Subarachnoid hemorrhage misdiagnosed as adjustment disorder

A 38-year-old woman with a history of recent grief and anxiety disorder, treated with alprazolam, was brought directly to the psychiatric emergency room after experiencing a sudden change in behavior. The patient was agitated and dysphoric, with no other changes at physical examination, except for nausea and vomiting. No other relevant personal, family (including intracranial aneurysms), or social history was known.

Adjustment disorder with anxiety symptoms, secondary to a recent diagnosis of cancer in a close family member, seemed the most plausible diagnosis to prehospital emergency providers. However, as the psychiatric team felt that an organic cause had not been clearly excluded, routine blood work and a computed tomography (CT) scan of the head were obtained.

Head CT revealed a frontal subarachnoid hemorrhage (SAH). Posterior cerebral angiography found two bilobar saccular aneurysms, one measuring 4 mm at the left middle cerebral artery bifurcation and a second one measuring 6 mm at the anterior communicating artery (Figure 1).

Figure 1
Head computed tomography scan revealing frontal subarachnoid hemorrhage and cerebral angiography showing two aneurysms, before and after endovascular coiling.

After imaging, the patient developed headache, meningism, and upper limb paresis. She was rapidly transferred to the Neurosurgery Department and underwent endovascular coiling of the larger aneurysm. Following treatment in a neurosurgery ward, the patient was discharged with no neurological deficit (National Institute of Health Stroke and Modified Rankin Scales). There were no psychological sequelae that justified psychiatric treatment.

Bizarre presentations of SAH have been recorded in the literature, including kleptomania, akinetic mutism, amnesic-confabulatory syndrome, Capgras misidentification syndrome, auditory hallucinations, and persecutory delusion.¹ However, there are very few reports of SAH presenting with psychiatric manifestations in the absence of classic symptoms such as acute headache or meningism.

SAH occurs in 9 per 100,000 persons/year, mainly in women.² Up to 85% of cases are aneurysmatic in origin, and the mortality rate is 50%, with 15% dying before any hospital treatment.³ Severe headache, vomiting, and neck rigidity are common symptoms.⁴ Surgical or endovascular ablation are the best therapeutic available options.⁵

We believe the frontal localization of the SAH in this patient led to sudden behavioral changes that were misunderstood by the ambulance staff. This case reminds us that, in the emergency setting, careful triage is necessary to avoid fatal outcomes, especially in hurried or high-risk referrals to psychiatry.

References

• ¹
  Mobbs RJ, Chandran KN, Newcombe RL. Psychiatric presentation of aneurysmal subarachnoid haemorrhage. ANZ J Surg. 2001;71:69-70.
• ²
  de Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry. 2007;78:1365-72.
• ³
  Van Gijn J, Kerr RS, Rinkel GJ. Subarachnoid haemorrhage. Lancet. 2007;369:306-18.
• ⁴
  Cohen-Gadol AA, Bohnstedt BN. Recognition and evaluation of nontraumatic subarachnoid hemorrhage and ruptured cerebral aneurysm. Am Fam Physician. 2013;88:451-6.
• ⁵
  Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711-37.

Publication Dates

• Publication in this collection
  Jan-Mar 2015

History

• Received
  25 June 2014
• Accepted
  18 Sept 2014