Neurology Case Based Discussion By Clare Di Bona ED Registrar Dec 2015

Case 1 Presenting Complaint: 59 yo female Awoke 10/10 frontal headache, constant Vomiting+++, photophobia++ Headache and vomiting worse on sitting forward History of Presenting Complaint: recently well, no history of trauma PMH: MVA chronic back pain. No history of headaches Regular Medications: panadeine forte, diazepam. NKDA

Case 1 Continued….. On Examination Afebrile, obs within normal limits Decreased visual field temporal aspect of R eye Tongue deviates to the right

Case 1 Continued…. Based on the history and examination develop a DDx for this patient’s headache. Describe the differential diagnosis based on the R sided hemianopia. Describe the differential diagnosis based on the R sided tongue deviation

Framework for DDx of Headache in the ED – Primary Versus Secondary Approach based on the American College of Emergency Physicians (see Tintinalli textbook ED reg office) – A Vitamin CDE approach – Murtagh approach – No right or wrong choice as long as you keep in mind the most likely, the potentially critical and know the distinguishing features!!

Primary Headaches – Migraine neuronal dysfunction rather than a vascular aetiology – Tension headache pericranial muscle tenderness and heightened sensitivity of pain pathways – Cluster. Pathophysiology unknown. Unilateral orbital, supraorbital, or temporal pain, accompanied by autonomic phenomena. Unilateral autonomic symptoms may include ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion

A Vitamin CDE Approach – Acquired traumatic brain injury MVA (young) or falls (elderly) is cause. Primary insult could include intra and extra parenchymal hemorrhages and diffuse axonal injury. Secondary insult exac by hypotention, hypoxia, fever, seizures. – Vascular SAH Epidural hematoma Subdural hematoma CVA Cavernous sinus thrombosis AV malformation Temporal arteritis Carotid or vertebral artery dissection

A Vitamin CDE Approach – Inflammatory Neuralgia, optic neuritis, iritis, sinusitis, otitis media, mastoiditis, temporal arteritis, meningitis – Trauma/Toxin Fractures: facial, base of skull Subdural haemorrhage, epidural haemorrhage CO poisoning, nitrates, withdrawal – Autoimmune: Cerebral vasculitis: giant cell, takayasu, polyarteritis nodosa, Wegner’s – Metabolic Hypoxia, hypoglycaemia, hypercapnia, high altitude cerebral oedema

A VITAMIN AB&C Approach – Infection Meningitis, encephalitis, abscess, sinusitis, dental, otitis media – Neoplastic Primary or secondary – Congenital – Degenerative: Optic Neuritis – & (and) Other/Idiopathic: – Glaucoma Post lumbar puncture – Endocrine/Electrical phaeochromocytoma

What is the significance of a temporal hemianopia? – See Ganong’s Review of Medical Physiology page 185 Figure 12-4 – GO BACK TO THE PATIENT AND RE-EXAMINE!! A single sided temporal loss of visual field doesn’t really fit!

What is the significance of the tongue deviation? Hypoglossal muscle provides motor supply to the muscles of the tongue If the tongue deviates to a side it suggests weakening of the muscle on that side

Patient update – After presenting this case to the ED consultant the signs could indicate the pathology was located in the middle cranial fossa ?venous sinus thrombosis ?CVA or SOL – Head CT with contrast was normal and she was admitted for consideration of MRI – Gen Med reg presented their patient to the consultant as having no neurology DDx viral meningitis or SDH (meant SAH). LP was NAD and the patient was discharged.