Clinical Reasoning: Sudden-onset pulsatile headache in a previously healthy young man

Abstract

A previously healthy 41-year-old man presented to the local hospital with a sudden-onset right-sided pulsatile headache, accompanied by vertigo, unstable gait, nausea, and vomiting. On admission, he additionally presented with left central facial paralysis, left-sided hemiparesis, and NIH Stroke Scale score of 2. The patient denied history of hypertension, diabetes, or any other high-risk factors for cerebral vascular diseases (CVD). Diffusion-weighted imaging (DWI) revealed multiple acute focal infarctions in the right frontoparietal lobe consistent with decreased blood supply through the right carotid artery (figure e-1A1 at Neurology.org).