Case 1: Hemorrhagic Mass Presenting as Seizure

Discussant: Jon S. Poling, MD, PhD Mentor: Eric Aldrich, MD, PhD


March 15, 2002

In This Article

Case Presentation

The patient is a 16-year-old, right-handed, white, adolescent male with a history of inflammatory bowel disease (IBD) that was diagnosed 6 months previously. He had not been feeling well for several weeks before admission because of left occipital headaches, nausea, and mineral diarrhea.

While vacationing in Bermuda, he was found confused and poorly responsive on the floor of his hotel bathroom by his mother. The mother had been alerted by kicking sounds at the door. She then called Emergency Medical Services.

A computed tomography (CT) scan of the head was performed at the local hospital (Figures 1A and B).

Standard, sequential, axial, noncontrasted head CT at the levels above and below the tentorium cerebelli showing 1 of the following.

Standard, sequential, axial, noncontrasted head CT at the levels above and below the tentorium cerebelli showing 1 of the following.

What is your best guess based on the presentation and scan?

  1. Hemorrhagic brain tumor

  2. Cerebellar stroke

  3. Acute blood clot and cytotoxic edema

  4. Hypertensive encephalopathy

A subarachnoid screw was placed for intracranial pressure monitoring by the outside neurosurgeon; the patient was intubated and sedated for combativeness and then airlifted to the Johns Hopkins Neurocritical Care Unit. The subarachnoid screw was removed on arrival so that urgent brain magnetic resonance imaging (MRI) could be performed. After the MRI, the patient was weaned off sedation and extubated without difficulty.

Previous medical history included otitis media (last episode > 5 years before this presentation) and IBD diagnosed in April 2000. A biopsy specimen showed nonspecific chronic inflammation. The patient was evaluated for infection and empirically treated with ciprofloxacin and metronidazole but without benefit. Treatment with prednisone was then begun.

Medications on transfer included prednisone (40 mg/d), multivitamin, iron, vitamin C, phenytoin, ranitidine, and acetaminophen. Home medications included prednisone (5 mg/d), iron, famotidine, salicylate, and steroid enemas. The patient was allergic to penicillin but could not remember the adverse reaction.

Social history revealed that the patient was an honor student entering the 11th grade who had not used alcohol, tobacco, or illicit drugs.

Family history revealed no history of blood clotting disorders or bowel disease.


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