高血壓危症合併雷擊頭痛後陣發性不平衡感及視力模糊

Episodic Unsteadiness and Blurred Vision After Hypertensive Crisis with Thunderclap Headache

高血壓危症極少會僅以雷擊頭痛為表徵。一56歲男性，因雷擊頭痛發作而送醫，急診發現高血壓危症，理學檢查、腰椎穿刺腦脊髓液檢驗及電腦斷層均無異常發現。自此，每日均苦於數次陣發性不平衡感及視力模糊，遂於6個月後求診於作者。理學檢查無異常發現，姿態變換測試或從蹲踞姿勢突然站起測試可引發同樣的症狀。腦波圖、24小時心電圖、眼振電圖、兩耳溫差測試及所有血液學檢查均無異常發現。頸部血管超音波顯示頸部動脈之輕度粥狀動脈硬化，擴散加權顯影及擴散係數分布圖磁振造影顯示中腦上丘的病變，飛行時間效應血管造影顯示椎基底動脈分支缺少。本個案之高血壓危症僅以雷擊頭痛為表徵，實屬罕見，雖無法確認高血壓危症與雷擊頭痛間的因果關係，但無庸置疑兩者關係密切，在發作當下影響到兩側中腦上丘，遂於爾後姿態變化時陣發不平衡感及視力模糊。經保守治療2個月後，症狀消失。追蹤迄今半年，症狀尚未復發。

Hypertensive crisis (HC) seldom presents with simply a thunderclap headache (TCH). A 56-year-old male had been sent to our emergency department because of TCH. Physical examination, lumbar puncture cerebral-spinal fluid analysis, and computed tomography were normal; however, HC was identified. Henceforward, he presented frequent episodic unsteadiness and blurred vision every day for 6 months. Physical examination was normal, but positioning test and squat to standing test induced the same symptom. lectroencephalogram, 24 hours’Holter, electronystagmogram, caloric test and blood examination were unremarkable. Neck duplex scanning showed atherosclerosis of carotid arteries. Diffusion weighted image and apparent diffusion coefficient magnetic resonance image revealed lesion of midbrain superior colliculus. Time-of-flight magnetic resonance angiogram showed deficient branches of vertebrobasilar artery. His HC presented with simple TCH, a very rare curiosity. Although the causation between HC and TCH was yet uncertain, they were closely related. Bilateral midbrain superior colliculus were affected during the attack, and afterwards, unsteadiness and blurred vision were incurred by changing position. Thus, conservative treatment was recommended. Two months later, the symptom subsided. In the following half a year, there was no recurrence.