Differential Diagnosis for the Patient's Condition

The patient's history of left sphenoidal meningioma and recent onset of severe headaches, along with the findings from the cranial MRI, guide the differential diagnosis. Here are the potential diagnoses categorized by their likelihood and importance:

• Single Most Likely Diagnosis

  • Recurrent or Residual Meningioma: The patient has a history of left sphenoidal meningioma and has undergone a previous craniotomy. The recent cranial MRI showing an increased size of the left sphenoid ridge meningioma (5.4 x 5.7 x 5.1cm) strongly supports this diagnosis. The symptoms of sudden, sharp headaches localized over the left temporal region could be attributed to the growing tumor pressing on surrounding structures.

• Other Likely Diagnoses

  • Tension Headache: Although the patient's headaches are severe, the fact that they are relieved by sleep and occur several times a day could also suggest a component of tension headache, possibly exacerbated by the stress of dealing with a recurrent tumor.
  • Medication Overuse Headache: The patient has been taking paracetamol for pain relief, which, although not frequent, could potentially contribute to medication overuse headache, especially if the patient has been taking it regularly for an extended period.
  • Diplopia due to Cranial Nerve Palsy: The patient's diplopia, which is relieved by closing one eye, could be due to a cranial nerve palsy (e.g., abducens nerve palsy) caused by the growing meningioma pressing on the nerve.

• Do Not Miss Diagnoses

  • Subarachnoid Hemorrhage or Other Intracranial Bleed: Although less likely given the gradual onset of symptoms, it's crucial to consider the possibility of an intracranial bleed, especially in a patient with a history of brain surgery and a growing tumor. A sudden severe headache (thunderclap headache) is a red flag for subarachnoid hemorrhage.
  • Infection or Abscess: Post-surgical infections or abscesses can present with headache and other neurological symptoms. Given the patient's history of craniotomy, this is a critical diagnosis not to miss.
  • Hydrocephalus: Obstructive hydrocephalus could occur due to the tumor obstructing the flow of cerebrospinal fluid, leading to increased intracranial pressure and symptoms such as headache, nausea, and vomiting.

• Rare Diagnoses

  • Meningioma-Associated Conditions: Rare conditions such as meningioma-associated neurofibromatosis type 2 or other genetic syndromes could be considered, especially if there's a family history or other systemic symptoms.
  • Pituitary Apoplexy: If the meningioma is pressing on the pituitary gland, there's a rare possibility of pituitary apoplexy, which is a medical emergency characterized by sudden headache, visual disturbances, and acute hypopituitarism.