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3D-Neuronavigation In Vivo Through a Patient's Brain During a Spontaneous Migraine Headache
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Clinical Reasoning: A 67-Year-Old Woman With Progressive Headache, Visual Hallucinations, and Seizures
Galina Gheihman1,2, Evan Samuel Madill2, Shannon Coy3
1Department of Neurology, Massachusetts General Hospital, Boston.
Neurology
|March 27, 2025
Summary
This case study details a rare neurological condition presenting with progressive headaches and visual disturbances. A definitive pathologic diagnosis was achieved through brain biopsy, guiding treatment and management strategies.
Area of Science:
- Neurology
- Neuro-ophthalmology
- Pathology
Background:
- Progressive headaches and meningismus can indicate serious underlying neurological conditions.
- New-onset focal neurologic deficits, including visual disturbances and gait unsteadiness, warrant thorough investigation.
- Leptomeningeal enhancement on MRI suggests leptomeningeal disease, necessitating a comprehensive differential diagnosis.
Purpose of the Study:
- To present a case of a 67-year-old woman with new-onset headaches and progressive neurologic deficits.
- To discuss the differential diagnosis, clinical presentation, and diagnostic workup of this rare entity.
- To correlate clinical and radiological findings with the pathologic diagnosis and outline treatment strategies.
Main Methods:
- Clinical case presentation with detailed history and physical examination findings.
- Neuro-imaging including brain MRI with FLAIR and contrast.
- Cerebrospinal fluid analysis and extensive laboratory testing.
- Brain biopsy for definitive histopathological diagnosis.
Main Results:
- The patient presented with headaches, meningismus, visual hallucinations, gait instability, and left homonymous hemianopsia.
- Brain MRI showed asymmetric FLAIR hyperintensities and leptomeningeal enhancement.
- Initial workup for infectious, inflammatory, and malignant causes was negative.
- Brain biopsy ultimately provided a definitive pathologic diagnosis.
Conclusions:
- A multidisciplinary approach is crucial for diagnosing rare neurological disorders presenting with complex symptoms.
- Brain biopsy remains essential for definitive diagnosis in cases with atypical presentations or unrevealing initial investigations.
- Accurate diagnosis facilitates targeted treatment and improves patient outcomes, including relapse prevention.
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