Case history
Case history #1
A 45-year-old woman was having dinner when she felt the sudden onset of a severe headache, unlike anything she had ever experienced. She vomited many times before her husband brought her to seek medical attention. On presentation she requires stimulation to maintain alertness and has mild nuchal rigidity. Her blood pressure is elevated but examination is otherwise normal. CT of the brain reveals subarachnoid blood in the anterior interhemispheric fissure. Angiography reveals a 7-mm aneurysm in the anterior communicating artery.
Case history #2
An anxious 30-year-old woman seeks medical attention because of recent worsening headaches and visual disturbances. She is a smoker and has a sibling who was admitted to the hospital for a ruptured cerebral aneurysm. Examination discloses slight ptosis of the left eye. On neurologic exam, her left pupil is dilated, minimally reactive to light, and pointing inferiorly and laterally at rest. CT of the brain shows no subarachnoid blood. Lumbar puncture is normal. Magnetic resonance angiography of the brain reveals a 5-mm aneurysm in the left posterior communicating artery.
Other presentations
At the brief moment of aneurysmal rupture, intracranial pressure rises to approach mean arterial pressure, thereby dropping the cerebral perfusion pressure. This may explain the transient or persisting decreased consciousness that can occur. The severity of the hemorrhage and its effects on intracranial pressure ultimately determine the severity of the presenting symptoms. Prodromal symptoms may point to the location of an unruptured aneurysm and suggest progressive enlargement, such as in a posterior communicating artery aneurysm compressing the third cranial nerve. A sudden unexplained headache in any location should arouse suspicion of subarachnoid hemorrhage.
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