A thunderclap headache
2013; Elsevier BV; Volume: 20; Issue: 7 Linguagem: Inglês
10.1016/j.jocn.2013.04.001
ISSN1532-2653
AutoresJoe Leyon, Tarun Gupta, Venkataramanan Srinivasan, Latha Senthil,
Tópico(s)Neurological Complications and Syndromes
Resumo1. AnswerD. Subarachnoid haemorrhage with Vein of Trolard thrombosis.2. DiscussionThe non-contrast CT scan (Fig. 1 of Images in Neuroscience: Question) shows subarachnoid haemorrhage (SAH) within a right frontal lobe sulcus. While the arterial phase image (Fig. 2 of Images in Neuroscience: Question) of the digital subtraction angiography is normal, the early and late venous phase images (Fig. 3a and b of Images in Neuroscience: Question) demonstrate a persistent linear filling defect within the Vein of Trolard confirming thrombus. MRI to assess cerebral parenchyma shows a tubular structure showing high signal on T1-weighted imaging (Fig. 4a of Images in Neuroscience: Question) confined within the pre-central sulcus, indicating thrombus within a vessel or SAH. There is high signal on fluid attenuated inversion recovery MRI and blooming artefact on gradient echo imaging around the previously described tubular structure extending further along the sulcus (Fig. 4b and c of Images in Neuroscience: Question). Together with the CT scan findings and the venogram images, the MRI findings confirm Vein of Trolard thrombosis with adjacent SAH.Thunderclap headache is classically described as severe headache, which takes less than a minute or a few minutes from its onset to peak.1Linn F.H. Rinkel G.J. Algra A. et al.Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache.J Neurol Neurosurg Psychiatry. 1998; 65: 791-793Crossref PubMed Scopus (192) Google Scholar The differential diagnosis for thunderclap headache includes SAH, cerebral venous sinus thrombosis, idiopathic benign recurrent headache disorder, arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, and hypertensive encephalopathy.2Dodick D.W. Thunderclap headache.J Neurol Neurosurg Psychiatry. 2002; 72: 6-11Crossref PubMed Scopus (110) Google Scholar, 3Maruyama H. Nagoya H. Kato Y. et al.Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only symptom.J Headache Pain. 2012; 13: 247-253Crossref PubMed Scopus (34) Google Scholar, 4Dodick D.W. Wijdicks E.F. Pituitary apoplexy presenting as a thunderclap headache.Neurology. 1998; 50: 1510-1511Crossref PubMed Scopus (67) Google Scholar, 5de Bruijn S.F. Stam J. Kappelle L.J. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group.Lancet. 1996; 348: 1623-1625Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar, 6Tang-Wai D.F. Phan T.G. Wijdicks E.F. Hypertensive encephalopathy presenting with thunderclap headache.Headache. 2001; 41: 198-200Crossref PubMed Scopus (37) Google Scholar, 7Embil J.M. Kramer M. Kinnear S. et al.A blinding headache.Lancet. 1997; 350: 182Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 8Schievink W.I. Wijdicks E.F. Meyer F.B. et al.Spontaneous intracranial hypotension mimicking aneurysmal subarachnoid hemorrhage.Neurosurgery. 2001; 48: 513-517Crossref PubMed Scopus (122) Google ScholarCerebral venous thrombosis confined to a cortical vein without involvement of the venous sinuses is rare.9Chang R. Friedman D.P. Isolated cortical venous thrombosis presenting as subarachnoid hemorrhage: a report of three cases.Am J Neuroradiol. 2004; 25: 1676-1679PubMed Google Scholar, 10Derdeyn C.P. Powers W.J. Isolated cortical venous thrombosis and ulcerative colitis.Am J Neuroradiol. 1998; 19: 488-490PubMed Google Scholar, 11Dorndorf D. Wessel K. Kessler C. et al.Thrombosis of the right vein of Labbé: radiological and clinical findings.Neuroradiology. 1993; 35: 202-203Crossref PubMed Scopus (21) Google Scholar In our patient, this was associated with SAH. This phenomenon of SAH secondary to isolated cortical venous thrombosis has been described in a few case reports and is likely due to venous hypertension. The irritiative effects of SAH and venous hypertension have been proposed to cause neurological findings in the absence of cerebral parenchymal infarction and haemorrhage. We highlight the importance of considering cortical vein thrombosis as an important and probably under-recognized cause of convexity SAH.Conflict of interest/disclosureThe authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. 1. AnswerD. Subarachnoid haemorrhage with Vein of Trolard thrombosis. D. Subarachnoid haemorrhage with Vein of Trolard thrombosis. 2. DiscussionThe non-contrast CT scan (Fig. 1 of Images in Neuroscience: Question) shows subarachnoid haemorrhage (SAH) within a right frontal lobe sulcus. While the arterial phase image (Fig. 2 of Images in Neuroscience: Question) of the digital subtraction angiography is normal, the early and late venous phase images (Fig. 3a and b of Images in Neuroscience: Question) demonstrate a persistent linear filling defect within the Vein of Trolard confirming thrombus. MRI to assess cerebral parenchyma shows a tubular structure showing high signal on T1-weighted imaging (Fig. 4a of Images in Neuroscience: Question) confined within the pre-central sulcus, indicating thrombus within a vessel or SAH. There is high signal on fluid attenuated inversion recovery MRI and blooming artefact on gradient echo imaging around the previously described tubular structure extending further along the sulcus (Fig. 4b and c of Images in Neuroscience: Question). Together with the CT scan findings and the venogram images, the MRI findings confirm Vein of Trolard thrombosis with adjacent SAH.Thunderclap headache is classically described as severe headache, which takes less than a minute or a few minutes from its onset to peak.1Linn F.H. Rinkel G.J. Algra A. et al.Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache.J Neurol Neurosurg Psychiatry. 1998; 65: 791-793Crossref PubMed Scopus (192) Google Scholar The differential diagnosis for thunderclap headache includes SAH, cerebral venous sinus thrombosis, idiopathic benign recurrent headache disorder, arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, and hypertensive encephalopathy.2Dodick D.W. Thunderclap headache.J Neurol Neurosurg Psychiatry. 2002; 72: 6-11Crossref PubMed Scopus (110) Google Scholar, 3Maruyama H. Nagoya H. Kato Y. et al.Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only symptom.J Headache Pain. 2012; 13: 247-253Crossref PubMed Scopus (34) Google Scholar, 4Dodick D.W. Wijdicks E.F. Pituitary apoplexy presenting as a thunderclap headache.Neurology. 1998; 50: 1510-1511Crossref PubMed Scopus (67) Google Scholar, 5de Bruijn S.F. Stam J. Kappelle L.J. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group.Lancet. 1996; 348: 1623-1625Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar, 6Tang-Wai D.F. Phan T.G. Wijdicks E.F. Hypertensive encephalopathy presenting with thunderclap headache.Headache. 2001; 41: 198-200Crossref PubMed Scopus (37) Google Scholar, 7Embil J.M. Kramer M. Kinnear S. et al.A blinding headache.Lancet. 1997; 350: 182Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 8Schievink W.I. Wijdicks E.F. Meyer F.B. et al.Spontaneous intracranial hypotension mimicking aneurysmal subarachnoid hemorrhage.Neurosurgery. 2001; 48: 513-517Crossref PubMed Scopus (122) Google ScholarCerebral venous thrombosis confined to a cortical vein without involvement of the venous sinuses is rare.9Chang R. Friedman D.P. Isolated cortical venous thrombosis presenting as subarachnoid hemorrhage: a report of three cases.Am J Neuroradiol. 2004; 25: 1676-1679PubMed Google Scholar, 10Derdeyn C.P. Powers W.J. Isolated cortical venous thrombosis and ulcerative colitis.Am J Neuroradiol. 1998; 19: 488-490PubMed Google Scholar, 11Dorndorf D. Wessel K. Kessler C. et al.Thrombosis of the right vein of Labbé: radiological and clinical findings.Neuroradiology. 1993; 35: 202-203Crossref PubMed Scopus (21) Google Scholar In our patient, this was associated with SAH. This phenomenon of SAH secondary to isolated cortical venous thrombosis has been described in a few case reports and is likely due to venous hypertension. The irritiative effects of SAH and venous hypertension have been proposed to cause neurological findings in the absence of cerebral parenchymal infarction and haemorrhage. We highlight the importance of considering cortical vein thrombosis as an important and probably under-recognized cause of convexity SAH. The non-contrast CT scan (Fig. 1 of Images in Neuroscience: Question) shows subarachnoid haemorrhage (SAH) within a right frontal lobe sulcus. While the arterial phase image (Fig. 2 of Images in Neuroscience: Question) of the digital subtraction angiography is normal, the early and late venous phase images (Fig. 3a and b of Images in Neuroscience: Question) demonstrate a persistent linear filling defect within the Vein of Trolard confirming thrombus. MRI to assess cerebral parenchyma shows a tubular structure showing high signal on T1-weighted imaging (Fig. 4a of Images in Neuroscience: Question) confined within the pre-central sulcus, indicating thrombus within a vessel or SAH. There is high signal on fluid attenuated inversion recovery MRI and blooming artefact on gradient echo imaging around the previously described tubular structure extending further along the sulcus (Fig. 4b and c of Images in Neuroscience: Question). Together with the CT scan findings and the venogram images, the MRI findings confirm Vein of Trolard thrombosis with adjacent SAH. Thunderclap headache is classically described as severe headache, which takes less than a minute or a few minutes from its onset to peak.1Linn F.H. Rinkel G.J. Algra A. et al.Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache.J Neurol Neurosurg Psychiatry. 1998; 65: 791-793Crossref PubMed Scopus (192) Google Scholar The differential diagnosis for thunderclap headache includes SAH, cerebral venous sinus thrombosis, idiopathic benign recurrent headache disorder, arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, and hypertensive encephalopathy.2Dodick D.W. Thunderclap headache.J Neurol Neurosurg Psychiatry. 2002; 72: 6-11Crossref PubMed Scopus (110) Google Scholar, 3Maruyama H. Nagoya H. Kato Y. et al.Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only symptom.J Headache Pain. 2012; 13: 247-253Crossref PubMed Scopus (34) Google Scholar, 4Dodick D.W. Wijdicks E.F. Pituitary apoplexy presenting as a thunderclap headache.Neurology. 1998; 50: 1510-1511Crossref PubMed Scopus (67) Google Scholar, 5de Bruijn S.F. Stam J. Kappelle L.J. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group.Lancet. 1996; 348: 1623-1625Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar, 6Tang-Wai D.F. Phan T.G. Wijdicks E.F. Hypertensive encephalopathy presenting with thunderclap headache.Headache. 2001; 41: 198-200Crossref PubMed Scopus (37) Google Scholar, 7Embil J.M. Kramer M. Kinnear S. et al.A blinding headache.Lancet. 1997; 350: 182Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 8Schievink W.I. Wijdicks E.F. Meyer F.B. et al.Spontaneous intracranial hypotension mimicking aneurysmal subarachnoid hemorrhage.Neurosurgery. 2001; 48: 513-517Crossref PubMed Scopus (122) Google Scholar Cerebral venous thrombosis confined to a cortical vein without involvement of the venous sinuses is rare.9Chang R. Friedman D.P. Isolated cortical venous thrombosis presenting as subarachnoid hemorrhage: a report of three cases.Am J Neuroradiol. 2004; 25: 1676-1679PubMed Google Scholar, 10Derdeyn C.P. Powers W.J. Isolated cortical venous thrombosis and ulcerative colitis.Am J Neuroradiol. 1998; 19: 488-490PubMed Google Scholar, 11Dorndorf D. Wessel K. Kessler C. et al.Thrombosis of the right vein of Labbé: radiological and clinical findings.Neuroradiology. 1993; 35: 202-203Crossref PubMed Scopus (21) Google Scholar In our patient, this was associated with SAH. This phenomenon of SAH secondary to isolated cortical venous thrombosis has been described in a few case reports and is likely due to venous hypertension. The irritiative effects of SAH and venous hypertension have been proposed to cause neurological findings in the absence of cerebral parenchymal infarction and haemorrhage. We highlight the importance of considering cortical vein thrombosis as an important and probably under-recognized cause of convexity SAH. Conflict of interest/disclosureThe authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. A thunderclap headacheJournal of Clinical NeuroscienceVol. 20Issue 7PreviewA 51-year-old man with past medical history of low grade leukemia presented to the emergency department with a history of intermittent left facial droop, left sided weakness and left sided focal motor seizures involving the face and arm, preceded by thunderclap headache. There was no history of trauma. He was afebrile and neurological examination revealed left hemiparesis with facial involvement. His peripheral blood count was within normal limits. Full-Text PDF
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