A 31-year-old man with sudden onset headache and vomiting

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Problem 46 A 31-year-old man with sudden onset headache and vomiting

You are working in the emergency department and a 31-year-old man is brought in after collapsing and vomiting while watching television at home the previous evening. It was reported that he had a generalized seizure. When he awoke he was complaining of a severe headache. He is known to drink alcohol excessively and has a 20 pack-year smoking history. He had been binge drinking over the weekend. There is no known history of hypertension.

Q.1

What is the differential diagnosis?

Q.2

What are the key features of the neurological examination in this patient?

On arrival he is alert but agitated, disorientated to time and obeying commands. He is afebrile, but has marked neck stiffness. His heart rate is 52/min and blood pressure 130/80 mmHg. Neurological examination shows no cranial nerve or focal neurological deficit. On investigation his haemoglobin is 127 g/L, white cell count 8.4 and platelets 111 000. His serum biochemistry (including calcium and glucose) is within normal limits and a serum troponin is negative. His chest X-ray is normal and an ECG shows sinus bradycardia with T-wave inversion.

Q.3

What is the next appropriate investigation and what difficulties might be encountered in obtaining this?

The patient required intravenous morphine and midazolam for the radiological investigation.

Q.4

What does the CT head scan (Figure 46.1) show?

Figure 46.1

On the advice of the consulting neurosurgeon, the patient was retrieved to the nearest neurosurgery centre and had further investigations to determine the cause of the subarachnoid haemorrhage.

Q.5

What are the two investigations shown in Figures 46.2 and 46.3 and what do they show?

Figure 46.2

Figure 46.3

Q.6

What treatment options are available for a patient with a ruptured cerebral aneurysm?

Endovascular coiling was attempted in the patient but was technically unsuccessful.

The patient underwent craniotomy and clipping of the aneurysm which was successful. The patient was making good progress until the third postoperative day when he became progressively confused, verbally abusive and drowsy.

Q.7

What are the diagnostic possibilities and what investigations would be helpful?

The patient’s blood pressure was 140/80 mmHg, temperature 38.6°C and oxygen saturation 100% on room air. A CT head showed no new intracerebral haemorrhage, no hypodensity consistent with infarction or hydrocephalus. The angiogram did not show any evidence of vasospasm. The serum sodium was 121 mmol/L, potassium 4.6 mmol/L, osmolality 266 mmol/kg (270–300), urine osmolality 116, urine sodium 177 mmol/L (40–100).

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