neurology grand rounds 1-17-14 (1) - kumc.edu grand rounds 1-17-14 (1).pdf · • lp – clear –...
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Neurology Grand Rounds
Scott Belliston DO PGY 3
1/17/14
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History
• Early 50’s female presented to KUMC with 6 days retro-orbital pain in right eye and intermittent horizontal binocular double vision when looking to the right.
• Associated symptoms
– Severe headache, vertigo, burning and abnormal sensation on right side of head, stiffness on right side of neck, worse with movement
• PMH of HTN and DM not currently treating due to lack of insurance
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Headache History
• She is not a headache person but over last 6-8
months had new onset of throbbing
headaches on the right. Associated with
nausea, photo/phonophobia, and lasting up to
24 hours.
• Some relief with Tylenol and Ibuprofen or
laying down in a cool dark room.
• She has 2-3 per week.
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Exam
• Vitals – temp 36.9, pulse 68, resp. 17, BP 135/81, O2 98%
• Mental status normal
• Cranial nerves normal
• Motor 5/5 proximal distal
• Sensory – decreased pinprick on right face and leg
• Reflexes 2/4 – toes down-going
• Coordination normal
• Gait normal
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Where What
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Differential Diagnosis
• Secondary headaches
• SAH
• RCVS
• Cavernous/sinus venous thrombosis
• Occipital AVM
• Carotid or vertebral artery dissection
• Chronic Subdural Hemorrhage
• Meningitis
• Mass
• Primary headaches
• Migraine
• Tension Type Headache
• Trigeminal Autonomic Cephalalgias
• Cluster headache
• Paroxysmal Hemicrania
• SUNCT/SUNA
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Labs
• Hgb 14.7
• WBC 6.2
• Plt 190
• Sodium 134
• Potassium 3.9
• Chloride 102
• CO2 26
• BUN 22
• Creatinine 0.69
• Glucose 291
• Hgb A1c 13.6
• LP – clear
– RBC 0
– WBC1
– Glucose 140
– Protein 35
– No xanthrochromia
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Red Flags
• Abnormal neurologic exam or symptoms that are atypical for aura, especially dizziness, lack of coordination, numbness or tingling, or worsening of headache with the Valsalva maneuver
• Increasing frequency of headaches or a change in headache quality or pattern
• Headaches that awaken patients from sleep
• New headaches in patients over 50
• First headache, worst headache, or abrupt-onset headache
• New headache in patients with cancer, immunosuppression, or pregnancy
• Headache associated with loss of consciousness
• Headache triggered by exertion
• Special consideration should be given to a person who is receiving anticoagulation.
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Migraines and Aneurysms
• Migraines as the presenting signs of aneurysms have been reported in association with fusiform middle cerebral artery aneurysm and saccular intracranial aneurysms.
• Unruptured saccular intracranial aneurysm cause a marked increase in the prevalence of migraine without aura but not in the prevalence of other types of headache.
• Hypothesis that increased sensory input from the sensory nerve endings around the aneurysms may sensitize the CNS and decrease threshold for spontaneous migraine attacks
ls
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28 yo with 15 years headaches that
resolved after sacrifice of carotid
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Theory
• Many mechanisms of migraine have been
proposed
• Abnormal release of neuropeptides including
calcitonin gene-related peptide, Substance P
and neurokinin
• Leads to sensitization the trigeminal system to
the pulsatility of cranial vessels
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Outcome in our patient
• To OR for right craniotomy and right MCA
aneurysm clipping
• She states headaches resolved, and she has
minimal pain from the incision. Immediately
after surgery she noted her headaches where
gone, as well as, her blurred/double vision
and dizziness
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Questions?
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References • Benndorf G, Naeini RM, Lehmann TN. Triple carotid aneurysms in a patient with migraine
attacks. Journal of neurology, neurosurgery, and psychiatry 2004;75:993.
• Bruyn GW, Intracranial Arteriovenous Malformation and Migraine Cephalalgia September 1984 4: 191-207, doi:10.1046/j.1468-2982.1984.0403191.x.
• Gentile S, Fontanella M, Giudice RL, Rainero I, Rubino E, Pinessi L. Resolution of cluster headache after closure of an anterior communicating artery aneurysm: the role of pericarotid sympathetic fibres. Clinical neurology and neurosurgery 2006;108:195-8.
• Goedee HS, Depauw PR, vd Zwam B, Temmink AH. Superficial temporal artery-middle cerebral artery bypass surgery in a pediatric giant intracranial aneurysm presenting as migraine-like episodes. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2009;25:257-61.
• Katzung BG. Chapter 16. Histamine, Serotonin, & the Ergot Alkaloids. In: Katzung BG, Masters SB, Trevor AJ. eds. Basic & Clinical Pharmacology, 12e. New York: McGraw-Hill; 2012.
• Lebedeva ER, Gurary NM, Sakovich VP, Olesen J. Migraine before rupture of intracranial aneurysms. The journal of headache and pain 2013;14:15
• Narbone MC, Rao R, Grugno R, Pellicano M. A late 'migraine': the only symptom of an intrasellar aneurysm. Headache 1997;37:527-8.
• Rahman NU, Jamjoom A, Jamjoom ZA. Unruptured posterior communicating artery aneurysm masquerading as migraine: report of two cases. JPMA The Journal of the Pakistan Medical Association 1997;47:172-4.
• Sinclair W. Dissecting Aneurysm of the Middle Cerebral Artery Associated with Migraine Syndrome. American Journal of Pathology. Dec 1953; 29(6): 1083-1091.
• Chapter 10. Headache and Other Craniofacial Pains. In: Ropper AH, Samuels MA. eds. Adams and Victor's Principles of Neurology, 9e. New York: McGraw-Hill; 2009.
• Chapter 18. I Have a Patient with Headache. How Do I Determine the Cause?.In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 2e. New York: McGraw-Hill;
• Zaorsky N, Intracranial Aneurysms – inferior view – heat map. Wikipedia Creative Commons: 2011. Available at: http://en.wikipedia.org/wiki/File:Wikipediaintracranialaneurysms-inferiorview-heatmap.jpg