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|Case #2 Calcium
|Case #3 Calcium
|Case #4 Glucose
|Case #5 Shakes
|Case #6 Weakness
|Case #7 Headache
|Case #8 Weakness
|Case #9 Weakness
|Case #10 Weakness
|Case #11 Weak face
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|Case #13 Shakes
|Case #14 Confusion
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|Case #16 Breathless
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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.
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.
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.
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.
Answer
What do you expect the CT to show ?
What is a thunderclap headache ?
2. Differential for a thunderclap headache
3. What is a warning or sentinel headache ?
What is the likely cause?
What is the most worrying complication now?
What other complications of SAH do you know ?
Are there any medications that are started
8. What are the treatment options for the aneurysm
What actions can be done to reduce the recurrence of further aneurysms
10. Question
References
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Case #7 Headache
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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.
Patients may develop
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
Coiling or clipping. Clipping requires general anaesthesia and a craniectomy. Coiling can be done by catheter either by a neurosurgeon or interventional radiologist
Treat Hypertension and smoking cessation