Case 6: Headache

21 year old female presented with 6 months history of intermittent headache associated with transient visual loss.

She presented to the clinic multiple times and saw a different general practitioner with headache for the last 6 months. She is generally well with no past medical problems.

She is currently on the pill and has been on it for the last few years.

She described the headache as throbbing and bilateral. There was no particular trigger. There was no associated vomiting or weakness. The headache usually does not wake her up at night.

She has had extensive investigations in the past , including CT and MRI Brain. MRI reported empty sella. Patient was prescribed a low dose of amitriptyline and had a good response.

She re-presented today because she found that the amitriptyline no longer worked. She has been experience headache almost daily. She also described transient visual field defect in a few occasions for 1-2 minutes. The vision returned to normal after that.

Question 1
What are your differential diagnoses?

Question 2
Is the MRI finding significant?

Question 3
What are the clinical presentations of IIH?

Question 4
What is the diagnostic criteria?

Question 5
What is the treatment?

Answer 1

This is a tricky case as she has had headache for some time and it is getting worse. Imaging results seem to be relatively normal. She now has new neurological symptom.

Using the murtagh model:
Red flags: malignancy, benigh intracranial hypertension, venous thrombosis, malignant hpertension
Common presentations: tension headache, migraine

Answer 2
Empy sella is a relatively common incidental finding, however, it has a well-established association with benign intracranial hypertension.

Given the headache, transient visual loss, patient's age (she is not overweight), gender, and the empty sella sign. She is likely to have benign intracranial hypertension.

Answer 3

Typical presentation of IIH is young, obese woman with headache with papilloedema on examination.

The most common symptoms of idiopathic intracranial hypertension were (1):

• Headache 84-92 percent
• Transcient visual obscuration (68-72%)
• Intracranial noises (52-69 %)
• Photopsia 48-54%
• Back pain 53 %
• Retrobulbar pain 44%
• Diplopia 18-38%
• Sustained visual loss 26-32%

On examination, the most common signs in IIH are:

• Papilledema
• Visual field loss 
• Sixth nerve palsy 

Answer 4 

The modified Dandy criteria:

• Symptoms and signs of increased intracranial pressure
• No other neurological abnormalities or impaired level of consciousness
• Elevated intracranial pressure with normal cerebrospinal fluid composition 
• A neuroimaging to exclude secondary cause
• No other cause of intracranial hypertension apparent

Answer 5 

• Carbonic anhydrase inhibitors: acetazolamide, topiramate
• Loop diuretics: Frusemide 
• Corticosteroids (not recommended on UpToDate)
• Indomethacin 
• intermittent lumbar puncture to relieve pressure

Case 5: Below Knee DVT

35 year old Female presented with ultrasound confirmed diagnosis of right below knee DVT.

She ruptured her ACL 2 weeks ago while playing netball. After the injury, she had a MRI and saw an orthopaedic surgeon. She wanted to have the knee reconstruction ASAP.

Few days ago, she started to feel throbbing pain in her right leg. Incidentally, she had an appointment with another GP at a different clinic for skin cancer check. During the consultation, she mentioned her lower limb swelling and an ultrasound was ordered which confirmed the below knee thrombus.

She was started on clexane and sent back to you.

Question 1
Other than clexane, what are other options?

Question 2
How long will you put her on anti-coagulation for?

Question 3
She is extremely concerned about her ruptured ACL. She wants to have it fixed ASAP. What do you tell her ?

Answer 1

I still remember prescribing clexane and warfarin for people with below knee DVT when I was an intern 5 years ago. With the new oral anticoagulants, there are many more options.

The available treatments (1):

• Subcutaneous low molecular weight heparin such as clexane in this case
• The oral factor Xa inhibitors rivaroxaban or apixaban
• Bridging clexane then warfarin 
• Dabigatran or edoxaban. (requiring 5 to 10 days course of heparin prior to commencement of treatment)

The standard practice now at most hospitals is rivaroxaban (starting with 15 mg for 3 weeks, then increase to 20 mg). Interestingly, therapeutic guideline in Australia is till recommending clexane and warfarin as first line treatment. 

Of course, there is no hard and fast rule in selecting anticoagulants. If in doubt, use clexane for the first few days so that you and the patient can have time to think about the options.

Answer 2

According to therapeutic guideline, a person with provoked DVT, the minimum length of treatment is 3 months. Usually we will re-assess with ultrasound to ensure the resolution of the thrombus prior to ceasing the anti-coagulation.

Answer 3

Many patients have a fixed perception that ruptured ACLs have to be fixed ASAP. They probably get the idea from the media. It often reports Australian footy player receives surgery right away after an ACL rupture, and 2 months later, they are playing on the field again! (They forgot to mention the players are getting paid few hundred thousand dollars per game.)

So far, there is no evidence that early ACL repairs improve outcome. The rehabilitation time after an ACL repair is long, usually 6 - 12 months. It takes motivation and effort to return to pre-injury level activities. I have seen many people with poor outcome from ACL re-constructions.

Many people can continue playing sports without ACLs. In short, there is absolutely no indication for an urgent ACL repair. (Of course, unless you are getting paid 100,000 per game)

I told her that no orthopaedic surgeon will risk her life (the chance of developing a PE from having the surgery) with an ACL reconstruction.

References:

Lip G, Hull R. Overview of the treatment of lower extremity deep vein thrombosis (DVT). In: UpToDate, Post TW(Ed), UpToDate, Waltham, MA. (Accessed on April 26,2017)

Friedberg R. Anterior cruciate ligament injury. In: UpToDate, Post TW(Ed), UpToDate, Waltham, MA. (Accessed on April 26, 2017)