Emergency Department Evaluation for Known Frontal Mass with New Headache
Yes, send this patient to the emergency department immediately—a 34-year-old with a known frontal intracranial mass who develops a new 3-day headache requires urgent neuroimaging to exclude hemorrhage, mass expansion, hydrocephalus, or other life-threatening complications.
Critical Rationale for Emergency Evaluation
Why This Patient Cannot Wait
Known intracranial mass lesions can present with sudden deterioration even after prolonged stability, and new or worsening headache is a cardinal warning sign of complications including hemorrhage, rapid tumor expansion, or obstructive hydrocephalus 1, 2.
Persistent headache exceeding 2-3 days in patients with known intracranial pathology warrants immediate investigation, as this duration suggests a structural rather than benign cause 1.
The American Heart Association emphasizes that new headache in patients with known intracranial pathology requires urgent exclusion of hemorrhage, venous thrombosis, or mass effect through immediate neuroimaging 3, 4.
High-Risk Features Present in This Case
Duration of 3 days makes viral illness or benign headache unlikely in the context of a known mass—this timeline suggests evolving structural pathology 1.
Frontal location carries specific risks including potential for obstructive hydrocephalus if the mass affects CSF pathways, or hemorrhage into the lesion 2.
Young age (34 years) does not protect against catastrophic complications from known intracranial masses, as demonstrated in case series where previously stable lesions deteriorated acutely 2, 5.
Specific Red Flags to Assess Immediately
Critical Questions for Triage
Associated symptoms that mandate immediate transfer: vomiting (especially if persistent or worsening), altered mental status, new focal neurological deficits, visual changes, seizures, or fever 3, 1, 2.
Headache characteristics suggesting emergency: sudden worsening in severity, different quality from prior headaches, awakening from sleep, or positional component 3, 1.
Signs of increased intracranial pressure: persistent vomiting, progressive lethargy, papilledema on examination, or bradycardia 3, 1.
Physical Examination Priorities
Neurological examination must document: level of consciousness, focal deficits (weakness, sensory loss, cranial nerve palsies), gait abnormalities, and fundoscopic examination for papilledema 3, 4.
Vital signs assessment: bradycardia with hypertension (Cushing's triad) indicates critically elevated intracranial pressure requiring immediate intervention 3.
Emergency Department Management Plan
Immediate Imaging Required
Non-contrast head CT is the first-line study to rapidly exclude hemorrhage into the mass, acute hydrocephalus, or significant mass effect 3, 4.
MRI brain with and without contrast should follow if CT is non-diagnostic, as it provides superior characterization of mass changes, edema, and vascular complications 6, 4.
Consider MR or CT venography if there is concern for cerebral venous thrombosis, which can complicate intracranial masses and present with progressive headache 6, 4.
Common Pitfalls to Avoid
Do not assume stable prior imaging means current symptoms are benign—intracranial masses can remain stable for years then deteriorate rapidly, particularly meningiomas which may have hormonal sensitivity 2.
Do not attribute symptoms to migraine or tension headache without excluding structural complications in a patient with known intracranial pathology 4, 1.
Do not delay transfer based on lack of focal neurological deficits—headache alone in this context is sufficient indication for urgent evaluation, as deterioration can be rapid once it begins 1, 2.
Disposition Considerations
Admission is likely required if imaging shows mass expansion, new hemorrhage, significant edema, or hydrocephalus 3, 2.
Neurosurgical consultation should be obtained in the emergency department if any acute changes are identified on imaging 2.
Even if imaging is reassuring, close outpatient follow-up within 24-48 hours with neurology or neurosurgery is mandatory, as symptoms may herald impending complications 3, 1.