Gruber’s Follow-Up Notes 07/12/2013

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61 yo F with PMHx of DM presents with chief complaint of headache. Patient describes acute onset left sided 10/10 headache that extends to the neck. Pain is associated with episode of blurry vision, vertigo resolving in seconds as well as left sided numbness lasting 2-3 hours.

Physical exam:
BP: 108/71 HR: 88 RR: 16 100% on RA, afebrile
No findings on physical exam.
No focal neurologic deficits.

Pertinent labs:
Creatinine 1.9 and K 6.
EKG shows minimal ST elevations in inferior leads
Troponin: 43

Discussion Points:
What about this presentation is concerning?
• Neck pain broadens the differential to include dissection.
• Headache with transient neurological complaints makes this case concerning and TIA.

This patient had transient blurry vision. If possible, you should determine it is monocular or binocular.
• Unilateral eye complaints would point more to Amaurosis Fugax
• Bilateral complaints indicate a central occipital pathology

How should you work up a patient where SAH and Carotid Dissection is in the differential?
• If possible at your institution, test of choice would be CTA or MRA of the brain and neck.

Do you use contrast in this patient considering a Cr of 1.9?
• This patient should be scanned with IV contrast to determine if a dissection is present, as well as identify an aneurysm causing SAH. Patient should be hydrated before, during and after the scan (given adequate EF).
• MRA, if available, is optimal, as you do not have worry about contrast dye load.
• Carotid ultrasound can be used to look at carotid and vertebral arteries but wouldn’t tell you about aneurysm as source for SAH

Would you treat hyperkalemia and would you give calcium?
• Treatment of potassium is indicated, but EKG showed know findings of hyperkalemia (peaked T waves, loss of PR, widening of QRS) and therefore calcium is not indicated

How do you connect the ST elevations with the patient initial complaint (headache radiating down the neck) and how do you confirm diagnosis?
• Cardiac and neurologic complaints and/or findings should always make you think Aortic dissection. Aortic dissection of arch often involves inferior wall changes. CTA of aorta or Transesophageal echo (TEE) would evaluate the entire aorta. MRA as alternative

Do you give a patient with ST elevations and + troponins heparin if dissection still in differential?
• Most agree that there should be a hesitation with the administration of heparin when dissection is still in the differential. However, it has been noted anecdotally that patients with dissections whom receive anticoagulation generally do well.

How can you blow this case?
• Most errors in medicine are problems of omission rather than commission. In this case, critical action which led to correct diagnosis was getting EKG and seeing that it was abnormal. Error would have been to not get EKG.
• Headache with neck pain deserves further workup in the ED regardless of age.
• Patients with headache neurological complaint or findings requires further workup in the ED regardless of age

Thank you for your contributions: Drs. Gruber and Taubman

One Comment

  • siuf

    “Dissection” is written all over the place, not always with an adjective. The patient’s symptoms are most consistent with vertebral dissection, not carotid dissection. The symptoms are posterior. If a patient has carotid dissection, the weakness / numbness findings are on the other side. Patients with aortic dissections usually present with L carotid dissection and hence R sided findings (think mca syndrome). The findings are often waxing waning.

    This would be unusual for a SAH. If you blow an aneursym to the point that you’re affecting your brain stem functions, I’d say you look like toast.

    Brain things give you ekg changes and heart things give you brain changes. It’s a chicken v. egg dilemma at times. The cc of headache makes me think that the neurologic issue is the egg.

    Heparin is fine if you’re considering carotid dissection. You wouldn’t want to be the one who gave the heparin to a patient with aortic dissection.

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