Headache as a first symptom of a leaky cerebral aneurysm

Differential diagnosis of acute severe headache

1. Dr Marwa Abo Omirah , MD Lecturer of neurology Fayoum university Headache as a first symptom of a leaky cerebral aneurysm

2. Ms. M, female patient 55 years old, not known to be DM or HTN, with history of cervical spondylosis which was treated conservatively Presented to emergency department with acute onset mild to moderate headache with nausea with severe cervical pain that was not responding to usual analgesics of 1 day duration.

3. Vital signs temp 37, pulse 80/ min, BP 110/70 Neurological Examination of the patient was free apart from neck rigidity and spasm. Fundus examination and Ct brain with out contrast were done and no abnormality detected. Mri cervical spine showed multiple disc prolapse with cervical spasm The headache was attributed to be cervicogenic headache and analgesic and muscle relaxants were described to the patient in ER with partial improvement of headache

4. 2 week later the patient had another attack of headache with nausea and dizziness The patient described that her headache to be more severe than the previous attack. MRI brain with out contrast was ordered for the patient that showed FLAIR sulcal space hyperintensity . The patient was discharged on non specific treatment.

5. The patient improved for 1 month Then suddenly the patient developed sudden disturbed conscious level and referred to the hospital On admission, GCS 8/15, pupils were equal and reactive on both sides Routine laboratory parameters were normal, Prothrombin time and INR were in normal range Ct brain showed right subarachnoid and subdural hemorrhage After few hours, there was deterionation of consiousness ; GCS 4/15 and she underwent urgent decompressive craniotomy

6. Then the patient was transferred to more specialized hospital where ct angiography was done CT angiogram revealed anterior communicating artery aneurysm rupture, which was treated with endovascular balloon‑assisted coiling then cranioplasty . The patient made a good recovery and was self‑ambulatory

7. conclusions In our case, brain imaging in the 1st week was not able to pick up on any warning leak. Patients may present with mild headache in consistence with a minor bleed (warning leak) before a major and full‑blown SAH can develop, known as a sentinel headache or warning headache. The majority of these minor hemorrhages occur within 2–8 weeks before overt SAH Thunderclap Headache with MRI brain showing FLAIR sulcal space hyperintensity is highly suggestive of subarachnoid hemorrhage and lumbar puncture with CSF analysis is recommended in this situation.

8. This case report highlights the need for considering, the diagnosis of sentinel headache due to a leaky cerebral aneurysm in all cases of a severe, sudden onset (thunderclap) headache. And timely performing all the appropriate diagnostic examinations, including LP if necessary, could prevent missing subsequent fatal consequences.

9. conclusion Underestimation or misdiagnosis of SH depends on: incorrect evaluation of the headache characteristics (unusual, severe, abrupt, and thunderclap) overestimation of cranial CT sensitivity (false negative increasing over the elapsing time) failure to perform LP in patients with negative CT incorrect evaluation of CSF findings ( xanthochromia may be absent in the first 12 h).

10. A high index of suspicion is warranted because diagnosis of the warning leak or sentinel hemorrhage before a catastrophic rupture may be lifesaving