2. RIGHT FRONTAL HEADACHE AND LEFT ARM
NUMBNESS IN A WOMAN WITH GASTRIC CARCINOMA
• CHIEF COMPLAINT
A 75-year-old right-handed woman was admitted for gastric carcinoma and then developed a right frontal headache with left arm numbness
and weakness
• HISTORY
Two weeks prior to admission, the patient noticed difficulty eating. She was admitted to the hospital on the general surgery service when a
large mass was found in her abdomen, and an endoscopic biopsy revealed gastric carcinoma. On the evening after admission, the nurse found
her lying on her left arm in an awkward position. The patient complained of a right frontal headache and left arm numbness. The surgical
intern found that she had left-sided weakness, and a neurology consult was called.
• PHYSICAL EXAMINATION
Vital signs: T = 36.8°C, P = 80, BP = 130/80; Neck: Supple with no bruits; Lungs: Clear; Heart: Regular rate with no murmurs;
Abdomen: Normal bowel sounds. An approximately 15 cm mass was palpable in the mid abdomen, with mild tenderness;
Extremities: No edema.
• NEUROLOGIC EXAM
MENTAL STATUS: Alert and oriented × 3. Language normal. Able to recall 1/3 objects after 5 minutes, and 2/3 objects with prompting
CRANIAL NERVES: Pupils 3 mm, constricting to 1 mm bilaterally. Normal fundi. Visual field full, but with extinction on the left side to
double simultaneous stimulation. Extraocular movements full, but with a right gaze preference. Facial sensation mildly decreased on the left
side to light touch and pinprick. Mild left facial weakness, sparing the forehead. Normal hearing. Normal gag, palate elevation, and
articulation. Tongue midline.
3. MOTOR: Left pronator drift. Power 5/5 throughout on the right side. Left arm strength 3/5 to 4/5. Left iliopsoas and quadriceps 5/5, and left
extensor hallicus longus 4+/5
SENSORY: Mildly decreased light touch, pinprick, temperature, vibration, and joint position sense on the left side. Dramatic extinction on the
left to double simultaneous stimulation. Decreased stereognosis and graphesthesia in the left hand,
GAIT : Not tested
REFLEXS : COORDINATION: Normal rapid alternating movements on the right. Left side not tested.
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4. DISCUSSION
The key symptoms and signs in this case are:
• Right frontal headache
• Weakness of the left face and arm more than the leg, with left Babinski’s sign
• Mildly decreased light touch, pinprick, temperature, vibration, and joint position sense on the left side, with decreased left stereognosis and
graphesthesia
• Left visual and tactile extinction
6. WHAT IS THE MOST LIKELY DIAGNOSIS ?
• Given the patient’s age
• Sudden onset of deficits
• Hypercoagulability associated with carcinoma
The most likely diagnosis is ischemic stroke BUT…
A hemorrhage in this area could also explain her deficits . Other possibilities include an abscess or a tumor such as brain metastasis, especially given this patient’s
history. It should be noted that in about 10% of brain tumors, symptoms develop rapidly, in a “stroke-like” manner
7. IMAGING AND CLINICAL COURSE
A head CT showed hemorrhage with surrounding edema in the right parietal lobe extending to
the face and arm regions of the precentral gyrus. The initial impression was hemorrhage into a
brain metastasis, or cerebral infarct with hemorrhagic conversion.
Shortly after her head CT the patient suddenly became unresponsive and seizure She was treated
with intravenous anticonvulsants (diazepam) and she improved, although she had two more brief
seizures over the next day and remained difficult to arouse. Repeat head CT showed no change
in the bleed
8. Head CT with intravenous contrast did not show any enhancing lesions consistent with
metastases. On careful review of the contrast CT, an empty delta sign was noted in the
superior sagittal sinus
What is the significance of the empty delta sign?
What possible diagnosis should now be considered, and what tests should be done
to investigate this possibility?
9. The sagittal sinus normally fills uniformly with contrast, and a relatively dark region in the middle suggests a filling defect, possibly due to a blood clot
Note that in retrospect, there was a suggestion of dense material (bright signal) in the sagittal sinus on the non-contrast scan as well
10. A magnetic resonance venogram showed no appreciable flow in the superior sagittal sinus. This image should be compared to the normal MR
venogram from another patient. Despite her hemorrhage, the patient was treated with low-level anticoagulation using subcutaneous heparin to prevent
further thrombosis. She spent 3 weeks in inpatient rehabilitation, with improvement in her left arm strength and ambulation, and eventually underwent
abdominal surgery for her gastric carcinoma.
11. RECOMMENDATION
• In patients with lobar ICH of otherwise unclear origin or with cerebral infarction that crosses typical arterial boundaries, imaging
of the cerebral venous system should be performed (Class I; Level of Evidence C).
• In patients with the clinical features of idiopathic intracranial hypertension, imaging of the cerebral venous system is
recommended to exclude CVT (Class I; Level of Evidence C)
• In patients with headache associated with atypical features, imaging of the cerebral venous system is reasonable to exclude
CVT (Class IIa; Level of Evidence C).
• In patients with CVT and a single seizure with parenchymal lesions, early initiation of antiepileptic drugs for a defined duration is
recommended to prevent further seizures(Class I; Level of Evidence B).
• For patients with CVT, initial anticoagulation with adjusted-dose UFH or weight-based LMWH in full anticoagulant doses is
reasonable, followed by vitamin K antagonists, regardless of the presence of ICH(Class IIa; Level of Evidence B).
• In patients with neurological deterioration due to severe mass effect or intracranial hemorrhage causing intractable intracranial
hypertension, decompressive hemicraniectomy may be considered (Class IIb; Level of Evidence C).
• For patients with CVT, steroid medications are not recommended, even in the presence of parenchymal brain lesions on CT/MRI,
unless needed for another underlying disease(Class III; Level of Evidence B).
