ABSTRACT

Figure 8.5 (a), (b) and (c) are from the same patient, a 37-year-old with a Wallenberg’s syndrome accompanied by retro-ocular headache with autonomic features resembling ‘continuous’ cluster headache.This case suggests that all the symptomatology typical of cluster headache can be secondary to a pure central lesion. (a) Angiography showing an occlusion of the left vertebral artery, with no sign of dissection; (b) T2-weighted MRI showing an infarct of the left posterior inferior cerebellar artery (PICA) territory; (c) close-up picture of the patient’s face showing left palpebral ptosis and conjunctival injection.Reproduced from Cid C,Berciano J, Pascual J.Retroocular headache with autonomic features resembling ‘continuous’ cluster headache in lateral medullary infarction. J Neurol Neurosurg Psychiatr 2000;69:134-41, with permission by the BMJ Publishing Group

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Figure 8.6 Very severe conjunctival injection (more pronounced in the patient’s left side) and uveitis in a 63-year-old woman presenting as bilateral periocular headache as the first sign of a confirmed Wegener’s syndrome. Headache and ocular manifestations resolved after aggressive treatment with steroids and cyclophosphamide. Reproduced with kind permission of Julio Pascual

Figure 8.7 Cranio-cervical MRI study of a 39-year-oldwoman complaining of brief (second-1 minute) occipital headache when coughing and other Valsalva maneuvers showing tonsillar descent. Sagittal MRI T1 W1 pulse sequence demonstrates low lying tonsils, normal fourth ventricle and normal posterior fossae anatomy indicative of Chiari I. Headache has disappeared after suboccipital craniectomy. Reproduced with permission from Pascual J, Iglesias F, Oterino A, et al. Cough, exertional and sexual headache. Neurology 1996;46:1520-4

Figure 8.9 Seventy-year-old man with giant-cell arteritis. A portion of the anterior branch of the left temporal artery is visibly swollen. It was tender and thickened on palpation. Reproduced with permission from Caselli RJ, Hunder GG. Giant cell arteritis and polymyalgia rheumatica. In: Silberstein SD, Lipton RB, Dalessio DJ, eds. Wolff ’s Headache and other Head Pain, 7th edn. New York: Oxford University Press, 2001:525-35

Figure 8.8 This 78-year-old man went to hospital due to constant temporal headache during the previous two months. On examination there was no pulsation in the left temporal artery, which appeared thickened and painful on palpation.The erythrocyte sedimentation rate was 96 mm in the first hour, while a temporal artery biopsy showed changes diagnostic of giant-cell arteritis. Courtesy of Jose¢ Berciano, University Hospital Marques de Valdecilla, Santander, Spain

Figure 8.11 Lyme disease most often presents with a characteristic ‘bull’s eye’ rash, erythema migrans, accompanied by non-specific symptoms such as fever, malaise, fatigue, myalgia and joint aches (arthralgia). Many patients complain of persistent daily headaches

Figure 8.10 Temporal artery biopsy specimen showing active inflammation in all three vascular layers (intima, media, adventitia). The lumen is partially shown, at the top of the figure, and is narrowed. In most temporal artery biopsy specimens with giant-cell arteritis, the media, especially the inner media in the region of the internal elastic Iamina, is involved to the greatest extent and the intimal and adventitial layers are involved to a lesser degree than in this patient (hematoxylin and eosin stain, 200x). Reproduced with permission from Casselli RJ, Hunder GG. Giant cell arteritis and polymyalgia rheumatica. In: Silberstein SD. Lipton RB, Dalessio DJ, eds. Wolff ’s Headache and Other Head Pain, 7th edn. New York: Oxford University Press, 2001:525-35

Figure 8.12 A 22-year-old man with a one-month history of a left hemicranial pain and cluster-like features. An axial CT scan post-enhancement demonstrated a multilocular lesion in the left frontal lobe with white matter edema, displacement of the falx to the right and enhancement of the rings measuring 3.5 cm at the widest. This is a pyogenic brain abscess approximately 14 days old. Reproduced with kind permission of Germany Goncalves Veloso

Figure 8.14 A 34-year-old healthy farmer reported a mild occipital headache for 4 weeks. The general and neurologic examinations were normal. (a) Sagittal T1 W1 MRI and (b) axial T1 W1 MRI showed a large cyst in the posterior fossa displacing the cerebellar hemispheres upwards; this is likely to be a congenital Dandy-Walker abnormality. Surgical approaches were contraindicated by the neurosurgical staff. After 3 years the patient remains asymptomatic, except for transient, mild headaches associated with emotional stress. Reproduced with kind permission of Pericles de Andrade Maranha~o-Filho

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Figure 8.13 A 53-year-old female patient with a strong pain in the left periocular and temporal region. She presented with autonomic signs, eyelid ptosis and conjunctival injection, ipsilateral to and concurrent with the pain.The duration of the pain was 40 min. It occurred three times per day and was worse at night. As a result of the painful episodes she had decreased sensitivity in the left facial region. The angiogram disclosed an occlusion at the proximal region of the external carotid artery on the left. Patient experienced total relief using verapamil. Reproduced with kind permission of Vera Lucia Faria Xavier

Figure 8.15 A 35-year-old man with a history of chronic daily headache and recent-onset partial motor seizures. (a) Axial CT scan shows multiloculated cysts in the left sylvian fissure; (b) axial CT scan at the same level.The subarachnoid lesion is not enhanced. The diagnosis is cysticercosis. Reproduced with kind permission of Suzana M.F. Malheiros

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Figure 8.16 A 34-year-old woman with a history of thunderclap headache during sport activity associated with blurred vision. (a) Axial CT scan shows multifocal high-density intraparenchymal lesions; (b) CT scan shows an irregularly enhancing rim of the three lesions each located bilaterally in the parietal lobes with surrounding edema. Note a fluid-fluid level within the right periventricular lesion.The lesions were confirmed as metastatic melanoma. Reproduced with kind permission of Suzana M.F. Malheiros

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Figure 8.17 A 60-year-old man with a six-month history of pressing/tightening headache that antedated the development of mild right hemiparesis. Axial post-contrast T1-weighted MR scan shows a large, enhancing, ill-delineated left basal ganglia mass.The diagnosis is anaplastic astrocytoma. Reproduced with kind permission of Suzana M.F. Malheiros

Figure 8.20 Sagittal T1 W1 non-enhanced MRI demonstrating a Chiari II malformation. Note the low-lying tonsils, flattening of the aqueduct, compression of the fourth ventricle and a widened cervical cord

Figure 8.18 A 29-year-old man with a history of suddenonset headache associated with exertional worsening. Axial FLAIR image demonstrates a hyperintense left fronto-temporal scallop-bordered mass (approximately 5 · 3.7 cm) well circumscribed with no edema. The diagnosis is primitive neuroendodermal tumor (PNET). Reproduced with kind permission of Suzana M.F. Malheiros

Figure 8.19 Sagittal T1 W1 MRI post-enhancement venous angioma. A right cerebellar linear enhancing structure with a trans-cerebellar course demonstrating uniform enhancement and classic umbrella shape

Figure 8.21 Two axial T1 W1 MRI non-enhancing images reveal a large hypointense, scallop-bordered mass with extension to the foramen of Luschka, compressing the brainstem and fourth ventricle which demonstrates hyperintensity on the T2-weighted image (b) so that it becomes iso-intense with the cerebral spinal fluid (CSF)

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Figure 8.22 A 40-year-old male with continued headache following head trauma from a motorcycle accident. An axial T1 non-enhanced image shows bilateral, concave, hyperintense collections that are 3 days to 3 weeks old. The diagnosis is subacute subdural hematoma

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Figure 8.23 A patient who presented with headache with papilledema.These are images demonstrating a filling defect or lack of filling of the superior sagittal sinus consistent with thrombosis

Figure 8.24 Carotid arteriogram showing an aneurysm which comes to a point consistent with this being the area of pathology. No areas of spasm are noted. Reproduced with kind permission of Nitamar Abdala

Figure 8.25 Two axial CT scans showing diffuse blood-filled CSF and cisternal spaces.There is increased density consistent with a diffuse subarachnoid hemorrhage. Reproduced with kind permission of Nitamar Abdala

Figure 8.26 A middle-aged male with left-sided head pain and hearing loss.Two posterior fossae T1 MRI post-enhancement images show a cerebellopontine angle component of 1 cm with an intracanalicular extension. Uniformly enhancing mass with a cisternal and intracanalicular component; widening of the internal auditory canal is consistent with a vestibular schwannoma. Reproduced with kind permission of Nitamar Abdala

Figure 8.28 A 32-year-old woman with a four-month history of a new-onset throbbing headache followed by sixth nerve palsy and ataxia. Axial post-contrast T1-weighted MR scans show a large, enhancing, well-delineated mass that expands and distorts the pons. The diagnosis is anaplastic astrocytoma. Reproduced with kind permission of Suzana M.F. Malheiros

Figure 8.27 Tolosa-Hunt syndrome is an idiopathic inflammatory condition that usually presents with painful ophthalmoplegia. An axial T1 MRI shows a soft tissue mass filling the lateral aspect of the right cavernous sinus compressing and medially displacing the carotid artery and extruding to the apex of the right orbit. Reproduced with kind permission of Nitamar Abdala

Figure 8.29 A 15-year-old girl with a history of progressive severe headache initiating 2 weeks before, associated with nausea, vomiting and decreased consciousness. (a) Axial CT scan shows ill-defined lowdensity changes in the white matter of both hemispheres; (b) axial CT scan at the same level shows multifocal subcortical white matter ring-enhancing lesions.The diagnosis is cysticercosis. Reproduced with kind permission of Suzana M.F. Malheiros

Figure 8.30 A middle-aged woman presenting with headaches is found to have an empty sella. A sagittal T1 MRI demonstrating a stretched pituitary infundibulum with no significant visible pituitary tissue

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Figure 8.31 Three-year-old boy with two prior episodes of spontaneously resolving oculomotor nerve palsy. (a) and (b), sagittal T1-weighted MR images before (a) and after (b) contrast administration show diffuse thickening and enhancement of the oculomotor nerve.The symptoms resolved spontaneously in 6 weeks. Reproduced with permission from Mark AS, Casselman J, Brown D, et al. Ophthalmoplegic migraine: Reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrastenhanced MR images. AJNR Am J Neuroradiol 1998;19:1887-91, copyright © American Society of Neuroradiology (www.ajnr.org)

Figure 8.32 Twenty-seven-year old woman with two prior episodes of headache and oculomotor nerve palsy. (a) and (b), axial non-contrast (a) and contrast-enhanced (b) T1-weighted images show focal nodular enhancement of the exit zone of the oculomotor nerve (see arrows). Follow-up study showed virtually complete resolution of the enhancement. Reproduced with permission from Mark AS, Casselman J, Brown D, et al. Ophthalmoplegic migraine: Reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrast-enhanced MR images. AJNR Am J Neuroradiol 1998;19:1887-91, copyright © American Society of Neuroradiology (www.ajnr.org)

Figure 8.33 Twelve-year-old boy with two prior episodes of ophthalmoplegic migraine. (a) and (b), axial T1-weighted MR images before (a) and after (b) contrast administration show enhancement of the oculomotor nerve (arrow in panel b) and thickening of its root entry zone. Follow-up studies showed virtually complete resolution of the enhancement. Reproduced with permission from Mark AS, Casselman J, Brown D, et al. Ophthalmoplegic migraine: Reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrast-enhanced MR images. AJNR Am J Neuroradiol 1998;19:1887-91, copyright © American Society of Neuroradiology (www.ajnr.org)

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Figure 8.34 Twenty-three-year-old woman with one prior episode of ophthalmoplegic migraine. (a) axial T1-weighted contrastenhanced MR image shows enhancement of the oculomotor nerve and thickening of its root entry zone; (b) follow-up study shows virtually complete resolution of the enhancement. Reproduced with permission from Mark AS, Casselman J, Brown D, et al. Ophthalmoplegic migraine: Reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrastenhanced MR images. AJNR Am J Neuroradiol 1998;19:1887-91, copyright © American Society of Neuroradiology (www.ajnr.org)

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Figure 8.35 Eight-year-old girl with one prior episode of spontaneously resolving oculomotor nerve palsy. (a) and (b), sagittal T1-weighted MR image before (a) and after (b) contrast administration show focal thickening and enhancement of the root exit zone (see arrows). The symptoms resolved spontaneously within 6 weeks. Reproduced with permission from Mark AS, Casselman J, Brown D, et al. Ophthalmoplegic migraine: Reversible enhancement and thickening of the cisternal segment of the oculomotor nerve on contrast-enhanced MR images. AJNR Am J Neuroradiol 1998;19:1887-91, copyright © American Society of Neuroradiology (www.ajnr.org)

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Figure 8.36 Sixty-three-year-old female presents with right eye pain and ptosis. Patient diagnosed with subarachnoid hemorrhage and an aneurysm was discovered and clipped. Reproduced with kind permission of Gary Carpenter

Figure 8.37 Elderly patient presents with complaint of recent memory difficulties, dizziness, headache and gait disturbances. Patient found to have obstruction of cerebrospinal fluid flow with large ventricles and periventricular leucomalacia. Reproduced with kind permission of Gary Carpenter

Figure 8.38 Forty-year-old female presents with sudden-onset, right-sided headache with nausea and vomiting, decreased right facial sensation, dysarthria, partial pointing of right arm, ataxia, increased deep tendon reflexes and sensory loss in left hand. Patient had history of breast cancer and CT showed leptomeningeal enhancement in tentorium consistent with carcinomatous meningitis. Reproduced with kind permission of Gary Carpenter

Figure 8.39 Seventy-year-old male presents with bilateral parietal headache and unsteady gait. Patient also has inappropriate affect and apraxia. Patient is found to have right frontal lobe glioblastoma with mass effect and developed a cerebrospinal fluid leak postoperatively. Reproduced with kind permission of Gary Carpenter

Figure 8.40 Twenty-six-year-old male presents with severe headache and pulsatile tinnitus. Bruits were auscultated over left carotid artery. Bruit was loud enough at times to be heard over the telephone. Cerebrospinal fluid exam was negative. Patient found to have carotid dissection anterior rupture and fistula with left cavernous sinus. Patient is thin with acrogyria. Reproduced with kind permission of Gary Carpenter

Figure 8.41 Twenty-eight-year-old female with a history of Dandy-Walker syndrome diagnosed at age 16 presents with sudden onset headache. Opening pressure of lumbar puncture was 32 cm H2O. After lumbar puncture patient developed scapula pain and headache when in upright position. Patient had high pressure to low pressure headache after the lumbar puncture and was treated with caffeine. Reproduced with kind permission of Gary Carpenter