HISTORY: 47-year-old female presented to ED after syncope on the Stairmaster, with bilateral axial neck pain and nausea. Bystanders reported she was “foaming at the mouth” and voided urine. On evaluation, she denied headache, photo- or phonosensitivity, speech changes, paresthesia, or paresis. She endorsed first episode of neck pain during an endurance run and presented to an urgent care. She denied past medical, surgical and family history. She endorsed recreational synthetic marijuana and alcohol.
PHYSICAL EXAMINATION: Vitals WNL, in rigid cervical spine collar. Trauma: Secondary exam without findings. Cervical spine clinically cleared by Nexus criteria. Mild TTP diffusely to bilateral posterior neck. ROM limited in all planes C4-T1 nerve roots were 5/5 and painless; sensation to light touch was intact in 4 extremities. Pulses intact. Neuro: CN II-XII were grossly intact. No visual neglect. No upper or lower motor signs, no cerebellar signs noted.
DIFFERENTIAL DIAGNOSIS:1. Cerebrovascular accident 2. Dehydration 3. Cardiogenic arrhythmia 4. Orthostasis
TEST AND RESULTS:Tests & Results: CT head: diffuse subarachnoid hemorrhage bilaterally. CT angiography head/neck: Ruptured 0.4 x 0.7 cm bilobed aneurysm from anterior communicating artery. 0.2 cm right posterior communicating artery aneurysm. BMP: metabolic acidemiaCreatinine (0.48 mg/DL) Low Glucose 129 mg/dL High Troponin (0.059 ng/mL): High PTT and INR: WNLEKG: NSR @63. III TWI.
FINAL WORKING DIAGNOSIS: Subarachnoid hemorrhage
TREATMENT AND OUTCOMES: Patient underwent cerebral angiogram with coil embolization of Acomm aneurysm. She was discharged to Neurology and Neurosurgery follow up. 8 months post-procedure, she had prophylactic Pcomm clipping. 10 months post-procedure, she suffered first-time status epilepticus after exercise. CT head revealed frontal subdural hematoma. Post-SAH patients are at risk for epilepsy, heightened by theoretical risk during exercise. Return to play can be challenging, as physical activity may increase risk of recurrent SAH and seizure activity. Our patient is managed with valproic acid and severe activity restriction and is eager to return to cardiovascular activity. Exercise prescription must be tailored by a risk evaluation and risk mitigation.