WIDI - N15) New onset seizure in a patient with headaches

N15) New onset seizure in a patient with headaches

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with seizures.
Review the DDx considerations in a patient with seizures.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with seizures.

History

A 33-year female presents due to new onset seizures. She endorses 3-month history of a headache described as constant throbbing associated with nausea. The symptoms have failed to resolve with preventative and abortive migraine pharmacotherapy.

Physical Exam

BP: 140/88, HR 80/min, RR 14/min, Temp 98F, O2 saturation 98%. Neuro: 3+ right radial deep tendon reflexes. 2+ reflexes otherwise 4+/5 strength in RUE. 5/5 strength in LUE, LLE, and RLE. CNs II-XII are intact.

Labs

None.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Stroke

Brain Tumor

Migraine

Brain abscess

A space occupying lesion is the most likely diagnosis in this patient with persistent headache and focal neurologic deficits.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

Considering the new onset seizures, the patient needs urgent evaluation.

First Imaging Study

What is the first imaging study you will order?

CT head with and without contrast

CT head without contrast

A CT head with and without contrast is an appropriate first imaging modality. The noncontrast CT can assess for lesion calcifications and blood while the contrasted study helps evaluate a lesion’s enhancement patterns.

View ACR Appropriateness Criteria

Well done. You were correct

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

MRI with and without contrast

None

An MRI can help further narrow the differential diagnosis.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

MRI

The lesion is homogeneously enhancing.

Yes

The lesion enhances homogeneously when comparing the contrast enhanced T1-weighted MRI to the non-contrast T1-weighted MRI.

The lesion is

Extra-axial

Intra-axial

The lesion is extra-axial – the ‘dural tail’ suggests that it arises from the dura mater. The thin rim of CSF between the brain and lesion (CSF cleft sign) also suggests this diagnosis.

Which of the following describes the lesion characteristics?

T1: Iso/hypoenhancing; T2: Hyperenhancing

T1: Iso/hypoenhancing; T2: Iso/hypoenhancing

T1: Hyperenhancing; T2: Hyperenhancing

T1: Hyperenhancing; T2: Iso/hypoenhancing

The lesion is iso- to hypoenhancing on T1 and hyperenhancing on T2 when compared to the brain parenchyma.

View Report

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What is your Diagnosis now that you have seen the imaging results?

Craniopharyngioma

Meningioma

Oligodendroglioma

The imaging findings are most consistent with a meningioma.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require urgent management considering the new-onset seizures.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 33-year-old female presenting with focal neurological deficits likely secondary to a meningioma. Neurosurgery should be consulted for surgical evaluation. Seizure prophylaxis medication should also be started.

Lessons Learned:
- Meningiomas are extra-axial masses that arise from meningothelial cells. Risk factors include older age, female sex, previous exposure to ionizing radiation, and genetic predisposition (NF2 and schwannomatosis).
- Symptoms from mass effect may include headaches, seizures and focal neurological deficits.
- CT and MRI classically reveals an enhancing, calcified, extra-axial mass.
- Imaging signs associated with meningioma include CSF cleft sign, a dural tail, and adjacent hyperostosis (especially on the skull base).
- Pathology, which would show ‘fried egg’ cells, psammoma bodies, and Rosenthal fibers confirm the diagnosis.
- Resection only is considered curative for WHO grade I tumors.

Socioeconomic Factors:
- Patients with lower socioeconomic status have lower rates of gross total resection and survival.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Abeer Dagra, MS3 - Content Contributor
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator