gms | German Medical Science

Objective: Patients suffering from subarachnoid Hemorrhage (SAH) may present with a variety of symptoms and different severity of the primary neurological decline reflecting the intensity of early brain injury. The first treating physician might misinterpret these symptoms resulting in a delay of the diagnosis. The aim of this study is to evaluate the spectrum of misdiagnoses and to analyze which medical specialties are involved, as well as the significance of a delay in correct diagnosis on the clinical course and outcome

Methods: The data was collected prospectively from 2003 to 2013. Patients diagnosed with disease different from aneurysmal SAH by the initially treating physician, and admitted to our department with a delay of at least 24 hours after the beginning of the symptoms, were included in this study. The various diagnoses that were ascertained instead of SAH were analyzed and which medical specialty had provided them. The delay between the onset of symptoms and the correct diagnosis was analyzed as were clinical course and neurological outcome. No data were available of patient who had died from a potential re-rupture second following misdiagnosis.

Results: Overall, 704 patients were treated with acute SAH. The inclusion criteria were matched in 76 patients (13.7%). Eleven specialties were involved in the initial patients’ treatment (28.9 % internist, 23% general practitioners, 18.7% emergency physicians, neurologists 15%). Unspecific headache – syndrome was diagnosed in the majority of cases (39.4% tension headaches or migraine attacks, especially in patients with a history of migraines (34.6%)). Fourteen percent of the patients were initially treated for cardiac pathologies. The time interval between initial symptoms and neurosurgical admission varied enormously (median 11 days). Fourty-two percent of the patients had high grade SAH (Hunt & Hess 3- 5). Statistically, higher Hunt & Hess score did not lead to an earlier diagnosis (p = 0.56) nor did localisation of the aneurysm (p=.75). Lower Fisher score was led to delayed diagnosis (p = 0.02). Interestingly, the absolute delay of diagnosis was not significantly associated with the outcome (p = 0.08) whereas Hunt & Hess grade on admission was a strong predictor for bad outcome (p = 0.00001) as was cerebral vasospasm on the first angiogram (p<0.05). A matched-pair subgroup analysis for patients with high grade SAH (Hunt & Hess 3 – 5) showed that admittance on the first day after SAH lead to better outcome compared to misdiagnosed and delayed patients.

Conclusion: A straightforward diagnosis of SAH despite diffuse and unspecific symptoms is crucial for the successful treatment of these patients, especially with high grade SAH. This data should sensitize all physicians.