HPI
A 68 year old white male is brought into your office by
his wife who is very concerned about her husband.
The man appears in great discomfort and explains that
he was working in the yard when out of nowhere he
suddenly developed what he calls the worst headache
of his life! He also claims to be having some neck pain
and double vision which is really worrying him. You
notice he seems a little confused and very tired. The
wife grabs you by the arm and pleads with you to help
her husband. She then asks, “is my husband going to
die?”
What questions would you like to ask?
HPI cont.
• What makes it better? Nothing
• What makes it worse? Nothing
• PMHx: Hypertension, DM2, Hyperlipidemia. Not a
person who usually experiences headaches, no
history of heart attack, stroke or vascular
symptoms
• Has annual physicals with PCP. Wife says all of his
problems are well controlled with medication,
which her husband takes religiously. But neither
can remember what medications he is taking
• All: None
• SxHx: None
• FMHx: Father had HTN, HLD, died of MI at 73. Mother has
history of migraine headaches, HTN and suffers from
dementia. Currently lives in a assisted living facility on the
outskirts of town.
• Social Hx: Happily married with 4 children, retired blimp
pilot. Drinks 2-3 PBR’s a days and has really cut back on
smoking lately, only smokes 1 pk/day of marlboro reds. Has
been smoking for 40yrs. Claims he does not using any illegal
drugs
What is included in your differential diagnosis?
Differential Diagnosis
• Headache
– Migraine
– Cluster
– Tension
• Trauma
– Did he really fall and hit his head?
– Did something fall on him and hit his head?
• Infection
– Stiff neck, vision issues.
• Heat exhaustion/stroke/dehydration
– What season is it? Is it hot out? How long was he outside?
• Stroke
• Tumor
What is your next step to assess this patient?
Physical Exam
•
Vitals:
– BP 157/94
– T 37.2
– RR 24
•
•
•
•
•
Gen: patient appears uncomfortable, holding head with both hands with eyes
closed.
CV: RRR, normal S1/S2, no murmurs, rubs or gallops appreciated.
Resp: CTA
Abd: Soft non tender, non distended belly with bowel sounds appreciated.
Neuro:
–
–
–
–
–
Alert and oriented x3.
Neck is tender to palpation with limited ROM
Strength UE/LE bilaterally 5/5
All reflexes in tact
Finger to nose, heel to shin slow but documented as normal. Rapid alternating hand
movements very slow
– Gait is normal, can walk on heels and toes without issue.
– Anything else?
Cranial Nerves
• I: rarely tested, we will say normal
• II: visual fields/acuity/fundoscopic exam all difficult to assess
because patient claims his double vision is making it tough to see
anything
• III/IV/VI: EOM intact, PERRL, normal eye lid opening
• V: facial sensation seems to be somewhat decreased on the left
• VII: eye brow raise reduced on left, labored smile, but seems to
easily frown.
• VIII: WNL
• IX/X: WNL
• XI: difficult to assess as patient claims it hurts to touch his head and
neck
• XII: WNL
Patient is getting more and more frustrated, what would you like to do next?
Labs?
• CBC: wnl
• WBC: wnl
• VDRL/RPR: negative
Now what?
Head CT
Will recognize 90% of ruptured aneurysms
Angiography
performed to identify where exactly the aneurysm is located and plan
treatment
Subarachnoid Hemorrhage
• Many describe as the “worst headache of my life”
• Many have no previous symptoms
• Risk factors include: HTN, atherosclerosis, renal
disease, vasculitis, drug use (esp. cocaine)
• the most frequent cause of clinically significant
subarachnoid hemorrhage is rupture of berry
(saccular) aneurysms
• Other causes: traumatic hematoma, rupture of
hypertensive intracerebral hemorrhage, vascular
malformations, tumors, and
Quick Review
• Aneurysm- an abnormal widening or
ballooning of a portion of an artery due to
weakness in the wall of the blood vessel
• Cause is not exactly clear. Some are present at
birth, some thought to be due to vessel wall
defects.
• Major locations include: heart (aorta), brain,
leg (popliteal artery), intestine (mesenteric
artery), spleen (splenic artery)
Berry/Saccular Aneurysm
- Most common type of
intracranial aneurysm.
- Most often found in the
anterior circulation near
major arterial branch
points within the COW
- Found in 2% general
population
Pathogenesis
• Again etiology is unknown; mostly sporadic
• Despite this, genetic factors are thought to be
involved as there is an increased incidence of
aneurysms in first degree relatives of those
affected.
• Also an increased risk on those with certain
disorders such as AD Polycystic Kidney
Disorder, Ehlers-Danlos syndrome type IV,
NF1, and Marfans
Fibrin within wall
Top left: Diagram of most vulnerable spots
within the COW, where aneurysms often
form.
Top Right: The effect of weakening of the
wall of a small intracerebral blood vessel,
with the formation of a small aneurysm. This
section has been stained for fibrin, which
appears red. Note seepage of fibrin into the
wall.
Bottom: gross view of berry aneurysm
Normal artery wall with slightly thickened intima, internal elastic
lamina (arrows) and well organized smooth muscle in the media with
a thin adventitia.
Clinical Features
• Rupture
– Most common in fifth decade
– More common in females
– Can occur at any time, but often associated with increased ICP such as
with sexual intercourse, straining, or lifting heavy objects
• Blood forced into the subarachnoid space leading to excruciating
HA, loss of consciousness, diplopia, sensory loss etc.
• Blood covers the surface of the brain
• 25-50% die with first rupture
• Complications: Further Hemorrhage, Hydrocephalus ( blockage of
arachnoid granulations), Permanent neurological defects.
Treatment
• Unruptured
– Depends on following factors: Size and Location,
patient age, overall state of health
– Options include: observation with serial imaging
along with tight BP control (CCB or BB’s), or
neurosurgery consult to consider surgical clipping
or coiling.
• Ruptured
– Re-bleed 20% of the time
– Therefore need surgical clipping/coiling
Board Questions
• Most common site for Berry Aneurysm?
Junction with ACA
• What does the CSF show? Xanthochromia
(yellowish tint due to broken down bilirubin)
• Common complaint? Worst headache of my
life
• Most common complication? Vasospasm
• What if suspect SAH, but CT inconclusive? Get
LP to look for xanthochromia
• http://pittsburghneurosciences.com/conditions/b
rain_aneurysm/treatments.html
• http://www.medicinenet.com/brain_aneurysm/p
age2.htm
• Goljan, Edward. Rapid Review Pathology, Elsevier
2009 Edition
• http://www.nlm.nih.gov/medlineplus/ency/articl
e/001414.htm
• http://radiopaedia.org/articles/ruptured-berryaneurysm-1