Block 13 Headache MCQ's

The most probable diagnosis in this case is a ruptured berry aneurysm. The patient's symptoms of the worst headache of her life, photophobia, vomiting, neck stiffness, and bilateral extension on plantar reflex are consistent with a subarachnoid hemorrhage, which is often caused by the rupture of a berry aneurysm. The presence of blood in the subarachnoid space and ventricles on the contrast MRI further supports this diagnosis. The patient's emergency neurosurgical treatment and survival also suggest that a ruptured berry aneurysm was the cause of her symptoms.

The correct answer is that the patient has a non-communicating hydrocephalus. This is indicated by the symptoms of severe headache, blurring of vision, difficulty in walking, and worsening memory and concentration. The brain CT and fundoscopy images may also show signs of hydrocephalus, such as enlarged ventricles or increased pressure in the brain. Non-communicating hydrocephalus occurs when there is a blockage in the flow of cerebrospinal fluid within the brain, leading to an accumulation of fluid and increased pressure.

The patient's symptoms of waking up in the middle of the night, sleep disturbances, and night-time headaches, along with the worsening of headaches early in the morning, suggest increased intracranial pressure. This, combined with the fact that the patient feels better at work, indicates that the brain tumor is potentially causing the symptoms. A ruptured aneurysm would present with sudden severe headache, not specifically related to sleep. Migraine headache would not typically cause sleep disturbances. Decreased glutamatergic neurotransmission and primary exertional headache do not fit the given symptoms.

As only 10% of people admitted to the emergency department with a thunderclap headache are suffering from an SAH, other possible causes are usually considered simultaneously, such as meningitis, migraine, and cerebral venous sinus thrombosis. Intracerebral hemorrhage, in which bleeding occurs within the brain itself, is twice as common as SAH and is often misdiagnosed as the latter. It is not unusual for SAH to be initially misdiagnosed as a migraine or tension headache, which can lead to a delay in obtaining a CT scan. In a 2004 study, this occurred in 12% of all cases and was more likely in people who had smaller hemorrhages and no impairment in their mental status. The delay in diagnosis led to a worse outcome. In some people, the headache resolves by itself, and no other symptoms are present. *************
This type of headache is referred to as "sentinel headache", because it is presumed to result from a small leak (a "warning leak") from an aneurysm.***************

A sentinel headache still warrants investigations with CT scan and lumbar puncture, as further bleeding may occur in the subsequent three weeks.

The symptoms of migraine headaches, vertigo, and dysarthria suggest a problem with the blood supply to the brainstem. The basilar artery is a major blood vessel that supplies the brainstem, and when it is involved, it can cause these symptoms. The middle cerebral artery primarily supplies the lateral aspects of the brain and is not likely to be the cause. The circle of Willis is a network of blood vessels that provides collateral circulation, but it is not a specific vessel. The internal carotid artery supplies blood to the anterior circulation of the brain and is not likely to be involved in these symptoms. Therefore, the most likely blood vessel involved in this case is the basilar artery.

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Hemianopsia or hemianopia is visual field loss that respects the vertical midline, and usually affects both eyes, but can involve one eye only. Homonymous hemianopsia, or homonymous hemianopia occurs when there is hemianopic visual field loss on the same side of both eyes. Hemianopias occur because the right half of the brain has visual pathways for the left hemifield of both eyes, and the left half of the brain has visual pathways for the right hemifield of both eyes.


Homonymous hemianopsa can be congenital, but is usually caused by brain injury such as from stroke, trauma, tumors, infection, or following surgery.

Vascular and neoplastic (malignant or benign tumours) lesions from the optic tract, to visual cortex can cause a contralateral homonymous hemianopsia. Injury to the right side of the brain will affect the left visual fields of each eye. The more posterior the cerebral lesion, the more symmetric (congruous) the homonymous hemianopsia will be. For example, a person who has a lesion of the right optic tract will no longer see objects on his left side. Similarly, a person who has a stroke to the right occipital lobe will have the same visual field defect, usually more congruent between the two eyes, and there may be macular sparing. A stroke on the right side of the brain (especially parietal lobe), in addition to producing a homonymous hemianopsia, may also lead to the syndrome of hemispatial neglect.

Transient homonymous hemianopsia does not necessarily mean stroke. For instance, it can constitute the aura phase of migraine. Concomitant presence of a moving scintillating scotoma is suggestive of migraine,[ but has been seen in cerebral cancer as well Computed tomography (CT scan) or MRI can be used to investigate if stroke, tumor,structural lesion, or demyelination is the cause of homonymous hemianopsia

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is the most common form of hereditary stroke disorder, and is thought to be caused by mutations of the Notch 3 gene on chromosome 19. The disease belongs to a family of disorders called the Leukodystrophies. The most common clinical manifestations are migraine headaches and transient ischemic attacks or strokes, which usually occur between 40 and 50 years of age, although MRI is able to detect signs of the disease years prior to clinical manifestation of disease.
CADASIL may start with attacks of migraine with aura or subcortical transient ischemic attacks or strokes, or mood disorders between 35 to 55 years of age. The disease progresses to subcortical dementia associated with pseudobulbar palsy and urinary incontinence.

Ischemic strokes are the most frequent presentation of CADASIL, with approximately 85% of symptomatic individuals developing transient ischemic attacks or stroke(s). The mean age of onset of ischemic episodes is approximately 46 years (range 30–70). A classic lacunar syndrome occurs in at least two-thirds of affected patients while hemispheric strokes are much less common. Notably, ischemic strokes typically occur in the absence of traditional cardiovascular risk factors. Recurrent silent strokes, with or without clinical strokes, often lead to cognitive decline and overt subcortical dementia.