A Thunderclap Headache Unmasking Hypertensive Caudate Haemorrhage: Successful Conservative Management of a Deep Intracerebral Bleed - An In-Depth Case Study

Abstract

A 46-year-old man reported a two-day history of sudden-onset severe headache while at work, followed by persistent headache and repeated vomiting. They had no history of seizures, loss of consciousness, focal neurological deficits, or speech impairment. On admission, they were conscious, oriented, and hemodynamically stable except for elevated blood pressure (140/100 mmHg). Neurological examination was unremarkable with a Glasgow Coma Scale score of 15/15 and preserved motor power in all limbs. Magnetic resonance imaging revealed an acute left gangliocapsular and caudate haemorrhage (2.1 × 1.4 × 2.5 cm) with intraventricular extension, mild mass effect, and multiple cerebral microbleeds suggestive of hypertensive small-vessel disease. Magnetic resonance angiography and subsequent digital subtraction angiography demonstrated no aneurysm, arteriovenous malformation, or other vascular abnormalities. The patient was hospitalized in the neurological ICU and managed conservatively with intravenous antihypertensive therapy, hypertonic saline, close neurological monitoring, serial neuroimaging, and supportive care. During hospitalization, blood pressure was gradually optimized, repeat computed tomography showed significant resolution of the hematoma, and no neurological deterioration occurred. The patient was released in a stable clinical condition without focal neurological deficits on optimised antihypertensive therapy, vitamin B12 and vitamin D supplementation, and lifestyle modification advice. At one-week outpatient follow-up, the patient remained neurologically intact, normotensive on medication, independent in daily activities, and reported complete resolution of headache without recurrence or new neurological symptoms.