Thunderclap Headache Associated With a Nonhemorrhagic Anaplastic Oligodendroglioma

Randolph W. Evans, MD

In This Article

Case Report

A thunderclap headache is a severe headache with sudden onset similar to a clap of thunder, with a maximum intensity within 1 minute. The primary types (thunderclap, cough, exertional, and sexual) can recur intermittently and are generally associated with a benign outcome. The diagnosis results from exclusion of a long list of secondary causes with the most common being subarachnoid hemorrhage. Other secondary causes include unruptured intracranial aneurysm, cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, ischemic stroke, acute hypertensive crisis, hypertensive reversible posterior leukoencephalopathy, third ventricle colloid cyst, intracranial infection, and complicated paranasal sinusitis.

The patient reported here suffered thunderclap headache associated with a nonhemorrhagic anaplastic oligodendroglioma of the left temporal lobe without hydrocephalus, which is a novel association.

This 27-year-old white man presented a chief complaint of severe headache and episodes of olfactory hallucinations. Thirteen days previously, he suddenly developed a top-of-the-head and generalized pressure type headache with an intensity of 8 to 9 out of 10, with maximum intensity within 1 minute, and associated with nausea but no other symptoms. The onset occurred while he was at work in an office, with no provoking activity. The intensity of the headache gradually subsided and completely resolved within 24 hours. The patient did not see a doctor about this episode until the consultation. He reported a several year history of headaches that occurred roughly once every 2 weeks, and were relieved by ibuprofen. He described them as a bitemporal throbbing with an intensity of 4 out of 10 without associated symptoms.

For the previous 9 months, the patient had experienced brief, 10- to 30-second episodes during which he perceived an intense smell and taste that he could not identify. During these episodes, he noted slight memory problems or confusion; for example, he could not remember a name, which persisted a short while after the smell and taste had receded. At first, the episodes occurred once daily or every other day. For some weeks before the consultation, the spells were variably occurring perhaps every other day or once a week, often in the mid-morning. He reported no history of generalized tonic-clonic seizures, head trauma, or meningitis. He had not seen a physician about the episodes.

Medical history was negative. He was taking no medications other than ibuprofen, and reported no illicit drug use. His mother had seizures when she was a teen.

Neurologic examination was entirely normal, including normal mentation, no cranial nerve abnormalities (normal fundoscopic examination), no focal limb weakness, and normal gait.

Later that day, a magnetic resonance imaging examination of the brain with and without contrast demonstrated a 3-cm irregularly enhancing mass posteriorly and medially in the left temporal lobe, with more extensive abnormal T2 signal infiltrating nearly the entire left temporal lobe about 7 × 6 × 5 cm in the anterior-posterior, transverse, and craniocaudad dimensions, respectively, with a 5-mm left-to-right midline shift and medial displacement of the left uncus (Figure 1). Mass effect on the body of the left lateral ventricle was noted, with enlargement of the atrium, and a slight degree of shift at the temporal horn of the left lateral ventricle. The enhancing mass indented the temporal horn just anterior to the atrium (Figure 2). No evidence of hemorrhage, infarct, or sinusitis was seen.

A T2 axial section without contrast demonstrates the 3-cm left temporal lobe tumor. Fluid-like signal centrally most likely represents necrosis. T2 signal consistent with edema and/or nonenhancing infiltrating tumor that extends more diffusely in the left temporal lobe.

A T1 axial section with contrast demonstrates the enhancing 3-cm tumor.

Magnetic resonance angiography (MRA) of the intracranial vessels demonstrated mass effect displacing the left middle cerebral artery and branches. Although magnetic resonance venography was not performed, the other studies showed normal filling of the cerebral veins. MRA of the neck was normal.

The patient was started on dexamethasone and levetiracetam. One week later, he underwent a radical subtotal left temporal lobectomy. The pathology examination revealed an anaplastic oligodendroglioma. Nine months after surgery, the patient was doing well on temozolomide and levetiracetam with no neurologic deficit or tumor recurrence seen on MRI. He experienced no further thunderclap headaches. He had 2 brief partial seizures within the first 2 months after surgery but no further episodes after the dose of levetiracetam was increased.

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