WIDI - N16) Headache and new-onset seizures

N16) Headache and new-onset seizures

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 a headache.
Review the DDx considerations in a patient with a headache.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with a headache.

History

A 65-year-old male is brought into the ED 30 minutes after a generalized tonic-clonic seizure. His daughter reports a 3-week history of increasing moderate intractable headache, worst in the morning, nausea, and dysarthria.

Physical Exam

BP: 135/85, HR 90, RR 17, Temp 15, O2 saturation 97% on room air. Neuro: No focal neurological deficits.

Labs

Results from CMP, blood glucose level, UDS, and blood alcohol levels are within normal limits.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Toxic ingestion

Multiple sclerosis

Stroke

Brain tumor

This patient’s new onset seizure occurring after a worsening headache with nausea and dysarthria are concerning for an intracranial mass lesion. A toxic ingestion is unlikely given the chronicity of symptoms and negative labs. Multiple sclerosis and ischemic strokes are unlikely to cause a seizure.

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

The patient requires urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

Head CT without contrast

Head CT with and without contrast

Skull radiographs

A brain CT with and without contrast is a good initial, quickly obtainable, imaging modality to evaluate for a brain tumor. This patient did not initially undergo a CT, so we review the MRI.

View ACR Appropriateness Criteria

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 brain with and without contrast

There is a lesion that predominantly involves which part of the corpus callosum?

Splenium

Body

Rostrum

The lesion crosses at the midline of the brain at the splenium of the corpus callosum, forming a “butterfly” appearance.

The pattern of the peripheral enhancement is:

Thin and smooth

Nodular and irregular

The lesion has nodular, irregular, ring enhancement.

View Report

Watch our video

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

Launch Dicom

Second Imaging Study

What is the next imaging study you will order?

Neck US

Head CT

None

No further imaging is required as the diagnosis is strongly suggested with the brain MRI.

Well done. You were correct

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

Astrocytoma

Glioblastoma

Pituitary macroadenoma

The imaging findings are highly consistent with a glioblastoma.

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 requires urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

A 65-year-old male is presenting with a newly diagnosed glioblastoma after new onset of seizures in the setting of progressively worsening headaches and dysarthria. Neurosurgery and neuro-oncology should be urgently consulted for evaluation. In the interim, the patient should be made NPO and started on IV fluids should he require surgery.

Lessons Learned:
- Glioblastomas, which are high-grade gliomas, are the most common primary brain tumors in adults, with a median age of onset of approximately 55 to 60.
- Glioblastomas are highly malignant, rapidly progressive brain tumors. The patient’s presentation will depend on the location of the tumor.
- Imaging classically shows a heterogeneous lesion with central necrosis and irregular peripheral enhancement that leads to vasogenic edema. Sometimes, there is a “butterfly configuration” as it crosses the midline through the corpus callosum.

Socioeconomic Factors: Higher SES is strongly associated with increased risk of glioblastoma.

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