Case Report

A 61 year-old female who was status post-gastrectomy and chemotherapy for gastric cancer presented to the emergency department with complaints of two syncopal episodes and on going headaches for the last month. Her syncopal episodes occurred on the day of admission and five days prior and were preceded by shaking, dizziness, and a feeling of being in a“different dimension.” The losses of consciousnesses lasted for several minutes and were accompanied by shaking, but were not associated with any urinary or bowel incontinence or tongue biting. The patient denied any fevers or new medications,and felt that the episodes were not associated with a specificactivity or time of day. The patient also complained of new onset headaches that had progressed in frequency over the last month from being present for only a few minutes a day to being present for the entire day. The headaches were described as a “brain freeze,” with 10 out of 10 pain that was not relieved by acetaminophen with codeine, ibuprofen, or morphine. The headaches were non-radiating and diffusely located throughout the head. The headaches were exacerbated by movement, and associated with an increase in nausea and vomiting. The patient did not have any lacrimation or rhinorrhea, and she denied anypast history of migraines, head trauma, or neck pain. Review of systems was negative except for a progressive increase in blurry vision with occasional white spots in her vision over the last three weeks. One week prior to admission she had an outpatient brain MRI (Figure 1a) done, and two days ago a head CT both of which showed no evidence of metastatic disease, hemorrhage,infarct, or mass lesion.