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A 46-year-old right-handed man presented to the emergency department with a 1-week history of headache. The headache was bilateral, predominantly posterior, worsened transiently on Valsalva manoeuvre and was refractory to simple analgesia. It did not vary with posture or time of day. He felt nauseated but had not vomited. There were no visual symptoms and specifically no blurring, obscuration or diplopia.
A few hours before presenting, there had been an unwitnessed collapse without prodrome, and he sustained a soft tissue injury to his neck. His partner had found him confused and drowsy and so called an ambulance.
He had previous episodic migraine, depression and gastro-oesophageal reflux. Borderline hypertension (143/90 mmHg) had been found at a neurology consultation for headache 18 months before; an MR scan of the brain at this time was normal.
He smoked 20 cigarettes per day and drank alcohol excessively (100 units per week). He did not use recreational substances.
On examination, his blood pressure was significantly elevated, averaging 210–245 mmHg systolic. He had a mild encephalopathy with a Glasgow Coma Scale score of 14/15 but no meningism. There was a left-sided partial ptosis (without anisocoria) and extensive bruising to the left side of the neck, sustained during the collapse. His pupils appeared and responded normally. Fundal examination (and later fundal photographs) was normal. Pursuit and saccadic eye movements were normal but there was upbeat nystagmus on upgaze. Muscle tone, strength and deep tendon reflexes were normal in all four limbs. The left plantar response was extensor and the right equivocal.
His blood tests were normal except for elevated serum creatine 209 µmol/L (45–84).
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Contributors HT devised the concept, performed the literature search and wrote the manuscript. SD and CA reviewed the manuscript prior to submission. CG was the responsible clinician for the patient and reviewed and revised the manuscript prior to submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned: externally reviewed by Sean O’Riordan, Dublin, Ireland.