Acute confusional state as presenting feature in aneurysmal subarachnoid hemorrhage: frequency and characteristics

In many patients with subarachnoid hemorrhage (SAH) there is a delay betwee n the onset of symptoms and admission to hospital. An important cause for t he delay is an initially erroneous diagnosis. The goal of this study was to determine the frequency of acute confusional state (ACS) as a presenting s ymptom of SAH and to describe the clinical and radiological characteristics of these patients. We studied all 717 patients registered from January 198 9 to July 1997 in the SAH database of the University Medical Center Utrecht . For patients who presented with ACS we reviewed the computed tomography s cans for baseline characteristics: the amount of cisternal blood, intravent ricular or intracerebral hemorrhage, and hydrocephalus. Details about featu res of onset were known for 646 patients. Nine patients (1.4%) presented wi th ACS. Ln five patients ACS was either preceded by a period of loss of con sciousness or accompanied by severe headache. Subtle focal deficits were fo und at initial neurological examination in four patients. Computed tomograp hy demonstrated a frontal hematoma in three patients and hydrocephalus in f our. The site of the ruptured aneurysm was at the anterior communicating ar tery in four patients, at the internal carotid artery in two, and at the ba silar artery in two. In our series, one per 70 patients with SAH presents w ith ACS. Keys to early diagnosis of SAH in patients presenting with ACS are a preceding period of loss of consciousness and severe headache on neurolo gical assessment.