Acute confusional state as presenting feature in aneurysmal subarachnoid hemorrhage: frequency and characteristics

Abstract

In many patients with subarachnoid hemorrhage (SAH) there is a delay between the onset of symptoms and admission to hospital. An important cause for the delay is an initially erroneous diagnosis. The goal of this study was to determine the frequency of acute confusional state (ACS) as a presenting symptom of SAH and to describe the clinical and radiological characteristics of these patients. We studied all 717 patients registered from January 1989 to July 1997 in the SAH database of the University Medical Center Utrecht. For patients who presented with ACS we reviewed the computed tomography scans for baseline characteristics: the amount of cisternal blood, intraventricular or intracerebral hemorrhage, and hydrocephalus. Details about features of onset were known for 646 patients. Nine patients (1.4%) presented with ACS. In five patients ACS was either preceded by a period of loss of consciousness or accompanied by severe headache. Subtle focal deficits were found at initial neurological examination in four patients. Computed tomography demonstrated a frontal hematoma in three patients and hydrocephalus in four. The site of the ruptured aneurysm was at the anterior communicating artery in four patients, at the internal carotid artery in two, and at the basilar artery in two. In our series, one per 70 patients with SAH presents with ACS. Keys to early diagnosis of SAH in patients presenting with ACS are a preceding period of loss of consciousness and severe headache on neurological assessment.

Delirium in the first days of acute stroke

“…Global ischaemia at onset due to sudden increase in intracranial pressure, hydrocephalus and intracerebral haematoma are likely mechanisms contributing to delirium in acute SAH. Reijneveld et al [22] related delirium to initial global ischaemia, although the majority of their patients had hydrocephalus, intraventricular haemorrhages or frontal haematoma. One of our cases also had an intrahemispheric basofrontal haematoma.…”

“…We detected delirium in 11 % of SAH patients. Based on a review of medical records, Reijneveld et al [22] found acute confusional state as a presenting feature in 1.4 % of aneurysmal SAH. Global ischaemia at onset due to sudden increase in intracranial pressure, hydrocephalus and intracerebral haematoma are likely mechanisms contributing to delirium in acute SAH.…”

Time-Dependent Test Characteristics of Head Computed Tomography in Patients Suspected of Nontraumatic Subarachnoid Hemorrhage

“…The diagnosis of SAH can be difficult because not all patients with SAH present with acute headache; however, they may present with atypical features such as isolated neck pain, back pain, chest pain, or an acutely confused state. [13][14][15][16][17][18] Therefore, we included all patients who had a diagnostic work-up for a clinical suspicion of SAH, including those with a less obvious clinical presentation without headache. Also, in our study all patients with a negative CT underwent lumbar puncture, which is, in our view, a better gold standard than the absence of rebleeding during follow-up, which was previously used in a substantial proportion of patients to rule out in retrospect the diagnosis of SAH.…”

Subarachnoid Hemorrhage in Clinical Practice

“…4.2 ) and absence of an aneurysm. The source of perimesencephalic hemorrhage probably is a venous one such as tear of an anomalous draining vein as these patients often have a primitive venous drainage on the side of the hemorrhage [ 60 ]. In a study using controls from the general population, smoking was a risk factor for perimesencephalic hemorrhage, but hypertension and excessive alcohol intake were not.…”

“…In these patients, it is usually straightforward that they should be transferred to a hospital. Rarely, patients with subarachnoid hemorrhage are in an acute confusional state without actively complaining of headache [ 60 ]. In these patients, the diagnosis of subarachnoid hemorrhage is often delayed because subarachnoid hemorrhage is a rare cause of acute confusional state and other causes are considered first [ 61 , 62 ].…”