A 46-year-old man comes to the emergency department complaining of severe headache for the past 2 days. He suffers from tension headaches but says that this headache is nothing like those. He feels nauseated and wants to move to a quiet, dark room. His temperature is 36.5° C (97.7° F), blood pressure is 163/90 mm Hg, and pulse is 102/min. Examination shows moderate pain and mild stiffness with neck flexion. There are no cranial nerve deficits or muscle weakness. Noncontrast head computed tomography scan shows subarachnoid hemorrhage. The patient is hospitalized and undergoes endovascular coiling. On the fifth day of hospitalization, he appears to be mildly confused and complains of tingling in his right hand. There is right-sided muscle weakness and mild facial droop. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 46-year-old man comes to the emergency department complaining of severe headache for the past 2 days.  He suffers from tension headaches but says that this headache is nothing like those.  He feels nauseated and wants to move to a quiet, dark room.  His temperature is 36.5° C (97.7° F), blood pressure is 163/90 mm Hg, and pulse is 102/min.  Examination shows moderate pain and mild stiffness with neck flexion.  There are no cranial nerve deficits or muscle weakness.  Noncontrast head computed tomography scan shows subarachnoid hemorrhage.  The patient is hospitalized and undergoes endovascular coiling.  On the fifth day of hospitalization, he appears to be mildly confused and complains of tingling in his right hand.  There is right-sided muscle weakness and mild facial droop.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d48d_9c42_bc81_3ffbf9baa710_MD0003_00 This patient has a subarachnoid hemorrhage (SAH) in the setting of severe headache and meningismus. SAH is most commonly due to a ruptured cerebral arterial aneurysm. Patients typically develop abrupt onset of severe headache (thunderclap headache). Meningeal irritation from the blood causes neck pain and/or stiffness. A noncontrast head computed tomography (CT) scan is positive for blood in >92%-95% of cases within the first 24 hours. Lumbar puncture is often required to definitely exclude SAH in patients with normal CT scan. Rebleeding is the major cause of death within the first 24 hours of presentation, especially within the first 6 hours of untreated SAH. Vasospasm can occur in up to 30% of SAH patients from days 3-10 after presentation and is the major cause of delayed morbidity and death. It is likely caused by arterial narrowing at the base of the brain due to degradation of the blood and its metabolites and can lead to cerebral infarction. CT angiography is preferred for detecting vasospasm, which can best be prevented with initiation of nimodipine. (Choice B) Hemiplegic migraine is a rare familial disorder that presents with migraine headache associated with unilateral motor deficits. However, the neurologic deficits usually occur at the time of the headache instead of days later, as seen in this patient. (Choice C) Although rebleeding risk can be high in untreated SAH, surgical repair of the aneurysm (eg, endovascular coiling in this patient) practically eliminates the rebleeding risk. (Choice D) Subacute hydrocephalus is a complication of SAH that can present with headaches. Patients tend to develop progressive mental decline and multiple neurologic deficits due to compression of the cranial nerves, brainstem, and/or cerebral cortex. However, subacute hydrocephalus does not usually present with a focal unilateral deficit, as seen in this patient. (Choice E) Todd's palsy usually occurs after a focal motor seizure. This patient did not have a history of a seizure and so his focal motor deficits are more likely due to another condition. Educational objective: Vasospasm is the major cause of delayed morbidity and mortality in subarachnoid hemorrhage and can result in cerebral infarction. Vasospasm can best be prevented with initiation of nimodipine. References: How we do it: acute management of subarachnoid hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/23452572)

A 46-Year-Old Man Comes to the Emergency Department Complaining of Severe