Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage

Abstract

Retrospective surveys of patients with subarachnoid haemorrhage suggest that minor episodes with sudden headache (warning leaks) may precede rupture of an aneurysm, and that early recognition and surgery might lead to improved outcome. We studied 148 patients with sudden and severe headache (possible sentinel headache) seen by 252 general practitioners in a 5-year period in the Netherlands. Subarachnoid haemorrhage was the cause in 37 patients (25%) (proven aneurysm in 21, negative angiogram in 6, no angiogram done in 6, sudden headache followed by death in 4). 103 patients had headache as the only symptom, 12 of whom proved to have subarachnoid haemorrhage (6 with a ruptured aneurysm). Previous bouts of sudden headache had occurred in only 2. Other serious neurological conditions were diagnosed in 18. In the remaining 93, no underlying cause of headache was found; follow-up over 1 year showed no subsequent subarachnoid haemorrhage or sudden death. In this cohort, acute, severe headache in general practice indicated a serious neurological disorder in 37% (95% CI 29-45%), and subarachnoid haemorrhage in 25% (18-32%). 12% (5-18%) of those with headache as the only symptom. The notion of warning leaks as a less serious variant of subarachnoid haemorrhage is not supported by this study. Early recognition of subarachnoid haemorrhage is important but will probably have only limited impact on the outcome in the general population.

Unruptured aneurysm producing thunderclap headache treated with endovascular coil embolization

“…[1,4,6] Also some retrospective surveys of patients with subarachnoid haemorrhage suggest that minor episodes with sudden headache (warning leaks) may precede rupture of an aneurysm, and that early recognition and treatment might lead to improved outcome. [7] In different studies the mechanisms underlying TCH due to unruptured aneurysms were diffuse, multifocal and segmental cerebral vasospasm in the absence of haemorrhage, morphologic changes like stretching, expansion, dissection, [8] local thrombosis in the wall [9] and limited leakage of blood which implies that partial rupture has occurred in to the subarachnoid space. [6,10] …”

The Critical Care Management of Aneurysmal Subarachnoid Hemorrhage

“…However, this classic description is seen in only 50% of patients presenting with aneurysmal SAH [8]. Conversely, in those patients prospectively screened for acute severe headache, only 6-17% were demonstrated to have SAH [9,10]. Common features at presentation can include seizure, loss of consciousness, and nausea and emesis preceding onset of headache [9].…”

“…Conversely, in those patients prospectively screened for acute severe headache, only 6-17% were demonstrated to have SAH [9,10]. Common features at presentation can include seizure, loss of consciousness, and nausea and emesis preceding onset of headache [9]. The concept of 'sentinel headache' remains controversial; it is thought to be related to changes in the wall of the aneurysm versus a microbleed.…”

Subarachnoid haemorrhage mimicking as myocardial infarction

“…12% (5-18%) of those with headache as the only symptom. 2 Nine studies of good quality, which reported the number of patients with aneurysmal subarachnoid haemorrhage with a history of sentinel headache, gave rates of 10% to 43%, true incidence may vary from near zero to about 40%. 3 Patients with acute vascular disorders of the CNS demonstrate an abundance of both rhythm and morphologic changes in their ECG.…”