(Updated with Answer) The Medical Challenge: The Headache of a Lifetime – What Should the Doctor Do?

Regina is a 45-year-old woman and owner of a coffee house in Seattle. An avid coffee connoisseur, she especially loves the Harrar coffee beans from Ethiopia. Her passion for coffee is matched only by her enthusiasm for cigarettes, and she knows a great deal about tobacco and its different tastes. On average, she has smoked a half pack per-day for the last twenty years.

This year Regina has decided to exercise in the evenings after her shop closes. One day, she leaves for the gym and begins to have a slight headache. She shakes it off and decides to go running. As she begins to run, her headache suddenly explodes in intensity. She gets off the treadmill and immediately feels faint. She falls to the floor and suddenly cannot understand what is happening. She becomes nauseous and then violently vomits. Regina is now in a coma.

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In the emergency room, Regina is unresponsive. She does not rouse when stimulated. When a painful stimulus is applied, she abnormally extends both her arms in response as opposed to grimacing or swatting away the painful stimulus. When a light is shined into her eyes, her pupils react quite sluggishly. Her breathing is irregular and alternates between shallow and deep. The doctors believe her breathing to be so abnormal that they decide to place a breathing tube in order to secure her airway. Now she is on a ventilator.

What happened? What should the doctors do next?

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The Emergency room doctors have to act fast. Clearly, Regina is in critical condition. The most striking feature of Regina’s condition is her inability to interact with the outside world. Her responses to noxious stimuli are extremely abnormal. Because of these clinical features, the ER physicians order a CT (Computed Tomography) scan to evaluate her brain as her clinical condition strongly suggests a neurologic cause.

In the CT scan shown, the cause of Regina’s condition comes immediately into view. She has suffered a spontaneous subarachnoid hemorrhage from a ruptured aneurysm in the brain.



Subarachnoid hemorrhage is a serious condition which can result from trauma, blood vessel malformations in the brain, and aneurysm ruptures as in Regina’s case. An aneurysm is a weakening in the wall of an artery that generally results in an out-pouching of the arterial wall. Over time, the wall of the aneurysm that keeps blood from spilling into the brain weakens and may eventually rupture. Upon rupture, patients can have a variable set of symptoms from a mild headache to coma to even death. In fact, the pre-hospital lethality of subarachnoid hemorrhage may be as high as 20-40%. If the aneurysm is not treated initially, the risk of re-bleeding from the aneurysm is 20% within the first two weeks after the initial hemorrhage.

Subarachnoid Hemorrhage is a certainly a major neurologic health problem in the United States. Its incidence (medical term used to define the frequency of a disease in a given population) approximates 10 per 100,000 though this incidence varies greatly by the specific population studied. For example, the Japanese have the highest frequency of subarachnoid hemorrhage in the world. The annual cost of this hemorrhage approach nearly 2 billion USD per year. Risk factors for subarachnoid hemorrhage are multiple. Females, smokers, and cocaine users have a relatively increased risk of suffering a hemorrhage compared to the rest of the population.

Subarachnoid hemorrhage requires emergent treatment. In Regina’s case, the hemorrhage has caused the water tanks in her brain(termed ventricles) to swell due to the clogging effect the blood has on the brain’s ability to reabsorb its natural fluid. As the brain does not know to stop producing its own natural fluid, the ventricles increase in size and the pressure in the brain dramatically rises. This increase in pressure can case a variety of symptoms including headaches, blurry vision, confusion, lethargy, coma and even death if left untreated. For Regina, she requires an emergent catheter placement (ventriculostomy) into these water tanks(ventricles) performed by a neurosurgeon. This requires a small incision in the scalp, a small hole drilled in the skull, and finally the catheter inserted into the ventricles.

Once her catheter has been placed, Regina has two treatment options. The first is surgery wherein a neurosurgeon finds the aneurysm and places a clip across the neck of the defect. The effect of this clip is to seal off the aneurysm from the normal artery and thus prevent any future re-bleeding or recurrence of the aneurysm. A second option termed endovascular coiling involves placing a catheter into an artery of the leg and then feeding it through the body’s natural blood vessel pathways into the brain using x-rays as a navigation system. Once the catheter is sitting next to the aneurysm, metal coils are placed into the pouch of the aneurysm. These coils then cause the blood to form a scab around the coils which effectively seals off the aneurysm from the normal artery. The best treatment option depends on the size, shape, location, and particularities of the individual patient.

Once the aneurysm is treated, however, Regina has a long road ahead of her. She will remain in the intensive care unit for at least two weeks at which time her entire body will need intensive optimization by the ICU doctors, Neurosurgeons, and nursing staff to prevent strokes in the brain and other end organ damage. Her recovery from this hemorrhage is uncertain. Perhaps one third of patients like Regina who survive can go on to make a great recovery, another one third will recover with mild to moderate disability, and the remainder will survive with profound disability requiring constant nursing care.

Still, despite these statistics, modern day management and research regarding subarachnoid hemorrhage is helping to improve patient outcomes. More importantly, though, careful vigilance regarding your general health and the availability of emergency medical care are the most important pieces of this complex puzzle.

Links:

www.Stroke.org – National Stroke Association Website

www.bafound.org – Brain Aneurysm Foundation Website

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