normal EEG), and earlier history of endocrine disease (diabetes mellitus, obesity, hirsutism, and hypothyroidism). Sagittal cranial T1-weighted MRI, CT scan, and x-ray showed bilateral thickening of the inner table of the frontal bone (figure).1 Her paternal family history suggests X-linked disease. Her endocrine dysfunctions and neuropsychiatric symptoms are interpreted as components of Morgagni-Stewart-Morel syndrome and may correlate with the severity of the frontal hyperostosis and the cortical atrophy.2 Attention to this clinical–radiologic correlation may help neurologists make correct diagnoses.