Sudden Headache Sudden Headache and Unresponsivenessand Unresponsiveness
in a 10 year-old boyin a 10 year-old boy
J. Stephen Huff, MD, FACEPEmergency Medicine and NeurologyUniversity of Virginia Health System
Charlottesville, Virginia
J. Stephen Huff, MD
Case presentation…
A 10 year old young man was having breakfast with his family. He complained of sudden onset of headache, walked to his mother, and became unresponsive. His father (a physician) said that he was unresponsive except for muttering incomprehensible words when stimulated. No abnormal movements were noticed.
J. Stephen Huff, MD
Case presentation…
Father carried the child to his car and drove him to the emergency department. The child arrived in the emergency department with diminished level of consciousness but with eyes open. He would not follow commands or speak but would look briefly at the examiner when questioned….
J. Stephen Huff, MD
Case presentation…
Pulse was 50; BP 100/62; temperature 36.3; oxygen saturation 99%. Pupils were equal, mid-position, and responsive to light. Gaze tended to be downward. The boy would withdraw the extremities to painful stimulation; muscle tone seemed diminished. He did not speak but would briefly look at people in the room….
J. Stephen Huff, MD
What is your differential diagnosis?What is your differential diagnosis?
Anatomic?
Pathophysiologic?
Etiologic?
J. Stephen Huff, MD
What is your differential diagnosis?What is your differential diagnosis?
Pathophysiologic / Etiologic?
Subarachnoid hemorrhage
Intracranial hemorrhage
J. Stephen Huff, MD
What is your differential diagnosis?What is your differential diagnosis?
What is causing the lesion?
Aneurysm?
Arteriovenous malformation?
Leukemia / blood dyscrasia?
Medications?
Tumor?
J. Stephen Huff, MD
What is your management plan?What is your management plan?
Stabilization
A, B, C’s
Diagnostic plan?
J. Stephen Huff, MD
What is your management plan?What is your management plan?
Stabilization
A, B, C’s
Diagnostic plan?
Physician accompanies patient to CT with proper equipment…
J. Stephen Huff, MD
J. Stephen Huff, MD
What is your CT diagnosis?
J. Stephen Huff, MD
Cerebellar hemorrhage
J. Stephen Huff, MD
What is your management plan?What is your management plan?
Stabilization
A, B, C’s….
What now?
J. Stephen Huff, MD
CT: Cerebellar hemorrhageCT: Cerebellar hemorrhage
Clinical--
Risk of sudden deterioration
brainstem compression
“Neurosurgical emergency”…
J. Stephen Huff, MD
Cerebellar hemorrhageCerebellar hemorrhage
May be life threatening…
Expanding mass posterior fossa…
Brainstem compression…
Sudden coma and apnea…
Salvage possible…
Lateral (hemispheric) better…
J. Stephen Huff, MD
What is your management plan?What is your management plan?
Stabilization
A, B, C’s….
Neurosurgical consultation…
PICU….
J. Stephen Huff, MD
J. Stephen Huff, MD
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Posterior fossa AVM
Origin- R superior cerebellar artery
Drain-hemispheric veins
Options ?
J. Stephen Huff, MD
What is your management plan?What is your management plan?
Inpatient course…
Diminished level of consciousness
Repeat CT-hydrocephalus
J. Stephen Huff, MD
Inpatient courseInpatient course
Ventriculostomy….
Resection of AVM…
Good clinical outcome….
J. Stephen Huff, MD
DDX: Pediatric intracranial DDX: Pediatric intracranial hemorrhagehemorrhage
Aneurysms
Blood dyscrasias
Tumors
Medications
Arteriovenous malformations
J. Stephen Huff, MD
Brain slice showing cross-Brain slice showing cross-section of large AVMsection of large AVM
J. Stephen Huff, MD
Brain slice showing intraparenchymal Brain slice showing intraparenchymal hemorrhage from AVMhemorrhage from AVM
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Tangle of abnormal arteries and veins
Linked by fistulas
High-flow AV shunting
Lacks capillary bed
Congenital
Course not predictable….
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Variety of architectures
Some small, close to surface
Others large, wedge-shaped
straddle vascular border zones
extend to ventricular wall
Associated aneurysms - about half
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Present before age 40
Only 12% symptomatic
2% of strokes“Advances in…therapy…have come at a faster
pace than information on the natural history…associated morbidity…and risks of invasive therapies.”
The Arteriovenous Malformation Study Group: Arteriovenous malformations of the brain in adults. N Engl J Med. 1999;340:1812-8.
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Presentations
Hemorrhage most common
Seizures
Partial
Generalized
Headache - nonspecific
Focal neurologic deficitsThe Arteriovenous Malformation Study Group: Arteriovenous malformations of
the brain in adults. N Engl J Med. 1999;340:1812-8.
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Re-hemorrhage
-18% risk (vs. 2%) annual risk
-may decline with time
Posterior fossa AVM’s
-about 7-18% of all AVM’s
higher hemorrhage risk?
higher morbidity?Symon L, et al: Arteriovenous malformations of the posterior fossa: a report on
28 cases and review of the literature. Brit J Neurosurg. 1995; 9:721
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Treatment - (or not?)
Surgery
if superficial, non-eloquent
Interventional radiology
coils, glues, balloons
Radiation therapy, gamma-knife
Aminoff MJ: Treatment of unruptured cerebral arteriovenous malformations. Neurology. 1987; 37:815
J. Stephen Huff, MD
Arteriovenous malformationsArteriovenous malformations
Controlled trials of therapy lacking…
Natural history unclear…
Goal: complete removal AVM
For symptomatic AVM’s
-hemorrhage=>surgery if small
-other therapies if larger
If asymptomatic?
J. Stephen Huff, MD
SAH and ICH can occur in children and young adults
Different causes and treatments than in adults…
AVM likely cause, not aneurysm
Take home messages:Take home messages:
J. Stephen Huff, MD
Questions?Questions?
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