Disclosures: Mark Linsenmeyer, MD:

Case Description: A 20-year-old female presented to our outpatient clinic with 2.5 years of post-concussive symptoms after a head injury in a cheerleading accident. Primary symptoms included a frontal headache, occipital headache (worse with Valsalva), photo- and phonophobia, vestibular symptoms, anxiety, and visual disturbance. Examination was unremarkable with the exception of a small palpable cranial defect and vestibular and ocular dysfunction in the form of dizziness and nausea during vestibular/ocular-motor screening. She was given behavioral strategies for post-concussive symptoms and was referred to vestibular therapy, exertion therapy, and neuro-ophthalmology. She was started on propranolol for headache prophylaxis and rizatriptan for migraine abortion. We obtained an x-ray of her skull and an MRI brain for a constellation of reasons including the palpable skull defect, high-energy mechanism of injury, and ongoing visual symptoms.

Setting: Outpatient concussion center.

Patient: 20-year-old female with history of anxiety as well as two additional sport-related concussions four and six years prior to presentation. These concussions’ symptoms resolved quickly and entirely without intervention. Assessment/

Results: MRI brain demonstrated Chiari malformation type I (CMI). Skull x-ray was unremarkable. While most of her symptoms improved with therapies and pharmacologic management targeting concussion, a posterior occipital headache persisted and was attributed to the previously-undiagnosed CMI. She was referred to neurosurgery.

Discussion: In this case, the patient’s post-concussive symptoms generally improved with individualized pharmacologic and therapeutic management, however her persistent occipital headaches suggested a secondary etiology. It is unclear whether the concussion precipitated the CMI symptoms or whether these would have occurred even without a concussion. Regardless, her diagnosis of occipital headaches due to CMI was delayed by 2.5 years due to two separate conditions with overlapping symptoms.

Conclusion: Providers for concussion must be aware of CMI as a potential etiology of persistent headache and symptoms unresponsive to therapies and medications.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/chiari-malformation-in-the-concussion-clinic-diagnosis-and-management-of-confounding-and-overlapping-symptoms-a-case-report/