Bad headache, numbness call for immediate action

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WAYNE GLOWACKI / WINNIPEG FREE PRESS ARCHIVES Diagnostic equipment in Health Sciences Centre�s neuro-angiography suite.

How would you like to save a life this week? After all, it's not only doctors who are involved in life-or-death situations. So all you have to do is remember this column.

A report in the Canadian Medical Protective Association (CMPA) bulletin shows one of the best ways to diagnose a problem is to think about its possibility. One of the best ways to miss the diagnosis is to ignore it. This sounds like a simple rule, but doctors are not robots. They can and do miss important diagnoses that may result in either severe disability or death.

For instance, a 61-year-old man, a smoker with a history of high blood pressure, was punched on the left side of the head during an assault. There was no loss of consciousness and all the patient complained of was a mild left-side headache and tenderness of the scalp.

But 12 hours after the incident, he experienced the onset of severe left-side headache along with numbness of the right arm, right leg and vomiting. Thirty-six hours after the onset of the headache, he was finally admitted to a small community hospital.

Examination showed his heart rate and breathing were normal, as was a neurological examination. He was given medication to control the vomiting and discharged with the diagnosis of concussion.

The following day, he returned to the emergency department with the same symptoms. His neurological examination again proved normal. He was given intravenous medication for nausea and discharged again with the same diagnosis.

The next evening, due to the persistent headache, he returned to emergency and was seen by a neurologist. A CT scan showed a subarachnoid hemorrhage and he was transferred to the care of a neurosurgeon at a larger hospital. Angiography showed three small aneurysms that required surgery. Three days later, he became confused and a CT scan showed marked spasm of the brain's arteries. Ultimately, he was left with significant mental and motor problems.

Subarachnoid hemorrhage means bleeding between the brain and the thin tissues covering it. Sometimes this cerebral aneurysm will spontaneously rupture or is the result of trauma in young people in a car accident or in the elderly from a fall. It's more common in women, and high blood pressure can be a factor. In some cases, there is a family history of subarachnoid hemorrhage.

Usually, if there's been no trauma, the main symptom is a severe headache that starts suddenly and is often worse at the back of the head. Always be on the alert if a patient says, "It's the worst headache ever." This is exactly what I told the doctor when I awakened one morning in my final year at Harvard Medical School. In my case, the headache to end all headaches was due to poliomyelitis.

Diagnosis is made by CT scans, MRIs and angiography. But even if a CT scan is done, the diagnosis can still be missed if there has been only a small amount of bleeding. The sooner the diagnosis is made and the bleeding stopped, the greater the chance of recovery. Of course, none of these diagnostic tests will be done if doctors are not thinking about the possibility of subarachnoid hemorrhage, as happened in the case of the 61-year-old.

Don't forget that during a lifetime, many have been hit on the head and developed a headache without getting a subarachnoid hemorrhage. But you can help save a life if, following a blow to the head, there's also neck pain, vomiting, a seizure, numbness in any part of the body, mood changes, confusion, increased irritability and decreased consciousness.

And be on high alert if there's no history of injury and suddenly someone says, "I have a headache to end all headaches, unlike any other headache." That is the time to call 911. Today, a person doesn't always have to be a doctor to save a life.

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Republished from the Winnipeg Free Press print edition May 11, 2012 A21