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“It’s all in your head”
Kyle McLaughlin
Sept. 1, 2005
Diagnostic Imaging Rounds
Case of R.M.
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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
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Nausea
Dizziness
Vague diplopia
Word finding
difficulties
– Mild personality
change
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PMHx- healthy
Meds- none, NKDA
FHx- unremarkable
P/E:
– Unremarkable
except poor R sided
Upper Extremity
Cerebellar testing
What next?
• DDx?
• Investigations?
• Imaging?
– Why?
What now?
• DDx?
• Disposition and Management?
Case of R.M.
• 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
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 Red Flags
Headache Red Flags
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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
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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) 39-53.
DDx of brain lesion
• Tumour
• Pus
• Blood
Tumour
• Adults
– Infratentorial:
• Mets (20-30%)
• Schwannoma (6%)
– Supratentorial:
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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 (CT with
contrast)
Blood
• 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
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