A 45 year old 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 :
Answer is C (Aneurysmal subarachnoid hemorrhage): The patient is presenting with classical features of a subarachnoid haemorrhage from rupture saccular (Berry) aneurysms. 'Sucklen headache in the absence offocal neurological deficit is the hallmark (?1 aneurysmal rupture'. (--) Neck ytilinesy & vounitin ore common associations. Focal neurological deficit according to the area involved is an impoant characteristic of both hypeensive haemorrhage and in haemorrhage from aeriovenous malformations. Neck stiffness is not seen in either. Clinical manifestation of Subarachnoid haemorrhage : Sudden transient loss of consciousness (occurs in nearly half of the patients) Excruciating severe headache: presenting complaint in 45% of cases (worst headache of patient's life) more common upon regaining consciousness when loss of consciousness is associated Neck stiffness & vomiting: are common associations Focal neurological deficit: uncommon. 'Sudden headache in the absence offocal neurological deficit is the hallmark of aneurysmal rupture.Q Associated prodromal symptoms (suggest location of progressively enlarging unruptured aneurysm) - Third cranial nerve palsy: aneurysm at junction of PCA & ICA - Sxith nerve palsy: aneurysm in cavernous sinus - Occipital and posterior cervical pain : inferior cerebellar aery aneurysm (Ant. or Post.) - Pain in c behind the eye: MCA aneurysm 'Aneurysms may undergo small ruptures or leaks, so called sentinel bleeds.' Investigations Non contrast CT scan: Investigation of choice (Lumbar puncture is not indicated prior to an imaging procedure) CSF picture: The hallmark of aneurysmal rupture is blood in CSFQ : Xanthochromic spinal fluie (Lumbar puncture should be performed if the CT scan fails to establish the diagnosis of SAH and no mass lesion or obstructive hydrocephalus is found to establish the presence of subarachnoid blood)
Hypeensive brain haemorrhage
Migraine
Aneurysmal subarachnoid haemorrhage
Aeriovenous malformation haemorrhage