Case 7

56 year old male, known hypertensive

Found collapsed at home by relatives.
On arrival, GCS 7. BP 170/90

What is the diagnosis?
How would you manage this patient?

Answer : Subarachnoid hemorrhage (SAH)

The CT scan shows presence of blood (the whitish stuff) within the subarachnoid space in the brain, sometimes referred to as the 'Mercedes sign' because it resembles the automaker's logo.

Causes

• Berry aneurysms (70%) - 30% of which in anterior communicating artery and 20% in posterior communicating artery
• Arteriovenous malformation (10%)
• No cause found (10-15%)

Typical presentation

• sudden onset of severe headache ('worst ever' headache)
• nausea and/ or vomiting
• neck pain
• photophobia
• loss of or altered consciousness

First test for patient with suspected SAH - plain CT head

• 93% sensitivity; but sensitivity diminishes with time
• if high suspicion of SAH but CT normal/ non-diagnostic, proceed with lumbar puncture (if no evidence of raised intra-cranial pressure), looking for xanthochromia and elevated RBC count (which does not diminish with successive collections)

A&E management

• Secure airway - in this patient whose GCS is only 7, endotracheal intubation following rapid sequence induction (RSI) to control airway and reduce risk of aspiration
• Supplemental oxygen, IV access and take blood for FBC/ UE/ Coagulation/ GXM
• Close monitoring of vital signs, keep systolic BP between 90-140 mmHg
  
• Contact neurosurgeon immediately with view to timely intervention (angiography/ coiling/ clipping etc)

I remember reading somewhere that an average doctor should expect to come across 3 cases of SAH in his/her career. Well, I have already seen two cases in my (relatively) short career - perhaps a doctor working in the ER will definitely see more of them.

I still remember the first case - a 30 year old lady with hx of migraine, who came in at 4 am with a headache which she claims is similar to her migraine attack. She was perfectly lucid and comfortable, and the only tiny red-flags I had were (1) I seldom see migraines at 4 am, and (2) there was very mild neck stiffness on examination. Being newly-employed in a private hospital where your license is much more on-the-line, I suggested a CT scan. She was reluctant but her husband persuaded her, and it turned out she had a SAH. She was admitted and underwent endovascular coiling immediately, and I hope she is doing well today.

So the lesson - the next tension-headache that walks in may not be a tension-headache. Keep your eyes open.