Acute Neurological Emergencies: Headache. Brad Bunney, MD Associate Professor Dept of Emergency Medicine. University of Illinois College of Medicine Chicago, IL.
University of Illinois College of Medicine
Michael Gerardi, MD, FAAP, FACEPVice-Chairman, Department of Emergency MedicineMorristown Memorial HospitalMorristown, New JerseyNina T. Gentile, MDAssociate ProfessorDivision of Emergency MedicineTemple University School of MedicinePhiladelphia, PADaniel G. Murphy, MD, FACEPVice Chair & Medical DirectorMaimonides Medical CenterBrooklyn, New York
One hour prior to ED presentation, a 42 year old man was jogging and “hit” by the worst headache of his life. It was associated with some nausea and the feeling as if he was going to pass out. He rested for 30 minutes but the headache persisted as a diffuse, throbbing pain radiating to the base of his skull.
EMS was called. The patient felt as if he could not concentrate, there was no confusion, nor was there any other focal neurologic complaint.
There was no past medical history, no medications, no family history, and no significant use of alcohol, tobacco or other drugs.
a. Non-contrast CT
b. LP after neg. CT
c. LP without CT
d. CT, LP, and angiography
1. Failure to appreciate spectrum of clinical presentation
2. Failure to understand limitations of CT
3. Failure to perform and correctly interpret the results of LP
1. Differentiate life-threatening from benign
2. Initiate prompt treatment
3. Provide prompt pain relief
4. Prevent drug seeking and refer
5. Minimize resource utilization in ED
6. Optimize patient use of ED
7. Increase pre-ED treatment and reduce ED use
Final Diagnosis Percentage
Infection - not intracranial 39.3
Tension HA 19.3
Hypertension related 4.8
Vascular (Migraine) 4.5
No diagnosis 6.0
Outcome of Patients with Good Initial Presentation in Misdiagnosed and Correctly Diagnosed Patients With SAH
Outcome Misdiagnosis (n=45) Correct Diagnosis (n=75)
Excellent/good 24 (53)* 68 (91)*
Fair 5 (11) 4 ( 5)
Poor/vegetative/dead 16 (36)* 3 ( 4)*
Values are number (%) in each clinical grade category.
Rebleeds and Deteriorations Before Treatment in Misdiagnosed and Correctly Diagnosed Patients With SAH
Misdiagnosis (n=54) Correct Diagnosis (n=163)
Rebleeds 21* 4
Deteriorations 5 0
Total 26 4
*12/21 of misdiagnosed and 3/4 of correctly diagnosed patients rebled within 5 days of presentation.
Variables CT-/LP- CT+ CT-/LP+
Photophobia 45 28 50
Stiff neck 26 37 100
Nausea 65 36 100
Lethargy 17 40 50
Time < 24 h 58 75 50
Migraine 20 11 0
Headache 48 27 0
Traumatic LP and SAH
Color gets lighter with subsequent tubes
RBC count in first & last tube
Clotting of blood in CSF
present withi4 hrs of SAH, max at 1 wk, persists for about 3 weeks
Xanthochromia in supernatant
rare with RBC count less than 200,000
The patient had labs drawn, was given 5mg of morphine and sent off to CT scan.
The CT scan revealed an acute SAH. The neurosurgeon ordered an angiogram which revealed an aneurysm.
The patient went to the OR that day and was release with a normal neurological status 4 days later.
Headache, nausea and vomiting, confusion, and focal or generalized seizures.