Subarachnoid hemorrhage presenting as acute chest pain: a variant of le coup de poignard

Le Coup de Poignard Rachidien: A Historical Perspective

A spinal subarachnoid hemorrhage (SAH) is uncommon. One of the earliest detailed analyses of a spinal SAH was in 1928 by the French physician Paul Michon, who coined the term "le coup de poignard rachidien" to describe the pathognomonic, intense spinal pain experienced by patients with spinal SAH, equating it to being stabbed by a dagger. Michon sub-classified spinal SAH into the upper and lower forms, pointing out that the stabbing spinal pain is more characteristic of SAH in the cervical and thoracic regions and especially in the interscapular region. Translation and subsequent analysis of Michon's original French paper published in La Presse Medicale in 1928 shed light on two cases in which patients presented with le coup de poignard rachidien and signs of spinal cord dysfunction but little, if any, intracranial symptoms. The patients both showed symptomatic relief following therapeutic lumbar puncture. Later, authors have questioned the notion that intense spinal or interscapular pain is mandatory in the diagnosis of spinal SAH and have additionally provided evidence contrary to Michon's assertion that intracranial symptoms, if any, occur later in the progression of spinal SAH and are largely insignificant.

Subarachnoid hemorrhage secondary to forceful sneeze

Subarachnoid hemorrhage (SAH) is a relatively less common but important neurological condition comprising 5% of all the cerebrovascular accidents. In most populations the reported incidence is 6-7 per 100,000 person-years and one-third of survivors become dependent. It is a serious but potentially treatable cause of neurological morbidity. Multiple authors have identified the most unusual novel associations and triggers of subarachnoid bleeds over the past decade. We herein report a rare case of subarachnoid hemorrhage leading to focal neurological deficit in a middle aged man secondary to forceful sneeze.

Spinal subarachnoid hemorrhage mimicking an acute abdomen

A 39-year-old woman with a history of systemic lupus erythematosum developed an acute abdomen. An intestinal ischemia was suspected and an exploratory laparotomy was performed. No abnormalities were found during surgery and five days later the patient was transferred to our institution. On admission, the patient presented a distended abdomen and paraparesis. The spinal tap showed hemorrhagic CSF and the MRI a subacute subarachnoid hemorrhage (SAH) of the dorsal-lumbar spine. Two days later, the patient suffered an episode of sudden headache. The CT scan revealed an acute SAH at the posterior fossa and digital subtraction angiography a dissection of the right V4 segment. Spinal subarachnoid hemorrhage is a rare syndrome particularly when associated with dissecting aneurysms of the intracranial segment of the vertebral artery. SSAH should be considered early in the differential diagnosis of any case with sudden back or abdominal pain of unknown etiology, even in the absence of neurological deficits.

Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest?

We aimed to investigate the utility of end-tidal carbon dioxide concentration as a prognostic indicator of initial outcome of resuscitation, we conducted a prospective study of EtCO2 in adult victims of out-of-hospital non-traumatic cardiac arrest. We prospectively studied 139 adult patients. The initial, final, average, minimal and maximal EtCO2 was significantly higher in resuscitated patients than in non-resuscitated patients. Using an initial, average and final EtCO2 value of 10 mmHg correctly identified 100% of the patients who were subsequently resuscitated with an acceptable specificity (74.1%; 90%; 81.4%). Important observation from this study is that none of the patients with an average, initial and final EtCO2 level of less than 10 mmHg were resuscitated. Data from this prospective clinical trial indicate that initial, average and final EtCO2 monitoring during CPR is correlated with resuscitation. End-tidal CO2 monitoring has potential as a noninvasive indicator of cardiac output during resuscitation and a prognostic indicator for resuscitation.

Spinal manifestations of vertebral artery dissection

Among 111 patients with vertebral artery dissection (VAD), two presented with spinal manifestations: one with a C5-C6 radiculopathy and the other with a cervical myelopathy. Of 13 previously reported cases of spinal manifestations of VAD (mean age 37 years), ischemic cervical myelopathy was noted in seven; cervical radiculopathy, often at C5-C6 and primarily motor, in five; and hemorrhagic complications in one, with chest pain being part of the presentation.

Endovascular treatment of vertebral artery dissections and pseudoaneurysms

Sixteen patients with dissecting aneurysms or pseudoaneurysms of the vertebral artery, 12 involving the intradural vertebral artery and four occurring in the extradural segment, were treated by endovascular occlusion of the dissection site. Patients with vertebral fistulas were excluded from this study. The dissection was caused by trauma in three patients (two iatrogenic) and in the remaining 13 no obvious etiology was disclosed. Nine patients presented with subarachnoid hemorrhage (SAH), two of whom had severe cardiac disturbances secondary to the bleed. The nontraumatic dissections occurred in seven women and six men, with a mean age on discovery of 48 years. Fifteen patients were treated with endovascular occlusion of the parent artery at or just proximal to the dissection site. One patient had occlusion of a traumatic pseudoaneurysm with preservation of the parent artery. Four patients required transluminal angioplasty because of severe vasospasm produced by the presenting hemorrhage, and all benefited from this procedure with improved arterial flow documented by transcranial Doppler ultrasonography and arteriography. In 15 patients angiography disclosed complete cure of the dissection. One patient with a long dissection of extracranial origin extending intracranially had proximal occlusion of the dissection site. Follow-up angiography demonstrated healing of the vertebral artery dissection but persistent filling of the artery above the balloons, which underscores the need for embolic occlusion near the dissection site. No hemorrhages recurred. One patient had a second SAH at the time of therapy which was immediately controlled with balloons and coils. This patient and one other had minor neurological worsening resulting from the procedure (mild Wallenberg syndrome in one and minor ataxia in the second). Symptomatic vertebral artery dissections involving the intradural and extradural segments can be effectively managed by endovascular techniques. Balloon test occlusion and transluminal angioplasty can be useful adjuncts in the management of this disease.

Spontaneous vertebral artery dissection initially mimicking myocardial infarction

BACKGROUND AND PURPOSE

Vertebral and carotid artery dissections may present with very different signs and symptoms, making early recognition difficult. However, diagnosis should be established as soon as possible to prevent unnecessary diagnostic investigations and to institute adequate treatment.

CASE DESCRIPTION

A 46-year-old man presented with severe intermittent pain of his left upper arm and general discomfort. During extensive cardiological evaluation for suspected myocardial infarction, a severe brain stem syndrome occurred. Ultrasound Doppler studies detected vertebral artery dissection, which was confirmed by angiography.

CONCLUSIONS

The unusual initial presentation of vertebral artery dissection delayed an early diagnosis and adequate treatment. Because noninvasive methods are available today, their applications are recommended in similarly uncharacteristic circumstances.

Recognition of subarachnoid hemorrhage

The medical records of 109 patients who presented to the emergency department during a five-year period with proven nontraumatic, spontaneous subarachnoid hemorrhage (SAH) were retrospectively reviewed. The clinical presentation, diagnostic modalities used, and accuracy of diagnosis by emergency physicians were analyzed. The most common historical features were headache (81 patients, or 74%), nausea or vomiting (85 patients, or 77%), and loss of consciousness (58 patients, or 53%). Nonexertional activities preceding SAH were more frequent than exertional events (57% vs 21%). Neurologic findings were present in 70 patients (64%) and consisted primarily of altered levels of consciousness. Thirty-eight patients (35%) had nuchal rigidity. Ninety-six emergency cranial computed tomography scans were performed, of which 91 were diagnostic for SAH (sensitivity, 95%). Lumbar puncture was performed on two patients with normal computed tomography scans and revealed bloody spinal fluid. The overall diagnostic accuracy by emergency physicians was 85%. The correct diagnosis was delayed in 16 patients (15%), the majority of whom had headaches and normal neurologic examinations. Atypical symptoms, the warning leak syndrome, and the need for prompt diagnosis and therapy are reviewed.