Cases 86 : A 56-year-old woman collapsing unconscious on the floor at home.

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History

A 56-year-old woman is brought to the emergency department by her partner. She had
initially complained of a severe headache before collapsing unconscious on the floor at
home. She has no significant past medical history but smokes 30 cigarettes a day. She has
now regained consciousness and is complaining of neck stiffness. Her initial assessment
is carried out using the system shown below.

Examination

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Questions

• What system has been used to assess the patient?
• What is the likely diagnosis?
• What are the possible underlying causes?

Answer

The Glasgow Coma Score (GCS) is composed of three parameters: verbal commands, eye
opening and motor responses. The patient is assessed on their ‘best’ response. The scores
are summed to give an overall value from 3 (being the worst) to 15 (being the best). In
this case the GCS is 13. While the score is useful in absolute terms, such as defining coma
(GCS 8), the main value of the GCS is being able to monitor the ongoing neurological
status of a patient by repeated assessment every 15min. A fall in the score of 2 or more
should prompt an urgent review of the patient, as this indicates a potentially significant
deterioration in their condition.
The most likely diagnosis in this case is of a subarachnoid haemorrhage. The classical symp-
toms are of a severe ‘thunderclap’ headache affecting the back of the head that reaches
maximal intensity within a few seconds.

Causes of bleeding into the subarachnoid space

  • 85 per cent: saccular aneurysms in the cerebral vasculature – ‘berry’ aneurysms
• 15 per cent: non-aneursymal subarachnoid haemorrhage:
• arterial dissection
• arteriovenous malformation
• tumour
• cocaine abuse
• trauma
• septic aneurysm


The initial management involves stabilizing the patient and arranging the following:
• blood tests: full blood count, renal function, coagulation screen and group
and save
• computerized tomography (CT) of the brain: to look for evidence of subarachnoid
blood and hydrocephalus
• lumbar puncture: if the CT scan does not show any pathology, then cerebral spinal
fluid should be sent for spectrophotometric analysis to look for the presence of
oxyhaemoglobin and bilirubin.
Differential diagnoses include transient ischaemic attacks, migraine or epilepsy. Patients
confirmed to have a subarachnoid haemorrhage should be referred to a neurosurgical unit
for further assessment (cerebral angiography) and treatment (embolization)


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