1 A history of multiple recurrences without severe neurologic sequelae argues strongly against subarachnoid hemorrhage and cervical artery dissection. The sudden, severe headaches have a broader differential diagnosis, including venous sinus thrombosis, posterior reversible encephalopathy syndrome, CNS vasculitis, reversible cerebral vasoconstriction, and meningoencephalitis. The spells of altered consciousness are most consistent with complex partial seizures. In this case, the history has two main components: spells of altered consciousness and episodes of severe headache. In developing a differential diagnosis, one must first distill the crux of the clinical syndrome from the history. The details of this illness were not known beyond the fact that he was treated for several months with an antibiotic. In addition to the childhood seizures, his past medical history was notable for a fungal infection of the lung in 1997 for which he had been admitted to an intensive care unit.
He also described difficulty in using his hands to perform tasks such as putting toothpaste on a toothbrush, which he described as being like “putting two magnets together.” Finally, he had lost about 25 pounds over the preceding 3 months. He developed a slowly progressive, mild dysarthria difficulty walking due to frequent “buckling” of the right knee and numbness in the right medial forearm and little finger. His wife described him as “vacant” and “not as active and happy-go-lucky” as usual. After the first episode of altered consciousness, his personality changed. He was admitted to another hospital for evaluation of these symptoms and transferred to our facility after a 1-hour spell of “unresponsiveness,” which resolved spontaneously, while there.įurther questioning revealed additional symptoms. These episodes occurred more frequently when lying in bed than when he was standing or sitting, and were associated with nausea. It was severe enough to cause him to fall to his knees and cry out in pain. The pain began in the shoulders, spreading to the occipital region and then the entire head over 1–2 minutes. He also developed recurrent, sudden, severe headaches that occurred several times per day. Over the next 2 weeks, he had several similar spells. He continued to drive normally, but had a befuddled facial expression and did not respond to questions from his wife. One week later, he suddenly became confused while driving. This lasted for a few hours, abating after several doses of ibuprofen and acetaminophen. Two weeks later, he experienced a severe headache of sudden onset without associated nausea, vomiting, or focal neurologic symptoms. His illness began 1 month earlier with fatigue and bilateral hand tremor. A 52-year-old right-handed man with a history of petit mal seizures as a child was transferred to our hospital after a spell of sudden loss of consciousness.
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