“Troubling headache….” Case Conclusion June 6, 2012
Posted by Andy Jagoda, MD in: Neurologic, Radiology , add a comment
Your second patient was more concerning. Although she had a known primary headache disorder, she described several red-flag features, including nuchal rigidity and pain worst at onset. You recalled a popular headache review paper that highlighted the danger of assuming all headaches in patients with known migraines are benign. You decided to order neuroimaging and, while waiting, moved on to another patient.
Later as you were printing out the discharge paperwork for some other patients, you examined the CT head from your first patient and were surprised to find blood in the basal cisterns. You took a deep breath – thankfully, you did not just refill her prescription.
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Troubling headache…. May 30, 2012
Posted by Andy Jagoda, MD in: Neurologic, Radiology , 28 comments
Your first patient of the day is a 46-year-old female with a history of migraine headaches who presents with a severe, constant pain that started suddenly while running. She admits this “feels different than my normal headaches.” On examination, she appears ill and is vomiting. Her neurologic examination demonstrates mild neck stiffness. She asks for a refill of her sumatriptan, which “always works for my headaches.” While she has a known primary headache disorder, the features of her headache are concerning.
What do you do next?
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“Something doesn’t add up…” Case Conclusion April 6, 2012
Posted by Andy Jagoda, MD in: Cardiovascular, Neurologic, Trauma , add a comment
The Conclusion Is…
A subdural or epidural hematoma would have to be extensive to cause hemiparesis, hemisensory loss, and neglect. A Todd paralysis after seizure was possible, but was considered only after ischemic causes were ruled out. Since the initial noncontrast head CT showed a small subdural hematoma, ischemic stroke was the next most-worrisome possibility. Concern for dissection should be raised when ischemic stroke is considered in the setting of trauma. A CTA was obtained that showed near occlusion of the right internal carotid artery. IV tPA was not administered for this traumatic dissection for concern of worsening or creating hemorrhagic complications. Interventional neuroradiology was consulted immediately, and the patient was placed on a heparin infusion as a bridge to the procedure. Stenting of the vessel was performed, and though it was not successful in reversing her neurological deficits, it may have prevented further ischemic damage.
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Something doesn’t add up… March 26, 2012
Posted by Andy Jagoda, MD in: Cardiovascular, Neurologic, Trauma , 31 comments
A 29-year-old woman is brought in by EMS after a motor vehicle accident in which she was an unrestrained driver. She was found by the medics lying across the steering wheel with a large gash on her forehead. At the scene, she was awake, but disoriented, and there was a strong odor of alcohol on her breath. Her ED assessment revealed a small right-sided subdural hematoma and a zygoma fracture. Her serum ETOH level was 260 dL/mL, and she was placed under observation status on the trauma service. Six hours later, she becomes agitated and then rapidly develops left-sided weakness and neglect. Your first thought is that she must have had a seizure and is left with a Todd paralysis . . . but it doesn’t quite add up, and you wonder what else might have happened.
Is there anything you should be doing?
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