Spontaneous subarachnoid hemorrhage accounts for approximately 10 percent of all acute cerebrovascular accidents and afflicts nearly 30,000 persons annually in the United States. Subarachnoid hemorrhage typically occurs in healthy individuals in their most productive years of adult life and is responsible for half of all fatal strokes in persons under 45 years of age. The overall mortality rate from subarachnoid hemorrhage is 50 percent. Fewer than one-third of survivors return to their premorbid state.
Early recognition and prompt intervention are of critical importance. Without prompt therapy, 50 percent of patients who survive the first 24 hours will die within two weeks. Fontanarosa retrospectively studied the clinical presentation and diagnostic features of 109 patients with nontraumatic spontaneous subarachnoid hemorrhage who were initially evaluated in an emergency department.
Medical records were analyzed to determine the initial symptoms, the circumstances surrounding the event and associated medical conditions. The clinical presentation, the diagnostic procedures and the diagnosis by the physicians in the emergency department were analyzed.
The most common historic features were nausea or vomiting in 85 patients (78. 0 percent), headache in 81 patients (74.3 percent) and loss of consciousness in 58 patients (53.2 percent). Sixty-two patients (56.9 percent) had been participating in nonexertional activities preceding subarachnoid hemorrhage, compared with 23 patients (21.1 percent) who had been participating in exertional events. The circumstances surrounding the event were either unknown or not documented in 24 cases (22.0 percent).
Neurologic abnormalities were present in 70 patients (64.2 percent) and consisted primarily of an altered level of consciousness. Thirty-eight patients (34.9 percent) had nuchal rigidity. In 96 patients, computed tomographic scanning was performed, and in 91, the scans were diagnostic of subarachnoid hemorrhage. Two patients with normal computed tomographic scans underwent lumbar puncture, which revealed bloody cerebrospinal fluid. The overall diagnostic accuracy of the emergency department physicians was 85.3 percent. The diagnosis was delayed in 16 patients (14.7 percent), the majority of whom had headaches and normal neurologic examinations.
The data indicate that physicians should be aggressive when evaluating patients with new or unusual headache or unexplained neurologic symptoms. Liberal use of computed tomographic scanning and, where indicated, selective lumbar puncture will improve recognition of subarachnoid hemorrhage. (Annals of Emergency Medicine, November 1989, vol. 18, p. 1199.)
COPYRIGHT 1990 American Academy of Family Physicians
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