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Case #7 Headache

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Anaesthetics and Critical Care

Obstetrics Gynaecology

Trauma and Orthopaedics

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Urology

Version Jan 2023

A 45-year-old lady presented with a sudden severe headache which occurred when she was hanging out the washing to dry. She collapsed in the garden and then recovered and was able to get inside and alert her husband who called an ambulance. She is holding her head and feels ill. Her GCS is now 15. She is taken for a CT scan of her head which is shown below. Her BP is 170/100 mmHg.

What do you expect the CT to show ?

What is a thunderclap headache ?

It is a sudden severe headache with maximal intensity within 2 minutes but in reality, one would expect seconds and is usually the worst headache ever experienced. Patients describe it as being hit around the head with a cricket bat. It represents sudden arterial bleeding and supposed meningeal irritation. There are a few causes in the differential but a SAH is almost always the first concern.

2. Differential for a thunderclap headache

Subarachnoid haemorrhage
Cerebral venous sinus thrombosis
Reversible cerebral vasoconstriction syndrome
Benign (idiopathic) thunderclap headache only diagnosed if SAH excluded
Coital headache: happens during sex

3. What is a warning or sentinel headache ?

It has been thought that some patients may have an earlier headache suggesting a SAH prior to the big one. This has been challenged. It is still in the books and whether it is a myth or real is unclear.

What is the likely cause?

The main cause of subarachnoid haemorrhage is a rupture of a berry aneurysm on branches of the circle of Willis. These are often asymptomatic until they rupture.

What is the most worrying complication now?

Once an aneurysm has bled the main fear is re-bleeding from the aneurysm. The initial bleed may settle but the aneurysm is untreated and may bleed again. It is important to get this patient to the neurosurgeons for consideration of either coiling the aneurysm or clipping the aneurysm. In the meantime, the patient is admitted to an area where they can be closely watched and blood pressure and fluid balance monitored with close monitoring of neurology and ABCs and telemetry as arrhythmias are not uncommon.

What other complications of SAH do you know ?

Patients may develop

Hyponatraemia from losing salt in urine or SIADH
Bleeding can cause an obstructive hydrocephalus
Re-bleeding
Chest infection and aspiration
Seizures
Vasospasm and ischaemic stroke
Arrhythmias

Are there any medications that are started

Yes, patients are usually started on Nimodipine which is a calcium channel blocker to reduce the risk of vasospasm of the arteries which can cause an ischaemic stroke. It is usually given oral or via NG or IV. Can be given for several weeks until the risk of vasospasm declines

8. What are the treatment options for the aneurysm

Coiling or clipping. Clipping requires general anaesthesia and a craniectomy. Coiling can be done by catheter either by a neurosurgeon or interventional radiologist

What actions can be done to reduce the recurrence of further aneurysms

Treat Hypertension and smoking cessation

10. Question

Answer

References

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