Warning leak and management outcome in aneurysmal subarachnoid hemorrhage

Abstract

The impact of warning leaks on management results in patients with aneurysmal subarachnoid hemorrhage (SAH) was evaluated in this prospective study. In a consecutive series of 422 patients with aneurysmal SAH, 84 patients (19.9%) had an episode suggesting a warning leak; 34 (40.5%) of these patients were seen by a physician without the condition being recognized. The warning leak occurred less than 2 weeks before a major SAH in 75% of the patients. A good outcome was experienced by 53.6% of patients who had a warning leak versus 63.3% of those who had no warning leak. In a subgroup of patients who had an interval of 3 days or less from warning leak to SAH, only 36.4% had a good outcome. The proportion of patients in good neurological condition (Hunt and Hess Grades I and II) who had a good outcome was 88.1% in the group with no warning leak versus 53.6% in the group whose SAH was preceded by a warning leak. A difference of 35% between these two groups reflects the impact of an undiagnosed warning leak on patient outcome, based on the assumption that patients with a warning leak had clinical conditions no worse than Hunt and Hess Grade II at the time of the episode. In the subgroup of patients with the short interval between warning leak and SAH, the difference was almost 52%. The difference in outcome also reflects the potential improvement in outcome that can be achieved by a correct diagnosis of the warning leak. If the correct diagnosis is made in patients seeking medical attention due to a warning leak, favorable outcomes in the overall management of aneurysmal SAH are estimated to increase by 2.8%. An active diagnostic attitude toward patients experiencing a sudden and severe headache is warranted as it offers a means of improving overall outcome in patients with SAH.

Definitive angiographic detection of subarachnoid haemorrhage compared with laboratory assessment of intracranial bleed in CT-negative patients

“…1 This bleed can sometimes take the form of a`warning leak', which may be followed by a further, often catastrophic, event; it is therefore important that it is diagnosed quickly. 2 If the patient presents within 12 h of the ictus then the detection of extravasated blood will normally be demonstrated on a computed tomography (CT) scan and be detected in about 98% of those who have su¡ered an intracranial bleed. 3 The positive rate of detection falls to about 50% 1 week after presentation and even less if presentation is later.…”

Newly onset: sudden & severe headache in a patient who overused analgesic

“…Other high-risk characteristics include fever, photophobia, tender pulsatile temporal arteries, progressive visual changes, confusion, weakness, pupillary asymmetry and loss of coordination. 6 Most of the time, CT brain angiography revealed no evidence of subdural haematoma or other brain pathology. On the other hand, if the headache is acute onset, very severe, episodic presentation every 24 hours to 1 week, 15 minutes to 3 hours duration and associated with lacrimation; it is most likely to be cluster headache.…”

“…The pathophysiology involve is via the limited leakage of blood from an aneurysm. 6 The presentation and neurologic findings are subtle and their ambiguity creates few potential differential diagnoses. High risk characteristics for the first time headaches include headaches occurring in patients over 40 years old, associated with exertion, female gender, hypertension, cigarette smoking, presenting with memory impairment, ataxia, drowsiness, sensory loss or signs of meningeal irritation.…”

Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

“…It is well established in the literature that patients who suffer a missed diagnosis of SAH do poorly. [5][6][7] A missed diagnosis is more likely to occur with subtle presentations and often results in death or permanent disability. In those patients where the ''sentinel'' hemorrhage is detected, the outcome is much more favorable.…”