jmj11 Posted September 11, 2013 Share Posted September 11, 2013 I'm presenting you a real case that I'm having a "discussion" about with an Insurance doc. A 47 year old lady in good health with no prior history of headache. She is gardening around August 8th and has a sudden onset of severe headache that brings her to her knees, not only the worse headache of her life, but the worse pain of her life. She goes into the house and lays down. She feels numbness growing on the right side of her face, within the next few hours feels very dizzy and can't hardly walk and has decreased hearing in her right ear. To make a long story short, she doesn't go to the ER because she is very stoic, never had medical problems and had never been in the ER. After two days of intense pain, she does go to her PCP. He orders an MRI and it is normal. No other tests are ordered and she is referred to us Over the subsequent 4 weeks all the symptoms remain but are slowly improving each day. Her head pain is at a 5/10 now, positive Romberg on exam and with a Dix-Hall-pike she has vertigo and brief nystagmus. Any other test you would order and if so, what are your concerns? Link to comment Share on other sites More sharing options...
MedicinePower Posted September 11, 2013 Share Posted September 11, 2013 Does her pain get any better when she lays down but gets worse then sitting/standing up? Sudden and acute head pain can be many pathologies. In women it is sometimes due to a Spontaneous CSF Leak, absent any trauma whatsoever. The MR might be completely normal, but an LP might show a low opening pressure. Link to comment Share on other sites More sharing options...
d2305 Posted September 11, 2013 Share Posted September 11, 2013 ESR and Bx. temproal arteritis. Link to comment Share on other sites More sharing options...
skyblu Posted September 11, 2013 Share Posted September 11, 2013 Dix-hallpike is only 75% specific. What kind of nystagmus did you elicit? Torsional = most likely BPPV, but upbeating or downbeating alone could indicate a CNS issue. Did Epley's maneuver help? Get LP, sed rate, and agree with temporal artery bx. Audiometry, evoked potentials. Link to comment Share on other sites More sharing options...
rcdavis Posted September 11, 2013 Share Posted September 11, 2013 I would agree with most of the above. but the thing that will kill her is the basilar artery (or cerebral artery) aneruysm, through which she had a sentinel leak 7 aug 13. mri are terrible at picking up blood, and i'll bet they missed the aneurysm. I would do a CT angio with contrast before going down too many other rabbit holes Link to comment Share on other sites More sharing options...
skyblu Posted September 11, 2013 Share Posted September 11, 2013 Xanthocrhomia on LP would pick up blood this far out much better than CT, though CTA might see the actual aneurysm Link to comment Share on other sites More sharing options...
jmj11 Posted September 11, 2013 Author Share Posted September 11, 2013 I would agree with most of the above. but the thing that will kill her is the basilar artery (or cerebral artery) aneruysm, though which she had a sentinel leak 7 aug 13. mri are terrible at picking up blood, and i'll bet they missed the aneurysm. I would do a CT angio with contrast before going down too many other rabbit holes YES!!!!!!!!!!!!! The insurance - radiologist denied MRA, CT A all . . . I got her name and charted that her denial was against my total clinical call and she is responsible for any poor outcome. I offered the patient to do it for cash . . . but of course she denied to go through with the exams. Link to comment Share on other sites More sharing options...
jmj11 Posted September 11, 2013 Author Share Posted September 11, 2013 Xanthocrhomia on LP would pick up blood this far out much better than CT, though CTA might see the actual aneurysm I totally agree, but at 4 weeks out (plus) I'm concerned about a false negative. Link to comment Share on other sites More sharing options...
skyblu Posted September 11, 2013 Share Posted September 11, 2013 Yes, I agree, 4 weeks is a long time. They don't do MRA's at the same time as the MRI's? You have to get them separately approved by insurance? Crazy. Link to comment Share on other sites More sharing options...
jmj11 Posted September 11, 2013 Author Share Posted September 11, 2013 Yes, I agree, 4 weeks is a long time. They don't do MRA's at the same time as the MRI's? You have to get them separately approved by insurance? Crazy. I just saw the patient the first time yesterday. The MRI was done almost 4 weeks ago by the PCP, who didn't think of doing an MRA and ordered only an MRI w/o. Link to comment Share on other sites More sharing options...
Acebecker Posted September 11, 2013 Share Posted September 11, 2013 On what basis is the insurance person denying this? Seriously... How is this person justifying their decision? Link to comment Share on other sites More sharing options...
jmj11 Posted September 11, 2013 Author Share Posted September 11, 2013 On what basis is the insurance person denying this? Seriously... How is this person justifying their decision? I have no idea. I gave them all the information that I did you just now (above) and in detail. We were on the phone with them for 45 minutes last night and it sound like it was approved. I got a written report faxed from them this morning, it was from the company that does radiological authorization reviews from Aetna, that said have their radiologist reviewed the case that there is no need for an MRA, but they would approve another MRI (makes no sense unless the radiologist gets paid for each rejection, which might be true). I only had time to fax them back a note that I'm holding them personally responsible for the outcome. Regarding GCA, the youngest patient I've ever seen with it was 57 and he also had PMR. This patient was 47 and in good health. I've never seen GCA come on as a thunderclap type of headache, with ataxia (gait) and hearing loss on the ipsilateral side, but I have seen it (the head pain) develop over the course of a day or so. So have you d2305 have seen such cases of GCA? Link to comment Share on other sites More sharing options...
d2305 Posted September 11, 2013 Share Posted September 11, 2013 No. But it sounded good at the time. I thought about an MRA/CTA, and acustic neuroma, but they should have seen something on the MRI. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted September 12, 2013 Moderator Share Posted September 12, 2013 I would agree with most of the above. but the thing that will kill her is the basilar artery (or cerebral artery) aneruysm, through which she had a sentinel leak 7 aug 13. mri are terrible at picking up blood, and i'll bet they missed the aneurysm. I would do a CT angio with contrast before going down too many other rabbit holes my thought as well with that story. sentinel bleed.. badness. know any smart local er docs? call them, discuss the case. if they agree with the need for cta, have them order it emergently as part of a return er visit for worsening h/a. , then insurance has to pay as part of the er visit. screw them, get the test done. I'm so glad I don't have to deal with that bs. need a test, do a test. Link to comment Share on other sites More sharing options...
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