Assistant Professor University of Arkansas for Medical Sciences Little Rock, Arkansas, United States
Case Diagnosis: Subarachnoid hemorrhage secondary to ruptured anterior communicating artery (ACOM) aneurysm and traumatic brain injury (TBI).
Case Description: 54 year old male with history of bipolar depression, schizophrenia, hepatitis C, and polysubstance abuse presented to emergency department (ED) with “the worst headache of [his] life” though was discharged home same day. He attempted to self-treat with methamphetamines and was arrested 3 days later for illicit drug use. Headache persisted in jail he repeatedly hit his head against a wall, resulting in altered mental status. He presented again to ED where imaging revealed bifrontal hemorrhagic contusions as well as subarachnoid and intraventricular hemorrhages (SAH/IVH) with subfalcine herniation and midline shift. Cerebral angiogram revealed ruptured ACOM aneurysm for which patient underwent orbital craniotomy and clip ligation. He was ultimately transferred to acute inpatient rehabilitation for comprehensive therapies.
Discussions: The clinical presentation of SAH is broad, ranging from simple headaches to focal neurological deficits. Initial workup includes head CT, though some studies show CT may be less sensitive with “minor leaks” or normal neurological status on exam. The consequences of missed diagnosis are high, resulting in poor clinical outcomes. In this case, the patient’s initial headache, likely attributed to SAH, may have been overlooked given psychiatric history and substance use. Multiple studies evaluated missed or delayed diagnosis of SAH with mortality rates of 6-17%, and severe morbidity and disability rates of 22-37%. Factors that contribute to poor clinical outcome include age > 65, worse JCS (Japan Coma Scale), re-rupture after initial misdiagnosis, and nonsurgical intervention.
Conclusions: This case highlights the importance of comprehensive patient history and broad differential diagnosis. While there may be multiple confounding factors, thorough evaluation can help guide work-up leading to earlier diagnosis and avoid poor outcomes. In this case, diagnosis was delayed and resulted in additional insult to this patient’s brain.