PART 1—GENERAL PRINCIPLES AND APPROACH TO HEADACHE
A 42-year-old woman was brought by a friend to her local hospital complaining of headache, nausea, fatigue, and altered sensation over her right side. Symptoms had gradually built over an hour. On examination, she was pale, somewhat drowsy with a Glasgow Coma Scale (GCS) of 15, and complained of the light bothering her eyes. Her neck was supple. She did not want to ambulate, and her speech was nonfluent with frequent paraphasic errors; she also had difficulty with naming and repetition. Her general physical and neurological examination was otherwise normal.
How should you formulate this problem? What secondary causes of headache should be considered?
In formulating this presentation, it is essential to recognize the patient’s primary problem of concern is nonfluent dysphasia, set within the context of headache, photophobia, nausea, and altered sensation over the right side. Initially she was unable to give an accurate history due to her dysphasia. As such, her headache should be considered secondary—relating to a structural lesion or other definable perturbation of brain function, until proven otherwise.
Any process that can perturb dominant-hemisphere temporo-parietal function can cause dysphasia. The tempo of onset is a clue as to the underlying pathophysiology: stroke, trauma, infection, and inflammation all can present acutely while tumor tends to be associated with a gradual onset of symptoms. Ischemic or hemorrhagic stroke as a cause of these symptoms must be excluded in the emergent context. Less common causes of acute-onset dysphasia include lesions typically associated with focal epileptiform activity on EEG, such as herpes simplex encephalitis.
What investigations should be ordered?
Given stroke is the diagnosis to exclude a plain CT brain is mandatory. This may show early changes related to an ischemic stroke, exclude an intra-axial bleed, and help exclude a space-occupying lesion.
Basic laboratory tests such as a full blood count and comprehensive metabolic profile, blood glucose level, coagulation screen, and blood cultures should be ordered.
A pregnancy test is mandatory in the early workup of any woman of child-bearing age, especially as she may be exposed to ionizing radiation.
A routine EKG is indicated. This may demonstrate an arrhythmia, such as atrial fibrillation, which could increase her stroke risk. It may also demonstrate ST-T changes indicative of cardiac ischemia, such as ST depression or elevation, or inverted T waves.
As she is presenting within the hyperacute period, where the use of intravenous thrombolysis or an intra-arterial intervention may be considered, in specialist centers she may also undergo a CT perfusion and CT angiogram, or an MRI brain with or without an MR angiogram. A lumbar puncture (LP) should be considered if meningoencephalitis remains a consideration.
CASE 27-1 (continued)
She was treated with an antiemetic and intravenous fluid. A plain CT brain, CT perfusion, and CTA from the origin of the vertebral arteries were unremarkable. ...