Opinions expressed in the Correspondence section are those of the authors, and not necessarily of the editors, ACEP, or UAEM

CORRESPONDENCE Weight Lifter's Cephalgia Treatment Questioned

To the Editor: As an experienced emergency physician and a practicing

neuroradiologist, I must take serious exception to Dr. Powell's statement ("Weight Lifter's Cephalgia," 11:449-451, August 1982) that, "Because of the completely normal ex- amination, CAT scan and lumbar puncture were not needed" (page 450).

His patient was a supposedly healthy 30-year-old man who had had two episodes of severe headache of acute onset during exercise (with essentially no history of previous in- tense headache) and a family history of "cerebral vascular accident" and brain tumor.

Any experienced neurologist or neuroradiologist can re- late numerous stories of people who had supposedly "nor- mal" physical examinations and yet who had serious, life- threatening neurological disorders. It is my opinion that, even if this patient had an immediate "negative" physical examination by a qualified neurologist, he should still undergo emergency CAT scan and lumbar puncture to rule out a recurrent subarachnoid hemorrhage (among other things). Such a condition must be diagnosed at the time of

presentation, for it may be life-threatening and the physical, laboratory, and radiographic findings are often transient and may not be present at the time of a "follow up" neurologi- cal evaluation.

Dr. Powell further states that, "Rarely is a medical cause of headache found." This is true in the case of long-standing recurrent cephalgia of any nature, but this should not be construed as reason to delay a needed work-up in a young, previously healthy patient with a history of recent onset of severe "excruciating" headache.

While, as a radiologist, I frequently find myself explaining to emergency physicians why certain CAT scans are not necessarily "emergency," I do not feel that any conscien- tious radiologist would recommend delaying examination of a patient with this history.

Richard Fremaux, MD Bay Radiology Associates, PA Panama City, Florida

To the Editor: I agree that numerous neurological problems can present

without many objective signs. I was most concerned about a subarachnoid hemorrhage given the presentation. During the history and physical examination I looked specifically for any localizing signs and symptoms, but I found none. The patient's headache was rapidly waning, and it was com- pletely gone before he was discharged. No nuchal rigidity was found. Indeed, toward the end of the encounter the pa- tient himself stated that he felt fine.

Nonetheless, I remained concerned, and I consulted with the neurologist on call. We were eventually dissuaded from further work-up because of the episodic and rapidly improv- ing nature of the complaint, a complaint that was positively identified with a unique stimulus. In the end it essentially became a clinical jud~nent on my part. We opted to forego CAT scan and lumbar puncture.

The decision was based on the clearcut stimulus, episodic nature of the problem, negative past history and rapid dis- appearance of all symptoms, coupled with a completely nor-

mal neurological examination. The patient was discharged after having received detailed instructions concerning avoidance of the stimulus, possible sequelae, and the need for attentive follow-up. He complied. As can happen with this form of benign exertional headache, the malady vanished with training, and the patient no longer has the problem.

If, on the other hand, the presentation had been different, suggesting the existence of a serious problem, I would have immediately alerted the CAT scan team, gotten the scan, and then done a lumbar puncture. In my mind, each patient must be evaluated individually, diagnostic tests run, treat- ment given, and appropriate disposition made as warranted.

Blake Powell, MD Emergency Department York Hospital York, Pennsylvania

Brachial Plexus Injury from Percutaneous of the Internal ,Jugular Vein

To the Editor: Percutaneous catheterization of the internal jugular vein

(IJV) has been shown to be a rapid, effective, and relatively safe way to introduce a central venous pressure line or Swan Ganz catheter into the central circulation to monitor cardiac function) It also serves as a route for temporary pacemakers, intravenous drugs and fluids during cardiac arrest , 2 and suppl ies a rou te for pa ren te ra l hyper- alimentation. 1 Many prefer this route to subclavian vein cannulat ion because of a lower incidence of serious complications. 3 IJV complications reported to date include

Cannulation

inadvertent puncture of carotid artery with hematoma (most common), air embolism, sepsis, thrombosis, medias- tinal extravasation of IV fluids, tracheal laceration, pleural puncture with pneumothorax and hydrothorax, and local tenderness at the insertion site. 1 The only neurologic com- plication reported to date is Parikh's case of permanent Hor- net's syndrome following IJV percutaneous cannulation. 4 Brachial plexus injury has been reported in subclavian vein

is6 catheterization. ' ' We describe a minor, but to our knowledge previously un-

112/58 Annals of Emergency Medicine 12:1 January 1983