“It’s all in your head” Kyle McLaughlin Sept. 1, 2005 Diagnostic Imaging Rounds Kyle McLaughlin Sept. 1, 2005 Diagnostic Imaging Rounds

Case of R.M. 28 M, 3 mos Hx of Headache Headache: diffuse, constant, 4-10/10 No previous Hx of H/A Tx for HTN and migraine with no success Booked for H/A clinic by Family MD 28 M, 3 mos Hx of Headache Headache: diffuse, constant, 4-10/10 No previous Hx of H/A Tx for HTN and migraine with no success Booked for H/A clinic by Family MD

Case of R.M. What else do you want to know?

Case of R.M. H/A worse with lying down, late at night and early a.m. Assoc. Sx –Nausea –Dizziness –Vague diplopia –Word finding difficulties –Mild personality change H/A worse with lying down, late at night and early a.m. Assoc. Sx –Nausea –Dizziness –Vague diplopia –Word finding difficulties –Mild personality change PMHx- healthy Meds- none, NKDA FHx- unremarkable P/E: –Unremarkable except poor R sided Upper Extremity Cerebellar testing PMHx- healthy Meds- none, NKDA FHx- unremarkable P/E: –Unremarkable except poor R sided Upper Extremity Cerebellar testing

What next? DDx? Investigations? Imaging? –Why? DDx? Investigations? Imaging? –Why?

What now? DDx? Disposition and Management? DDx? Disposition and Management?

Case of R.M. Diagnostic Imaging: –CT head- Dx with astocytoma –MRI- low grade glioma Diagnostic Imaging: –CT head- Dx with astocytoma –MRI- low grade glioma

Case of R.M. Transferred to Neurosurgery, started on Dexamethasone Craniotomy for excision of brain tumour 3 days later Negative culture Biopsy result: primitive neuroepithelial tumour Transferred to Neurosurgery, started on Dexamethasone Craniotomy for excision of brain tumour 3 days later Negative culture Biopsy result: primitive neuroepithelial tumour

Headaches and Brain Tumours Headache present in 50-60% of brain tumours Pain secondary to: –Vessel traction, distention and dilation –Direct pressure on CN with pain afferents –Inflammation around pain sensitive structures (venous sinuses, portion of the dura, dural arteries, cerebral arteries) Headache present in 50-60% of brain tumours Pain secondary to: –Vessel traction, distention and dilation –Direct pressure on CN with pain afferents –Inflammation around pain sensitive structures (venous sinuses, portion of the dura, dural arteries, cerebral arteries)

Headache Red Flags

New or changed Exertional Onset at night or early a.m. Progressive in nature Fever or systemic Sx Meningismus Neuro Sx Valsalva maneuver worsens Age: New onset >50 y.o. or in children New or changed Exertional Onset at night or early a.m. Progressive in nature Fever or systemic Sx Meningismus Neuro Sx Valsalva maneuver worsens Age: New onset >50 y.o. or in children

Conditions to Rule Out Space occupying lesion Meningitis, encephalitis Stroke Subarachnoid hemorrhage Systemic illness (thyroid, HTN, pheochromocytoma, etc.) Temporal arteritis Traumatic head injuries Serious ophthalmologic and otolaryngologic etiology Purdy, A., Kirby, S. Headaches and brain tumours. Neuro Clin Am 22 (2004) Space occupying lesion Meningitis, encephalitis Stroke Subarachnoid hemorrhage Systemic illness (thyroid, HTN, pheochromocytoma, etc.) Temporal arteritis Traumatic head injuries Serious ophthalmologic and otolaryngologic etiology Purdy, A., Kirby, S. Headaches and brain tumours. Neuro Clin Am 22 (2004)

DDx of brain lesion Tumour Pus Blood Tumour Pus Blood

Tumour Adults –Infratentorial: Mets (20-30%) Schwannoma (6%) –Supratentorial: Astrocytoma (40-50%) Mets (20-30%) Meningioma (15%) Oligodendroglioma (5%) Adults –Infratentorial: Mets (20-30%) Schwannoma (6%) –Supratentorial: Astrocytoma (40-50%) Mets (20-30%) Meningioma (15%) Oligodendroglioma (5%)

Astrocytoma

Meningioma

Pus Brain abscess –Local spread (i.e. OM, mastoiditis, sinusitis) –Hematogenous spread (i.e. immunosuppressed, lung abscess, empyema) –Dural disruption –Granuloma (TB, sarcoid) Brain abscess –Local spread (i.e. OM, mastoiditis, sinusitis) –Hematogenous spread (i.e. immunosuppressed, lung abscess, empyema) –Dural disruption –Granuloma (TB, sarcoid)

Brain Abscess (CT with contrast)

Blood Hematoma/hemorrhage –Epidural, subdural, SAH, etc. Vascular Abnormality –Aneurysm, AV malformation Ischemic cerebral infarction Hematoma/hemorrhage –Epidural, subdural, SAH, etc. Vascular Abnormality –Aneurysm, AV malformation Ischemic cerebral infarction

Indications for imaging in headache Sudden onset of “worst h/a of life” New h/a in HIV + A h/a that: –Worsens with exertion –Assoc with decreased alertness or mental status change –Awakens from sleep –Changes in pattern over time –Assoc with papilledema –Assoc with focal neurological deficit Mettler: Essentials of Radiology, 2nd ed, 2005 Sudden onset of “worst h/a of life” New h/a in HIV + A h/a that: –Worsens with exertion –Assoc with decreased alertness or mental status change –Awakens from sleep –Changes in pattern over time –Assoc with papilledema –Assoc with focal neurological deficit Mettler: Essentials of Radiology, 2nd ed, 2005

Imaging choices CT –More accessible, quicker –Good initial scan in ruling out many etiologies (i.e.hemorrhage) MRI –Superior soft tissue contrast –Good for further differentiation of: Brain tumour Undiagnosed intracranial lesions CT –More accessible, quicker –Good initial scan in ruling out many etiologies (i.e.hemorrhage) MRI –Superior soft tissue contrast –Good for further differentiation of: Brain tumour Undiagnosed intracranial lesions