1. Headache With Right Upper Extremity Weakness and Dysphasia in an Adolescent Andy Jagoda, MD, FACEP Professor of Emergency Medicine Mount Sinai School of Medicine New York, New York

2. Andy Jagoda, MD, FACEP Case Presentation l0-year-old boy brought ED for evaluation of headache, aphasia, and right upper extremity weakness One half hour prior to arrival the family had been at a shopping mall when the boy suddenly grabbed his head, cried out that he had a terrible headache, and sank to the floor without striking his head. No motor activity or urinary incontinence Parents noted that he was not using his right arm. He had two episodes of forceful, projectile vomiting. Difficulty with speech

3. Andy Jagoda, MD, FACEP Case Presentation No PMH except for a heart murmur –Echocardiographically proven to be due to a bicuspid aortic valve. No history of trauma, headaches, or drug use There was no significant family history.

4. Andy Jagoda, MD, FACEP Case Presentation Alert and in moderate distress, holding his forehead in his left hand BP 116/76, P 120, RR 18, T 97.6° C No sign of trauma, pupils were equal and reactive to light, fundi had sharp disk margins, and the neck was supple and nontender. Cardiac examination I/VI systolic ejection murmur CN II -XII were normal including EOM, and no facial droop

5. Andy Jagoda, MD, FACEP Case Presentation Motor 5/5 strength in all muscles on the left side and the right leg, but there was 0/5 strength in all the muscles groups in the right upper extremity DTRs were +2 on the left: o/2 on the RUE; toes were downgoing Sensation intact; right upper extremity localized pinprick No meningeal signs The patient could understand and carry out three- step commands Speech: Difficulty with naming and with repetition

6. Andy Jagoda, MD, FACEP Case Presentation Placed in a semiprone position with his head elevated at 45 degrees, and airway management equipment was readied at the bedside ECG monitor showed normal sinus rhythm Bedside glucose determination 80 mg / dL Blood was sent for a CBC, electrolytes, BUN, Cr, glucose, and PT, PTT Urine sent for a toxicology screen STAT noncontrast head CT was ordered

7. Andy Jagoda, MD, FACEP Case Presentation The patient remained stable over the first hour in the ED except for one more episode of vomiting His aphasia persisted The arm weakness began to resolve All of the laboratory tests returned within normal limits

8. Andy Jagoda, MD, FACEP The initial ED differential diagnosis of this patient ’ s presentation includes all of the following except: A.Hemorrhagic stroke B.Embolic stroke C.Migraine headache D.Complex partial seizure

9. Andy Jagoda, MD, FACEP One of the more common focal neurologic findings reported in SAH is: A.Dilated unilateral pupil B.Unilateral facial droop C.Deviated tongue D.Dysphagia

10. Andy Jagoda, MD, FACEP Speech is usually controlled by which side of the brain?: A.Right B.Left

11. Andy Jagoda, MD, FACEP Patients presenting within on hour of symptom onset with a suspected SAH who have a negative head CT and normal CSF analysis are best managed: A.Head CT with contrast B.Emergency cerebral angiogram C.Discharged with close follow-up D.Repeat LP at 12 hours post symptom onset

12. Andy Jagoda, MD, FACEP Case Presentation: Summary 10 year old with sudden onset, severe headache and focal neurologic deficit Aphasia and hemiplegia –Indicated a lesion in the left frontal region No predisposing illnesses Normal blood sugar

13. Andy Jagoda, MD, FACEP Aphasia Aphasia: language deficit –Non-fluent (Broca ’ s): Lesion in inferior frontal gyrus Understand but difficulty with expression Associated with hemiparesis (face and UE) _ Motor weakness contributes to non-fluent speech –Fluent (Wernicke ’ s): Lesion in temporal lobe Aware but unconcerned that speech is nonsensical

14. Andy Jagoda, MD, FACEP

16. Differential Diagnosis Intracranial catastrophe –Hemorrhagic stroke –Embolic stroke –Thrombotic stroke –Neoplasm –Vasculitis CNS infection CNS infection Toxicologic emergency Toxicologic emergency Metabolic emergency Metabolic emergency Seizure Seizure Todd ’ s paralysis Todd ’ s paralysis

17. Andy Jagoda, MD, FACEP Subarachnoid Hemorrhage Mental status change / meningeal findings Focal deficits are not characteristic Aneurysms compressing CN III can result in a dilated pupil or complete CN III palsy –Parasympathetics course on the outside of CN III CT / LP diagnostic tests –May take up to 12 hours for CSF to be positive

18. Andy Jagoda, MD, FACEP Embolic Stroke in Children Cardiac valve disease Septal defects Arrhythmias Carotid / Vertebral artery dissections

19. Andy Jagoda, MD, FACEP Thrombotic Stroke Sickle cell disease Myelodysplasias / Neoplastic disease Vasospasm / vasculitis

20. Andy Jagoda, MD, FACEP Clinical Course Demerol / Phenergan for symptoms Returned from CT (2 hours post onset of symptoms) Symptoms improving / headache persisting Vomited twice Noncontrast CT read as “ normal ” Next test... ?

21. Andy Jagoda, MD, FACEP Clinical Course LP performed –Opening pressure 140 mm / H 2 O –Clear fluid / no xanthochromia –Protein and glucose normal –No cells Next test... ?

22. Andy Jagoda, MD, FACEP Decision Making Clinical presentation was not characteristic of a SAH or of a MCA stroke If SAH was a consideration, options included: –Observation and repeat LP –Angiogram

23. Andy Jagoda, MD, FACEP Clinical Course Admitted for observation Symptoms resolved overnight with normal examination in the am EEG showed no abnormalities Final diagnosis: Hemiplegic migraine 3 months later, patient had a similar episode

24. Andy Jagoda, MD, FACEP Migraine Migraine with aura Migraine without aura Complicated migraines –Auras lasting more than one hour Opthalmoplegic Hemiplegic Migraine equivalents

25. Andy Jagoda, MD, FACEP Migraine without aura At least 5 attacks fullfilling the following Durations of 4 – 72 hours Presence of at least 2 of the following: –Unilateral location –Pulsating quality –Moderate or severe intensity –Aggrevation by routine physical activity Presence of at least one of the following: –Nausea and / or vomiting –Photophobia –Phonophobia

26. Andy Jagoda, MD, FACEP Migraine with aura At least 2 attacks fullfilling the following All aura symptoms are fully reversible Aura symptoms indicate focal cerebral cortical and / or brainstem dysfunction At least 1 aura symptom develops gradually over >4 minutes or, > 2 symptoms occur in succession No one aura symptom lasts > 60 minutes Headache follows aura with a free interval of < 60 minutes

27. Andy Jagoda, MD, FACEP Migraine: Pathophysiology Vascular theory (not confirmed by blood flow studies) –Aura due to vasoconstriction –Headache due to vasodilatation Neural hypthosis –Symptoms due to abnormal function of the cerebral cortex and not due to vasospasm / dilatation –Mediated by serotonin Neurovascular hypothesis –Vasodilatation and extravasation of neuropeptides –Neurogenic inflammation

28. Andy Jagoda, MD, FACEP Hemiplegic Migraine Two types: –Familial –Non-familial (FHM) or sporadic Headache plus visual, sensory, aphasic, and or motor symptoms –Usually two aura types are present –Headache usually begins at the same time of the aura

29. Andy Jagoda, MD, FACEP Hemiplegic Migraine FHM is autosomal dominant, inherited subtype –Gene mutation within the neuronal calcium channel –Aura is generally prolonged Usually begin before age 25 Female:Male 3:1 MRA demonstrated constriction / vasodilatation Prolonged symptoms (days) and infarction have been reported

30. Andy Jagoda, MD, FACEP Hemiplegic Migraine: Treatment Serotonin receptor modulators –No studies using sumitriptan in children –Study in adolescents (12-18 years) has shown DHE and metoclopramide to be effective in 90% –Promethazine has anecdotely been advocated as the anti-emetic of choice in children Case reports suggest calcium channel blockers (verapamil) to be effective in FHM

31. Andy Jagoda, MD, FACEP Conclusions Sudden severe headache suggests a vascular etiology Strokes involving the MCA will usually involve face and arm Aphasia associated with a MCA stroke is described as “non-fluent” involving naming and difficulty with repetition (exacerbated by motor compromise) Hemiplegic migraine is a type of complicated migraine with a prolonged aura due to genetic mutation of the neuronal calcium channel Treatment of hemiplegic migraine involve serotonin modulating drugs; Ca channel blockers are a consideration