Journal of Clinical Neuroscience 22 (2015) 1833–1834
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Central retinal vein occlusion in a migraine patient Felix Benninger a,⇑, Tal Saban b, Israel Steiner a a b
Department of Neurology, Rabin Medical Center, Campus Beilinson, Jabotinsky 39, Petach Tikva 49000, Israel Department of Opthalmology, Rabin Medical Center, Campus Beilinson, Petach Tikva, Israel
a r t i c l e
i n f o
Article history: Received 18 March 2015 Accepted 21 March 2015
Keywords: Aura Central retinal vein occlusion Migraine Misdiagnosis
a b s t r a c t We describe a 31-year-old woman with a history of migraines without aura, who presented to our emergency department due to a monocular visual disturbance. This was misdiagnosed as being related to her migraine, however, it was subsequently found to be caused by a central retinal vein occlusion. Patients suffering from migraine can experience visual disturbances in the form of auras. The neuropathological basis for this phenomenon is thought to be a spreading depression in the visual cortex, causing a hemifield active visual phenomenon. Missing the diagnosis of central retinal vein occlusion is common, especially in the setting of an initially normal fundoscopy examination. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction Patients suffering from migraine can experience visual disturbances in the form of auras. The neuropathological basis for this phenomenon is thought to be a spreading depression in the visual cortex, causing a hemifield active visual phenomenon. Missing the diagnosis of central retinal vein occlusion is common, especially in the setting of an initially normal fundoscopy examination. 2. Case report A 31-year-old woman presented to the emergency department (ED) due to a migrainous headache accompanied by visual disturbance of the right eye lasting 5 hours. The patient had been suffering from migraine headaches since she was 15 years old, which were never accompanied by a visual aura, and was being treated with prophylactic medication using a beta-blocker and amitriptyline, as well as 40 mg of eletriptan for pain abortive treatment. She presented to the ED due to an active bright flashing light in her right eye, which dazzled her and was constantly present for approximately 5 hours. The visual disturbance was accompanied by a familiar pulsating unilateral headache. By the time she presented to the examining neurologist, the visual disturbance had passed and the headaches were almost completely resolved. Her neurologic exam was within the normal limits. A following ophthalmologic exam showed normal fundoscopy, a visual acuity of 6/6.8 in the right and 6/6 in the left eye, and no signs of relative afferent pupil defect or increased intraocular pressure, and she was discharged home. During the next 3 weeks she experienced further comparable intermittent episodes of various durations and presented again to ⇑ Corresponding author. Tel.: +972 526756300; fax: +972 39378220. E-mail address: [email protected] (F. Benninger).
the ED during one of those attacks. This time, her visual symptoms in the right eye did not pass and were again accompanied by a pulsating unilateral headache. The ophthalmologic examination revealed dilated tortuous veins, dot and blot hemorrhages, and a marked macular and disk edema as well as diffuse exudates on fluorescein angiography (FA) prompting the diagnosis of central retinal vein occlusion (CRVO) as the cause of her visual disturbances (Fig. 1A, B). The autoimmune and coagulopathy screening was negative, and 4 weeks later her symptoms resolved spontaneously and she had a normal ophthalmologic exam, including FA (Fig. 1C).
3. Discussion Expanding binocular scintillations, scotomas, and zig-zag lines (fortifications), typically followed by headache, are diagnostic markers for migrainous visual aura [1–3]. Even though these phenomena occur in the hemifield, many patients report their visual experiences as monocular, probably as they attend more to the temporal visual field [1,4,5]. True monocular visual loss during migraine is based on the concept of retinal spreading depression and is classified as a retinal migraine [6]. The positive visual phenomena tend to be simpler and the criteria for retinal migraine by the International Headache Society require exclusion of other etiologies (a normal ophthalmologic examination) [7]. We present a woman with a history of migraine, a monocular positive visual disturbance of long duration, and an initially normal ophthalmologic examination which was misdiagnosed as migraine aura without headache (acephalgic migraine) or possibly retinal migraine. Only upon recurrence of her symptoms, the typical signs of CRVO as a cause of the visual disturbance were discovered. Most cases of CRVO are idiopathic [8,9] but an association with migraines has been suggested [10]. The rarity of true retinal migraines warrant a thorough ophthalmologic follow-up examination in all
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Case Reports / Journal of Clinical Neuroscience 22 (2015) 1834–1837
Fig. 1. Fundoscopy in the acute phase showing tortuous veins, dot and blot hemorrhages, and marked disk edema (A) as well as exudates on fluorescein angiography (B) typical for central retinal vein occlusion. One month later, the fluorescein angiography is normal and no edema is present (C).
patients with transient monocular visual disturbances and initially normal fundoscopy, as the misdiagnosis of CRVO is common [11]. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Olesen J. The headaches. Philadelphia: Lippincott Williams & Wilkins; 2006. [2] Richards W. The fortification illusions of migraines. Sci Am 1971;224:88–96. [3] Russell MB, Olesen J. A nosographic analysis of the migraine aura in a general population. Brain 1996;119:355–61. [4] Daroff RB. Retinal migraine. J Neuroophthalmol 2007;27:83. http://dx.doi.org/ 10.1097/WNO.0b013e3180331435. [5] Eriksen MK, Thomsen LL, Olesen J. The Visual Aura Rating Scale (VARS) for migraine aura diagnosis. Cephalalgia 2005;25:801–10. http://dx.doi.org/ 10.1111/j.1468-2982.2005.00955.x.
[6] Grosberg BM, Solomon S, Friedman DI, et al. Retinal migraine reappraised. Cephalalgia 2006;26:1275–86. http://dx.doi.org/10.1111/j.1468-2982.2006. 01206.x. [7] Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629–808. http://dx.doi.org/10.1177/ 0333102413485658. [8] Fong ACO, Schatz H. Central retinal vein occlusion in young adults. Surv Ophthalmol 1993;37:393–417. http://dx.doi.org/10.1016/0039-6257(93) 90138-W. [9] McIntosh RL, Rogers SL, Lim L, et al. Natural history of central retinal vein occlusion: an evidence-based systematic review. Ophthalmology 2010;117:1113–23. http://dx.doi.org/10.1016/j.ophtha.2010.01.060. [10] Friedman MW. Occlusion of central retinal vein in migraine. AMA Arch Ophthalmol 1951;45:678–82. http://dx.doi.org/10.1001/archopht.1951. 01700010693010. [11] Hill DL, Daroff RB, Ducros A, et al. Most cases labeled as ‘‘retinal migraine’’ are not migraine. J Neuroophthalmol 2007;27:3–8. http://dx.doi.org/10.1097/ WNO.0b013e3180335222.
http://dx.doi.org/10.1016/j.jocn.2015.03.057
A massive pelvic mucocele presenting as a cystic sacral mass Christine Boone a, C. Rory Goodwin a, Genevieve Crane b, James Pendleton a, Daniel Sciubba a,⇑ a b
Neurosurgery Department, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA Pathology Department, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
a r t i c l e
i n f o
Article history: Received 30 March 2015 Accepted 5 April 2015
Keywords: Complication Crohn’s disease Mucinous cystadenoma Sacrum Spine Surgery
a b s t r a c t We present a man, with a complex medical and surgical history, who had a large pelvic non-appendiceal cystadenoma, presenting as a cystic sacral mass causing obstructive urinary symptoms and renal failure. Mucocele should be included in the differential diagnosis of patients who present with large sacral masses, and who have a significant history of pelvic and abdominal surgery and inflammatory bowel disease. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction
⇑ Corresponding author. Tel.: +1 141 0502 9982. E-mail address: [email protected] (D. Sciubba).
Sacral and presacral masses are often asymptomatic and difficult to diagnose. Abdominal or pelvic mucoceles are rare, and most commonly arise in the appendix as benign, neoplastic mucinous cystadenoma.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case Reports
Central retinal vein occlusion in a migraine patient Felix Benninger a,⇑, Tal Saban b, Israel Steiner a a b
Department of Neurology, Rabin Medical Center, Campus Beilinson, Jabotinsky 39, Petach Tikva 49000, Israel Department of Opthalmology, Rabin Medical Center, Campus Beilinson, Petach Tikva, Israel
a r t i c l e
i n f o
Article history: Received 18 March 2015 Accepted 21 March 2015
Keywords: Aura Central retinal vein occlusion Migraine Misdiagnosis
a b s t r a c t We describe a 31-year-old woman with a history of migraines without aura, who presented to our emergency department due to a monocular visual disturbance. This was misdiagnosed as being related to her migraine, however, it was subsequently found to be caused by a central retinal vein occlusion. Patients suffering from migraine can experience visual disturbances in the form of auras. The neuropathological basis for this phenomenon is thought to be a spreading depression in the visual cortex, causing a hemifield active visual phenomenon. Missing the diagnosis of central retinal vein occlusion is common, especially in the setting of an initially normal fundoscopy examination. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction Patients suffering from migraine can experience visual disturbances in the form of auras. The neuropathological basis for this phenomenon is thought to be a spreading depression in the visual cortex, causing a hemifield active visual phenomenon. Missing the diagnosis of central retinal vein occlusion is common, especially in the setting of an initially normal fundoscopy examination. 2. Case report A 31-year-old woman presented to the emergency department (ED) due to a migrainous headache accompanied by visual disturbance of the right eye lasting 5 hours. The patient had been suffering from migraine headaches since she was 15 years old, which were never accompanied by a visual aura, and was being treated with prophylactic medication using a beta-blocker and amitriptyline, as well as 40 mg of eletriptan for pain abortive treatment. She presented to the ED due to an active bright flashing light in her right eye, which dazzled her and was constantly present for approximately 5 hours. The visual disturbance was accompanied by a familiar pulsating unilateral headache. By the time she presented to the examining neurologist, the visual disturbance had passed and the headaches were almost completely resolved. Her neurologic exam was within the normal limits. A following ophthalmologic exam showed normal fundoscopy, a visual acuity of 6/6.8 in the right and 6/6 in the left eye, and no signs of relative afferent pupil defect or increased intraocular pressure, and she was discharged home. During the next 3 weeks she experienced further comparable intermittent episodes of various durations and presented again to ⇑ Corresponding author. Tel.: +972 526756300; fax: +972 39378220. E-mail address: [email protected] (F. Benninger).
the ED during one of those attacks. This time, her visual symptoms in the right eye did not pass and were again accompanied by a pulsating unilateral headache. The ophthalmologic examination revealed dilated tortuous veins, dot and blot hemorrhages, and a marked macular and disk edema as well as diffuse exudates on fluorescein angiography (FA) prompting the diagnosis of central retinal vein occlusion (CRVO) as the cause of her visual disturbances (Fig. 1A, B). The autoimmune and coagulopathy screening was negative, and 4 weeks later her symptoms resolved spontaneously and she had a normal ophthalmologic exam, including FA (Fig. 1C).
3. Discussion Expanding binocular scintillations, scotomas, and zig-zag lines (fortifications), typically followed by headache, are diagnostic markers for migrainous visual aura [1–3]. Even though these phenomena occur in the hemifield, many patients report their visual experiences as monocular, probably as they attend more to the temporal visual field [1,4,5]. True monocular visual loss during migraine is based on the concept of retinal spreading depression and is classified as a retinal migraine [6]. The positive visual phenomena tend to be simpler and the criteria for retinal migraine by the International Headache Society require exclusion of other etiologies (a normal ophthalmologic examination) [7]. We present a woman with a history of migraine, a monocular positive visual disturbance of long duration, and an initially normal ophthalmologic examination which was misdiagnosed as migraine aura without headache (acephalgic migraine) or possibly retinal migraine. Only upon recurrence of her symptoms, the typical signs of CRVO as a cause of the visual disturbance were discovered. Most cases of CRVO are idiopathic [8,9] but an association with migraines has been suggested [10]. The rarity of true retinal migraines warrant a thorough ophthalmologic follow-up examination in all
1834
Case Reports / Journal of Clinical Neuroscience 22 (2015) 1834–1837
Fig. 1. Fundoscopy in the acute phase showing tortuous veins, dot and blot hemorrhages, and marked disk edema (A) as well as exudates on fluorescein angiography (B) typical for central retinal vein occlusion. One month later, the fluorescein angiography is normal and no edema is present (C).
patients with transient monocular visual disturbances and initially normal fundoscopy, as the misdiagnosis of CRVO is common [11]. Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. References [1] Olesen J. The headaches. Philadelphia: Lippincott Williams & Wilkins; 2006. [2] Richards W. The fortification illusions of migraines. Sci Am 1971;224:88–96. [3] Russell MB, Olesen J. A nosographic analysis of the migraine aura in a general population. Brain 1996;119:355–61. [4] Daroff RB. Retinal migraine. J Neuroophthalmol 2007;27:83. http://dx.doi.org/ 10.1097/WNO.0b013e3180331435. [5] Eriksen MK, Thomsen LL, Olesen J. The Visual Aura Rating Scale (VARS) for migraine aura diagnosis. Cephalalgia 2005;25:801–10. http://dx.doi.org/ 10.1111/j.1468-2982.2005.00955.x.
[6] Grosberg BM, Solomon S, Friedman DI, et al. Retinal migraine reappraised. Cephalalgia 2006;26:1275–86. http://dx.doi.org/10.1111/j.1468-2982.2006. 01206.x. [7] Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629–808. http://dx.doi.org/10.1177/ 0333102413485658. [8] Fong ACO, Schatz H. Central retinal vein occlusion in young adults. Surv Ophthalmol 1993;37:393–417. http://dx.doi.org/10.1016/0039-6257(93) 90138-W. [9] McIntosh RL, Rogers SL, Lim L, et al. Natural history of central retinal vein occlusion: an evidence-based systematic review. Ophthalmology 2010;117:1113–23. http://dx.doi.org/10.1016/j.ophtha.2010.01.060. [10] Friedman MW. Occlusion of central retinal vein in migraine. AMA Arch Ophthalmol 1951;45:678–82. http://dx.doi.org/10.1001/archopht.1951. 01700010693010. [11] Hill DL, Daroff RB, Ducros A, et al. Most cases labeled as ‘‘retinal migraine’’ are not migraine. J Neuroophthalmol 2007;27:3–8. http://dx.doi.org/10.1097/ WNO.0b013e3180335222.
http://dx.doi.org/10.1016/j.jocn.2015.03.057
A massive pelvic mucocele presenting as a cystic sacral mass Christine Boone a, C. Rory Goodwin a, Genevieve Crane b, James Pendleton a, Daniel Sciubba a,⇑ a b
Neurosurgery Department, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA Pathology Department, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
a r t i c l e
i n f o
Article history: Received 30 March 2015 Accepted 5 April 2015
Keywords: Complication Crohn’s disease Mucinous cystadenoma Sacrum Spine Surgery
a b s t r a c t We present a man, with a complex medical and surgical history, who had a large pelvic non-appendiceal cystadenoma, presenting as a cystic sacral mass causing obstructive urinary symptoms and renal failure. Mucocele should be included in the differential diagnosis of patients who present with large sacral masses, and who have a significant history of pelvic and abdominal surgery and inflammatory bowel disease. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction
⇑ Corresponding author. Tel.: +1 141 0502 9982. E-mail address: [email protected] (D. Sciubba).
Sacral and presacral masses are often asymptomatic and difficult to diagnose. Abdominal or pelvic mucoceles are rare, and most commonly arise in the appendix as benign, neoplastic mucinous cystadenoma.
