Sentinel Headache

CLINICAL HISTORY A 35-year-old woman was seen with a chief complaint of the 2 worst headaches of her life. Six days previously, she awoke from sleep about 6 am with a non-stabbing pressure on the top of her head like her head was going to explode with an intensity of 10/10 with light and noise sensitivity but no nausea or other symptoms. She went to the emergency department that afternoon where a CT scan of the brain was negative. A lumbar puncture (LP) was not suggested. The headache resolved after about 18 hours. Three days previously, at about 10 am, she was having sex with her husband. At orgasm, she had an exactly similar headache with an intensity of 9/10 at the onset without associated symptoms. She took acetaminophen with codeine and the headache lasted about 8 hours. She had no further headaches. She told her sister, who is a physician, about the headaches, and who suggested a neurology consultation. There is a prior history of headaches for a few years about once a week described as a bifrontal non-throbbing pain with an intensity of 3/10 without associated symptoms relieved by acetaminophen in about one hour. Past medical history was negative. Family history of her mother with a hemorrhagic stroke at age 60. Neurological examination was normal. An MRI of the brain the day of the initial consultation was normal. An MRA of the brain was reported as showing asymmetric flow-related enhancement of the distal right middle cerebral artery, which appeared to be due to overlapping arterial branches. No definite aneurysm was identified but a CTA was suggested. The CTA revealed a 4 mm aneurysm at the middle cerebral artery trifurcation. An cerebral angiogram the next day confirmed a 4 mm saccular aneurysm arising from the right middle cerebral artery trifurcation and a 2 mm saccular aneurysm arising at the junction of the M1 and minor M2 segments of the left middle cerebral artery. Both aneurysms had wide necks and were not amenable to endovascular treatment. An LP the same day produced clear cerebrospinal fluid (CSF) with the following results: glucose 54 mg/dL, protein 26 mg/dL, WBC 2/cmm, RBC 31/cmm. Spectrophotometry for xanthochromia is not available at this large medical center teaching hospital. The neurosurgeon was not entirely certain which, if either, aneurysm, had bled. The next day, the patient underwent clipping of the right middle cerebral artery aneurysm. Intraoperative inspection of the aneurysm revealed dense fibrous scarring with some hemosiderin staining around it. Case history submitted by: Randolph W. Evans, MD, 1200 Binz #1370, Houston, TX 77004, USA.