6.4.3 Headache attributed to secondary angiitis of the central nervous system (SACNS)

Identification: Male patient, 45 years old, previously healthy, with a history of well-controlled hypertension. Clinical History: The patient presents with a severe, progressive holocranial headache for 4 weeks, associated with episodes of nausea, vomiting, and transient visual disturbances. He also reports episodes of confusion and mild muscle weakness on the right side of the body for 1 week. He denies fever, weight loss, or systemic symptoms. There is no history of recent trauma or previous infections. Physical Examination: Neurological: Mild confusion, right hemiparesis (strength 4/5), asymmetric deep tendon reflexes (more pronounced on the right). Fundoscopy: Bilateral papilledema. The remainder of the physical examination was unremarkable. Complementary Exams: Cranial Magnetic Resonance Imaging (MRI): Multiple areas of T2/FLAIR hyperintensity in the subcortical white matter and areas of post-contrast meningeal enhancement, suggestive of vascular inflammation. MR Angiography: Segmental and irregular narrowing of intracranial arteries, consistent with vasculitis. Cerebrospinal Fluid (CSF): Lymphocytic leukocytosis (30 cells/mm³), elevated proteins (80 mg/dL), normal glucose. Cultures and infectious agent screening negative. Inflammatory markers: Elevated ESR and CRP. Meningeal artery biopsy: Confirmed the presence of granulomatous inflammation of the vascular wall, consistent with angiitis.