Hot Seat #155: DenouementPosted on: September 2, 2020, by : Brian Lee
Case Summary: 17-year-old female presenting with 1 week of persistently worsening headache, initially with benign exam but ultimately found to have cranial nerve abnormalities.
Here’s how you answered:
Denouement: Patient was admitted to the neurology service for MRI/MRA and pain control. MRA completed the next morning showed an aneurysm without evidence of hemorrhage. Patient was taken to the OR urgently with neurosurgery, and had an uncomplicated post-operative course.
Discussion: Initially, the group discussed the approach and differential to a child with persistent headaches, with special attention to secondary causes of pediatric headache. Drs. Chamberlain and Gutierrez commented on the importance of ruling out idiopathic intracranial hypertension (pseudotumor cerebri), though the absence of papilledema is uncharacteristic. Dr. Cohen mentioned that POCUS could evaluate for papilledema if fundoscopic exam was sub-optimal. For those readers who wish to review important causes of secondary headaches, a recent review can be found here.
When the patient re-presented with new cranial nerve deficits, the group was unanimous in recommending neuroimaging for this patient. In pediatric patients, cranial nerve 3 palsy could result from intracranial lesions, orbital disease, or even myastenia gravis (though in patients with MG, the pupil tends to be spared). Ischemia is a common cause in adult patients. To evaluate for these etiologies, CTA, MRA, or angiography are often employed. A review of adult patients presenting with CN3 palsy recommends CT/CTA if aneurysm is suspected, though notes MRI/MRA is the modality of choice for non-aneurysmal etiologies.
Conclusion: While pediatric headache is relatively common, cranial nerve 3 palsy is not. For patients presenting with this exam finding, emergent neuroimaging should be undertaken. Specific decisions on imaging modality should be made in concert with radiology and neurology.