A 40-year-old man comes to the emergency department due to severe headache associated with photophobia and nausea for the past several hours. The patient reports mild cold symptoms a week ago. He has a 2-year history of hypertension and has smoked a pack of cigarettes daily for 15 years. His father died of stroke at the age of 75. Temperature is 37.7 C (100 F), blood pressure is 170/100 mm Hg, and pulse is 92/min and regular. He appears to be uncomfortable and had an episode of nonbilious vomiting in the emergency department. Neurologic examination shows 4/5 motor strength and 2+ deep tendon reflexes bilaterally in the upper and lower extremities. Sensation to light touch and pinprick is normal. CT scan of the head without contrast is shown below. Which of the following is the most likely cause of this patient's headache?

Question

A 40-year-old man comes to the emergency department due to severe headache associated with photophobia and nausea for the past several hours.  The patient reports mild cold symptoms a week ago.  He has a 2-year history of hypertension and has smoked a pack of cigarettes daily for 15 years.  His father died of stroke at the age of 75.  Temperature is 37.7 C (100 F), blood pressure is 170/100 mm Hg, and pulse is 92/min and regular.  He appears to be uncomfortable and had an episode of nonbilious vomiting in the emergency department.  Neurologic examination shows 4/5 motor strength and 2+ deep tendon reflexes bilaterally in the upper and lower extremities.  Sensation to light touch and pinprick is normal.  CT scan of the head without contrast is shown below.  Which of the following is the most likely cause of this patient's headache?

Quizplus · Accepted Answer

11ec25c8_d159_9a84_bc81_a153e77bf3e2_MD0003_00 This hypertensive patient with acute severe thunderclap headache (maximal intensity reached in <1 minute) and symptoms of meningeal irritation (eg, nausea/vomiting, photophobia) is suffering from nontraumatic subarachnoid hemorrhage (SAH). Other features may include seizure or focal neurologic deficits (uncommon). Nontraumatic SAH is most commonly due to a ruptured saccular (berry) aneurysm. subarachnoid hemorrhage CT scan without contrast is the preferred initial imaging study and typically reveals acute hemorrhage (high-density signal) surrounding the brainstem and basal cisterns. This patient has bleeding in the frontal interhemispheric cistern (red arrow), left sylvian cistern (blue arrow), and peripontine cisterns (green arrows). Those with negative head CT scans and suspected SAH should undergo lumbar puncture, which classically reveals elevated opening pressure and xanthochromia. Patients with a confirmed diagnosis should be evaluated further with cerebral angiography and treated with surgery (craniotomy with aneurysm clipping) or endovascular methods (coiling/stenting of the aneurysm). (Choice A) Cerebral amyloid angiopathy is the second most common cause of intracerebral hemorrhage after hypertension and is typically lobar in location. It most often occurs in patients age >75 and is due to abnormal beta-pleated amyloid protein deposition in cerebral blood vessels, leading to arteriopathy and vessel fragility. Cerebral amyloid angiopathy (Choice B) Aseptic meningitis can present with severe headache, nausea/vomiting, photophobia, neck stiffness, and fever; however, CT scan of the head is usually normal. (Choice C) Cerebral arteriovenous malformation is the most common cause of intracerebral hemorrhage in children. (Choice D) Cerebral venous thrombosis typically occurs in patients with hypercoagulable conditions (eg, contraceptive use, malignancy) and presents with headache, confusion, seizures, and focal neurologic deficits. The diagnosis is confirmed using MRI of the brain with venography as CT scan often reveals no abnormalities. (Choice E) Hypertensive encephalopathy is characterized by marked blood pressure elevation with progressive headache, nausea/vomiting, and nonlocalizing neurologic symptoms (eg, confusion, restlessness) due to cerebral edema. Acute hemorrhage on CT scan of the head is not characteristic. (Choice G) Vertebral artery dissection typically occurs with head/neck trauma and presents with local pain and focal neurologic deficits due to cerebral ischemia caused by thromboembolism or hypoperfusion. Concomitant disruption of the posterior inferior cerebellar artery often leads to lateral medullary (Wallenberg) syndrome (vertigo/nystagmus, ipsilateral cerebellar signs, loss of pain/temperature sensation in the ipsilateral face and contralateral body, bulbar weakness, ipsilateral Horner syndrome). Educational objective: Nontraumatic subarachnoid hemorrhage is most commonly due to ruptured saccular (berry) aneurysm and typically presents with thunderclap headache and symptoms of meningeal irritation (eg, nuchal rigidity, photophobia, nausea). Noncontrast CT scan usually reveals acute bleeding around the brainstem and basal cisterns. References: Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. (http://www.ncbi.nlm.nih.gov/pubmed/9737490) Management of aneurysmal subarachnoid hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/19114880)

A 40-Year-Old Man Comes to the Emergency Department Due to Severe