CHAPTER 13 SUBARACHNOID HEMORRHAGE
1. What is the most common cause of spontaneous subarachnoid hemorrhage?
Rupture of a cerebral artery aneurysm is the most common cause of spontaneous subarachnoid hemorrhage in adults in middle life. In children and teenagers, arteriovenous malformations (AVM) are common. Small subarachnoid hemorrhages are usual after head trauma and may be the cause of early posttraumatic headache.
2. A 40-year-old woman in the emergency department complains of the worst headache of her life that has its onset during sexual intercourse. On examination, she is slightly sleepy and has a stiff neck but no other signs. What diagnosis should be considered?
This is a classic story for subarachnoid hemorrhage. The sudden onset of “the worst headache of my life” is the tipoff. Most commonly, it occurs during the Valsalva maneuver—while straining at stool or during sexual intercourse. Patients commonly demonstrate stiff neck and some alteration of level of consciousness. The absence of localizing signs on neurologic exam does not contradict the diagnosis. A few specific types of subarachnoid hemorrhage will include localizing signs (see Question 3).
3. A patient comes to the emergency department with the sudden onset of a severe headache. The patient is awake and alert, but the left eyelid is drooping, the left pupil is dilated, and the left eye is exodeviated. What is the problem?
The patient has a third-nerve palsy. Third-nerve palsy and headache are often thought of as signs of uncal herniation. However, the patient is awake. Furthermore, there is no hemiparesis. An isolated third-nerve paresis with severe headache is a common presentation of a ruptured aneurysm in the posterior communicating artery. The third nerve passes between the posterior communicating artery and the superior cerebellar artery. Rupture of the aneurysm may put pressure on the third nerve, causing ptosis, mydriasis, and exodeviation of the eye.
4. What are the international headache society criteria for subarachnoid hemorrhage?
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