A 5-year-old boy is brought to the emergency department due to confusion and weakness. The patient was accompanying his mother on a shopping trip 2 hours ago when he developed a severe headache, followed by vomiting. His mother took him home and allowed him to rest. Thirty minutes ago, he appeared excessively drowsy and could not move the left side of his body. The patient has had no recent illnesses and takes no medications. He has a history of hereditary hemorrhagic telangiectasia. Temperature is 37.2 C (99 F) and blood pressure is 140/90 mm Hg. Examination shows a somnolent boy who withdraws from painful stimuli. There are a few telangiectasias along the lips and tongue. Cardiopulmonary examination is unremarkable. The abdomen is soft with normal bowel sounds. Which of the following features would most likely be found on CT scan of the head?

Question

A 5-year-old boy is brought to the emergency department due to confusion and weakness.  The patient was accompanying his mother on a shopping trip 2 hours ago when he developed a severe headache, followed by vomiting.  His mother took him home and allowed him to rest.  Thirty minutes ago, he appeared excessively drowsy and could not move the left side of his body.  The patient has had no recent illnesses and takes no medications.  He has a history of hereditary hemorrhagic telangiectasia.  Temperature is 37.2 C (99 F) and blood pressure is 140/90 mm Hg.  Examination shows a somnolent boy who withdraws from painful stimuli.  There are a few telangiectasias along the lips and tongue.  Cardiopulmonary examination is unremarkable.  The abdomen is soft with normal bowel sounds.  Which of the following features would most likely be found on CT scan of the head?

Quizplus · Accepted Answer

11ec25c8_d5aa_309c_bc81_8f36590509bc_MD0003_00 This patient had an acute onset of headache and vomiting with subsequent focal neurologic deficits and somnolence. In an individual with hereditary hemorrhagic telangiectasia (HHT), these findings are concerning for a hemorrhagic stroke. In children, hemorrhagic stroke is rare and most commonly caused by rupture of an underlying vascular malformation, such as an arteriovenous malformation (AVM). AVMs are usually isolated, congenital, anomalous connections between arteries and veins, resulting in high pressure flow through weak vessels. HHT is an autosomal dominant disorder associated with mucocutaneous telangiectasias and multiorgan (eg, lungs, liver, brain) AVMs and, therefore, an increased risk of hemorrhagic stroke. arteriovenous malformation (AVM) mucocutaneous telangiectasias Presentation of hemorrhagic stroke can include sudden onset of headache, vomiting, hypertension, or altered mental status due to increased intracranial pressure. Seizures are common with intracerebral hemorrhage, and patients often have focal neurologic deficits (eg, contralateral hemiparesis), as seen in this patient. Diagnosis is confirmed by visualization of an intraparenchymal, intraventricular, or subarachnoid bleed on head CT scan. In this case, an intraparenchymal bleed from a ruptured AVM would be seen on imaging as a hyperdense fluid collection with irregular margins in the right cerebral cortex. (Choice A) Typically caused by trauma (resulting in the dura being stripped under the bone), an epidural hematoma (EDH) is seen as a biconvex hyperdensity that generally does not cross suture lines. Spontaneous EDH is extremely rare and far less likely than hemorrhagic stroke in a patient with HHT. (Choice C) A middle cerebral artery ischemic stroke appears as hypoattenuation and edema of the corresponding cerebral cortex. Although symptoms can include sudden-onset focal neurologic deficits, seizure, and headache, this patient's rapidly declining mental status is concerning for increasing intracranial pressure from hemorrhage. In addition, HHT makes a ruptured AVM more likely than an ischemic stroke. (Choice D) A medulloblastoma is an enhancing cerebellar mass that can present with signs of increased intracranial pressure (eg, morning headache and vomiting). However, patients typically have subacute cerebellar symptoms (eg, ataxia, poor coordination), which are not seen here. (Choice E) Temporal lobe abnormalities (eg, hypodensity, hemorrhage) are seen in herpes simplex virus encephalitis, which can present with headache, focal neurologic deficits, and mental status changes. This patient's lack of fever makes this diagnosis unlikely. Educational objective: Hemorrhagic stroke presents with sudden headache, focal neurologic deficits, and altered mental status. Risk factors in children include vascular malformations (eg, arteriovenous malformation [AVM]). Head CT scan of a ruptured AVM typically shows an intraparenchymal bleed (ie, hyperdense fluid collection with irregular margins). References: Links between strokes and hereditary hemorrhagic telangiectasia: a population-based study. (http://www.ncbi.nlm.nih.gov/pubmed/30520389) Intracerebral nontraumatic hemorrhagic stroke in children: case series and literature review. (http://www.ncbi.nlm.nih.gov/pubmed/32011561)

A 5-Year-Old Boy Is Brought to the Emergency Department Due