Neurology
CHALLENGING CASES
Richard Leigh, MD
Post Partum Headache I
 34 y/o healthy woman 3 days post partum
after an uncomplicated delivery with epidural
anesthesia develops headache, photophobia,
neck stiffness
 On exam she has papilledema and
constricted visual fields.
Post Partum Headache I
 Differential Diagnosis:
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Cerebral venous sinus thrombosis
Reversible vasoconstriction syndrome (RCVS)
Preeclampsia/eclampsia
Pituitary apoplexy
Benign intracranial hypertension
Post dural puncture headache
Carotid or vertebral artery dissection
Meningitis/Encephalitis
ICH/SAH
Post Partum Headache I
 MRI shows: Subdural Hematoma
Post Partum Headache II
 35 y/o healthy woman 10 days post partum
after an uncomplicated delivery of twins with
epidural anesthesia develops presents with
headache which is worse when she stands up.
 On exam she has no papilledema and is
neurologically intact.
Post Partum Headache II
 MRI shows: Pachymeningeal Enhancement
Post Partum Headache II
 She was diagnosed with a post LP headache
and treated conservatively.
 Thecal sac was likely disrupted during the
placement of her epidural
 Headache persisted and she represented 10
days later with worsening headache
Post Partum Headache II
 MRI shows: Subdural Hematomas
Post Partum Headache II
 Two weeks later she was presented with
recurrent headache, now worse when she lay
down.
 On exam she had double vision with lateral
gaze and papilledema on fundascopic exam
 MRI unchanged
 Started on acetazolamide (diamox) with
improvement in her headache
Post Partum Headache I & II
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Puncture of the thecal sac prior to delivery
Over draining of the CSF during delivery
Post paratum hypotension leading to SDH
Resolution of the CSF leak leading to
increased intracranial pressure due to too
much contents in the cranial vault
 Responded to CSF production inhibition
 With resolution of the SDH they were weaned
off of the acetazolamide .
The Pressure Dependent Exam
 55 y/o gentleman with a h/o hypertension
presents after 24 hours of fluctuating left arm
weakness
 On exam his left arm drifts down; but when
the head of the bed is put flat, his arm comes
back up!
The Pressure Dependent Exam
DWI
ADC
FLAIR
The Pressure Dependant Exam
DWI
PWI - TTP
FLAIR
The Pressure Dependant Exam
TOF - MRA
SWI
SWI mIPs
The Pressure Dependant Exam
Perfusion Quantified
The Pressure Dependant Exam
– One Week Later
DWI
FLAIR
PWI - TTP
The Pressure Dependant Exam
Perfusion Quantified
Hypertensive Crisis
 66 y/o gentleman with a h/o hypertension
and hyperlipidemia presents with confusion
and headache.
 With systolic blood pressures in the 200’s he
was confused with a mild left arm weakness.
Hypertensive Crisis
 MRI showed: PRES (posterior reversible
encephalopathy syndrome)
Hypertensive Crisis - PRES
 Differential Diagnosis
 HTN
 Renal Disease
 Pregnancy/eclampsia
 Autoimmune disease
 Chemotheraputics
 Immunosuppressants
 Porphyria
Hypertensive Crisis - PRES
 Started on a
nicardipine drip for
blood pressure control
 Became acutely
hemiplegic on the left
side when SBP cam
below 150
Hypertensive Crisis – PRES
with MCA occlusion
 Angiogram
confirmed complete
occlusion of the
right middle cerebral
artery.
PRES due to HTN from an M1
stenosis with a pressure
dependant exam
DWI
PWI – TTP
FLAIR
Wake-up Stroke Case
67 y/o gentleman with h/o CAD, HTN, Tobacco use presents to an OSH after
waking with left sided weakness, last known normal puts him out of an IV
tPA window thus he is tranfered to JHH for IA therapy. Hyper acute MRI
reveals:
DWI
ADC
FLAIR
Wake-up Stroke Case
Qualitative assessment of the DWI/PWI reveals:
Target mismatch?
PWI
ADC
FLAIR
Wake-up Stroke Case
Using Olea Sphere software (formerly Perfscape), ADC volume (<600) and
Tmax volume (<6 secs) is overlaid on the FLAIR. SIR values can also be
generated using the ADC ROI. Olea images are going to be uploaded to PACs.
PWI
ADC
FLAIR
(Olea Overlay)
Wake-up Stroke Case
 Volumetrics reveal:
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DWI volume of 13cc
6 sec PWI deficit of 67cc
10sec PWI deficit of 40cc
Mismatch Ratio 5.15
Target Profile!
 Patient taken for IA thrombectomy using the
stentriever device with successful recanalization
of the right MCA.
 Patient walked out of the hospital with only a
mild residual weakness of the left arm (4/5)