Atypical Hypertensive Hemorrhage: Follow the Classic Symptom

In their case report, “Sudden Headache in a Woman With Hypertension” (CONSULTANT, July 2002, page 1049), Drs Gary Quick and Maggie Law describe a patient with uncharacteristically severe headache and very high blood pressure. Because she was neurologically intact, her presentation was “deceptively benign.” Although a head CT scan (Figure) revealed an intracranial cerebral hemorrhage, they note that many physicians would not have ordered the scan in this setting. In addition to the sudden onset of headache-in a patient with no history of similar headaches-and the persistently elevated blood pressure that was refractory to clonidine, would the authors also consider the patient’s paracervical tenderness and neck pain that increased with flexion to be warning signs of an intracranial or subarachnoid hemorrhage? These neurologic/musculoskeletal findings would have led me to consider ordering a lumbar puncture and/or brain imaging.

-- John Mosby, MD
Corpus Christi, Tex

We chose to present this case to readers because the patient’s neurologic examination was normal and her presentation thus appeared benign. She was sitting on the stretcher smiling and conversing without a hint of distress. Because of the paucity of historical and clinical abnormalities, many physicians would have changed her antihypertensive regimen and discharged her without ordering a CT scan or lumbar puncture. We obtained a head CT scan primarily because the patient had a headache of sudden onset and uncharacteristic severity. However, it is entirely appropriate to consider the patient’s paracervical tenderness and neck pain as warning signs of an intracranial or subarachnoid hemorrhage. Clinicians seldom fail to recognize the classic presentation of myocardial infarction, appendicitis, or intracranial hemorrhage. However, the patient whose history, course, or physical examination findings are atypical presents a diagnostic challenge. One take-home message from this case: stick to certain principles-such as the sudden onset of headache or the presence of neck signs or symptoms-to guide the diagnostic workup when other aspects of pathology are absent.

-- Gary Quick, MD
Muskogee Regional Medical Center Muskogee, Okla