by: Kaitlyn Dixon M.D.

Author: Jordan Spaude M.D.

Author: Dan Harwood M.D.

HPI:

A 63 y.o. female with PMH of migraines and chiari malformation presents with headache. Patient reports that for the past 10 days, she has had a right-sided migraine that she describes as similar in quality to her prior migraines but longer-lasting. However, at 2 PM yesterday, she experienced an acute worsening of the severity of her headache – additionally, the pain became bilateral and occipital at this time. The patient reports dizziness, nausea, and photophobia, and her husband states that the patient has been slower to respond to questions for the past day. Denies vomiting, visual changes, or fever.

Vitals: BP: 133/90 | Pulse: 71 | Temp: 98.1F | Respiratory Rate: 18 | SpO2: 99%

Neuro exam is non-focal. Patient appears tired, but responds to questions appropriately. 

Clinical Course:

Patient given Tylenol, 10 mg IV Compazine, and 1 L lactated ringers with significant improvement in symptoms. Given change in headache quality from prior migraines and acute worsening of headache, CT Head wo contrast ordered. 

CT revealed a large hemorrhagic neoplasm in the right frontal region with associated mass effect and 1.2 cm leftward midline shift resulting in obstructive hydrocephalus. Patient subsequently noted to be increasingly somnolent compared to initial presentation. Neurosurgery was emergently consulted who recommended decadron, Keppra for seizure prophylaxis, and admission to the Neuro ICU.

Headache Pearls:

The majority of headaches are due to primary headaches such as tension headache, migraine, or cluster headache. However, as 18% of patients with chief complaint of headache may be experiencing a secondary headache disorder. Many of these secondary headaches represent life-threatening emergencies such as intracranial bleeding or CNS infection. The SNOOP mnemonic is a helpful tool for remembering “red flag” headache symptoms to identify headache patients who warrant further imaging/laboratory work-up in the ED. Additionally, improvement in symptoms with medication does not decrease the likelihood of a secondary headache disorder.

Systemic: Systemic signs or conditions such as fever, weight loss, immunocompromise, HIV, cancer

Neuro: Neurologic findings including mental status changes, vision changes, seizure, confusion, or focal neuro findings on exam

Onset: Onset that is acute with progression to worst severity within minutes

Older: Older patient (50 y.o. or older) with new headache or a progressive headache

Previous: No history of previous headaches, or in a patient with history of headaches, a change in severity/symptoms/location from prior headaches

Pregnancy: Headache in pregnant or post-partum patient

References:

Ashenburg Nick, Marcolini Evadne, Hine Jason. Approach to Headache. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/rec8eRzSrPsVUiMuV/Approach-to-Headache#h.pq7xksb5a2qy. Updated October 8, 2022. Accessed December 22, 2023.

Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003;3:87–92.

Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144. doi:10.1212/WNL.0000000000006697

Author: Vincent Li M.D.

HPI

• 68 year old female with PMHx HTN, HLD, breast cancer in remission who  presents after near syncopal event
• Similar episodes this week that occurred with rising from seated position
• No chest pain, SOB, palpitations, numbness, weakness, vision or gait changes, tongue biting, urinary  incontinence
• Denied unilateral leg pain or swelling, prolonged immobilization, active cancer, prior VTE
• Pulse ox noted at 92% on RA in ED, requiring 2L to maintain O2 sat > 96%
• Physical exam is unremarkable, lungs clear

Vitals

T 98.4F, HR 99, BP 112/55, RR 18, O2 97% on 2L NC

Clinical Course

• ECG showed NSR @ 98 BPM, no ischemic ST or T changes
• Labs unremarkable except for D-dimer, which  was elevated at 5.4.
• CXR showed non-specific RLL opacity
• Bedside cardiac ultrasound showed  increased RV:LV > 1
• CTA chest showed right pulmonary artery embolism extending into lobar and  segmental branches, minimal RV dilatation, patchy R lung consolidation suggestive of infarcts vs  pneumonia, moderate R pleural effusion, and diffuse osseous metastases
• Heparin gtt started and critical care was consulted; patient ultimately admitted to the INCU for submassive PE
•  Ultimately transitioned to Eliquis and discharged on HD5 with outpatient heme/onc followup for new metastatic breast cancer

Pulmonary embolism pearls

• PE categorized as massive, submassive, and low-risk
• Massive PE: hemodynamic instability (systolic BP < 90 mmHg for > 15  minutes or SBP > 40 mmHg from baseline, or clear evidence of shock /  vasopressor requirement – treatment is intravenous thrombolytics
• Submassive PE: evidence of R heart strain (by imaging or biomarkers such as troponin, pro-bnp) without hemodynamic instability   – treatment is systemic anticoagulation with heparin or low molecular weight heparin, consider catheter based thrombolysis or clot extraction (no mortality benefit)
• Non-massive or submassive PE – oral anticoagulant, consider discharge if low risk by evidence based scoring system (such as sPESI)

References

1. Garrett, John S., and Anant Patel. “Pulmonary Embolism.” Edited by Jeremy Berberian.  Corependium, 2023, Accessed 26 Dec. 2023. 

2. Tintinalli, Judith E., et al. “Venous Thromboembolism Including Pulmonary Embolism.”  Tintinalli’s Emergency Medicine, Ninth ed., McGraw Hill, New York, 2020, pp. 389–399.

Submitted by Rahul Gupta M.D.

HPI

• 43-year-old female p/w sudden onset vertigo, nausea, vomiting, and severe R sided headache 1 hour PTA
• HA is R sided, radiates into neck
• No weakness, numbness, tingling, speech changes
• Pt notes balance issues
• States that the vertigo is positional in nature.

Physical Exam

Vitals: BP 210/89, P 75, RR 18, SPO2 98%

• Neuro exam: Cn II-XII intact, motor strength normal, normal finger to nose, no nystagmus noted
• Gait was unable to be assessed secondary to vertigo

DDx

• subarachnoid hemorrhage, posterior circulation stroke, primary headache, vertebral artery dissection, peripheral vertigo

Case course

• A stroke alert was called
• CTA Head and neck demonstrated R vertebral artery occlusion. MRI demonstrated an acute infarct of the cerebellar vermis.

Pearls:

• Initial work-up of vertigo is stratifying between central and peripheral vertigo. The below table provides general patterns for both, but this is variable in nature.

• HINTS exam should be performed only when patient has persistent vertigo, nystagmus, and a normal neurological exam. When used correctly and performed appropriately, the HINTS exam has impressive sensitivity (100%) and specificity (96%) for posterior circulation stroke as compared to MRI
• See the HINTS exam in action here:

• The Dix-Hallpike maneuver can be performed if BPPV is in the differential. Dix-Hallpike is only 50-85% sensitive for BPPV. If positive, consider the Epley Maneuver for treatment.
  • Consider teaching the patient the maneuver if they find relief after the Epley maneuver.
  • Other treatments for peripheral vertigo include:
    • 1^st line: Diphenhydramine 25-50mg IM/IV/po q4hr, Meclizine 25mg po QID
    • 2nd line: Diazepam 2-10 mg po/IV q4h-q8h, Lorazepam 0.5-2mg po/IM/IV q4h-q8h

References

1. Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493
2. Kuo CH, Pang L, Chang R. Vertigo – part 1 – assessment in general practice. Aust Fam Physician. 2008;37(5):341-7
3. Newman-Toker, D. E., Kattah, J. C., Alvernia, J. E., & Wang, D. Z. (2008). Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology, 70(24 Pt 2), 2378–2385. https://doi.org/10.1212/01.wnl.0000314685.01433.0d
4. Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81