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Título

AN UNUSUAL CAUSE OF HEMICRANIAL HEADACHE – A CASE REPORT

RESUMO

Case presentation: A 67-years-old woman presents in an outpatient clinic with a 4 month history of new onset left headache and progressive periorbital pain. Few days before the consultation, she noticed discrete binocular diplopia on rightward gaze. Considering red flags (new onset, age > 40 years, persistent hemicrania) a brain magnetic resonance imaging (MRI) was requested. The MRI shows a round expansive lesion at the medial corner of the left orbit, well-defined margins, measuring 1,5x1,1x1,0cm, extraconal, touching the left rectus medialis muscle inferomedially. The lesion had intermediate signal in T1 and high signal in T2 at its internal portion and diffusion restriction and post-contrast heterogeneous enhancement, predominantly peripherally. Hypotheses of Schwannoma or metastasis were considered for the case. Upon the metastasis hypothesis, new imaging tests were performed. A chest CT revealed a 1,8 cm spiky nodule at the right posterior basal segment of the lung and lymphomegalies compatible with secondary implant, neck CT showed multiple lymphomegalies, abdominal CT showed hepatic nodules suggestive of secondary implants. Blastic image at L1 suggestive of secondary implant. The patient was diagnosed with stage 4 non-small cell lung cancer and referred to oncology service.
Discussion: Although a minority of patients presenting with headache have a secondary cause, screening for these cases by questioning and evaluating some red flags can be useful to reduce costs, false-positives and/or incidental findings provided by routine use of blood tests and neuroimaging. Considering this purpose, a common mnemonic currently used is SNNOOP10. Eye is a rare site of lung cancer metastasis although metastasis to the eye represents by far the most common form of intraocular and orbital cancer. A review of 42 case reports of ocular metastasis in lung cancer found that the most common lung cancer that metastasizes to the eye is adenocarcinoma. In this study, ocular symptom was the first referred symptom in 83% (35) cases. The choroid was the most common site for ocular metastasis.
Final Considerations: In our case, recent onset, age above 50 years, neurologic dysfunction and progressive nature warranted further investigation, which was of utmost importance to the diagnosis. We therefore encourage further neurological investigation of patients presenting with headache red flags in order to better establish the diagnosis.

Palavras Chave

Headache; Red Flags; Cancer; Metastasis; Diagnosis