ABSTRACT
V.I.C.I.O.U.S.
Vascular: Thunderclap onset (i.e. immediate):
Haemorrhage: Aneurysmal subarachnoid; intracerebral
Thrombosis: Venous sinus thrombosis; ischaemic stroke (in conjunction with acute hemiparesis)
Reversible cerebral vasoconstriction syndrome (RCVS):
PC: Recurrent thunderclap headaches over 1–4 weeks, mimics subarachnoid haemorrhage
Ix: CT angiogram shows vasoconstrictions that reverse by 6 weeks; but no aneurysms; CT may show infarcts or cerebral convexity subarachnoid haemorrhage
Other: Dissection, vasculitis
Infection/Inflammation: Acute or subacute onset (i.e. over hours or days):
Meningitis:
Neutrophilic CSF: Meningococal, pneumococcal, listeriosis, fungal; OR early viral or TB
Lymphocytic CSF: Viral (enterovirus, HIV), TB, Lyme, syphilis; OR partially treated bacterial; autoimmune vasculitis, SLE, Behçet syndrome; sarcoidosis
Brain abscess
Encephalitis: Infective (e.g. herpes simplex virus) or post-infective (acute demyelinating encephalomyelitis)
Compression: Recurrent paroxysmal, or thunderclap:
Intraventricular or periventricular tumour, causing transient obstructive hydrocephalus, (e.g. colloid cyst of 3rd ventricle) PC: Drop attacks, acute bilateral visual loss
Posterior fossa lesion: Tumour, Arnold–Chiari malformation
Pituitary enlargement: Apoplexy, due to infarction of pituitary macroadenoma; post-partum hypophysitis
Intracranial pressure ↑ or ↓:
Primary intracranial hypertension:
PC: Headache worse on stooping or lying flat; visual disturbance (obscurations; 6th cranial nerve palsy); tinnitus, triggered by weight gain
Spontaneous intracranial hypotension, due to spinal CSF dural leak
PC: Headache worse on standing initially, but may become posture-independent later. May be triggered by exertional event, e.g. lifting
Ophthalmic – acute glaucoma: Unilateral but not necessarily ocular
U: coUgh or other ‘situational’ cause, e.g. exertion, coital cephalgia:
Commoner in people who suffer with migraines
Recurrent paroxysmal thunderclap headache
Systemic:
Hypertensive crisis (e.g. pre-eclampsia, phaeochromocytoma) causing PRES (posterior reversible encephalopathy syndrome) with characteristic MRI cerebral white matter lesions; vasculitis
Infection, e.g. sinusitis, tonsillitis, dental abscess, UTI, atypical pneumonia (e.g. mycoplasma) – may all cause meningism and encephalopathy, esp. in children and elderly
Toxins: Carbon monoxide
https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429446405/b9046b8d-f890-4c55-a52a-551490b30e56/content/unfig6_2.tif" xmlns:xlink="https://www.w3.org/1999/xlink"/>