What headache? Pediatric arteriovenous malformation

Case presentation

A 13-year-old male presents with acute onset of mental status changes. He was found in his room, lying facedown. Emergency medical services was called. On their arrival, the patient was conversing but appeared sleepy; he was responsive to questions but confused. He was attempting to speak but was able to manage only a few words.

Once in the Emergency Department, the patient was able to speak more easily and seemed to be more at his baseline. He reports having a left frontal headache prior to “passing out.” He denies illegal substance use. He has no history of prior episodes of “passing out” and is otherwise healthy. There is no family history of sudden cardiac death but there is a cousin with epilepsy.

He continues to complain of a left frontal headache. He does remember standing up and then “the lights went out.” His vital signs reveal no fever, a heart rate of 90 beats per minute, a respiratory rate of 18 breaths per minute, and a blood pressure of 112/63 mm Hg. He has a normal physical examination other than a large frontal hematoma with tenderness to palpation.

The patient states that he has been having left frontal headaches for the past 2 weeks, which he describes as “severe sometimes.” He has had some morning nausea and did have nonbilious/nonbloody morning emesis 2 days ago.

Imaging considerations

There are several imaging options available to the clinician when a pediatric patient presents with acute mental status changes. The initial imaging modality of choice may be dependent on the suspected diagnosis and institutional resources.