ARTERIOVENOUS MALFORMATION HEMORRHAGE MUST BE RECOGNIZED IN A TIMELY FASHION TO ALLOW FOR NECESSARY TREATMENT

When a patient presents to an emergency department with the new onset of headache, lethargy or altered mental status without the development of a "focal" neurological deficit, it is imperative that intracranial hemorrhage be high in the differential diagnosis list. One can suffer a subarachnoid hemorrhage or an intracerebral hemorrhage without focal neurological deficit but with severe headache and altered mental status. What should be done to evaluate such a patient? A CT scan of the head. When should it be performed? quickly. Why? Because the causes of subarachnoid hemorrhages are treatable if diagnosed and treated before the lesion rebleeds. The same is applicable to arteriovenous malformations (AVMs)within the brain.
In my client's case, there was the new onset of a severe headache with lethargy. He was taken to a local hospital where he was evaluated in the ER. He was admitted to the floor for observation but no imaging studies were ordered. Some eight hours later, he decompensated neurologically and became comatose. One pupil dilated. He had an immediate CT scan that showed an intracerebral hemorrhage from an AVM. Surgery was performed to evacuate the blood clot and relieve the pressure. There was some permanent injury to the brain as a result of this delayed diagnosis. Time is of the essence when there is an intracranial hemorrhage and all medical care personnel have to look for such hemorrhages as a source of sudden severe headache in aptients who come to the ER.