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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
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.