SECONDARY HEADACHES CASES ALEKSANDRA RADOJIČIĆ. Social history: former smoker, denies alcohol use. Family history: father had hypertension and
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1 European Headache School Belgrade 2012 DIFFERENTIAL DIAGNOSIS OF SECONDARY HEADACHES CASES ALEKSANDRA RADOJIČIĆ HEADACHE CENTER, NEUROLOGY CLINIC, BELGRADE CASE 1 M. D. 51 years Medical history: hypertension Social history: former smoker, denies alcohol use Family history: father had hypertension and Family history: father had hypertension and diabetes mellitus, deceased. No family history of headaches
2 PRESENTING COMPLIANT 8 months history of right-sided headache, localized at the occipital region and behind the ear The pain is mostly dull, middle grade intensity It occurs only by night, a few hours after falling asleep, and lasts several hours. 4 months later he noticed hearing disturbances on the right and also developed ipsilateral nasal congestion PRESENTING COMPLIANT Ears/nose/throat specialist (ENT): Otitis chr. adhesiva lat. dex, Pansinusits In the next three months headaches gradually increased in frequency and intensity He takes analgesics every night
3 NEUROLGIST Hypnic headache Cervicogenic headache Headache attributed to disorder of ears/ rhinosinusitis Further investigation is needed! LATER... Brain CT: normal Two months later he developed double vision Neurological examination: right-sided Horner s syndrome weakness of the right m. rectus lateralis conductive hearing loss on the right pyramidal, extrapyramidal and cerebellar signs normal, no sensory loss
4 M.D. DIFFERENTIAL DIAGNOSIS Headache attributed to disorder of ears/ rhinosinusitis Nasopharyngeal tumor Tolosa Hunt syndrome
5 DIAGNOSTIC TESTING Blood tests: normal, except ESR 40 mm/h Ophalmologist: right abducent nerve palsy Chest X-Ray: normal Radiography of cervical spine: spondylosis Carotid Duplex Ultrasound Examination and Transcranial Doppler: normal DIAGNOSTIC TESTING Auditory evoked potentials: conductive hearing loss, changes not consistent with acoustic neurinoma Lyme antibody: negative HIV test: negative Lumbar puncture: CSF analysis: proteins 0,69 g/l, glucose 3,9 mmol/l, lymphocytes 2, erythrocyte 32 Isoelecrtic focusing: normal
6 DIAGNOSTIC TESTING Brain MRI: Tumorous mass in the nasopharynx with palatum infiltration, infratemporal propagation, propagation to the sphenoid sinus, infiltration of the foramen magnum and epidural propagation at the craniocervical junction. Infiltration of the right sinus cavernosus. With gadolinium administration, tumorous mass significantly enhances Mastoiditis lat. dex, pansinusitis
7 DIAGNOSTIC TESTING nasopharyngoscopy: tumor infiltrating posterior upper nasopharyngeal wall spreading to right lateral wall. patohistološki: Nasopharyngeal nediferentovani mass biopsy-pathohistology: karcinom epifarinksa! nasopharyngeal carcinoma Radiotherapy was initiated which partially ameliorated most of his symptoms Follow up CT
8 CASE 2 P.S., 39 years Past history: menstrual migraine without aura Presenting symptoms: headache and neck pain Patient presents to the emergency department 24 hours after onset of sudden headache and neck pain CASE HISTORY Dull, constant headache of moderate intensity localized mostly behind left eye, with left temporal, ear and neck pain Worsening of pain by swallowing No associated photophobia, phonophobia, nausea, or vomiting
9 CASE HISTORY Physical examination: BP 150/100 mmhg Neurological examinaton: left-sided mild ptosis and miosis (Horner s syndroma) no other neurological abnormalities were found Brain CT: normal
10 DIFFERENTIAL DIAGNOSIS Headache attributed t to arterial hypertension Headache and neck pain attributed to cervical artery dissection Headache attributed to temporomandibular joint (TMJ) disorder Headache attributed to peritonsillar abscess DIAGNOSTIC TESTING Carotid Duplex Ultrasound Examination: Normal diameters of CCA and ICA (left ICA smaller). No signs of atherosclerosis, normal velocity patterns in carotid and vertebral arteries. No signs of dissection! Transcranial Doppler: normal Blood tests: within a normal range
11 A DAY LATER Persistent left-sided headache, moderate to severe, Horner s sign still present Mild fever Acute tonsillitis and otitis media lat.sin. ENT specialist: antibiotic treatment THEE DAYS LATER transient numbness and weakness in her right arm with speech disturbances, spontaneously recovered after 10 minutes transient weakness repeated two hours later and lasted 5 minutes without impairment of consciousness headache persists
12 DIFFERENTIAL DIAGNOSIS Migraine i aura TIA Epileptic p seizure DIAGNOSTIC TESTING Electroencephalogram (EEG): normal ECG: normal Echocardiogrm: normal Chest X-Ray: normal Radiography of cervical spine: normal
13 TEN DAYS LATER... Digital subtraction cerebral panangiogram: occlusion of the left ICA just above bifurcation. Repeated Carotid Duplex Ultrasound Examination confirms the absence of blood flow in left ICA, TCD shows signs of collateral circulation DSA
14 SIXTEEN DAYS LATER Brain MRI: normal MR cerebral angiography: extracranial subocclusion of left ICA! SEVERAL DAYS LATER... Carotid Duplex Ultrasound Examination: Recanalization of the left ICA with increased blood flow velocities. Medially of this flow is present hypoechogenic zone with smooth edges, 20 mm wide and several cm long. These findings suggested the re-establishment of blood flow after dissection!
15 DIAGNOSIS disekcija leve ACI Dissection of left ICA possible association of causal factors: o mild neck trauma and inflammation of the tonsil development of intramural thrombus TIA ICA occlusion early recanalization CASE 3 V.B. 75 YEARS Past medical history: A year ago he suffered from recidivant herpes zoster ophtalmicus - Keratitis herpetica recidivans- o.d. - Glaucoma simplex chronicum- o.s. Hypertension
16 PRESENT COMPLAINTS Presents with two-day history of constant t severe pain in the right temporal area, mostly dull, sometimes throbbing No associated phenomena Painkillers were ineffective FOLLOWING DAY. Headache worsens Fever, T= 37.7 C, fatigue, mild nausea short (10 s) left eye obscurations, repeated several times Emergency department Neurological examination: normal
17 DIAGNOSTIC TESTING AT THE ED Brain CT Lumbar puncture Blood test: t ESR EMERGENCY DEPARTMENT... ESR= 82 mm/h CRP= mg/l (<8) DG: Giant cell arteritis susp.
18 PHYSICAL EXAMINATION Both superficial temporal arteries (STA) thick, tortuous, rigid, and painful on palpation with prominent pulsations Clinical suspicion on giant cell arteritis What next? Start steroids immediately Confirm diagnosis: STA color-duplex sonography Perform STA biopsy: wait for histopathology confirmation
19 ..WHAT DID WE DO? Prednisone oral 80 mg daily initiated immediately with excellent response: no headache in 1 week time Blood tests: ESR= 20 mm/h CRP= 3.5 mg/l all in 2 weeks time STA COLOR-DUPLEX SONOGRAPHY: Tortuous STA, with thickened, inflamed walls secondary to segmental dark halos on both sides in all STA branches, no occlusions Findings consistent with suspected diagnosis of GCA
20 STA color-duplex examination: Bilateral halo, diameter mm BIOPSY AND HISTOPATHOLOGY STA biopsy (right STA, ramus frontalis, 2x 0.5 cm) Monocyte inflammatory infiltration of the arterial vessel walls with few giant cells Confirms diagnosis of GCA!
21 FOLLOW UP IN 4 WEEKS Follow-up STA color- Duplex examination: halo not present or < 5 mm CASE 4 V.B. 55 years 4 months history of bitemporal headaches Past Medical History hypertension, chronic sinusitis, and a remote history of bleeding gastric ulcer Social History: He denies any tobacco, alcohol, or sedative drug use Family History: Multiple family members are known to have coronary artery disease and hypertension
22 PRESENTING SYMPTOMS Intermittent at first, aggravated with standing or sitting, resolved after lying down The headaches became progressively more severe and constant over-the-counter medications ineffective 2 months after headache onset he had occasional nausea, and a burning sensation in his scalp Headaches worsened upon coughing, sneezing Complained of memory difficulties HEADACHE RED FLAGS? New-onset headache in patient older than 50 years of age Worsening of headache with coughing Worsening cognition and memory Bilateral character of headaches Accompanying nausea
23 PHYSICAL EXAMINATION afebrile, stable vital signs normal temporal artery pulsations bilaterally Normal neurological examination Brain MRI with gadolinium: diffuse pachymeningeal (dural) thickening with diffuse meningeal enhancement DIAGNOSTIC TESTING Brain MRI with contrast
24 DIFFERENTIAL DIAGNOSIS Carcinomatous meningitis Giant cell arteritis Central nervous system Lyme disease Spontaneous intracranial hypotension Sarcoidosis DIAGNOSTIC TESTING Blood tests: normal (ESR 7 mm/h) Chest X-Ray: normal HIV, hepatitis, and Lyme serologies: negative ANA, ANCA negative CSF analysis: 3 lymptocite, glucose 4,2 mmol/l, proteins 0.60 g/l Gram stain and bacterial culture, fungal and mycobacterial cultures were negative No oligoclonal bands were detected ACE within a normal range
25 DIFFERENTIAL DIAGNOSIS Subdural empyema Spontaneous intracranial hypotension Neurosarcoidosis Cerebral venous sinus thrombosis DIAGNOSIS SPONTANEOUS INTRACRANIAL HYPOTENSION What is the most appropriate next step for this patient? Ventriculoperitoneal shunt to control intracranial pressure Cisternogram to identify area of CSF leak CT myelogram to identify area of CSF leak Strict bed rest and hydration to speed resolution of CSF leak Epidural blood patch to stop CSF leak
26 TREATMENT Our patient did not improve with bed rest and hydration We performed 2 lumbar EBPs, the second of which resulted in substantial improvement of symptoms Within 1-2 weeks he returned to work BELGRADE, MAY,
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