This video is intended to serve as an overview of the approach to diagnosing a patient with thunderclap headache (fastest "worst headache" of life). Learners will define the thunderclap headache, review three major categories of dangerous pathologies (five cerebrovascular pathologies, three disorders causing intracranial pressure dysregulation, and one type of cerebral infection) and review the structure and function of the neurovascular unit and the associated disorders. We will also discuss CT-based early diagnostic workup (non-contrast head CT and CTA with contrast) for a patient with thunderclap headache, and briefly review the management and outcomes of one particular cause of thunderclap headache - reversible cerebral vasoconstruction syndrome. The video is summarized with a protocolized approach.

00:00 - INTRO
00:58 - OBJECTIVES
01:49 - CASE
03:27 - DEFINITION of Thunderclap Headache
06:17 - Pathological DIFFERENTIAL DIAGNOSIS
08:46 - Cerebrovascular Pathologies
10:25 - Aneurysmal Subarachnoid Hemorrhage
15:15 - Reversible Cerebral Vasoconstriction Syndrome
17:27 - Spontaneous Cervical Dissections
20:29 - Neurovascular Unit and Disorders of Vascular Tone
22:18 - Autoregulation Curve
23:28 - Posterior Reversible Encephalopathy Syndrome
25:47 - Cerebral Venous Thrombosis
28:46 - Intracranial Pressure Abnormalities
33:44 - Cerebral infections
38:30 - DIAGNOSTIC WORK-UP
38:35 - Non-contrast Head CT
44:08 - CT Angiogram with contrast
50:50 - BACK TO THE CASE...
53:51 - RCVS2 score
54:39 - MANAGEMENT AND OUTCOMES of RCVS
57:39 - SUMMARY/ALGORITHM

Created, produced and narrated by:
Abigail Knowles
MD Candidate, Class of 2024
Rutgers Robert Wood Johnson Medical School

with
Igor Rybinnik MD
Associate Professor
Neurology Clerkship Director
Division of Stroke and Critical Care
Rutgers Robert Wood Johnson Medical School

Content experts:
Ram Gowda MD, Igor Rybinnik MD
Division of Stroke and Neurocritical Care
Department of Neurology
Rutgers Robert Wood Johnson Medical School

Images adapted from:
- Hendricks BK, Hartman J, Cohen-Gadol AA. Operative Neurosurg 2018;15(6):613-23
- Brisman JL, Song JK, Newell DW. NEJM 2006;355:928-39
- Adapted from Schievink WI. NEJM 2001;344(12):898
- Kandel ER, et al. Principles of Neural Science 5th Edition. McGraw Hill, 2012
- Coelho-Santos V, Shih AY. WIREs Dev Biol 2020;9:e363.
- Kaplan L, Chow BW, Gu C. Nature 2020, 21, 416-431
- Gorelick PB, et al. Stroke 2017;48:e00
- Gregg L, 2020
- Houk JL, et al. JNS 2021,136(6):1796-1803
- Farb RI, et al. AJNR 2019;40:745–53
- Case courtesy of Albakheet SS, Radiopaedia.org, rID 52865
- Case courtesy of Di Muzio B, Radiopaedia.org, rID 55441
- Case courtesy of Gaillard F, Radiopaedia.org, rID 169151

References:
- Goldstein JN, et al. Cephalalgia 2006;26(6):684-690
- Cephalalgia 2018 Jan;38(1):1-211
- Devenney E, et al. J Headache Pain 2014;15:49
- Roberts T, et al. Emerg Med J 2022;39:803–809
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- Bejot Y, et al. Stroke 2014;45:37-41
- Rose JC, Mayer SA. Neurocrit Care 2004;1:287-99
- Lidington D, et al. Front Neurol 2021;12:1-29
- Anderson RG, et al. Frontiers of Neurology 2020;11(463):1-10
- Duman T, et al. JSCVD 2017;26(8):1848–57
- Beaumont TL, et al. J Neurosurg 2016;125:1420-1430
- O’Neill AH, et al. J of Clinical Neuroscience 2018;53:122–126
- Donegan D, Erickson D. J of the Endocrine Society 2022;6:1–10
- Schievink WI. NEJM 2021;385:2173-8
- Dobrocky T, et al. Lancet Neurol 2022;21:369–80
- Dobrocky T, et al. JAMA Neurol 2019;76(5):580-587
- Cheema S, et al. J Neurol Neurosurg Psych 2023;94:835–843
- Roberts T, et al. Emerg Med J 2022;39:803–9
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- Perry JJ, et al. JAMA 2013;310:1248–55
- Rocha EA, et al. Neurology 2019;92(7):e639-47
- John S, et al. Cephalalgia 2016;36(4):387

Music, Sounds:
- "Feels" by Patrick Patrikios

DISCLAIMER: Please note that this material was simplified for educational purposes. For patient management, please review your clinical society's guidelines and engage expert consultation where appropriate. Also, the opinions of the presenters do not necessarily reflect those of Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, RWJBarnabus Health, or Rutgers University as a whole.