Unrecognized Warning Leak in Ruptured Intracranial Aneurysm

Abstract

Early detection of the warning symptoms of subarachnoid haemorrhage (SAH) may be an effective way to achieve a significant reduction of morbidity and mortality. The present study is part of a survey of all cases of SAH observed in 16 neurosurgical and in 8 neurological departments in Italy between June 1985 and June 1986. Out of 619 patients, 364 cases with aneurysm confirmed by angiography and a detailed clinical history were evaluated. Of these, 308 patients were operated. Warning symptoms were present in 74 cases (20.3%). Headache (present in 98.6% of cases) associated with vomiting (51.4%), dizzines (20.3%) and transient loss of consciousness (12.2%) was the most common event. Symptoms lasted less than 24 h in 71.6% of cases and occurred within 1 month before a major bleeding in 62.2% of cases. In 86.5% of cases, warning leak was severe enough for patients to seek medical care. In only 7 cases a suspected diagnosis of SAH was made. In the group with minor leak the grading (Hunt-Hess score) on admission was worse than in the group without it (51.4 vs. 34.1 % with grade III or more, p < 0.01). The incidence of intraventricular and intracerebral haemorrhages was slightly higher in the group with warning leak. Patients with multiple aneurysm had the same frequency of warning signs as patients with single aneurysms, the size and the location of aneurysms have no influence on the warning leak. The group without minor leak had a higher incidence of favourable outcomes at discharge (good recovery, 46.9 vs. 33.8%, p < 0.05). A minor leak is an important event and can indicate a negative outcome of major bleeding. A minor SAH can be correctly and promptly diagnosed on the basis of warning symptoms with a great improvement of the prognosis.

Warning leak and management outcome in aneurysmal subarachnoid hemorrhage

“…Patients having a warning leak before an aneurysmal SAH had a worse overall outcome than those without a warning leak, even though the difference in outcome was not statistically significant. The adverse prognostic effects of the warning leak reported by other authors 12,16,32,34 are confirmed by our study. However, in a study by Juvela, 14 the presence of a warning leak was found to have no impact on outcome or on the occurrence of complications after the major rupture.…”

“…The reported incidence of warning signs in SAH patients ranges from 13.5% to 60%. 2,5,6,12,14,16,21,24,28,30,[32][33][34][35] Papers in which high rates are reported include, in addition to headache, less specific symptoms such as purely somatic symptoms and transient neurological dysfunction without headache as a premonition of the SAH. 21,34 In the present study we focused on patients with a history of having experienced a generalized or localized headache with an acute onset.…”