Symptoms of a Brain Aneurysm
There are some patient complaints that cause a fair amount of angst for physicians, because certain words conjure up fear of missing a potentially fatal diagnosis that might be curable if found early. It has been drilled into most medical students that a patient complaining of "the worst headache of their life" likely has a subarachnoid hemorrhage due to a leaking brain aneurysm and action needs to be taken immediately. Even with improved technology, the diagnosis of a brain aneurysm hasn't changed much in a generation. However, not all patients with headaches need a CT scan and/or a lumbar puncture. Unfortunately, the worst headache term is sometimes exaggerated by patients and the art of medicine is appreciating the severity of a patient's pain and deciding how aggressive to be in trying to make the diagnosis.
Before a disastrous bleed occurs from a ruptured aneurysm, a patient will often develop an intense sentinel, or "warning," headache due to a tiny leak. In the time between the initial small leak and the large bleed there is an opportunity to make a difference in a patient's life. If a sentinel bleed occurs, two things need to happen:
Most people will suffer from a significant headache in their lifetime, but how many need to be aggressively evaluated for a possible brain aneurysm? Patients who have leaking blood that irritates brain appear markedly ill.
For a patient with a potential leaking brain aneurysm, a CT scan of the head is the first step.
This is the classic approach to diagnosis, but some physicians advocate performing a less invasive CT angiogram to look for the aneurysm. This decreases the miss rate from 5% to 1%, but for many people even that risk is too high. For those people unlikely to accept any risk, it is better to proceed with tests.
It is easier to prove a positive diagnosis than try to prove something that isn't there. This is especially true when the tests necessary to diagnose a brain aneurysm are invasive and unpleasant. Until science provides better tools, subarachnoid hemorrhage from a leaking brain aneurysm remains a challenge for both physicians and patients. Trying to decide who would benefit from testing is truly the art of medicine. It takes experience to forgo CT scans, angiograms, and lumbar punctures and instead rely on talking to the patient and performing a physical exam.
Last Editorial Review: 2/9/2012