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“It’s all in your head”

This case study discusses the diagnostic imaging approach for a 28-year-old male experiencing persistent, severe headaches. Initial evaluations ruled out common causes, leading to a brain CT scan that revealed an astrocytoma. The patient's associated symptoms included nausea, dizziness, and mild cognitive changes. Subsequent MRI confirmed a low-grade glioma. The case emphasizes the importance of recognizing red flags in headache presentations and the need for timely imaging to rule out serious conditions such as brain tumors. Management involved neurosurgical intervention and corticosteroid therapy.

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“It’s all in your head”

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

  2. 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

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

  4. 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 Case of R.M.

  5. What next? • DDx? • Investigations? • Imaging? • Why?

  6. What now? • DDx? • Disposition and Management?

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

  8. 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

  9. 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)

  10. Headache Red Flags

  11. 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

  12. 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) 39-53.

  13. DDx of brain lesion • Tumour • Pus • Blood

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

  15. Astrocytoma

  16. Meningioma

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

  18. Brain Abscess (CT with contrast)

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

  20. 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

  21. 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

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