Title : Missed warning signs – ruptured cerebral aneurysm in a young, healthy woman
Abstract:
Background:
Cerebral aneurysms are potentially life-threatening conditions that may present with nonspecific symptoms, often delaying diagnosis. This case underscores the critical importance of meticulous history-taking and physical examination, particularly in patients with atypical headache presentations.
Case Presentation:
A 40-year-old woman with no significant medical history presented with a two-week history of persistent headache following a resolved viral illness. The headache was constant, moderate in intensity, located in the temples and behind the eyes, and unresponsive to over-the-counter medications. Associated symptoms included nausea, photosensitivity, phonophobia, and dizziness. She denied neurological symptoms and was hemodynamically stable with a normal limited neurological exam. Diagnosed with status migrainosus, she was prescribed prednisone and referred to neurology. However, the following day, she was found unresponsive and subsequently diagnosed with a ruptured cerebral aneurysm. Imaging revealed extensive subarachnoid and subdural hemorrhage, and she died three days later.
Discussion s Conclusion:
This case raises an essential question: In seemingly benign headache presentations, what historical or physical findings warrant immediate imaging or emergency evaluation?
Below is the documented history and physical exam:
History of Present Illness (HPI): "The patient is a 40-year-old female presenting with a two-week history of headache following a resolved viral illness. Accompanied by dizziness. She has tried over-the-counter medications, including Mucinex, sinus medications, ibuprofen, Tylenol, and Excedrin, with temporary or no relief. Pain is located in the temples and behind the eyes. She reports sensitivity to sound and light but denies slurred speech, confusion, weakness, or blurred vision. Sleep has been unaffected, but she notes inadequate hydration over the past two days."
Physical Examination:
- Vital Signs: BP 120/76 | Height: 1.651 m (5'5") | Weight: 80 kg (176.6 lbs) | BMI: 29.35 kg/m²
- General Appearance: Normal.
- Head, Eyes, Nose, Throat (HENT): Normocephalic. Extraocular movements intact. Conjunctivae normal. Pupils equal, round, and reactive to light.
- Neurological: Alert and oriented. No focal deficits.
- Psychiatric: Normal mood, behavior, thought content, and judgment.
Although the patient’s presentation lacked classic red flags for cerebral aneurysm or subarachnoid hemorrhage, critical elements of the history and physical exam were incomplete. Missing historical components include:
- Pain quality, severity, and radiation.
- Exacerbating and alleviating factors.
- Timing and progression of symptoms.
- Personal and family history of migraines or vascular conditions.
- Social history.
Similarly, the physical examination was limited. Key omitted components include:
- Cranial nerve assessment.
- Motor strength and sensory testing.
- Deep tendon reflexes.
- Fundoscopy.
- Gait evaluation.
- Assessment for cervical rigidity.
A diagnosis of status migrainosus requires a prior history of migraines, which this patient did not have. The absence of this history should have prompted further diagnostic evaluation to identify an alternative etiology.
This case highlights the critical role of comprehensive history-taking and physical examination in the assessment of atypical headache presentations. Identifying subtle but significant clinical clues can guide appropriate diagnostic imaging and timely intervention, potentially preventing catastrophic outcomes.
The purpose of this case report is to emphasize the components of a thorough headache evaluation in outpatient clinical settings.
