Clinical Reasoning: A 52-year-old man with spells of altered consciousness and severe headaches

Abstract

A 52-year-old right-handed man with a history of petit mal seizures as a child was transferred to our hospital after a spell of sudden loss of consciousness. His illness began 1 month earlier with fatigue and bilateral hand tremor. Two weeks later, he experienced a severe headache of sudden onset without associated nausea, vomiting, or focal neurologic symptoms. This lasted for a few hours, abating after several doses of ibuprofen and acetaminophen. One week later, he suddenly became confused while driving. He continued to drive normally, but had a befuddled facial expression and did not respond to questions from his wife. He returned to normal within 10 minutes. Over the next 2 weeks, he had several similar spells. He also developed recurrent, sudden, severe headaches that occurred several times per day. The pain began in the shoulders, spreading to the occipital region and then the entire head over 1–2 minutes. It was severe enough to cause him to fall to his knees and cry out in pain. These episodes occurred more frequently when lying in bed than when he was standing or sitting, and were associated with nausea. He was admitted to another hospital for evaluation of these symptoms and transferred to our facility after a 1-hour spell of “unresponsiveness,” which resolved spontaneously, while there. Further questioning revealed additional symptoms. After the first episode of altered consciousness, his personality changed. His wife described him as “vacant” and “not as active and happy-go-lucky” as usual. He developed a slowly progressive, mild dysarthria; difficulty walking due to frequent “buckling” of the right knee; and numbness in the right medial forearm and little finger. He also described difficulty in using his hands to perform tasks such as putting toothpaste on a toothbrush, which he described as being like “putting two magnets together.” Finally, …