Transcript The differential for thunderclap headaches Neurology Resident

The differential for thunderclap
headaches
Neurology Resident Teaching Series
-itis, -oma, -emia
-itis ----- inflammation
-oma ----- mass effect
-emia ----- vascular
Other
-itis, -oma, -emia
-itis
CNS vasculitis
-oma
Colloid cyst (third ventricle)
Pituitary apoplexy
-emia
Cervical artery dissection
Cerebral venous sinus thrombosis
Hypertensive encephalopathy
Subarachnoid hemorrhage or Sentinel hemorrhage
Reversible cerebral vasoconstriction syndrome
Other
Migraine
Primary thunderclap headache
Spontaneous intracranial hypotension
permanent neurologic deficit
-itis
CNS vasculitis
-oma
Colloid cyst (third ventricle)
Pituitary apoplexy
-emia
Cervical artery dissection
Cerebral venous sinus thrombosis
Hypertensive encephalopathy
Subarachnoid hemorrhage or Sentinel hemorrhage
Reversible cerebral vasoconstriction syndrome
Other
Migraine
Primary thunderclap headache
Spontaneous intracranial hypotension
sudden or rapid death
-itis
CNS vasculitis
-oma
Colloid cyst (third ventricle)
Pituitary apoplexy
-emia
Cervical artery dissection
Cerebral venous sinus thrombosis
Hypertensive encephalopathy
Subarachnoid hemorrhage or Sentinel hemorrhage
Reversible cerebral vasoconstriction syndrome
Other
Migraine
Primary thunderclap headache
Spontaneous intracranial hypotension
Diagnostic testing
-itis
CNS vasculitis ----- CT, MR, or conventional angiography, +/- brain biopsy
-oma
Colloid cyst (third ventricle) ----- CT or MRI Head (third ventricle cyst, lateral ventricle dilation)
Pituitary apoplexy ----- CT or MRI Head (hemorrhage)
-emia
Cervical artery dissection ----- CT, MR, or conventional angiography
Cerebral venous sinus thrombosis ----- CT or MR venography +/- MRI Head (edema, ischemia, hemorrhage)
Hypertensive encephalopathy ----- MRI Head (CT is insensitive)
Subarachnoid hemorrhage or Sentinel hemorrhage ----- CT Head, +/- Lumbar puncture
Reversible cerebral vasoconstriction syndrome ----- MRI Head +/- MRA Head
Other
Migraine ----- normal clinical examination
Primary thunderclap headache ------ normal clinical examination
Spontaneous intracranial hypotension ----- lumbar puncture, +/- MRI Head (pachymeningeal enhancement)
Summary
• Thunderclap headaches can be categorized by basic pathologic mechanisms: -itis
(inflammation), -oma (mass), and -emia (vascular).
• Some thunderclap headaches result in permanent neurologic damage, whether by
ischemia, hemorrhage, or mass effect. It is important to exclude these possibilities before
settling on a benign diagnosis.
• Subarachnoid hemorrhage and third ventricle occlusion by a colloid cyst can rapidly
progress to death.
• Advanced diagnostic imaging can be useful in confirming or excluding diagnoses for
thunderclap headache.