35 years old woman presented to the emergency room with sudden onset visual disturbance. On initial physical exam, she described a right hemianopic field defect which persisted for 35 minutes. Following day, she developed a mild generalized headache and neck stiffness which persisted for approximately 5 days.
She has no significant past medical history. She never smoked and there was no family history of migrane. The rest of the physical exam was normal.
The following Laboratory Studies were normal or negative: CBC, ESR, Chem 7, Lupus anticoagulant, anticardiolipin antibody, antinuclear factor and serologic test for syphilis.
1-What is the Diagnosis?
2- Which non-invasive diagnostic test would you order and why?
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7 comments:
1) given this limited information: most likely it's ruputured aneurism. other differnetial would be CVA due to drug abuse given young age and no other CVA risk facots or Multiple sclerosis
2)Initialy we should get a CT scan of head without contrast to confirm bleed. If the CT scan would be negative, than MRI/MRA would be indicated.
The subsequent development of persistent,non-specific headache and neck stiffness makes the diagnosis of migrainous attack unlikely. The clinical diagnosis should be vertebrobasilar TIA.
The diagnosis is confirmed by the identification of blood in the arterial wall on MRI of the neck and disturbed blood flow within the vertebral artery demonstrated by MRA.
This condition should always be excluded in a young person presenting with vertebrobasilar TIA
I would also consider Multiple sclerosis in this patient. in that case an MRI would be the right dhice of investigation.
Since she had a right hemianopic visual defect, she must have suferred a intracerebral bleed.Generalised headache and neck rigidity can be explained by intraventricular extension of the bleed.Cause of bleed could be AV malformation (aneurysm causes SAH)or a bleed into a tumor.
CT scan without contrast would be the first choice to rule out a bleed.It is quickly obtained and gives a good idea if it is a hemorrhage
This looks like a TIA which could be due to bleed from rupture of aneurysm or from some mass occcupying lesion in the brain.
Do a CT without contrast followed by a MRI scan.
This looks like a TIA which could be due to bleed from rupture of aneurysm or from some mass occcupying lesion in the brain.
Do a CT without contrast followed by a MRI scan.
basilar migraine/ basilar TIA
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