<div>TITLE PAGE</div><div>Article Type</div><div>Clinical picture</div><div>Title</div><div>POUNDing score of Intracranial
Lipomas</div><div>Authors</div><div>Yuta Aikawa, Takanobu Sato, Ryo Ichibayashi</div><div>Affiliations</div><div>Division of Emergency Medicine Department of Internal Medicine, Toho
University Medical Center, Sakura Hospital, Chiba, Japan</div><div>Corresponding Author</div><div>Ryo Ichibayashi, MD, PhD</div><div>ORCID iD https://orcid.org/0000-0002-1273-4875</div><div>Division of Emergency Medicine Department of Internal Medicine</div><div>Toho University Medical Center, Sakura Hospital</div><div>564-1 Shimosizu</div><div>Sakura-shi, Chiba 285-8741, Japan</div><div>Phone: +81-43-462-8811</div><div>Fax: +81-43-462-8835</div><div>e-mail: ryou.ichibayashi@med.toho-u.ac.jp</div><div>Running title</div><div>Intracranial Lipomas</div><div>Keywords</div><div>Lipomas, Headache, Intracerebroventricular, Diagnostic imaging</div><div>Conflict of interest</div><div>The authors have no conflict of interest to disclose.</div><div>Financial support</div><div>The author(s) received no financial support for this article’s research,
authorship, and/or publication.</div><div>Patient consent</div><div>Written informed consent was obtained from the patient to publish this
report by the journal’s patient consent policy.</div><div>Author contribution</div><div>TS wrote and drafted the manuscript. YA, KI, and RI helped draft the
manuscript. All authors read and approved the final manuscript.</div><div>Data availability statement</div><div>The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to privacy
and ethical considerations.</div><div>Acknowledgments</div><div>None.</div><div>Key clinical message</div><div>Most intracranial lipomas are asymptomatic, but headache is the most
common symptom. The POUNDing score is sometimes high. Therefore, it is
necessary to monitor imaging findings in parallel with the treatment of
migraine.</div><div>Clinical picture</div><div>A 29-year-old woman presented to the emergency department with a
2-month-old headache. Her headache was a unilateral throbbing headache
like she had never experienced before. Her headache lasted more than 4
hours and was accompanied by vomiting. Otherwise, she had no abnormal
neurological findings. She has a history of obsessive-compulsive
disorder. She is on regular oral paroxetine hydrochloride and
cloxazolam. She gained 30 kg weight in 4 years. So far, she has not seen
a doctor because of her headache, although she has acknowledged it many
times. She was conscious, had blood pressure 120/80 mmHg, pulse 60/beat,
body temperature 35.0°C, pupil 5 mm/5 mm, and bilateral light reflex. No
neck stiffness or unconsciousness was noted in her. Her blood tests
showed no abnormalities. She underwent a head CT to rule out
subarachnoid hemorrhage. Her head CT showed no intracranial hemorrhagic
lesions. However, she had bilateral lateral ventricles and low-density
structures in the right ventricle. CT values ranged from -20 to -80.
When the head CT was set to the condition of the lung field, it was
visually confirmed that it was not air (Fig. 1A). As a result, she was
diagnosed with an intraventricular lipoma. The POUNDing score was 5
points, suggesting the possibility of migraine.<sup>1</sup> After
her symptoms improved with analgesics, she was sent home for outpatient
follow-up. Intracranial lipoma is a rare benign tumor. Most are located
in the midline within the cranium. Lipomas around the corpus callosum
are associated with the hypomorphic and amorphic of the corpus callosum.
Many cases are asymptomatic, with headache being the most common
symptom. It is often found incidentally on head CT. Intracranial lipomas
with headaches are found not only in the ventricle but also in other
sites.<sup>2</sup> At first glance, it can be mistaken for air
mixed in the skull. When the CT value is measured, it shows a numerical
value from 0 to -100 and is diagnosed as adipose tissue. It is rarely
removed by surgery and is observed. The pounding score is a scale for
diagnosing migraine. There are no reports of its use for intracranial
lipoma. In our case, lipomas were found in the proper and third
ventricles, and the right ventricle was more significant than the left
(Fig. 1B). Headache due to intracranial lipoma was also considered.
Still, from the result of the POUNDing score, it was diagnosed as a
headache due to a migraine. Intracranial lipomas that have complained of
headaches may include cases of migraine. Therefore, even if the
intracranial lipoma is diagnosed, measuring the POUNDing score and
differentiating migraine is necessary. On the other hand, the causal
relationship between intracranial lipoma and headache has not been
elucidated. For this reason, even if symptoms improve with analgesics,
follow-up imaging is necessary when ventricular laterality, giant
lipoma, and unexplained headache persist.</div><div>References</div><div>1. M. Tejero Mas, R. Burgos Blanco, J.J. Aguirre Sánchez, F. Buitrago
Ramírez. The mnemonic POUNDing rule in the diagnosis of patients with
migraine. <i>Rev Clin Esp</i> . 2018; 218(7): 388-389. doi:
10.1016/j.rce.2018.05.004</div><div>2. Bilir O, Yavasi O, Ersunan G, Kayayurt K, Durakoglugil T. Incidental
Finding in a Headache Patient: Intracranial Lipoma. <i>Western
Journal of Emergency Medicine</i> . 2014;15(4):361-2. doi:
10.5811/westjem.2014.4.21298</div><div>Figure １A・B　Head CT</div><div>Upper row： A is a lipoma in the right ventricle and B in the third
ventricle. （white arrow）</div><div>Lower row： It can be confirmed that both A and B are not air under lung
field conditions. （black circle）</div>