Am Fam Physician. 2009 Mar 1;79(5):374-376.
to the editor: A 45-year-old woman with a history of migraines and a recent diagnosis of hypertension presented with a two-day history of increasing headache. She had taken over-the-counter medications with some relief. On the second day, the patient awoke with terrible pain located in the occiput and radiating to the forehead, associated with photophobia, nausea, and vomiting. The headache was unlike any she had ever experienced. Physical examination revealed a dehydrated, distressed woman with a blood pressure of 180/120 mm Hg, pulse of 110 beats per minute, and body temperature of 97°F (36.1°C). There were no neurologic deficits. A computed tomography (CT) scan of the head showed a subarachnoid hemorrhage (see accompanying figure).
The patient was admitted and underwent cerebral angiography two days later, which demonstrated multiple aneurysms. She remained unconscious after brain surgery and required mechanical ventilation. Her condition continued to deteriorate. After a nuclear brain scan demonstrated absence of blood flow to the brain, the patient was pronounced brain dead.
Patients presenting with subarachnoid hemorrhage have a high likelihood of being misdiagnosed initially. In a hospital-based series of 482 patients admitted with sub-arachnoid hemorrhage, initial misdiagnosis occurred in 12 percent of patients.1 Failure to obtain a head CT scan at initial contact was the most common error, occurring in 73 percent of misdiagnosed patients. Among patients with subarachnoid hemorrhage who had normal mental status at first contact (45 percent), the misdiagnosis rate rose to 20 percent; this was associated with a nearly fourfold increase in mortality at 12 months as well as increased morbidity among survivors.2
Sudden “thunderclap” (also known as sentinel) headache, regardless of severity or headache history, should raise the clinical suspicion for subarachnoid hemorrhage. Noncontrast head CT, with or without lumbar puncture, usually establishes the diagnosis of subarachnoid hemorrhage.2 Cerebral angiography should be considered if diagnostic doubt remains.3
Subarachnoid hemorrhage may be caused by trauma or occur spontaneously. It is a medical emergency that can lead to death or severe disability even if recognized and treated at an early stage.4 Treatment includes careful observation for signs of intracranial mass effect, medication, and early neurosurgical intervention. Ten to 15 percent of persons with subarachnoid hemorrhage die before arriving at the hospital,5 and only one half survive to hospital discharge. It is important that family physicians recognize subarachnoid hemorrhage in a timely fashion, because early identification of sentinel headache is key to reducing mortality and morbidity rates.
Author disclosure: Nothing to disclose.
REFERENCESshow all references
1. Van Gijn J, van Dongen KJ, Vermeulen M, Hijdra A. Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology. 1985;35(4):493–497....
2. Wintermark M, Uske A, Chalaron M, et al. Multislice computerized tomography angiography in the evaluation of intracranial aneurysms: a comparison with intra-arterial digital subtraction angiography. J Neurosurg. 2003;98(4):828–836.
3. Wardlaw JM, White PM. The detection and management of unruptured intracranial aneurysms. Brain. 2000;123(Pt 2):205–221.
4. Van der Jagt M, Hasan D, Bijvoet HW, et al. Validity of prediction of the site of ruptured intracranial aneurysms with CT. Neurology. 1999;52(1):34–39.
5. Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1994;25(11):2315–2328.
Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: firstname.lastname@example.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.
Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.
Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.
Copyright © 2009 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions