Her headache was wrongly attributed to Migraine !

Clinical scenario:

     A 28-year old lady presented with  severe headache of 3 days duration.
Her history of headache dated back to  five  years prior to current presentation .
The headache would occur  every 4-5 months and she had been diagnosed as common migraine .She had been put  on migraine prophylaxis.

 On this occasion her  headache  was  quite severe in intensity more so  in occipital region and was of  thunderclap nature . It  was  associated with nausea,vomiting but there was no history of fever .
She , however,  complained of  blurring of vision for the last  3 days .

 On examination: The patient had an average built and her vitals were normal . Systemic examination was normal too.
Neurological examination :-
She was conscious oriented in time place and person.
Cranial nerves:  
 Pupils:equal and reactive with relative afferent pupillary defect(RAPD) more in left eye
 Visual acuity: Right eye:20/25,Left eye:20/30.
 Extra ocular movements(EOMs): Normal eye movements in all directions.
  Fundi: Bitemporal optic atrophy.(Figure 1)

Fig 1  Bilateral Optic atrophy 

The detailed Visual fields examination showed  Binasal hemianopia as shown in Figure 2

Fig 2 Visual field : Binasal hemoanopia 

Apart from above abnormalities her neurological examination was normal .
There were no meningeal signs.
Investigations : 
Her Hemogram, ESR and tests on liver and kidney fucntions were normal .
Keeping in view visual field defects and optic atrophy and MRI MRV and MRA  was done and she was diagnosed to have Hypothalamic cavernoama .
She was sent for Gamma knife surgery. 
 .

Fig 3 Hypothalamic Cavernoma, Popcorn apperance (yellow and red arrows)

Teaching message:
Cavernous malformations are the least common vascular anomaly of central nervous system.It may be asymptomatic or cause various neurological deficits. Surgical intervention is recommended only if it is symptomatic. This case reminds us how serious diseases can masquerade in old complaints. Patients should never be profiled and chronic complaints should always be revisited.

Further reading:-

Cavernous hemangioma brain

This case was Contributed by:

Dr. Naif Edah Alomairi.
Consultant Neurologist.
Head of the dept.of internal medicine 
College of Medicine 
Taif university KSA