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A patient with prolonged headache and lethargy
The iournal of Emergency Medune, Vol 4, pp 319-323. 1986
Prlnted In the USA
A PATIENT WITH PROLONGED
0 Dr John McGill: I received a call from an outside physician regarding a patient he initially saw seven hours prior to calling me. The patient was a 41-year-old obese woman with a history of diabetes who came to his clinic complaining of a frontal headache of five days’ duration. She also complained of mild anorexia, nausea, and vomiting. Because of these symptoms, she had not taken her insulin for three days. She had a history of migraine headaches and had been treated successfully in the past with FiorinaP. For her current headache, she had been taking Tylenol@ with some relief. However, because of the persistent nature of her headache, she sought medical attention. In the clinic, the patient was found to be somnolent, but easily arousable, alert, and oriented when stimulated. Vital signs were normal. The neurologic exam was reported as being nonfocal and her discs were clear. The patient was given half her normal insulin dose and sent home. Rethinking the case, however, the physician became more concerned about the patient’s persistent lethargy. Considering the possibility of drug overdose, he sent a nurse to the patient’s home. She found the patient clinically unchanged. There were multiple prescription medications in the house. The bottles were empty, but the prescription dates were old. The nurse brought the patient back to the clinic where they observed her for a while before
v
finally calling our emer-
CopyrIght
??
HEADACHE
1986 Pergamor Journals Lid
AND LETHARGY
gency department. The physician felt there was a manipulative aspect to her presentation, but was concerned about a possible overdose. Because his clinic didn’t have toxicologic screening ability, he wanted to send her to us. On examination in our emergency department, the patient was a massively obese woman, weighing approximately 300 lbs, sleeping on the cart. Her blood pressure was 1lo/60 mm Hg; pulse rate, 72 beats per minute; respirations, 18/min; and temperature 37.5”C. She was easily arousable, and with stimulation, was alert and oriented. She complained of an intermittent frontotemporal headache that was not throbbing and allowed her to sleep comfortably through the night. It was not like her typical migraines. She had achieved moderate relief with Tylenol. She stated that she had not taken an overdose and, though she had a fair amount of stress in her life, she did not feel depressed. She denied neck pain and weakness. The patient related that she had received Vistaril 100 mg IM at the clinic and had taken some Benadryl at home. Her neurologic examination was nonfocal and discs were clear. Reflexes were full and symmetric. With moderate stimulation and assistance, a normal sensori-motor examination was obtained. It was interesting to note that although she knew what we were asking her to do, she seemed apathetic, requiring constant prodding to complete the motor exam. The most disturbing aspect of
Emergency Case Records originates from case conferences held at Denver General Hospital’s Department of Emergency Medical Services and is coordinated by Steven Silverstein, MD and John McGill, MD.
0736-4679/86 $3.00 + .OO 319
320
her presentation was her degree of lethargy. Because the recent administration of hydroxyzine pamoate (Vistaril@) and diphenhydramine (Benadryl@) confused the issue, the patient was observed for several hours in the emergency department and was given ibuprofen (MotrirF’) to relieve her headache. Computed tomography (CT) would have been desirable at that time but the scanner was down, 0 Dr Tom Drake: How did the patient describe the onset of the headache? 0 Dr McGill: It came on gradually while she was sitting in a chair. It was not exacerbated by exertion and was never severe. Cl A physician: Did she live alone? 0 Dr McGill: No, she lived with family and her son was with her in the ED. I asked him if his mother had been acting normally. He said that she had been sleeping a great deal and, unlike her usual self, wasn’t scolding him when he made noise. ?? Dr MarkovchickzDid anyone give thought to CO2 retention and check an arterial blood gas?
Emergency
Case Records
0 Dr Rosen: One other thing that comes to mind in a patient who has somnolence and an unusual headache is carbon monoxide poisoning. It might be worth checking a carbon monoxide level. Cl Dr Markovchick: People with CO poisoning usually improve after they get up in the morning and out of the bedroom. Their headache goes away, they feel better, and the next morning their symptoms return. That was not this woman’s pattern. ? ?Dr McGill: No, she was somnolent throughout. This was documented during her clinical stay. 0 Dr Markovchick: So you decided to let her metabolize her Vistaril@ and Benadryl@ and see if her mental status improved? Cl Dr McGill: Yes. Another readily available diagnostic modality is lumbar puncture (LP), especially if one was suspecting subarachnoid hemorrhage or infection. However, my primary concern was a possible mass lesion. In this setting, I felt that an LP was contraindicated. ? ?Dr Gerald Gordon: Were the findings of her fundoscopic examination normal?
? ?Dr McGill: No, that was not considered. 0 Dr McGill: Yes. Cl Dr Rosen: The patient probably merited an emergency CT scan. When our scanner is down we have several options. One is to send the patient to one of our affiliated institutions for the scan. The other is to do a carotid angiogram. In this woman’s case, owing to her obesity, I would suggest that it would be much wiser to get her scanned elsewhere. Maury, would she fit in the gantry? Cl Dr Maurice O’Connor: You bring up a good point. People should be aware that there is a limited space in the scanner. Marked obesity may make a CT scan of the chest, abdomen, or pelvis impossible. They must be able to fit under the gantry.
0 Dr Adam Cwinn: Did she have any head tenderness? Cl Dr McGill: No; no facial or scalp tenderness. Cl Dr Rosen: Was she hungry? 0 Dr McGill: No, she complained of nausea and intermittent vomiting. These are significant additions to her symptom complex of lethargy and headache. We often admit this type of patient to our ED observation unit overnight, get a neurology consultation, and wait for the CT scan to become functional the next day. However,
Prolonged
Headache
321
and Lethargy
on this occasion, the CT scanner required a part from out-of-town. Because of the potential delay, I obtained a neurology consultation and advised admission. Regarding the decision on whether or not an emergent CT was needed, I felt that because the patient’s condition had remained stable over the past several days and she was nonfocal, she could be followed clinically until the CT scanner was running the next day.
0 Dr Gruber: Let’s discuss what happened next. Neurology evaluated the patient and agreed that her exam was nonfocal. She was admitted to the neurology service with the diagnosis of unexplained lethargy. A CT scan was planned once the scanner became operational. The patient was admitted to a ward bed and got some pain relief with oral analgesics. At 9:00 the following evening, the CT scan was obtained. What did it show Maury?
I? Dr Markovchick: Before the advent of CT scan, if you suspected a subarachnoid hemorrhage and the patient was not herniating, you performed an LP. This would be difficult in a 300-lb woman.
0 Dr O’Connor: I’d like to direct your attention to the scan in the right tempoparietal area (Fig 1). This is a noncontrast study and you can see increased density in this area. There is about a 7-mm mass effect with shift. The neuroradiologists felt this was typical of a venous infarct. There are few other things that look like this with the increased attenuation on the noncontrast study, edema, shift, and effacement of the folds as you go superiorly.
Cl Dr McGill: If you’re thinking subarachnoid bleed (SAH), you’re right. However, although it was considered, with SAH and her degree of lethargy, one would normally expect a history of sudden onset of severe headache rather than a well-localized mild headache of five days’ duration.
Figure 1. CT scan demonstrating
Cl Dr Gordon: How old was this process?
a venous infarct in the right frontotemporal
area.
Emergency
322
0 Dr O’Connor:
Perhaps several days.
0 A physician: You say this is a venous infarct, but isn’t that the density of a bleed? ? ?Dr O’Connor: Yes, hemorrhage pooled in the area; an infarct with bleeding. 0 Dr Gruber: Following the abnormal CT scan results, the neurology resident reexamined the patient and found a subtle left arm drift and a left homonymous hemianopsia. 0 Neurology resident: Prior to her CT scan, the patient’s old records were helpful in determining whether or not she was being manipulative. Her last hospital admission was 4 years ago, she had no ED visits, and few clinic visits. This history made us take her more seriously. 0 Dr Gruber: The exact cause of the infarct was unclear and the patient underwent carotid angiography.
Figure 2. Carotid angiogram
Case Records
0 Dr O’Connor: Here is a lateral view at about 17 seconds (Fig 2). You can see the anterior venous pattern with normal filling of the veins and sagittal sinus. Posteriorly however, the veins are dilated and the saggital sinus is not visualized. In this case, the radiographic diagnosis was sagittal sinus thrombosis.
0 Dr Gruber: Neurology agreed that this was a case of venous hemorrhagic infarct secondary to superior sagittal sinus thrombosis. The patient was treated conservatively and has done quite well in the hospital. Because superior sagittal thrombosis is uncommon, I have asked the neurology resident to make a few comments about this entity. 0 Neurology Resident: The symptoms of a cerebral venous thrombosis include headache, delirium, drowsiness, diplopia and seizures, often focal in nature. The signs include increased intracranial pressure with papilledema, nuchal rigidity
(lateral view) demonstrating
superior sagittal sinus thrombosis.
Prolonged
Headache
and Lethargy
323
and focal neurologic signs, most often hemiparesis or a hemisensory loss. Patients generally appear somewhat restless, confused, and obtunded. The most common primary sites of superior sagittal sinus thrombosis are the cavernous sinus and lateral sinus. In the superior sagittal sinus, blood flows anterior to posterior and drains the larger cerebral veins from both hemispheres. The causes of superior sagittal sinus thrombosis are either infective or noninfective. Infective thromboses result from infection in the nasal cavity, extensions from the lateral or cavernous sinuses, from epidural or subdural infections, or as extensions of osteomyelitis. Although cavernous sinus and lateral sinus thromboses are almost always infective in nature, this is not the case with superior sagittal sinus thromboses. A significant percentage of them have noninfective etiologies. The noninfective causes include terminal disease, marasmus, cyanotic congenital heart disease, hypercoagulability, including sickle cell disease and polycythemia (primary or secondary) antithrombin III deficiency, protein C deficiency, and other hypercoagulative states. Trauma and tumor have also been found to be predisposing factors. Other cases appear to be purely idiopathic. When the patient initially presents, focal neurologic signs and symptoms may be entirely absent, as they were in this case. Sometimes, symptoms of increased intracranial pressure, including headache, nausea and vomiting, and blurred vision, are the presenting complaints. In other patients, generalized lethargy may be the only pre-
senting sign. As the clot extends into larger cerebral veins, focal signs and symptoms develop as a result of hemorrhage into both grey and white matter. The definitive diagnosis is made by carotid angiography. Could we return to the Cl A physician: question of performing a lumbar puncture in this patient? Is it safe to do an LP if the neurologic exam is nonfocal? Maybe this is not the case. 0 Dr Rosen: I don’t think that it would have made any difference in this woman. 0 Dr McGill: I would maintain that an LP in this patient is relatively contraindicated. Infection was very low on the differential. If you feel that an immediate diagnosis is necessary, transferring the patient to obtain the CT scan would be more advisable than doing an LP in someone with this presentation. 0 Dr Rosen: In this case, the real key is persistent lethargy. We didn’t know whether it was caused by the Vistaril@ and the Benadryl@ or whether it was part of her clinical syndrome. Once we got that clarified, I think this patient definitiely needed a CT scan. The timing of it may have had some significance. In this case it didn’t change our management. We found a lesion that would not have responded to early therapy or surgical intervention. This might not have been the case. I think we tend not to push to get the diagnostic procedure when it is inconvenient to do so.
REFERENCES I. Hesselbrock sagittal
R, Sawaya sinus thrombosis
R, Tomsick T: Superior after closed head injury.
Neurosurgery 1985; 16:825-828.
2. Imai WK, Everhart FR, Sanders JM: Cerebral venous sinus thrombosis. Report of a case and review of the literature. Pediafrics1982; 70:965-970.
Prlnted In the USA
A PATIENT WITH PROLONGED
0 Dr John McGill: I received a call from an outside physician regarding a patient he initially saw seven hours prior to calling me. The patient was a 41-year-old obese woman with a history of diabetes who came to his clinic complaining of a frontal headache of five days’ duration. She also complained of mild anorexia, nausea, and vomiting. Because of these symptoms, she had not taken her insulin for three days. She had a history of migraine headaches and had been treated successfully in the past with FiorinaP. For her current headache, she had been taking Tylenol@ with some relief. However, because of the persistent nature of her headache, she sought medical attention. In the clinic, the patient was found to be somnolent, but easily arousable, alert, and oriented when stimulated. Vital signs were normal. The neurologic exam was reported as being nonfocal and her discs were clear. The patient was given half her normal insulin dose and sent home. Rethinking the case, however, the physician became more concerned about the patient’s persistent lethargy. Considering the possibility of drug overdose, he sent a nurse to the patient’s home. She found the patient clinically unchanged. There were multiple prescription medications in the house. The bottles were empty, but the prescription dates were old. The nurse brought the patient back to the clinic where they observed her for a while before
v
finally calling our emer-
CopyrIght
??
HEADACHE
1986 Pergamor Journals Lid
AND LETHARGY
gency department. The physician felt there was a manipulative aspect to her presentation, but was concerned about a possible overdose. Because his clinic didn’t have toxicologic screening ability, he wanted to send her to us. On examination in our emergency department, the patient was a massively obese woman, weighing approximately 300 lbs, sleeping on the cart. Her blood pressure was 1lo/60 mm Hg; pulse rate, 72 beats per minute; respirations, 18/min; and temperature 37.5”C. She was easily arousable, and with stimulation, was alert and oriented. She complained of an intermittent frontotemporal headache that was not throbbing and allowed her to sleep comfortably through the night. It was not like her typical migraines. She had achieved moderate relief with Tylenol. She stated that she had not taken an overdose and, though she had a fair amount of stress in her life, she did not feel depressed. She denied neck pain and weakness. The patient related that she had received Vistaril 100 mg IM at the clinic and had taken some Benadryl at home. Her neurologic examination was nonfocal and discs were clear. Reflexes were full and symmetric. With moderate stimulation and assistance, a normal sensori-motor examination was obtained. It was interesting to note that although she knew what we were asking her to do, she seemed apathetic, requiring constant prodding to complete the motor exam. The most disturbing aspect of
Emergency Case Records originates from case conferences held at Denver General Hospital’s Department of Emergency Medical Services and is coordinated by Steven Silverstein, MD and John McGill, MD.
0736-4679/86 $3.00 + .OO 319
320
her presentation was her degree of lethargy. Because the recent administration of hydroxyzine pamoate (Vistaril@) and diphenhydramine (Benadryl@) confused the issue, the patient was observed for several hours in the emergency department and was given ibuprofen (MotrirF’) to relieve her headache. Computed tomography (CT) would have been desirable at that time but the scanner was down, 0 Dr Tom Drake: How did the patient describe the onset of the headache? 0 Dr McGill: It came on gradually while she was sitting in a chair. It was not exacerbated by exertion and was never severe. Cl A physician: Did she live alone? 0 Dr McGill: No, she lived with family and her son was with her in the ED. I asked him if his mother had been acting normally. He said that she had been sleeping a great deal and, unlike her usual self, wasn’t scolding him when he made noise. ?? Dr MarkovchickzDid anyone give thought to CO2 retention and check an arterial blood gas?
Emergency
Case Records
0 Dr Rosen: One other thing that comes to mind in a patient who has somnolence and an unusual headache is carbon monoxide poisoning. It might be worth checking a carbon monoxide level. Cl Dr Markovchick: People with CO poisoning usually improve after they get up in the morning and out of the bedroom. Their headache goes away, they feel better, and the next morning their symptoms return. That was not this woman’s pattern. ? ?Dr McGill: No, she was somnolent throughout. This was documented during her clinical stay. 0 Dr Markovchick: So you decided to let her metabolize her Vistaril@ and Benadryl@ and see if her mental status improved? Cl Dr McGill: Yes. Another readily available diagnostic modality is lumbar puncture (LP), especially if one was suspecting subarachnoid hemorrhage or infection. However, my primary concern was a possible mass lesion. In this setting, I felt that an LP was contraindicated. ? ?Dr Gerald Gordon: Were the findings of her fundoscopic examination normal?
? ?Dr McGill: No, that was not considered. 0 Dr McGill: Yes. Cl Dr Rosen: The patient probably merited an emergency CT scan. When our scanner is down we have several options. One is to send the patient to one of our affiliated institutions for the scan. The other is to do a carotid angiogram. In this woman’s case, owing to her obesity, I would suggest that it would be much wiser to get her scanned elsewhere. Maury, would she fit in the gantry? Cl Dr Maurice O’Connor: You bring up a good point. People should be aware that there is a limited space in the scanner. Marked obesity may make a CT scan of the chest, abdomen, or pelvis impossible. They must be able to fit under the gantry.
0 Dr Adam Cwinn: Did she have any head tenderness? Cl Dr McGill: No; no facial or scalp tenderness. Cl Dr Rosen: Was she hungry? 0 Dr McGill: No, she complained of nausea and intermittent vomiting. These are significant additions to her symptom complex of lethargy and headache. We often admit this type of patient to our ED observation unit overnight, get a neurology consultation, and wait for the CT scan to become functional the next day. However,
Prolonged
Headache
321
and Lethargy
on this occasion, the CT scanner required a part from out-of-town. Because of the potential delay, I obtained a neurology consultation and advised admission. Regarding the decision on whether or not an emergent CT was needed, I felt that because the patient’s condition had remained stable over the past several days and she was nonfocal, she could be followed clinically until the CT scanner was running the next day.
0 Dr Gruber: Let’s discuss what happened next. Neurology evaluated the patient and agreed that her exam was nonfocal. She was admitted to the neurology service with the diagnosis of unexplained lethargy. A CT scan was planned once the scanner became operational. The patient was admitted to a ward bed and got some pain relief with oral analgesics. At 9:00 the following evening, the CT scan was obtained. What did it show Maury?
I? Dr Markovchick: Before the advent of CT scan, if you suspected a subarachnoid hemorrhage and the patient was not herniating, you performed an LP. This would be difficult in a 300-lb woman.
0 Dr O’Connor: I’d like to direct your attention to the scan in the right tempoparietal area (Fig 1). This is a noncontrast study and you can see increased density in this area. There is about a 7-mm mass effect with shift. The neuroradiologists felt this was typical of a venous infarct. There are few other things that look like this with the increased attenuation on the noncontrast study, edema, shift, and effacement of the folds as you go superiorly.
Cl Dr McGill: If you’re thinking subarachnoid bleed (SAH), you’re right. However, although it was considered, with SAH and her degree of lethargy, one would normally expect a history of sudden onset of severe headache rather than a well-localized mild headache of five days’ duration.
Figure 1. CT scan demonstrating
Cl Dr Gordon: How old was this process?
a venous infarct in the right frontotemporal
area.
Emergency
322
0 Dr O’Connor:
Perhaps several days.
0 A physician: You say this is a venous infarct, but isn’t that the density of a bleed? ? ?Dr O’Connor: Yes, hemorrhage pooled in the area; an infarct with bleeding. 0 Dr Gruber: Following the abnormal CT scan results, the neurology resident reexamined the patient and found a subtle left arm drift and a left homonymous hemianopsia. 0 Neurology resident: Prior to her CT scan, the patient’s old records were helpful in determining whether or not she was being manipulative. Her last hospital admission was 4 years ago, she had no ED visits, and few clinic visits. This history made us take her more seriously. 0 Dr Gruber: The exact cause of the infarct was unclear and the patient underwent carotid angiography.
Figure 2. Carotid angiogram
Case Records
0 Dr O’Connor: Here is a lateral view at about 17 seconds (Fig 2). You can see the anterior venous pattern with normal filling of the veins and sagittal sinus. Posteriorly however, the veins are dilated and the saggital sinus is not visualized. In this case, the radiographic diagnosis was sagittal sinus thrombosis.
0 Dr Gruber: Neurology agreed that this was a case of venous hemorrhagic infarct secondary to superior sagittal sinus thrombosis. The patient was treated conservatively and has done quite well in the hospital. Because superior sagittal thrombosis is uncommon, I have asked the neurology resident to make a few comments about this entity. 0 Neurology Resident: The symptoms of a cerebral venous thrombosis include headache, delirium, drowsiness, diplopia and seizures, often focal in nature. The signs include increased intracranial pressure with papilledema, nuchal rigidity
(lateral view) demonstrating
superior sagittal sinus thrombosis.
Prolonged
Headache
and Lethargy
323
and focal neurologic signs, most often hemiparesis or a hemisensory loss. Patients generally appear somewhat restless, confused, and obtunded. The most common primary sites of superior sagittal sinus thrombosis are the cavernous sinus and lateral sinus. In the superior sagittal sinus, blood flows anterior to posterior and drains the larger cerebral veins from both hemispheres. The causes of superior sagittal sinus thrombosis are either infective or noninfective. Infective thromboses result from infection in the nasal cavity, extensions from the lateral or cavernous sinuses, from epidural or subdural infections, or as extensions of osteomyelitis. Although cavernous sinus and lateral sinus thromboses are almost always infective in nature, this is not the case with superior sagittal sinus thromboses. A significant percentage of them have noninfective etiologies. The noninfective causes include terminal disease, marasmus, cyanotic congenital heart disease, hypercoagulability, including sickle cell disease and polycythemia (primary or secondary) antithrombin III deficiency, protein C deficiency, and other hypercoagulative states. Trauma and tumor have also been found to be predisposing factors. Other cases appear to be purely idiopathic. When the patient initially presents, focal neurologic signs and symptoms may be entirely absent, as they were in this case. Sometimes, symptoms of increased intracranial pressure, including headache, nausea and vomiting, and blurred vision, are the presenting complaints. In other patients, generalized lethargy may be the only pre-
senting sign. As the clot extends into larger cerebral veins, focal signs and symptoms develop as a result of hemorrhage into both grey and white matter. The definitive diagnosis is made by carotid angiography. Could we return to the Cl A physician: question of performing a lumbar puncture in this patient? Is it safe to do an LP if the neurologic exam is nonfocal? Maybe this is not the case. 0 Dr Rosen: I don’t think that it would have made any difference in this woman. 0 Dr McGill: I would maintain that an LP in this patient is relatively contraindicated. Infection was very low on the differential. If you feel that an immediate diagnosis is necessary, transferring the patient to obtain the CT scan would be more advisable than doing an LP in someone with this presentation. 0 Dr Rosen: In this case, the real key is persistent lethargy. We didn’t know whether it was caused by the Vistaril@ and the Benadryl@ or whether it was part of her clinical syndrome. Once we got that clarified, I think this patient definitiely needed a CT scan. The timing of it may have had some significance. In this case it didn’t change our management. We found a lesion that would not have responded to early therapy or surgical intervention. This might not have been the case. I think we tend not to push to get the diagnostic procedure when it is inconvenient to do so.
REFERENCES I. Hesselbrock sagittal
R, Sawaya sinus thrombosis
R, Tomsick T: Superior after closed head injury.
Neurosurgery 1985; 16:825-828.
2. Imai WK, Everhart FR, Sanders JM: Cerebral venous sinus thrombosis. Report of a case and review of the literature. Pediafrics1982; 70:965-970.