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Worst Headache Of Life


Consult Page

65F with worst headache of life, nausea, vomiting, confusion. CT + subarachnoid hemorrhage

Initial Imaging

Figure 27.1, An axial head CT without contrast shows diffuse, thick subarachnoid hemorrhage with blood in the lateral and third ventricles (A) the basal cisterns and left greater than right Sylvian fissures (B) and the fourth ventricle (C) There is early hydrocephalus with prominent temporal horns, third ventricles, and lateral ventricles.

Walking Thoughts

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    What is the current GCS of the patient? Is she able to protect her airway?

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    Is the patient on any anticoagulant or antiplatelet medications? If so, have reversal agents been given?

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    Are coagulation labs available or pending?

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    What medical comorbidities does the patient have?

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    What is the age and baseline function of the patient?

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    Does this patient need acute cerebrospinal fluid (CSF) diversion with an external ventricular drain (EVD)?

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    Does the patient have a CT angiogram (CTA) available? Does the patient need a cerebral angiogram?

History of Present Illness

A 65 year old female with a history of hypothyroidism and hypertension presents to the emergency department (ED) with thunderclap headache. Per family, the patient was resting at home when she suddenly developed an excruciating, worst headache of life with unrelenting nausea and vomiting. She became progressively lethargic and confused. The family called emergency medical services, and the patient was brought to the ED.

The patient’s son denies any history of anticoagulant or antiplatelet medications, loss of consciousness, or seizure-like activity. A head CT without contrast shows thick, diffuse subarachnoid hemorrhage (SAH) in the basal cisterns extending into the left greater than right sylvian fissures, along with intraventricular hemorrhage (IVH) without casted ventricles. There is mild hydrocephalus with dilated temporal horns but without transependymal edema. CTA of the head and neck demonstrates a 4 mm posteroinferiorly-projecting, saccular posterior communicating artery aneurysm ( Figure 27.2 ). Of note, the patient does have a 50 pack-year smoking history but does not have a familial history of cerebral aneurysms.

Figure 27.2, Coronal (A) and sagittal (B) CTA head with contrast shows a 4 mm posteroinferiorly-projecting posterior communicating artery aneurysm (arrows).

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