Skull Bone/Calvarial Infarction and Spontaneous Epidural Hematoma as Cause of Severe Headache in the Emergency Department
An 18-year-old male adolescent presented with severe headache for 2 days. The pain was localized to the back of the head, radiated to the back of the neck, and was associated with photophobia. He denied fever, photophobia, nausea, vomiting, weakness/numbness/tingling of the extremities, aphasia/speech changes, or gait changes. The pain was not relieved by ibuprofen (Motrin) or paracetamol (Tylenol). The patient also admitted to ingesting several alcoholic drinks and smoking both tobacco and marijuana at a party 2 days prior to the onset of headache. Prior medical history included homozygous sickle cell disease (SCD) with clinically silent remote cerebral parenchymal infarctions identified on prior magnetic resonance imaging (MRI) (not shown). Physical examination upon arrival was significant for pulse oximetry of 93% and respiratory rate of 34 breaths/min. Initial laboratory analysis showed white blood cell count of 23.6 × 103/μL and hemoglobin of 9 g/dL. Head computed tomography (CT) was requested to further evaluate the cause of headache.