History and Physical
A 21-year-old male with a history of sickle cell anemia (HbSS) and acute chest syndrome presented to the ER with a severe headache. He had been discharged from the pediatric unit for lower extremity pain a few weeks prior.
He required prior exchange transfusions and intubation, with other complications including salmonella osteomyelitis, cholestasis, and nephropathy. He had been on hydroxyurea therapy since he was 13 years old.
The night prior to this admission, he developed a new 10/10 headache. It was located on the forehead and radiated to the entire head. He denied a visual aura. The pain was sharp and aching. There was a history of persistent photophobia and phonophobia but no nausea or vomiting. The headache improved with lying down, dim light, and sleeping. It did not respond to acetaminophen or oxycodone, but responded partially to Toradol, metoclopramide, and Dilaudid and ultimately required a hydromorphone pump. He had no history of fever, trauma, or toxic exposures. A stroke code was called; NIH Stroke Scale (NIHSS) was 0. A noncontrast head CT and computed tomography angiography (CTA) were normal. Brain MRI without contrast was unremarkable.
His review of systems revealed fatigue, chest and right-sided neck pain, myalgia, and weakness.
He denied the use of recreational drugs, including cocaine. His past medical history was also significant for heart valve vegetation, gallstones, and proteinuria. He denied allergy to medications. Vaccinations were up to date.
There was no family history of migraine headaches, aneurysms, or brain tumors.
On physical examination, his weight was 46 kg, height 165 cm, blood pressure 127/74, pulse 75, and temperature 36.2°C. Pain was 6/10. He was lying with his eyes closed and looked ill and thin. His forehead and the right side of the neck were tender, but he had no neck stiffness or lymphadenopathy.
Neurological examination revealed normal mental status for age. Cranial nerves, including fundoscopy exam, were normal. The motor, reflexes, sensory, cerebellar examinations were normal; gait exam was limited due to pain.
DIAGNOSTIC WORKUP
On admission, CTA of the head and neck demonstrated no significant hemodynamic stenosis or large vessel occlusion. Brain MRI showed a right frontal subdural collection ( Fig. 78.1 ). Follow-up MRI demonstrated multifocal bone infarcts ( Fig. 78.2 ) and subperiosteal hemorrhages ( Fig. 78.3 ).
Subdural hematoma. Brain MRI, axial T1, shows right frontal hyperintense crescentic collection ( arrow ).
Bone infarcts. Brain MRI, axial T2 with fat suppression, demonstrates multifocal marrow edema ( arrows ) with associated subperiosteal hemorrhages, subdural effusions, and scalp edema.
