Thread by @KirtanPatolia

Differential diagnoses of ⛈️Thunderclap headache⚡ are indeed thunderous.

Here is a brief 🧵.

@AaronLBerkowitz @caseyalbin @rabihmgeha @DxRxEdu @sargsyanz @AnnKumfer @rav7ks @gabifpucci @jackpenner @RosenelliEM @Sharminzi @CPSolvers

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#1 Subarachnoid hemorrhage

Aneurysmal SAH
Cortical SAH (due to RCVS)

- Seizures
- Meningismus
- Altered mental status
- RBC & Xanthochromia in CSF

Look out for possible
sequelae: Rebleeding, vasospasm & ischemia, hydrocephalus

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nejm.org/doi/10.1056/NE…

#2 RCVS

-Multifocal multivessel vasoconstriction (string of beads)
-Recurrent episodes (triggers- bathing, Valsalva, bending, urinating, strong emotions)

Risk factors: Postpartum state, SSRIs, Calcineurin inhibitors, vasoactive drugs, sympathetic overactive states

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#3 Cerebral Venous sinus thrombosis

-Focal neurologic deficits
-Headache
-Visual loss
-Dense triangle sign and cord sign on CT
-Hemorrhagic infarction

Risk factors: Pregnancy, hypercoagulable states, PNH, nephrotic syndrome, OCP, Infections, Behcet's.

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#4 Arterial dissection (Cervical & Vertebral)

- Neck pain
- TIA/Stroke
- Retinal infarcts
- Horner syndrome

Can be spontaneous/idiopathic or due to neck manipulation, trauma, HTN, FMD, vasculitis, drugs.

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#5 Pituitary apoplexy

- Hemorrhage into the pituitary tumor
- Nelson syndrome (following adrenalectomy)

Presents as headache, nausea, vomiting, visual loss, diplopia, and hormone deficits, especially cortisol due to loss of ACTH secretion.

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#6 Spontaneous intracranial hypotension

Also called sagging brain syndrome

- Orthostatic headache
- Auditory muffling & tinnitus
- Dizziness
- Visual changes

Presents with diffuse and smooth pachymeningeal enhancement.

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#7 Etiologies causing or associated with raised ICP

- Aqueductal stenosis
- Colloid cyst of the third ventricle
- Brain tumor
- Intracranial hemorrhage

#8 Vascular causes

- Ischemic stroke
- Hypertensive crisis
- Subdural hematoma
- Giant cell arteritis
- Spinal epidural hematoma
- Retroclival hematoma

#9 Miscellaneous

- Complicated sinusitis
- Pheochromocytoma
- Cardiac cephalgia

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Here is an excellent paper

journals.lww.com/continuum/Full…

Thanks for reading.
Any insights or suggestions appreciated

@nsrosenberg @ASanchez_PS @MariaMjaleman @valeroldan23 @DrSakhii