Headache case 4

Headache case 4

A 39-year-old woman presents to the emergency department after collapsing at a party. An interview with her boyfriend indicates that she complained of a severe headache prior to her collapse. He states that she has no significant past medical history and takes occasional
vitamin supplements. Her blood pressure is 200/120 mm Hg, pulse is 37/min, and respirations are 5/min. The patient is unresponsive to commands or painful stimuli. There is moderate papilledema. The remainder of the examination is unremarkable. An electrocardiogram
demonstrates normal sinus rhythm without T wave inversions or ST segment changes.
Q 1
Which of the following is the most likely diagnosis?
/ A. Anterior communicating artery aneurysm rupture
/ B. Atonic seizure
/ C. Cocaine induced myocardial infarction
/ D. Posterior inferior cerebellar artery aneurysm rupture
/ E. Vein of Galen malformation


Q 2
Which of the following conditions would predispose this patient to having this condition?
/ A. Atherosclerosis
/ B. Diabetes
/ C. Hemophilia
/ D. Marfan syndrome
/ E. Protein C deficiency
/ F. Protein S deficiency

Q 3
A CT scan would most likely demonstrate blood in which of the following areas?
/ A. Fourth ventricle
/ B. Lateral ventricles
/ C. Subarachnoid space
/ D. Subdural space
/ E. Superior sagittal sinus
/ F. Third ventricle


Q4
Which of the following drugs could have precipitated this patient's condition?
/ A. Cocaine
/ B. Hashish
/ C. Lysergic acid diethylamide (LSD)
/ D. Morphine
/ E. Pindolol

Q5
Which of the following is more likely to be present in patients with this condition than in normal persons?
/ A. Early AIzheimer disease
/ B. Fronto-temporal brain atrophy
/ C. Medullary thyroid carcinoma
/ D. Osteosarcoma
/ E. Renal cysts

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Headache case 4 answers

A1
The correct answer is A. This patient is presenting with a loss of consciousness, bradycardia, hypertension, and decreased respirations. While loss of consciousness has a wide differential diagnosis, the triad of bradycardia, hypertension, and decreased respirations is known as Cushing's triad, and is indicative of increased intracranial pressure. The finding of papilledema confirms that there is increased intracranial pressure. The differential diagnosis at this point is a spontaneous hemorrhage due to aneurysm rupture, trauma, vascular malformation rupture, or possibly a massive ischemic stroke. Of the choices given, anterior communicating artery aneurysm rupture is the most likely diagnosis. Aneurysms are outpouchings of the arteries of the Circle of Willis that occur most commonly at the anterior communicating artery, middle cerebral artery, or posterior communicating artery. They most commonly present with hemorrhage or headache. In this case, there is likely hemorrhage and increased intracranial pressure leading to secondary brain herniation. Treatment of this patient consists of lowering intracranial pressure and treating the aneurysm surgically.
An atonic seizure (choice B) is a fainting spell in which the patient becomes hypotonic, but recovers over a short interval. There would be no signs of increased intracranial pressure.
Myocardial infarction (choice C) from cocaine or other etiology would usually have electrocardiogram abnormalities and there would be no signs of increased intracranial pressure.
Posterior inferior cerebellar artery aneurysm rupture (choice D) is a possibility but these aneurysms are rare, compared to anterior communicating artery aneurysms.
Vein of Galen malformations (choice E) are a remnant of the fetal circulation that presents in children as a posterior fossa mass. Actual hemorrhage of these lesions is relatively rare.

A2
The correct answer is D. Connective tissue diseases, such as Marfan syndrome, weaken blood vessel walls and predispose to aneurysms of any blood vessels in the body. Marfan syndrome is an autosomal dominant disorder that has been linked to the FBN1 gene on chromosome 15. FBN1 encodes the protein fibrillin, which is involved in the formation of elastic fibers found in connective tissue. Without the structural support provided by fibrillin, many tissues are weakened, with severe consequences, e.g., aneurysm formation.
Atherosclerosis (choice A) is not thought to be associated with intracranial aneurysms, which are believed to form from congenitally weak areas at the junctions of blood vessels. Aortic aneurysms are closely associated with atherosclerosis.
Diabetes (choice B) is not thought to be associated with intracranial aneurysms. However, diabetes leads to an increased incidence of atherosclerosis, which may lead to aortic aneurysms.
The hemophilias (choice C) are blood clotting disorders that do not predispose patients to aneurysms. These patients bleed profusely from even minor vessel trauma, however.
Protein C deficiency (choice E) and protein S deficiency (choice F) are blood clotting disorders leading to thrombosis of arteries and veins. This does not predispose a patient to aneurysms, however.

A3
The correct answer is C. The subarachnoid space consists of the space between the pia, which adhere to the brain, and the arachnoid membrane. The circle of Willis, including the anterior communicating artery, lies in the subarachnoid space. Subarachnoid hemorrhage is a common presenting symptom of ruptured intracranial aneurysms. Aneurysmal subarachnoid hemorrhage is usually within the basilar cisterns, where the circle of Willis lies, while posttraumatic subarachnoid hemorrhage is usually over the cerebral convexities. Hemorrhage into the epidural or subdural space is usually secondary to trauma. Epidural hematomas occur from injury to the middle meningeal artery and subsequent hematoma formation, and are usually associated with a fracture of the temporal bone.
Intraventricular hemorrhage (choices A, B, and F) is a much less common presentation of a ruptured aneurysm. Usually there will be subarachnoid hemorrhage and intraventricular hemorrhage, rather than isolated intraventricular hemorrhage. Intraventricular hemorrhage often leads to ependymitis and hydrocephalus from dysregulation of the normal cerebrospinal fluid production and resorption physiology.
Subdural hematomas (choice D) are usually secondary to trauma, not bleeding aneurysms. Subdural hematomas form from injury to the bridging veins between the venous sinuses and the cortical draining veins. Subdurals are common in elderly patients because they usually have some degree of brain atrophy and these bridging veins are stretched thin.
There is normally blood present in the superior sagittal sinus (choice E), which drains the cortical veins from the top of the cerebrum.

A4
The correct answer is A. The key here is to find the drug that leads to hypertension, and thus is likely to cause an aneurysm to rupture. Cocaine leads to episodic hypertension due to its sympathomimetic effects. It may be snorted, smoked, or injected. Cocaine use is associated with cardiac arrhythmia, myocardial infarction, stroke, and cerebral or aortic aneurysm rupture. Although not a cause of intracranial aneurysm formation, it may lead to aneurysm rupture. Cocaine is used for its central effects on dopaminergic neurons, and the sympathomimetic effects described above are unwanted side effects.
Hashish (choice B) and marijuana contain delta-9- tetrahydrocannabinol (THC), which is used for its effects on the central nervous system. Other physical effects include reddening of the eyes, dryness of the mouth and throat, moderate increase in the heart rate, tightness of the chest (if the drug is smoked), drowsiness, unsteadiness, and muscular incoordination. Hypertension is not a common effect of THC.
Lysergic acid diethylamide (LSD) (choice C) is a psychotropic amide with many poorly-understood central nervous system effects. Significant hypertension does not generally occur with LSD.
Morphine (choice D) is an opiate analgesic, and would tend to lower blood pressure, rather than increase it.
Pindolol (choice E) is a nonselective beta-adrenergic receptor blocker. In addition, pindolol has partial agonist activity, with significantly greater agonist than antagonist effects at beta-2 receptors. It has negative inotropic and chronotropic effects and thus is used as an antihypertensive agent. It would help prevent hypertension.

A5
The correct answer is E. Patients with adult polycystic kidney disease have a much higher incidence of berry aneurysms than the general population. Hypertension that may accompany the eventual renal failure can contribute to aneurysm rupture and subarachnoid hemorrhage.
Early Alzheimer-like changes (choice A) are observed in patients with Down syndrome.
Fronto-temporal brain atrophy (choice B) is seen in Pick disease.
Medullary thyroid carcinoma (choice C) is seen with increased frequency in multiple endocrine neoplasia (MEN) IIa and IIb.
Osteosarcoma (choice D) is more frequent in patients with familial