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The differential for thunderclap headaches

The differential for thunderclap headaches. Neurology Resident Teaching Series. -itis, -oma, -emia. -itis ----- inflammation -oma ----- mass effect -emia ----- vascular Other. -itis, -oma, -emia. -itis CNS vasculitis -oma Colloid cyst (third ventricle)

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The differential for thunderclap headaches

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  1. The differential for thunderclap headaches • Neurology Resident Teaching Series

  2. -itis, -oma, -emia • -itis ----- inflammation • -oma ----- mass effect • -emia ----- vascular • Other

  3. -itis, -oma, -emia • -itis • CNS vasculitis • -oma • Colloid cyst (third ventricle) • Pituitary apoplexy • -emia • Cervical artery dissection • Cerebral venous sinus thrombosis • Hypertensive encephalopathy • Subarachnoid hemorrhage or Sentinel hemorrhage • Reversible cerebral vasoconstriction syndrome • Other • Migraine • Primary thunderclap headache • Spontaneous intracranial hypotension

  4. permanent neurologic deficit • -itis • CNS vasculitis • -oma • Colloid cyst (third ventricle) • Pituitary apoplexy • -emia • Cervical artery dissection • Cerebral venous sinus thrombosis • Hypertensive encephalopathy • Subarachnoid hemorrhage or Sentinel hemorrhage • Reversible cerebral vasoconstriction syndrome • Other • Migraine • Primary thunderclap headache • Spontaneous intracranial hypotension

  5. sudden or rapid death • -itis • CNS vasculitis • -oma • Colloid cyst (third ventricle) • Pituitary apoplexy • -emia • Cervical artery dissection • Cerebral venous sinus thrombosis • Hypertensive encephalopathy • Subarachnoid hemorrhage or Sentinel hemorrhage • Reversible cerebral vasoconstriction syndrome • Other • Migraine • Primary thunderclap headache • Spontaneous intracranial hypotension

  6. Diagnostic testing • -itis • CNS vasculitis ----- CT, MR, or conventional angiography, +/- brain biopsy • -oma • Colloid cyst (third ventricle) ----- CT or MRI Head (third ventricle cyst, lateral ventricle dilation) • Pituitary apoplexy ----- CT or MRI Head (hemorrhage) • -emia • Cervical artery dissection ----- CT, MR, or conventional angiography • Cerebral venous sinus thrombosis ----- CT or MR venography +/- MRI Head (edema, ischemia, hemorrhage) • Hypertensive encephalopathy ----- MRI Head (CT is insensitive) • Subarachnoid hemorrhage or Sentinel hemorrhage ----- CT Head, +/- Lumbar puncture • Reversible cerebral vasoconstriction syndrome ----- MRI Head +/- MRA Head • Other • Migraine ----- normal clinical examination • Primary thunderclap headache ------ normal clinical examination • Spontaneous intracranial hypotension ----- lumbar puncture, +/- MRI Head (pachymeningeal enhancement)

  7. Summary • • Thunderclap headaches can be categorized by basic pathologic mechanisms: -itis (inflammation), -oma (mass), and -emia (vascular). • • Some thunderclap headaches result in permanent neurologic damage, whether by ischemia, hemorrhage, or mass effect. It is important to exclude these possibilities before settling on a benign diagnosis. • • Subarachnoid hemorrhage and third ventricle occlusion by a colloid cyst can rapidly progress to death. • • Advanced diagnostic imaging can be useful in confirming or excluding diagnoses for thunderclap headache.

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