Case 16: headache and "drop attacks"

Posted: March 16, 1997

Resident: Bryan Payne, MD
Attending: Deepak Awasthi, MD

CLINICAL PRESENTATION: 36 year black female with a history of polycystic kidney disease presented to the emergency room with a severe headache and "drop attacks". The patient denies any nausea and/or vomiting, tonic/clonic movements, loss of consciousness, stiff neck, photophobia, visual changes, weakness, sensory changes. The "drop attacks" were described as sudden loss of strength in both lower extremities. This started two days prior to admission and was followed on the day prior to admission with severe headaches (not completely relieved by analgesics). In addition, the patient described difficulty with walking- unstable gait. She was brought to the ER by the family in the car and was then placed in a wheelchair because of difficulty walking.
Past history is significant for polycystic kidney disease with chronic reanl failure, no history of hypertension, diabetes mellitus, heart disease or neurological disorder.

EXAMINATION: Vital signs: T- 99, P-85, BP- 200/90 , R- 18
Patient was awake and alert, but mildy confused (she did not know the date). She followed all commands appropriately. There was a paucity of speech. General exam was normal (no murmurs, regular rate and rhythm).

Neuro exam revealed the patient to be awake/ alert. Speech was slow and very few words were spoken. However, the patient was able to name objects and follow commands. Cranial nerves II-XII intact. Pupils equal and reactive. Motor exam: decrease strength in both lower extremities (left> right)- diffuse 3/5 on left, 4/5 on right; good strength in both upper extremities. No sensory level. Sensation intact to pinprick, light touch and propioception. No graphesthesia. Gait abnormal because of weakness in lower extremities. No dysmetria. Reflexes normal bilaterally and no abnormal reflexes.

What is your differential diagnosis? Localization of lesion? Diagnostic study you will order?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: Our differential diagnosis included a parasagittal mass, intracranial hemorrhage (including subarachnoid hemorrhage). We felt the pathology was probably in the brain and thus we ordered a CT scan of the head without (and possibly with) contrast. A select image of the non-contrast axial CT scan is shown below:

The cranial CT scan revealed a subarachnoid hemorrhage with significant portion of the hemorrhage being in the supracallosal area.
At this point an angiogram was ordered (4 vessel). We were thinking of an anterior communicating artery aneurysm. The lateral left carotid angiogram is shown below:

The angiogram (select view shown above) revealed a left pericallosal artery aneurysm. No other aneurysms were seen.

Since the patient was grade I neurologically, she was taken to the OR early and through a frontal craniotomy, the interhemipsheric cistern and subsequently the supracallosal cistern were entered. Both distal A2 , pericallosal and callosomarginal vessels were identified. The neck of the aneurysm was defined and clipped with preservation of the parent vessels. Intraoperative pict is shown below:

This pict shows the aneursym clipped. The A2 vessels are coming towards us. The right pericallosal artery can be seen on the right side of the picture.

POSTOPERATIVE COURSE: patient developed a transient period of akinetic mutism (10 days) which gradually improved and has now resolved. The patient's lower extremity strength is now normal with no episodes of "drop attacks". She continues to be on anti-epileptic medications. Postoperative angiogram revealed no residual aneurysm and good patency of all vessels.

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