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Case Study: Delayed Diagnosis of Cerebral Aneurysm/Subarachnoid Hemorrhage

A completely healthy 29-year-old woman was admitted to the emergency room at 6:05pm suffering from sudden thunderclap headache and a confused mental status. These symptoms can signal some very dangerous conditions, but can also be signs of nothing more than a migrane. These symptoms could signal subarachnoid hemorrhage, meningitis, migraine, or cerebral venous sinus thrombosis stroke.

Because of the potentially devasating consequences of some of these conditions, time is of the essence in diagnosing the true cause though there is no identified window within which treatment must be given. The young woman's neurological exam was abnormal but without focal deficits, which are specific signs doctors look for to assist their diagnosis. Focal signs indicate that the symptoms' cause is more likely to be a tumor or dead tissue instead of meningitis.

Though she displayed no focal deficits, she had high blood pressure ranging from 150/105 to 182/111. Though the ER physician examined her at 6:41pm and ordered a head CT scan. However, the test was not performed until almost 10pm despite that she suffered dramatic neurological deterioration at about 9pm.

When the CT scan was finally done, it revealed extensive bleeding in her brain called subarachnoid hemorrhage. A small hole called a Burr hole was drilled in her head to relieve pressure and she was transferred to a different hospital at 2am for a craniotomy.

Unfortunately, she suffered a devastating neurologic injury from the severe hemorrhage and is permanantly disabled.

Experts opined that she entered the hospital with a sentinel bleed, which is an early warning sign of the possibility a greater bleed may follow. She required an immediate CT scan. If she would have been transferred earlier had the diagnosis of subarachnoid hemorrhage had been made earlier, then the second, greater bleed could possibily have been prevented.

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