Challenging Cases
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CHALLENGING CASES Neurology Richard Leigh, MD
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Neurology. Challenging Cases. Richard Leigh, MD. Post P artum Headache I. 34 y/o healthy woman 3 days post partum after an uncomplicated delivery with epidural anesthesia develops headache, photophobia, neck stiffness On exam she has papilledema and constricted visual fields. - PowerPoint PPT Presentation
Transcript of Challenging Cases
CHALLENGING CASESNeurology
Richard Leigh, MD
Post Partum Headache I
34 y/o healthy woman 3 days post partum after an uncomplicated delivery with epidural anesthesia develops headache, photophobia, neck stiffness
On exam she has papilledema and constricted visual fields.
Post Partum Headache I
Differential Diagnosis: Cerebral venous sinus thrombosis Reversible vasoconstriction syndrome (RCVS) Preeclampsia/eclampsia Pituitary apoplexy Benign intracranial hypertension Post dural puncture headache Carotid or vertebral artery dissection Meningitis/Encephalitis ICH/SAH
Post Partum Headache I
MRI shows: Subdural Hematoma
Post Partum Headache II
35 y/o healthy woman 10 days post partum after an uncomplicated delivery of twins with epidural anesthesia develops presents with headache which is worse when she stands up.
On exam she has no papilledema and is neurologically intact.
Post Partum Headache II
MRI shows: Pachymeningeal Enhancement
Post Partum Headache II
She was diagnosed with a post LP headache and treated conservatively. Thecal sac was likely disrupted during
the placement of her epidural Headache persisted and she
represented 10 days later with worsening headache
Post Partum Headache II
MRI shows: Subdural Hematomas
Post Partum Headache II
Two weeks later she was presented with recurrent headache, now worse when she lay down.
On exam she had double vision with lateral gaze and papilledema on fundascopic exam
MRI unchanged Started on acetazolamide (diamox)
with improvement in her headache
Post Partum Headache I & II Puncture of the thecal sac prior to
delivery Over draining of the CSF during delivery Post paratum hypotension leading to SDH Resolution of the CSF leak leading to
increased intracranial pressure due to too much contents in the cranial vault
Responded to CSF production inhibition With resolution of the SDH they were
weaned off of the acetazolamide .
The Pressure Dependent Exam 55 y/o gentleman with a h/o
hypertension presents after 24 hours of fluctuating left arm weakness
On exam his left arm drifts down; but when the head of the bed is put flat, his arm comes back up!
The Pressure Dependent Exam
DWI ADC FLAIR
The Pressure Dependant Exam
DWI PWI - TTP FLAIR
The Pressure Dependant Exam
TOF - MRA SWI SWI mIPs
The Pressure Dependant Exam
Perfusion Quantified
The Pressure Dependant Exam – One Week Later
DWI FLAIR PWI - TTP
The Pressure Dependant Exam
Perfusion Quantified
Hypertensive Crisis
66 y/o gentleman with a h/o hypertension and hyperlipidemia presents with confusion and headache.
With systolic blood pressures in the 200’s he was confused with a mild left arm weakness.
Hypertensive Crisis
MRI showed: PRES (posterior reversible encephalopathy syndrome)
Hypertensive Crisis - PRES Differential Diagnosis
HTN Renal Disease Pregnancy/eclampsia Autoimmune disease Chemotheraputics Immunosuppressants Porphyria
Hypertensive Crisis - PRES Started on a
nicardipine drip for blood pressure control
Became acutely hemiplegic on the left side when SBP cam below 150
Hypertensive Crisis – PRES with MCA occlusion
Angiogram confirmed complete occlusion of the right middle cerebral artery.
PRES due to HTN from an M1 stenosis with a pressure dependant exam
DWI PWI – TTP FLAIR
Wake-up Stroke Case
DWI ADC FLAIR
67 y/o gentleman with h/o CAD, HTN, Tobacco use presents to an OSH after waking with left sided weakness, last known normal puts him out of an IV tPA window thus he is tranfered to JHH for IA therapy. Hyper acute MRI reveals:
Wake-up Stroke Case
PWI ADC FLAIR
Qualitative assessment of the DWI/PWI reveals:Target mismatch?
Wake-up Stroke Case
PWI ADC FLAIR (Olea Overlay)
Using Olea Sphere software (formerly Perfscape), ADC volume (<600) and Tmax volume (<6 secs) is overlaid on the FLAIR. SIR values can also be generated using the ADC ROI. Olea images are going to be uploaded to PACs.
Wake-up Stroke Case
Volumetrics reveal: DWI volume of 13cc 6 sec PWI deficit of 67cc 10sec PWI deficit of 40cc Mismatch Ratio 5.15 Target Profile!
Patient taken for IA thrombectomy using the stentriever device with successful recanalization of the right MCA.
Patient walked out of the hospital with only a mild residual weakness of the left arm (4/5)
