Case 7

56 year old male, known hypertensive

Found collapsed at home by relatives.
On arrival, GCS 7. BP 170/90

What is the diagnosis?
How would you manage this patient?

Answer : Subarachnoid hemorrhage (SAH)

The CT scan shows presence of blood (the whitish stuff) within the subarachnoid space in the brain, sometimes referred to as the 'Mercedes sign' because it resembles the automaker's logo.

Causes

• Berry aneurysms (70%) - 30% of which in anterior communicating artery and 20% in posterior communicating artery
• Arteriovenous malformation (10%)
• No cause found (10-15%)

Typical presentation

• sudden onset of severe headache ('worst ever' headache)
• nausea and/ or vomiting
• neck pain
• photophobia
• loss of or altered consciousness

First test for patient with suspected SAH - plain CT head

• 93% sensitivity; but sensitivity diminishes with time
• if high suspicion of SAH but CT normal/ non-diagnostic, proceed with lumbar puncture (if no evidence of raised intra-cranial pressure), looking for xanthochromia and elevated RBC count (which does not diminish with successive collections)

A&E management

• Secure airway - in this patient whose GCS is only 7, endotracheal intubation following rapid sequence induction (RSI) to control airway and reduce risk of aspiration
• Supplemental oxygen, IV access and take blood for FBC/ UE/ Coagulation/ GXM
• Close monitoring of vital signs, keep systolic BP between 90-140 mmHg
  
• Contact neurosurgeon immediately with view to timely intervention (angiography/ coiling/ clipping etc)

I remember reading somewhere that an average doctor should expect to come across 3 cases of SAH in his/her career. Well, I have already seen two cases in my (relatively) short career - perhaps a doctor working in the ER will definitely see more of them.

I still remember the first case - a 30 year old lady with hx of migraine, who came in at 4 am with a headache which she claims is similar to her migraine attack. She was perfectly lucid and comfortable, and the only tiny red-flags I had were (1) I seldom see migraines at 4 am, and (2) there was very mild neck stiffness on examination. Being newly-employed in a private hospital where your license is much more on-the-line, I suggested a CT scan. She was reluctant but her husband persuaded her, and it turned out she had a SAH. She was admitted and underwent endovascular coiling immediately, and I hope she is doing well today.

So the lesson - the next tension-headache that walks in may not be a tension-headache. Keep your eyes open.

Case 3

35 year old male

'Doctor, am I having a stroke? Do I need a scan of my brain'?

What medications would you prescribe? How would you prognosticate his illness?


Answer : Bell's palsy (on the left side)

This is a rather common case we see in the ER, and patients are invariably frightened that they are having a CVA. Bell's palsy is an idiopathic lower-motor neurone (LMN) palsy affecting the facial nerve (7th cranial nerve).

The main clinical signs are illustrated here:

Let's review the difference between upper & lower motor neuron lesions of the 7th nerve:

• In general, due to the cross-innervation of nerve fibres, a LMN lesion results in paralysis or weakness of both upper and lower parts of the face, whereas an upper motor neuron (UMN) lesion usually spares the upper part of the face (i.e patient can wrinkle forehead on that side). Note however that this is not always absolute.

• Other signs to look for (more for exam purposes):

1. Inspect ear and do otoscope to look for vesicles (Ramsay-Hunt Syndrome)
2. Test taste function (chorda tympani involvement)
   
3. Check for hyperacusis (nerve to stapedius involvement)

Neuroimaging is usually not indicated in a straightforward case of Bell's palsy. Patient should be reassured that they are not having a stroke.

Treatment

• Prednisolone (1mg/kg BW, up to 60 mg/day) for 7-10 days - recent trials have shown significant improvement in outcome if started within 72 hrs of symptom onset
  
• Acyclovir - benefit is less certain compared to steroids.
• Eye protection - artificial tears and taping of eye at night if it cannot be voluntarily closed
• Refer to neurologist/ ENT for further follow-up.

Prognosis

• 85% complete recovery, 10% residual deficits, 5% severe sequelae
• Poor prognosticating factors include:

1. Older patients
   
2. History of recurrent facial nerve palsy
3. Complete facial paralysis during the acute phase
4. Longer time taken to recover
5. Presence of postaurticular pain, abnormal taste, tearing
6. Diabetic patients
7. Pregnant patients