A 38-Year-Old Man With Double Vision, Numbness, and Headache

Olusegun John Oluwole, MBBS

Disclosures

July 28, 2020

Discussion


This patient has history of one or two milder headaches every 2-3 months, which suggests a possible primary headache disorder. However, the development of a more severe headache or a new headache pattern, as in this case, should always prompt consideration of and investigation for underlying secondary causes.[1]

The loss of consciousness at the onset of this patient's first episode, the headache severity, and the presence of neurologic deficits make subarachnoid hemorrhage a valid consideration. However, the absence of neck stiffness, normal plain head CT findings, and the absence of xanthochromia on CSF analysis make subarachnoid bleeding less likely.

The presence of neurologic deficits in this case should also raise concerns about acute ischemic stroke. Nevertheless, the absence of traditional cardiovascular risk factors, such as hypertension, diabetes, dyslipidemia, and heart disease, and normal brain imaging findings reasonably rule out this possibility. Normal CSF analysis does not support meningitis or encephalitis.

Head MR venography was performed to exclude cerebral venous thrombosis and showed normal outline without any filling defects in all the dura venous sinuses. Head and neck MR angiography findings were also normal and showed no evidence of aneurysmal dilatations, arterial dissections, or cranial cerebral vasculitis. After having reasonably excluded secondary causes in the differential diagnosis, a diagnosis of hemiplegic migraine was considered as most appropriate in this case.

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