Hot Seat #159: DenouementPosted on: October 22, 2020, by : Mary Beth Howard
The Case: 11yo F presenting after an episode of altered mental status at home with normal exam but abnormal CT head.
Here’s how you answered the questions:
Discussion: The initial dilemma in this case lies in the fact that the patient had a concerning episode at home and then arrives asymptomatic with a normal exam. Faculty and fellows were somewhat split on discharging versus initiating a work up (most would start with head imaging). Dr. Rucker’s mnemonic of TIPS AEIOU (see below) is helpful in cases like this one to remind us of our ‘can’t miss’ diagnoses and decide if a work up is warranted.
Luckily (or unluckily, depending on your perspective) this patient is not discharged home and has an abnormal CT and recurrence of mild symptoms. The next step is not completely clear. Many fellows would consult Neurosurgery given the lack of clarity, while attendings would obtain vascular imaging. If imaging is obtained, the question becomes CTA/CTV (faster, easily accessible) or MRA/MRV (may delay, takes longer, patient needs to be cooperative however a better study if this patient is having a stroke).
Denouement: As patient was initially stable and without pain, decision was made to obtain MRI/MRA/MRV with and without contrast to facilitate diagnosis. As she was about to got to MRI, began to endorse mild headache, and imaging was changed to CTA to rule out continued unstable bleeding which would require emergent intervention.
CTA showed: There is a hemorrhagic lesion involving the left frontal lobe. There is a punctate focus of enhancement within it could represent a punctate focus of active bleeding for a small focus of early enhancement. Please see the report on the subsequently performed MRI for additional details.
And subsequent MRI studies showed:
1. There is a lesion in the left frontal lobe which has an appearance most consistent with a cavernous angioma. There are additional approximately 9 lesions in the supratentorial brain most consistent with additional cavernous angiomas.
2. Normal MRV of the head.
3. Normal MRA of the head.
Patient was admitted to the PICU and monitored. Started on Keppra for seizure prophylaxis. Neurosurgery deemed no intervention at this time. Discharged on HD#2.
Subsequent follow ups are re-assuring and neurosurgery will continue to monitor clinically.
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