February 1, 2023

Case presentation

A 25-year-old right-handed Scottish man was admitted with a severe bifrontal pulsating headache, without pressure or postural features. This developed on a background 2-month history of a constant dull holocephalic headache, with nausea, vomiting, abrupt onset vertigo, right hemiparesis and incoordination. His past history included allergic rhinitis, for which he was taking mometasone nasal spray and loratadine. He had no prior personal or family history of headache. He was a non-smoker and consumed 20 units of alcohol per week.

He was afebrile, alert and orientated, with normal observations and no meningism. Examination showed a right hemiparesis with a brisk right knee jerk, equivocal plantars and right-sided ataxia. Tone, sensation and cranial nerves were intact. Blood investigations showed an erythrocyte sedimentation rate (ESR) of 22 mm/1st hour, with an otherwise negative vasculitis screen.

What is the differential diagnosis?

A new progressive headache with abnormal neurological signs on examination raises suspicion of a…

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