Thunderclap Headache

Question 1

differentials of thunder clap headache ?

Answer 1

SAH

migraine

cavernous sinus thrombosis

PITUITORY APOPLEXY

posterior reversible encephalopathy syndrome

acute hypertensive crisis

cervical artery dissection

Question 2

Causes of SAH

Answer 2

intracranial aneurysm / berry aneurysm
= hypertension , ADPKD, Ehlers dans syndrome and coarctation of aorta

AV malformation

pituitary apoplexy

Question 3

features of SAH ?

Answer 3

Suden onset
worst headache of their life
occipital
typically peaking in intensity over 1-5 mins

nausea and vomiting

meningism - photophobia , neck stiffness

coma , seizures

ECG changes may be seen especially in the ST

Kernig’s sign (takes 6h to develop),

retinal, subhyaloid and vitreous bleeds (=Terson’s syndrome; it carries a worse prognosis: mortality  ≈ 5)1.37

Focal neurology at presentation may suggest site of aneurysm (eg pupil changes indicating a IIIrd nerve palsy with a posterior communicating artery aneurysm) or intracerebral haematoma.

SAH patients may earlier have experienced a sentinel head- ache, perhaps due to a small warning leak from the offending aneurysm

Question 4

investigations of SAH ?

Answer 4

bedside
ECG

BLOODS - FBC , UE , COAG SCREEN , GROUP AND SAVE

=========
CT head should be done within 6 hours of symptom onset

and if it is negative there is no reason to do LP

======
however if CT head is normal after 6 hours do an LP atleast 12 hours - to develop xanthochromia

Question 5

TX of SAH

Answer 5

referral to neurosurgery should be made

=======

Maintain cerebral perfusion by keeping well hydrated, and aim for SBP 160mmHg.
Treat high BP only if very severe

=======
neuro obs should be started

VTE PROPHYLASIX IS IMPORTANT = for non-traumatic SAH within 24 h after admission or 24 hours after stable imaging of the intracranial hemorrhage

analgesia

bed rest

=====
under the guidance of a senior or specialist - we can start nimodipine
to prevent vasospasm

======
if caused by intracranial aneurysm they ca cause rebreeding - so they need fast intervention within 24 hours - neurosurgery for coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon

Question 6

complications of SAH?

Answer 6

Re-bleeding
often in the 1st few days.

Cerebral ischaemia due to vasospasm may cause a permanent CNS deficit, and is the commonest cause of morbidity. If this happens, surgery is not helpful at the time but may be so later.

Hydrocephalus, due to blockage of arachnoid granulations, requires a ventricular or lumbar drain.

Hyponatraemia is common but should not be managed with fluid restriction