Shanice Williams: A 52-Year-Old Female With a Severe Headache and a Progressive Alteration of Consciousness

Learning Objectives

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Learn the common causes of intracranial hemorrhage.
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Develop an understanding of the clinical presentation of subarachnoid intracranial hemorrhage.
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Develop an understanding of how the physical findings can help the clinician determine the anatomic location of intracranial hemorrhage.
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Understand the difference between primary and secondary headaches.
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Develop an understanding of the role of computed tomography (CT) and CT angiography in the evaluation and treatment of subarachnoid intracranial hemorrhage.
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Develop an understanding of the treatment options for subarachnoid intracranial hemorrhage.
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Develop an understanding of the concept of “first or worst.”
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Develop an understanding of the differential diagnosis of headache.
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Understand the risk factors for subarachnoid intracranial hemorrhage.
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Learn how to identify factors that cause concern.

Shanice Williams

Shanice Williams is a 52-year-old bookkeeper with the chief complaint of., “My head…my head…my head.” Shanice was accompanied to the Emergency department (ED) by her husband, Bill, who provided the majority of the history, as Shanice was very somnolent. Her husband stated that Shanice was in their laundry room when he heard her cry out. He rushed to the laundry room, where he found Shanice sitting on the floor, leaning against the dryer, holding her head, and crying out in pain. He asked her what was wrong, and all she could say is what he thought was “my head…my head…my head.” Bill grabbed Shanice’s cell phone, which had fallen to the floor, and called 911. “Doctor, the ambulance arrived in about 3 minutes along with about 19 firefighters. The EMT said her blood pressure was off the charts, and he thought she was having a stroke. They loaded her into the ambulance, and I followed them to the hospital. At first, they told me to stay in the waiting room, but a couple of minutes later a nurse came out and asked me to come back so I could tell them what happened.”

I was covering neurology and arrived at the bedside at about the same time as Bill, who quickly related what had happened. I explained to Bill that the ED physician believed that Shanice was suffering a stroke, so we needed to quickly determine what kind of stroke it was to best determine treatment options. I asked Bill when was the last time Shanice seemed normal, and he said, “Right when she walked into the laundry room, about 45 minutes ago, I think.” Bill continued, “Doctor, do whatever you need to do to help Shanice! Should I call the kids?” I told him that while we were examining Shanice and getting a CT, he could go back out to the waiting area and I would come get him as soon as I had some answers. He could certainly call their kids and tell them for now that Shanice was safe and that we were getting the answers we needed to best treat her. “Bill, just a few quick yes-or-no questions: Is Shanice diabetic? Is she on blood thinners? Has she had a previous stroke? Does she have high blood pressure? Does she have atrial fibrillation or other types of abnormal heart beats? Any use of illicit drugs, cocaine, meth? Allergic to seafood or iodine?” Bill shook his head and answered no to all of these questions.

Shanice’s vitals on admission to the ER were as follows: Her respirations were 20, her pulse oximetry was 98 on 2 L oxygen via nasal cannula, her pulse was 88 and regular, her blood pressure was 180/100, and she was afebrile. Her fingerstick blood sugar determination was 100. I performed a quick physical examination using the National Institute of Health Stroke Scale (NIHSS) to establish a neurologic baseline before we took Shanice to CT. Her level of consciousness revealed that she was somnolent but arousable with minor stimulation. Shanice was able to tell me how old she was, but she could not correctly identify what month it was. She was able to correctly respond to the commands “open and close your eyes” and “grip and release your hand.” Shanice was able to follow my finger with her eyes on command. The visual threat maneuver suggested that Shanice had no visual loss. Mild facial asymmetry was noted on the left when Shanice was asked to “show me your teeth,” “raise your eyebrows,” and “close your eyes.” She was able to maintain position of her arms bilaterally when the arms were extended with the palms down. There was also no lower extremity drift identified when each leg was extended 30 degrees. With encouragement, Shanice was able to “touch your finger to your nose” and “touch your heel to your shin.” No sensory deficit was identified. I showed Shanice the NIHSS “Kitchen Disasters” picture and asked her what she saw ( Fig. 10.1 ). Severe aphasia was identified, but when asked to point at was wrong in the picture, she correctly identified the overflowing sink and the child falling off the stool. She was unable to name any of the items on the NIHSS “Name That Item” card but was able to correctly point to the items when I named them ( Fig. 10.2 ). She was unable to read any of the sentences or say any of the words on the NIHSS sentence or word list. There was no evidence of visual or spatial inattention, and her fundoscopic examination was within normal limits. Her lungs were clear, her abdomen was soft without mass or organomegaly, and there was no obvious murmur or carotid bruit. At this point, the door-to-needle time was 22 minutes; we needed to get a move on to get her to CT.

It took less than 10 minutes to get a CT and I had my answer.

Key Clinical Points—What’s Important and What’s Not

The History

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A history of sudden onset of severe “first or worst” headache with an alteration in consciousness
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Patient is afebrile
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No history of anticoagulants
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No history of previous stroke
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No history of cardiac arrythmia
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No history of diabetes
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No history of illicit drug use
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No allergy to seafood or iodine
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An inability to speak clearly

The Physical Examination

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Patient is afebrile
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Patient is hypertensive
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Patient is somnolent but rousable with mild stimulation
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Patient is aphasic
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Patient has mild facial asymmetry
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Patient has no gross motor or sensory deficit
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Fundoscopic examination is normal

Other Findings Of Note

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Normal cardiac examination
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Normal pulmonary examination
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Normal abdominal examination
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No carotid bruit
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Fingerstick blood glucose was 100
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Pulse oximetry on 2 L oxygen via nasal cannula was 98

What Tests Would You Like to Order?

The following tests were ordered:

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CT scan of the brain with CT angiography
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Repeat blood glucose
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Troponin
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International normalized ratio (INR)
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Activated partial thromboplastin time (aPTT)
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Electrocardiogram (ECG)

Test Results

CT scan of the brain revealed a significant subarachnoid hemorrhage (SAH) ( Fig. 10.3 ). CT angiography revealed a ruptured aneurysm of the right middle cerebral artery ( Fig. 10.4 ). Repeat blood sugar was 97. Troponin, INR, and aPPT were all normal. Normal ECG.