A 44-year-old Chinese man presented with severe headache, nausea, and vomiting that began acutely while he was receiving acupuncture for the treatment of neck pain. He experienced the sudden onset of severe occipital headache minutes after the insertion of an acupuncture needle at the “feng fu” trigger point, which is located 3 cm below the external occipital protuberance. The needle was removed after the onset of severe headache. There were no other neurological symptoms such as seizures or loss of consciousness when the patient presented to our emergency department 7 hours later. He had a 5-month history of neck pain that was diagnosed as cervical spondylosis. Previous cervical x-ray films revealed the loss of cervical lordosis with bone spur formation on the vertebral bodies of C4 to C6. He had no history of hypertension, hereditary bleeding disorders, blood dyscrasia, vasculitis, or neoplasm. On physical examination, he was alert and oriented but in excruciating pain. His vital signs were stable. He had nuchal rigidity and a positive Kernig sign. Both pupils were equal and reactive to light. There were no cranial nerve deficits. Sensory and motor functions of the extremities were intact.
Immediate noncontrast computed tomography (CT) scan of the head showed hemorrhage in the fourth ventricle and small amounts of blood in the third and frontal horns of the lateral ventricles. A lumbar puncture revealed bloody fluid in all three tubes. Analysis of the cerebrospinal fluid showed red blood cells, 3.4 × 10 5/μL; and white blood cells, 1000/μL, with 50% neutrophils and 48% lymphocytes. The patient was admitted for observation and administered nimodipine intravenously. Over the next 28 days, the patient's only symptoms were persistent severe occipital headache and posterior cervical pain requiring opioids initially and acetaminophen subsequently to control the pain. A repeat CT scan of the head performed 10 days later showed complete resolution of the hemorrhage, and a repeat lumbar puncture showed red blood cells 2/μL. Magnetic resonance angiography (MRA) with gadolinium (using a General Electric 0.5 Tesla magnetic resonance imaging [MRI] scanner) performed 20 days after admission did not reveal any saccular aneurysms or arteriovenous malformations. Magnetic resonance imaging of the brain was also normal. In a follow-up visit 5 months after the incident, the patient was back at work and had complete resolution of his headache and nuchal rigidity.