Interesting Headache Case - Test Your Skills

[MedicinePower]

Sounds like a CSF leak. Keep in mind that no imaging is actually good at weighting CSF leaks and, in fact, many times the leaks are lost between imaging slices.

Do an epidural blood patch and see what happens.

[d2305]

A cns leak wouldn't cause facial Sx. 

[YoungH89]

Working in a large teaching ER you dont realize how difficult it can be to get some of these studies as an outpatient. I had a pregnant patient the other day with progressive left sided headache and hx of a "clot in my head " in prior pregnancy. MRV ordered and patient was back in the department withtin 2 hours... 

[jmj11]

Here's the updated MRV report after I spoke to the neuro-radiologist.

I will also try to attach one image. I have spent the last 30 minutes trying to get one image from our radiology file to my personal tablet and then in a form that I can attach here. I hope this comes through. I don't see any patient identifiers so if I've missed one, please let me know.

 

PROCEDURE: ANGIOGRAM HEAD WITHOUT CONTRAS

INDICATIONS: HEADACHES

TECHNIQUE:

Sagittal T1 spin echo through the brain. Coronal 2D time-of-flight MR venogram, with 3-

dimensional maximum-intensity-projection (MIP) reformats of the intracranial veins then

performed.

COMPARISON: Island Hospital, CT, HEAD WITHOUT CONTRAST, 11/02/2017, 16:19. Island

Hospital, MR, BRAIN WITHOUT CONTRAST, 11/29/2017, 10:05.

FINDINGS:

Image quality: Excellent.

Veins: Sagittal, straight, transverse, and sigmoid sinuses all appear patent on the right. There

is marked attenuated diminutive appearance of the left transverse and sigmoid sinus with

extension into the jugular vein.

Brain: Limited images through the brain parenchyma show no intracranial bleeds or mass

effects.

IMPRESSION:

1. Marked, diminutive appearance of the left transverse and sigmoid sinus with extension

into the jugular vein as above. Findings are highly suspicious for venous thrombosis.

Clinical history notes onset of symptoms to be late subacute/early chronic. This could

represent partial recanalization. Followup imaging should include MRV as well as MRI

brain with and without contrast.

The above findings were discussed with Michael Jones PA, 11/30/17 at 12 PM.

Dictated by: Kelley Cline, M.D. on 11/30/2017 at 16:55

Approved by: Kelley Cline, M.D. on 11/30/2017 at 16:58

 

 

 

[narcan]

Very nice catch. I think there's a great take home lesson here for all of us in that it's not at all easy to call up a radiologist and argue with their interpretation. It can be hard to argue your case with any physician. But when you take true ownership of your patients, you do those things, and you make physicians explain why they're right.

In this case, I suspect the first radiologist knew his read was wrong as soon as you pointed it out to him, but to save face, he said "oh I see a tiny amount of flow, but I'll send it to a neuroradiologist if you want". That might've been my favorite part.

But nonetheless, great work, and I'm going to take your save here as inspiration for myself. Thanks for sharing.