The differential for thunderclap headaches
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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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The differential for thunderclap headaches

The differential for thunderclap headaches

  • Neurology Resident Teaching Series


Itis oma emia

-itis, -oma, -emia

  • -itis ----- inflammation

  • -oma ----- mass effect

  • -emia ----- vascular

    • Other


Itis oma emia1

-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


  • Permanent neurologic deficit

    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


  • Sudden or rapid death

    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


  • Diagnostic testing

    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)


  • Summary

    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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