A 45 year old hypertensive male patient presented in the casualty with two hours history of sudden onset of severe headache associated with nausea and vomiting on clinical examination the patient had necks stiffness and right sided ptosis. Rest of the neurological examination was normal. What is the clinical diagnosis :
Ans. is 'c' i.e. Aneurysmal subarachnoid hemorrhageRef. Harrison 17th/e p 1727 & 16th/e p 2388 (15th/e p2388Also see Q 99 of May 2003.This is a classical presentation of subarachnoid Haemorrhage.Excluding head trauma, the most common cause of SAH in rupture of a saccular aneurysm.C/F of subarachnoid hemorrhageSudden headache is the absence of focal neurological deficit is the hallmark of aneurysmal rupture.The patient often calls the headache the worst headache of his lifeBrief period of unconsciousnessNuchal rigidity and other signs of meningeal irritation.The hallmark of aneurysmal rupture is blood in the C.S.F.Right sided ptosis in this patient can be explained by compression of the third cranial nerve by the aneurysm.An aneurysm at the junction of the posterior communicating artery and the internal carotid artery compresses III C. N. and causes its palsy, whereas an aneurysm of intracavernous part of the carotid artery compresses III & VI cranial nerves.The first point of the clinical features of SAH need a little more explanation.Although sudden headache in the absence of focal neurological symptoms is the hallmark of aneurysmal rupture, focal neurologic deficits may occur.Anterior communicating artery or middle cerebral bifurcation aneurysms may rupture into the adjacent brain or subdural space and form a hematoma large enough to produce mass effect.The common deficits that result include hemiparesis, aphasia and abulia (inability to exercise will power, lack of impulse to activity, a mental and physical slowness).Clinical features of Hypertensive HaemorrhageHemorrhage generally presents as abrupt onset of focal neurological deficit (according to the area involved)Focal neurological deficit gradually worsens and is accompanied by signs of increased intra cranial pressure (ICP) such as headache and vomiting.In hypertensive bleeding the hemorrhage is intracerebral.Arteriovenous malformation HaemorrhageAlthough AVM can cause SAH but they are a rare cause.AVMs cause intra parenchymal Haemorrhage rarely spilling into the subarachnoid space.Its Haemorrhage, therefore causes focal neurological deficit according to the part involved.
Hypertensive brain haemorrhage
Migraine
Aneurysmal subarachnoid haemorrhage
Arteriovenous malformation haemorrhage
Cerebrovascular