A 30-year-old man is brought to the emergency department due to a worsening headache. The patient has had episodic right-sided headaches over the past 6 months. Thirty minutes ago, he began experiencing a right temporal headache while at rest, which gradually worsened to severe pain over the next several minutes. He also had nausea and an episode of vomiting. The patient is now somnolent and difficult to rouse. He has no other medical conditions and had a normal medical evaluation a year ago for military enlistment. Temperature is 37 C (98.6 F), blood pressure is 150/90 mm Hg, pulse is 64/min, and respirations are 14/min. The patient withdraws all extremities to painful stimuli, but left-sided deep tendon reflexes are increased. There is no neck rigidity. Which of the following is the most likely underlying cause of this patient's current condition?

Question

A 30-year-old man is brought to the emergency department due to a worsening headache.  The patient has had episodic right-sided headaches over the past 6 months.  Thirty minutes ago, he began experiencing a right temporal headache while at rest, which gradually worsened to severe pain over the next several minutes.  He also had nausea and an episode of vomiting.  The patient is now somnolent and difficult to rouse.  He has no other medical conditions and had a normal medical evaluation a year ago for military enlistment.  Temperature is 37 C (98.6 F), blood pressure is 150/90 mm Hg, pulse is 64/min, and respirations are 14/min.  The patient withdraws all extremities to painful stimuli, but left-sided deep tendon reflexes are increased.  There is no neck rigidity.  Which of the following is the most likely underlying cause of this patient's current condition?

Quizplus · Accepted Answer

This patient with a right-sided headache developed nausea, vomiting, and a decreased level of consciousness, suggesting an intracerebral hemorrhage (ICH). The presentation of ICH varies with the location of bleeding; this patient's left-sided hyperreflexia suggests a possible right hemispheric lobar hemorrhage. Symptoms tend to progress over minutes to hours as the hemorrhage expands. Elevated intracranial pressure can result in headache, nausea/vomiting, and altered mental status. Although ICH can be caused by a variety of mechanisms, this patient's young age and history of right-sided headaches suggests a ruptured arteriovenous malformation (AVM). AVMs occur when an artery directly anastomoses with the veins without an interposed capillary bed. The high-pressure system predisposes patients to aneurysm formation and/or spontaneous bleeding. Most AVMs are congenital, although de novo formation may occur. Patients are typically diagnosed before age 40, most commonly after developing an ICH. Other presenting symptoms may include recurrent headache, seizure, or focal neurologic deficit (due to compression). (Choice B) Carotid artery atheromas typically cause ischemic stroke. Common symptoms include unilateral weakness and aphasia, which often fluctuate and progress in a stuttering fashion. Atheroma would be unexpected in this young patient without risk factors (eg, hyperlipidemia, diabetes). (Choices C and E) Cerebral amyloid angiopathy (CAA) and hypertensive vasculopathy are both potential causes of ICH. However, CAA typically presents in elderly patients and is associated with dementia, whereas hypertensive vasculopathy would be unexpected in a patient without a prolonged history of hypertension. Although uncontrolled hypertension can cause headaches, recurrent unilateral headaches would be unexpected. (Choice D) Dural venous sinus thrombosis can present with headache and signs of intracranial hypertension. However, rapid progression to coma with focal neurologic deficits is more consistent with ICH. In addition, venous sinus thrombosis typically occurs in the setting of hypercoagulability (eg, pregnancy, malignancy), infection, or head injury. (Choice F) Paroxysmal atrial fibrillation can result in cardioembolic disease; however, symptoms are typically maximal at onset rather than progressive, as seen in ICH. In addition, multiple vascular territories are often affected, leading to a variety of neurologic deficits. Educational objective: Intracerebral hemorrhage (ICH) typically presents with progressive headache, nausea/vomiting, and altered mental status over a period of minutes to hours. ICH in young patients is commonly due to arteriovenous malformation, which may also present with recurrent headache, seizure, or focal neurologic deficits.

A 30-Year-Old Man Is Brought to the Emergency Department Due