Delayed Diagnosis of Intracranial Aneurysms
Delayed Diagnosis of Intracranial Aneurysms
Subarachnoid hemorrhage from intracranial aneurysms is a potentially life-threatening illness. The overall mortality from a subarachnoid hemorrhage remains between 40% and 50% over the first few days after the initial hemorrhage. When patients are seen with a major neurologic deficit, it is usually no secret that an intracranial catastrophe has occurred. This is confirmed with computed tomography (CT), and in patients who have not been devastated by the hemorrhage, treatment can often lead to a reasonable outcome. The diagnosis of subarachnoid hemorrhage can be difficult to make, however, if the patient has minimal signs and symptoms. It is ironic that these are the very patients who have the best chance of doing well with treatment if the diagnosis is made early and they are treated appropriately.
In the report by Vannemreddy et al regarding the diagnosis of intracranial aneurysms, several important points are made. Misdiagnosis and delay in diagnosis remain significant problems for patients with intracranial aneurysms. Other studies have documented that 20% to 25% of patients have a misdiagnosis or delay in diagnosis of aneurysm at initial presentation. In Vannemreddy et al's study, 14.8% of patients had a significant delay in diagnosis before definitive treatment, with the delay varying from 2 days to a few months. In this study, 58% of patients were still in good clinical condition at the time of readmission (Hunt and Hess clinical grade I); unfortunately, 20% of patients were in grade II and 12.5% were in grade III, with one grade IV patient. The fact that these grades were significantly different from the initial grade when the patients first sought medical attention is important. It cannot be emphasized strongly enough how early diagnosis and treatment of this illness can not only save lives but also prevent morbidity in terms of poor neurologic outcome.
In the emergency department setting, it is estimated that approximately 1% of all emergency room visits are for headache. Of these, 1% are from subarachnoid hemorrhage from intracranial aneurysm. It therefore becomes a difficult task for the emergency department physician and primary care physician who see headaches on a daily basis to try to define which patients might have an intracranial aneurysm. Careful history-taking or clinical examination may reveal features that point to an intracranial aneurysm versus one of the many other causes of headaches. If the diagnosis of subarachnoid hemorrhage is suspected, the clinician should obtain a CT scan. Most emergency departments have easy access to this. If the CT scan does not reveal subarachnoid hemorrhage, the clinician must proceed with lumbar puncture. This is an invasive procedure, and often patients will not consent; however, this should be discussed if the physician's level of suspicion is high enough to obtain a CT scan.
The article by Vannemreddy et al reiterates some important issues about the management of subarachnoid hemorrhage from intracranial aneurysms. One of the crucial points at which physicians must intervene and make a difference in the outcome of disease is at initial diagnosis and management. If this opportunity is missed, patients suffer. These authors should be commended for their work.
Subarachnoid hemorrhage from intracranial aneurysms is a potentially life-threatening illness. The overall mortality from a subarachnoid hemorrhage remains between 40% and 50% over the first few days after the initial hemorrhage. When patients are seen with a major neurologic deficit, it is usually no secret that an intracranial catastrophe has occurred. This is confirmed with computed tomography (CT), and in patients who have not been devastated by the hemorrhage, treatment can often lead to a reasonable outcome. The diagnosis of subarachnoid hemorrhage can be difficult to make, however, if the patient has minimal signs and symptoms. It is ironic that these are the very patients who have the best chance of doing well with treatment if the diagnosis is made early and they are treated appropriately.
In the report by Vannemreddy et al regarding the diagnosis of intracranial aneurysms, several important points are made. Misdiagnosis and delay in diagnosis remain significant problems for patients with intracranial aneurysms. Other studies have documented that 20% to 25% of patients have a misdiagnosis or delay in diagnosis of aneurysm at initial presentation. In Vannemreddy et al's study, 14.8% of patients had a significant delay in diagnosis before definitive treatment, with the delay varying from 2 days to a few months. In this study, 58% of patients were still in good clinical condition at the time of readmission (Hunt and Hess clinical grade I); unfortunately, 20% of patients were in grade II and 12.5% were in grade III, with one grade IV patient. The fact that these grades were significantly different from the initial grade when the patients first sought medical attention is important. It cannot be emphasized strongly enough how early diagnosis and treatment of this illness can not only save lives but also prevent morbidity in terms of poor neurologic outcome.
In the emergency department setting, it is estimated that approximately 1% of all emergency room visits are for headache. Of these, 1% are from subarachnoid hemorrhage from intracranial aneurysm. It therefore becomes a difficult task for the emergency department physician and primary care physician who see headaches on a daily basis to try to define which patients might have an intracranial aneurysm. Careful history-taking or clinical examination may reveal features that point to an intracranial aneurysm versus one of the many other causes of headaches. If the diagnosis of subarachnoid hemorrhage is suspected, the clinician should obtain a CT scan. Most emergency departments have easy access to this. If the CT scan does not reveal subarachnoid hemorrhage, the clinician must proceed with lumbar puncture. This is an invasive procedure, and often patients will not consent; however, this should be discussed if the physician's level of suspicion is high enough to obtain a CT scan.
The article by Vannemreddy et al reiterates some important issues about the management of subarachnoid hemorrhage from intracranial aneurysms. One of the crucial points at which physicians must intervene and make a difference in the outcome of disease is at initial diagnosis and management. If this opportunity is missed, patients suffer. These authors should be commended for their work.
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