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| The Nightmare Headache - Subarachnoid Hemorrhage |
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by Bob Blumm, MA, PA-C, DFAAPA - December 6, 2010
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Let’s call her Mrs. Smith, a patient in my practice who had a zest for life. Her life ended shortly after horseback riding and then exerting herself having a bowel movement. She was found 48 hours later by Police and family after she did not return home over the weekend. She lay on the bathroom floor exiting life without dignity and totally unprepared. A few weeks earlier she developed sudden onset headache pain but attributed it to the stress she was having from a scheduled surgery. This headache is called a sentinel headache and will usually precede a more lethal headache that if undetected or untreated rapidly, is usually a post mortem diagnosis. In the case of Mrs. Smith, her Office of the Medical Examiner removed her 3 pound brain and after dissection discovered a ruptured aneurysm in her subarachnoid space. Her diagnosis was a SAH.
The headache universe consists of primary and secondary headaches. The primary headache is seen in every family practice office, urgent care center and emergency room, every day. The secondary headaches are few but among them is this headache that comes like a thief in the night, attacking a majority of people over the age of fifty who previously have not suffered from headaches. This type comes suddenly, gains locomotion like a train going downhill and culminates in rupture of the affected vessel and a high rate of morbidity and mortality. It can have an etiology related to trauma or exercise or can awaken a person from sleep reaching out with its deadly hand. Approximately 15%of patients die prior to reaching an ER because they have “waited it out.” Another 40% of patients die within a week of the rupture due to the devastating ischemia and hypoxia.
We despise hearing about these diseases that steal the lives of young parents and grandparents and wonder how or if they can be avoided. Nothing in medicine can be totally avoided but the chances of becoming a victim from this type of secondary headache can be as simple as decreasing one’s intake of alcohol and totally abstaining from even one more cigarette. There is considerable debate concerning the relationship between SAH and hypertension and this is a reasonable question. When looking at those who have died even earlier, the greatest contributing factor was the abuse of cocaine and the ingestion of amphetamines as these drugs have a combined result of creating early spike of pressure and creating the aneurysm growth and early rupture.
This catastrophic disease can be reduced substantially with a good history and physical exam giving close attention to descriptions, timing, location and associated signs and symptoms. Headaches that are considered first time headaches in people over fifty are red flags to this problem. These people will need a non-contrast CT exam followed by a spinal tap to finalize a diagnosis and to treat this condition. The prodrome is the sentinel leak and the initial questioning of the patient is related to is this a first time headache or have you had a similar headache in the past two or three weeks. These prodromal headaches can cause nausea, vomiting, photophobia, malaise and other signs that will cause the astute clinician to add to the differential because they have had a stiff neck, fever or vertigo. Whenever one is considering SAH they are simultaneously ruling out meningitis.
A physical exam will sometimes reveal focal neurological signs therefore special consideration needs to be given to an ophthalmological exam to R/O papilledema, retinal hemorrhages, nuchal rigidity, and increase of ICP, cranial nerve palsies and an elevation of the patient’s blood pressure. Ruling in and ruling out are the only manner of securing an accurate diagnosis. Prudent laboratory tests include a CBC, PT/PTT, SMA7 and blood type. Myocardial ischemia can result from the increase of catecholamine’s and therefore a ECG is necessary and a focus should relate to non-specific ST changes and inverted T waves which are indicators of ischemia. Prolonged qrs segments, u waves and increased qt intervals are all clinical signs that cannot be ignored. If the index of suspicion is high then the patient should be monitored in an ICU bed with a neurosurgical protocol and a repeat lumbar puncture performed after 12 hours. While in the ICU the patient will be seen by a neurosurgeon that may choose to perform an MRI is he/she is significantly impressed by the exam or as a result of other tests. A mapping of the brain will soon direct the surgeon to the location and size and shape of the lesion and a surgical clipping will ensue. The neurosurgical department will assign a number from the Hunt and Hess grading system that correlates to their present condition.
A final diagnosis and treatment will be identified and the patient may be placed on a C-channel blocker, mannitol and a loop diuretic such as lasix. Oxygen will be given and the HOB will be elevated to facilitate venous drainage. A decision will soon be made for surgery and the patient will be closely guarded over the next 72 hours for a rebleed. It is the responsibility for the clinician who makes the initial diagnosis or who first sees the patient to be astute in their diagnostic workup with particular care given to the history of a sentinel bleed. This was one of the lectures that were focused upon at the Fall meeting of the AFPPA. It remains urgent for clinicians to attend these conferences as they tend to focus on areas of medicine that can influence our future as well as that of the patient and the family.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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