Lesson of the Week: Subarachnoid haemorrhage presenting as head injury

doi:10.1136/bmj.310.6988.1186

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Damianos E Sakas, consultant neurosurgeona,
Lal S Dias, consultant neurosurgeonb,
David Beale, consultant neuroradiologista

^a Walsgrave Hospital, Coventry CV2 2DX
^b North Staffordshire Royal Infirmary, Stoke on Trent ST4 7NL

Correspondence to: Mr D E Sakas, Midland Centre for Neurosurgery and Neurology, Smethwick, Warley, West Midlands B67 7JX.

Accepted 9 August 1994

Headache, nausea, vomiting, and transient loss of consciousness occur in two thirds of people who experience subarachnoid haemorrhage.1 Loss of consciousness may result in an abrupt fall and trauma to the head immediately after the haemorrhage. The distinction between subarachnoid haemorrhage and head injury may therefore be blurred sometimes, with the spontaneous subarachnoid haemorrhage remaining unrecognised. We believe that this clinical problem has not been properly addressed. We report on four patients with head injury, in whom a spontaneous subarachnoid haemorrhage preceded the trauma, and suggest guidelines for investigating and managing such patients.

Case reports

CASE 1

A 45 year old man became unconscious after he fell 6 m from scaffolding. On admission he was convulsing, with pupils of equal size and reacting to light. He had a laceration of the scalp and an orbital fracture. Computed tomography showed a small amount of subarachnoid blood, which was attributed to the injury. The possibility of a spontaneous cerebrovascular haemorrhagic event as the cause of the fall was raised. Cerebral angiography showed a giant aneurysm in the right middle cerebral artery. At surgery, wide-spread subarachnoid haemorrhage and substantial recent clotting in the area surrounding the aneurysm confirmed that the aneurysm had recently bled. Despite successful clipping of the aneurysm the patient died three days later.

CASE 2

A 54 year old male engineer fell 6 m from a ladder and hit his head on a concrete surface. On admission he was localising and opening his eyes to painful stimuli, with incomprehensible verbal responses. He had a frontal linear fracture, an orbital haematoma, and a temporal extracranial contusion but no obvious localising neurological deficit. He had …