Endgames Case report

Sudden onset of headache and recent breathlessness

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1844 (Published 13 November 2008) Cite this as: BMJ 2008;337:a1844
  1. Radhakrishnan Ramaraj, resident physician
  1. 1Department of Internal Medicine, University of Arizona College of Medicine, Tucson, AZ 85724, USA
  1. drkutty2{at}gmail.com

    A 70 year old man presented with a 30 minute history of throbbing left sided headache that woke him from sleep. He had no history of headache or recent head injury. He also described a four day history of breathlessness when climbing one flight of stairs.

    He was taking tablets for type 2 diabetes mellitus, hypertension, and congestive cardiac failure. He did not smoke and drank seven units of alcohol a week.

    The patient was alert and oriented, with a heart rate of 100 beats/minute and a blood pressure of 150/90 mm Hg. Respiratory rate was 16 breaths per minute, oxygen saturation was 98% on air, and his lungs were clear to auscultation. An early diastolic murmur was heard at the base of the heart. He had no temporal artery tenderness or neck stiffness.

    Haemoglobin was 13.2 g/l; white blood cell count was 7×109 cells/l; urea and electrolytes, liver function, and renal function were normal; and the erythrocyte sedimentation rate was 30 mm/hour (normal <20 mm/hour in men over 50). Electrocardiography showed sinus tachycardia. The results of chest radiography and computed tomography of the brain were normal.

    He reported increasing headache with radiation down the cervical spine. At this time, blood pressure was 173/88 mm Hg in the right arm and 140/62 mm Hg in the left arm.


    • 1. What is the likely diagnosis?

    • 2. What are the causes?

    • 3. What investigations would you perform urgently and why?

    • 4. How would you manage this condition?

    • 5. What clinical and anatomical factors predict prognosis?


    Short answers

    • 1. Aortic dissection—dissection of the arch of the aorta and the carotids. This led to the unusual presentation with headache.

    • 2. Predisposing factors are hypertension (72% of cases), atherosclerosis (31%), and previous cardiac surgery (18%). Marfan’s syndrome, bicuspid aortic valve, or previous aortic surgery are more …

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