Clinical Characteristics of Subarachnoid Hemorrhage With or Without Headache

Subarachnoid Haemorrhage in a Patient With Suspected Infective Endocarditis in a District General Hospital: A Case Report-Based Literature Review

We describe the case of a 70-year-old lady who presented to a district general hospital during an evening with fevers, feeling generally unwell. She was found to have weakness in her left upper limb and went on to have tonic-clonic seizures whilst in the Accident and Emergency Department. CT scan of the brain showed subarachnoid haemorrhage, in absence of headache, in the right frontal, superior parietal and left occipital regions. Her C-reactive protein level was elevated at 426 mg/L and her urine dip was normal. Chest radiograph showed small bilateral pleural effusions. In addition to the above-mentioned findings on clinical examination, she also had pansystolic murmur although did not have any other feature of infective endocarditis (IE). In view of the above findings, normal chest examination and no urinary symptoms, the decision was made to treat this as a case of IE empirically. She subsequently went into fast atrial fibrillation requiring direct current (DC) cardioversion and intensive care unit admission due to hypotension. The next day, echocardiography confirmed vegetations and blood cultures were positive for Staphylococcus aureus. Her MRI scan of the brain confirmed parenchymal haemorrhages and haemorrhagic infarcts. She completed a 6-week course of antibiotics and clinically improved. Despite being critically unwell, appropriate antibiotics were initiated within hours of her admission in view of clinical suspicion of underlying IE, which aided her recovery.

Effectiveness of Low-Dose Intravenous Fentanyl for Postoperative Headache Management After Neck Clipping of Ruptured Intracranial Aneurysms

BACKGROUND

After subarachnoid hemorrhage (SAH), headache management is often difficult owing to the need to use multiple analgesic drugs. Fentanyl is an opioid we can use after surgery, and it can decrease pain post SAH. The aim of this study was to investigate the effectiveness and safety of fentanyl for management of headache after SAH.

METHODS

Twenty-two patients who underwent surgical clipping for ruptured intracranial aneurysms and complained of severe headache after the surgery were enrolled. Among them, 9 patients were given fentanyl combined with other analgesic drugs. The numeric rating scale score and dietary intake were measured in the acute phase after the SAH.

RESULTS

The numeric rating scale scores were significantly lower in the fentanyl (+) group. The maximum numeric rating scale decreased to <5 points within 16.5 ± 2.9 days in the fentanyl (-) group and within 12.0 ± 2.6 days in the fentanyl (+) group. The median numeric rating scale decreased to <5 points over 14.0 ± 4.2 days in the fentanyl (-) group and >7.7 ± 3.8 days in the fentanyl (+) group. At day 14, the fentanyl (+) group showed significantly better dietary intake than that of the fentanyl (-) group.

CONCLUSIONS

Using fentanyl after surgical clipping for ruptured intracranial aneurysms might decrease headache and produce few adverse effects. Adequate headache control showed improved dietary intake after SAH.

The Longitudinal Course of Pain and Analgesic Therapy Following Aneurysmal Subarachnoid Hemorrhage: A Cohort Study

OBJECTIVE

The purpose of this study was to determine the duration, intensity, location, and usual treatment of pain throughout hospitalization following subarachnoid hemorrhage.

BACKGROUND

Headache following subarachnoid hemorrhage can be sudden and severe. Little is known about the longitudinal course of headache or its analgesic therapy following the initial diagnosis of subarachnoid hemorrhage.

METHODS

A prospectively maintained database of 564 patients diagnosed with cerebral aneurysms collected from 10/2009 to 2/2013 was searched for conscious patients with subarachnoid hemorrhage. Available electronic records were queried for pain scores (0-10/10), location, and analgesic consumption.

RESULTS

Forty-six adults with subarachnoid hemorrhage met eligibility criteria for inclusion. Mean [CI 95] daily pain was 3.8 [3.2, 4.4] and maximal daily pain was 5.8 [5.1, 6.6]. Eighty-nine percent of patients reported severe pain of 7-10/10, and 63% of patients reported 10/10 pain at some point during hospitalization. While mean [CI 95] pain declined over the course of hospital stay at a rate of 0.06 [0.04, 0.07] units/day (P < .001), mean [CI 95] maximal daily pain changed at a rate of -0.03 [-0.06, 0.01] units/day, which is not significantly different than zero (P = .15). Pain was located primarily in the head in 76% of subjects but pain in the back, neck, limbs, and eyes was also reported. All patients received oral acetaminophen with increasing daily doses. All but three patients, received opioids, most commonly intravenous fentanyl and oral oxycodone. The mean [95 CI] intravenous morphine equivalent dose of opioids consumed was 15.7 [10.3, 21.1] mg/day and changed at a rate of -0.11 [-0.37, 0.15] mg/day which is not significantly different than zero (P = .40).

CONCLUSION

Despite steady consumption of analgesics, the pain reported by conscious patients while recovering from subarachnoid hemorrhage in the hospital is often severe and persists throughout hospitalization.

Atypical Presentation of Aneurysmal Subarachnoid Hemorrhage: Incidence and Clinical Importance

BACKGROUND

The symptoms of sudden severe headache and/or diminished consciousness characterize the onset of aneurysmal subarachnoid hemorrhage (SAH). However, several studies have suggested that some patients show an atypical presentation at the onset: symptoms lacking sudden headache and diminished consciousness. The aim of this study was to investigate the incidence and clinical features of cases with atypical onset.

METHODS

Retrospective observational study based on the data collected prospectively from all patients with SAH admitted to our hospital was performed. Cases with a sudden headache at the onset were classified as the headache onset group, and cases with onset symptoms other than headache were classified as the atypical onset group. The clinical parameters were compared between the two groups.

RESULTS

Of the 368 patients with SAH, 75 (20.4%) showed diminished consciousness from onset, 279 (75.8%) comprised the headache onset group, and 14 (3.8%) comprised the atypical onset group. The main symptoms in the atypical onset group were nausea or vomiting, vertigo or dizziness, and neck pain or back pain. The rate of misdiagnosis of SAH and the rate of rebleeding after misdiagnosis were higher in the atypical onset group (P = .045 and P = .043, respectively). The interval from onset to diagnosis was longer in the atypical onset group (P = .033). The atypical onset group demonstrated a more severe clinical grade on admission (P = .009), a lower rate of ruptured aneurysm repair (P < .001), and a poorer outcome (P = .003).

CONCLUSIONS

Atypical onset is rare but has a great impact on the clinical course through rebleeding exacerbated by misdiagnosis or delayed diagnosis, resulting in poor outcomes.