Consultant.
No. 8
Sudden Headache in a Woman With Hypertension
By
GARY QUICK, MD-Series Editor, Emergency Medicine Section - and MAGGIE LAW, MD |
July 1, 2002
Muskogee Regional Medical Center
Dr Quick is attending physician in the department of emergency medicine
at Muskogee Regional Medical Center in Muskogee, Okla.
Dr Law is in the department of internal medicine at the same institution.
A 37-year-old woman presents to the emergency department
with a diffuse, sharp, pounding headache,
which started 2 hours earlier. She rates her discomfort as
4 on a scale of 1 to 10. Neck muscle soreness is also present,
but the pain does not radiate.
The patient has not experienced syncope; visual disturbance;
chest pain; light-headedness; dyspnea; difficulty
in walking, using her hands and feet, or swallowing; paresthesias;
altered mental status; slurred speech; vertigo; face,
ear, or jaw pain; nasal discharge; palpitations; diaphoresis;
abdominal pain; nausea; vomiting; or
diarrhea. She has not had any acute
illnesses recently.
She has hypertension for which
she erratically takes antihypertensive
medication, the name of which she
has forgotten. She has no personal or
family history of migraine or other
headache syndrome.
She does not smoke or use illicit
drugs; however, she drinks heavily 2
or 3 times a week. She is married and
lives with her family.
Temperature is 37°C (98.6°F);
pulse rate, 90 beats per minute; respiration
rate, 20 breaths per minute;
and blood pressure (BP), 190/110 mm Hg. The patient appears
to be in no acute distress.
Scalp and temporal arteries are not tender; pupils
are symmetric and reactive to light. Eye motions are normal,
and no cranial nerve deficits are apparent. Speech is
clear; gag reflex is intact. Tongue protrudes in the midline.
Fundoscopic examination shows the optic disc margins
are sharply defined; no hemorrhages are noted. Venous
pulsations are present.
No pronator drift or cerebellar dysfunction. Upper
and lower extremity reflexes are equal and symmetric. No
Babinski reflex; Romberg test is negative.
WHAT'S WRONG:
1. What is the rationale behind the decision to order
the scan?
The classic indications for CT are altered mental
status or abnormal results of a neurologic examination—
usually a focal deficit. Neither of these indications is
present here. The key factors in the decision to order a
CT scan for this patient are:
- The sudden onset of headache in a patient with no history
of similar headache.
- The persistently elevated BP that failed to respond to 2
doses of oral clonidine.
2. What does the CT scan show?
The noncontrast head CT scan shows a hemorrhage
in the frontal horn of the lateral ventricle.
A second slice shows a left intracranial cerebral
hemorrhage (ICH) in the basal ganglia region that extends
into the lateral ventricle (Figure). No midline shift
or evidence of brainstem herniation is present. A mild
amount of early hydrocephalus may be present, as indicated
by the relatively generous size of the lateral ventricle
and the mild cortical effacement.
3. What should be done next to evaluate and/or
treat this patient?
In view of these CT findings, a neurosurgical consultation
is requested and the patient is switched to a nitroprusside
drip at 0.5 µg/kg/min and titrated to 2
µg/kg/min, which rapidly controls the BP at 160/100
mm Hg. She experiences an 8-beat episode of ventricular
tachycardia without chest pain or altered consciousness.
ICH is thought to be the cause of the dysrhythmia.
If the dysrhythmia becomes sustained, intravenous
amiodarone will be administered; otherwise, the patient
will simply be observed.
Hospital course
The findings on a second head CT scan obtained 4
days later (not shown) are also compatible with acute
hemorrhagic infarction of the left basal ganglion. The
volume of hemorrhage into the left lateral ventricle has
decreased since the earlier scan, and there is no evidence
of hydrocephalus. The amount of hemorrhage
within the ventricle has also decreased since the initial
scan. A small area of encephalomalacia that indicates
probable small-vessel ischemic infarction is noted in the
right parietal lobe.
The neurologist and neurosurgeon advise against
surgical intervention because of the absence of hydrocephalus
and the patient's normal physical examination.
Her regimen is rapidly switched to oral antihypertensive
therapy: hydralazine, 75 mg qid, and amlodipine, 10 mg
every morning.
The patient undergoes a dipyridamole stress test on
day 4. This study is negative for cardiac ischemia and reveals
an ejection fraction of 50%. A carotid ultrasound
scan performed on day 5 shows no evidence of hemodynamically
significant carotid stenosis.
Outcome
The patient experiences no further hemorrhage or
headache, and she is discharged on the ninth hospital
day. She continues to do well clinically and demonstrates
acceptable BP control with oral hydralazine and amlodipine
therapy.
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