Chronic Headaches with Confusion


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A 60 year-old man presented to the ED complaining of right-sided headaches for one year.  Recently, his girlfriend began noticing occasional episodes of confusion.  He finally agreed to present for evaluation when the headache became severe the day before.  His neurological exam was completely normal except for that depicted on the following video. 


This proved to be an interesting case as the findings on CT scan were a bit surprising in light of the paucity of findings on exam.  As is evident on the video, the patient exhibits a central facial nerve palsy.  As differentiated from a peripheral palsy, intact forehead movement indicates an upper motor neuron lesion.  The only finding on this patient's exam was weakness of the lower facial musculature when he attempted to smile.  

The CT scan, as shown below, revealed a
large (5 x 4 cm) right frontal parenchymal hemorrhage.  A small amount of surrounding edema is noted.  The appearance and history was suspicious for hemorrhage into an underlying lesion, likely a meningioma.  Meningiomas are commonly found in the frontal lobes and tend to occur between ages 40 and 60 yr.


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