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Clinical Scenario 3: Worst Headache of Life Introduction

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Okay, so we've completed the two scenarios.

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The first, a new neurologic deficit where

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we're concerned mostly about stroke.

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The second scenario, which is head

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trauma, where we're mostly concerned

0:12

about motor vehicle collisions and falls.

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The third most common of the clinical scenarios

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that you see in the emergency department for

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neuroradiology is "worst headache of life."

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Those words—WHOL—you might see on the request slip,

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or "thunderclap headache" or "10 out of 10 headache."

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Those are the buzzwords for the potential

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for subarachnoid hemorrhage associated

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with an aneurysm bursting, and this is a

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neurosurgical and neuroimaging emergency.

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The evaluation starts with a CT

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scan to look for that hemorrhage.

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In the absence of

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hemorrhage demonstrated on CT scanning,

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the next most commonly performed procedure is a

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lumbar puncture, and that is because not only will

1:01

subarachnoid hemorrhage cause the worst headache

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of life, but also meningitis. Meningitis, we

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usually do not see anything on the CT scan, and it's

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required to look at the lumbar puncture, cerebrospinal

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fluid to see whether there is an infection.

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Unfortunately, I, as a migraineur,

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often have the worst headache of my life.

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It seems like every migraine I have is the worst

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headache of life, and therefore, there are a lot of

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patients who come in complaining of the worst headache

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of life that do not have a subarachnoid hemorrhage and

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do not have meningitis, or are just having a severe migraine.

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So this is another example where we

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get a CT scan to rule out hemorrhage

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or to rule out intracranial pathology in

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a patient who has the worst headache of life.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Emergency

Brain

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