Case presentation

醫學七 蕭皓天 8831121

Supervisor 許明欽醫師

Basic data

Name ：羅 X 化 Age ： 43 y/o Gender ： male Dominant ： Right hand Admission date ： 94/10/20

Chief complaints

Severe headache for 1 months with progression

Present illness

Well before One month ago ： occipital headach

e suddenly after sitting up for 10 mins.

Present illness

Accentuated ： upright position Relieved ： recumbent Timing ： seconds or minutes after

sitting or standing Severity ： made him didn’t like to

get up from bed

Present illness

Frequency ： every times when upright position

Quality ： throbbing No aura, no photophobia, no phonop

hobia

Present illness

9/19 ： Our ER, brain CT ： normal Recent one week ： more severe, ext

ended to vertex Nausea, vomiting and hiccup 10/20 ： Dr. 許’ s OPD Admission

Social History

Smoking ： 1 ppd/day Alcohol (-) Betal nut (-)

Other History

Hypertension (-) Diabetes mellitus (-) Operative history (-) Head traumatic history (-) Lumbar puncture history (-) Allergy ： nil Family history ： not contributory

Physical examination Moderate nutritional and well-developed,

looks inpatient, irritant and general weakness

T/P/R ： 36.3C, 80/min, 18/min, BP ：134/77 mmHg

HEENT ： normal Neck ： no bruit, no jugular vein

engorgement, no thyroid enlargement

Physical examination

Chest ： no chest wall deformity, clear BS

Heart ： regular heart beat, no murmur Abdomen ： soft, flat, no tender, norm

oactive bowel sound Extremities: no cyanosis, no pitting ede

ma

Neurological examination

Consciousness ： alert, oriented No overt high cortical dysfunction Cranial nerve ： intact Eye ： no papilledema Neck ： supple, no Kernig sign, no Bru

dzinski sign

Neurological examination Pyramidal system:

No atrophy Muscle power ： Full MRC grading bilateral

ly Symmetric normoreflexia No pathologic long tract sign

Extrapyramidal system: No rigidity, no spasticity, no tremor

Sensory system ： intact

Neurological examination

Cerebellum ： Finger to nose: Smooth Romberg test: Stable, tandem gait ： ok

Autonomic system ： palpitation(-), nausea(+), vomiting(+),

constipation(-), diarrhea(-) No sphincter dysfunction

Lab data

GPT/ALT 108 IU/L BUN 24 mg/dl TCH 227 mg/dl LDL-C 167 mg/dl TG 237 mg/dl

Headache

What kind of headache suggests a serious underlying

disorder ?

Headache Symptoms That Suggest a Serious Underlying Disorder

"Worst" headache ever First severe headache Subacute worsening over days or weeks Abnormal neurologic examination Fever or unexplained systemic signs Vomiting precedes headache Induced by bending, lifting, cough Disturbs sleep or presents immediately upon awak

ening Known systemic illness Onset after age 55

Headache presents as above indicates intra-cranial tumor, hemorrhage (Ex.SAH)meningitis…etc

Tentative diagnosis

Acute orthostatic headache

Isolated orthostatic headache DDx Intracranial hypotension CSF volume depletion - spontaneous most likely ！ - dural puncture - surgery - penetrating trauma Colloid cyst of 3rd ventricle Brain CT(-)

After admission…

MRI was arranged immediately

10/20 Brain MRI T1WI (isointensity)

10/20 Brain MRI T2WI (hyperintensity)

Brain CT 9/19 vs 10/21

Clinical course

Subdural hemorrhage diagnosed by neuroimage

=> Neurosurgeon suggested operation He and his family refused

Discharged against advice on 94/10/21

Question 1

According to the clinical picture, spontaneous intracranial hypotension leading to bil. SDH was suspected, were

there similar cases in the world ？

Intracranial hypotension

A generalized sagging of the brain with downward displacement of the cerebellar tonsils

Downward displacement leads to bringing vein break SDH

Syndrome of orthostatic headaches and diffuse pachymeningeal gadolinium enhancement. Mayo Clinic Proceedings, 72:400-413, 1997.

Patients had diffuse meningeal enhancement, 69% had evidence of subdural CSF collections and 62% showed a descent of the brain

31 y/o male, previously healthy Headache ： occipito-parieto-temporal Accentuated ： upright position Relieved ： recumbent Getting worse and worse, nausea, vomit

ing NE, lab ： normal

Subdural effusion

Diffuse dural thickening

with enhencement

CSF ： low pressure (10cm H2O) SIH was diagnosed Consciousness↓, epidural blood

patch and surgical drainage was performed

Consciousness recovered and headache subsided

.

Spontaneous intracranial hypotension associated with bilateral chronic subdural hematomas – Case report Neurol Med Chir (Tokyo). 2000 Sep;40(9):484-8. 34-year-old female ： severe postural

headache and meningism. MRI ： diffuse pachymeningeal enhan

cement. Bil. chronic SDH 4 weeks after the ons

et of the symptoms. MRI showed descent of the midline structures of the brain.

Spontaneous intracranial hypotension associated with bilateral chronic subdural hematomas – Case report Neurol Med Chir (Tokyo). 2000 Sep;40(9):484-8.

An uncommon and probably unrecognized condition, because of the usually benign course.

However, SIH is not entirely benign.

Spontaneous intracranial hypotension associated with bilateral chronic subdural hematomas – Case report Neurol Med Chir (Tokyo). 2000 Sep;40(9):484-8.

SIH should be considered no identifiable risk for ICH, particularly in young patients.

Neurosurgical intervention may be required for the underlying cerebrospinal fluid leak and subdural effusion

Question 2

Why MRI was performed first ？

Intracranial hypotension

Diffuse meningial thickening - Compensatory venous engorgement secondary to the chronically low CSF volume▲ Subdural effusions

CT versus MRI CT ： very limited value. Usually normal a

nd only quite infrequently may show subdural fluid collections or increased tentorial enhancement

Sensitivity 85%, specificity 65% MRI ： diffuse pachymeningeal enhanceme

nt, which is the most common MRI abnormality.

Sensitivity > 95%, specificity > 90%

Level II

Return to our patient MRI was important for diagnosis of intr

a-cranial hypotension There were several cases like this patie

nt in the world Spontaneous intra-cranial hypotension

’s prognosis is good. It’s a pity that he re

fused further treatment such as epidural patch and operation

Question 3

Should our ER perform CT ？

In patients with atypical headache patterns, a history of seizures, or focal neurologic signs or symptoms, CT or MRI may be indicated Class III

Historical or physical abnormalities are not sensitive for intracranial process, but abnormal physical or historical findings increase the likelihood of positive CT findings

Class II

Study supports the importance of a neurologic examination; however, 29 of 34 Patients with focal findings didn’t have positive CT findings, and 4% of patients with normal neurologic examination findings had positive CT results Class II

Clinical findings and historical findings had a low positive predictive value but absence had a high negative predictive value Class II

Conclusion

Atypical headache with either abnormal physical, neurologic, historical findings or a history of seizures CT or MRI was indicated

CT was not very essential for this patient

Comment 李宜恭主任： SIH 診斷的 golden standard ？ Ans ： Lumbar puncture. 許明欽醫師：這個病人為什麼沒有做，是因為

本來打算在手術完之後，做 lumbar puncture確立診斷，同時加做 cisternography 來判斷到底是哪裡在漏 CSF ？ ( 不先做 lumbar puncture 是擔心有 herniation 的危險性 ) 只是病人要求出院，這些 study 工作才未完成。

Comment 李宜恭主任：對這個病人來說，做 CT 還

是有必要，因為他還是符合危險頭痛其中幾項，在沒辦法完全排除出血或腫瘤的前提下，做 CT 是可接受的。而且這個病人症狀有緩解 ( 休息和 bed rest 本來就會讓病人覺得恢復 ) ，沒有繼續留下來觀察尚屬合理。

Comment 許明欽醫師：大多數 SIH 會自己好，因

此 ER 讓病人出院是合理處置。重點還是在於病人症狀有減輕，影像學又沒有 finding 。

Comment Int. 傅斯誠： bil. SDH 在什麼情形下會

發生？ 許銘欽醫師：通常還是以 trauma 最常

見。

Thanks ！