• Users Online: 220
  • Print this page
  • Email this page

Table of Contents
Year : 2019  |  Volume : 7  |  Issue : 4  |  Page : 128-130

A case of sentinel headache misdiagnosed: A catastrophe

Department of Medicine, M R Medical College, Kalaburagi, Karnataka, India

Date of Submission03-Aug-2019
Date of Acceptance06-Aug-2019
Date of Web Publication18-Oct-2019

Correspondence Address:
Dr. Fida Hussain Mitha Bhai
M R Medical College, Kalaburagi, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AJIM.AJIM_23_19

Rights and Permissions

Headache is the main complaint in outpatients consulting the neurologist and of adult patients presenting to an emergency department (ED) complaining of a headache. About a quarter of all patients presenting to the ED with a sudden-onset severe headache, described as the “worst of their lives,” have a subarachnoid hemorrhage. Patients may report symptoms consistent with a minor hemorrhage such as mild headache before a major rupture, which has been called a sentinel headache. Hereby, we describe a case of warning headache, an underestimated diagnosis.

Keywords: Cerebrospinal fluid analysis, sentinel headache, subarachnoid hemorrhage, warning headache, xanthochromia

How to cite this article:
Bhai FH, Biradar S. A case of sentinel headache misdiagnosed: A catastrophe. APIK J Int Med 2019;7:128-30

How to cite this URL:
Bhai FH, Biradar S. A case of sentinel headache misdiagnosed: A catastrophe. APIK J Int Med [serial online] 2019 [cited 2022 Sep 26];7:128-30. Available from: https://www.ajim.in/text.asp?2019/7/4/128/269559

  Introduction Top

Subarachnoid hemorrhage (SAH) accounts for only 5% of all strokes, and outcome for patients with SAH remains poor, with population-based mortality rates as high as 45% and significant morbidity among survivors. A large multinational World Health Organization (WHO) study found that the age-adjusted annual incidence of SAH varied 10-fold between different countries, from 2.0/100,000 population in China to 22.5/100,000 in Finland.[1] The WHO MONICA stroke study, done in Europe and China, reported a 30-day case fatality rate of 42%.[1] The risk for permanent disability is high among survivors, and the dependency rate is approximately 50%. Ruptured cerebral aneurysms account for 75%–85% of SAH for nontraumatic SAH.

The onset of headache may be associated with ≥1 additional signs and symptoms, including nausea and/or vomiting, stiff neck, a brief loss of consciousness, or focal neurological deficits (including cranial nerve palsies).

Patients may report symptoms consistent with a minor hemorrhage before a major rupture, which has been called a sentinel bleed or warning leak.

  Case Report Top

A 37-year-old male presented to our hospital with a history of headache for 7 days and altered sensorium for 1 h. The headache was insidious in onset moderate to severe in intensity diffuse type but more in the frontal region and was not associated with blurring of vision and vomiting. For which he had consulted in another hospital and was diagnosed to have hypertension, he was initiated on antihypertensive medications. He was still symptomatic and went for a second opinion with a physician and was advised to undergo brain imaging (both computed tomography [CT] and magnetic resonance imaging [MRI]) [Figure 1] and [Figure 2], which revealed a normal study. An hour ago, the patient had become unresponsive, wherein he had a fixed gaze, frothing at mouth with a postictal confusion for about 5–10 min. He had bladder and bowel incontinence on the way to the hospital. In ER, the patient had one episode of nonbilious, projectile vomiting. There was no associated history of fever, tongue bite, head injury, or any other previous medical illness. He was a known alcoholic and his last drink was around 1 month back.
Figure 1: Computed tomography brain – Normal study

Click here to view
Figure 2: Magnetic resonance angiography brain – Normal study

Click here to view

On examination, in ICU patient was conscious but irritable with a Glasgow Coma Score – E4V4M6. Both the pupils were normal in size and reactive to light, and the patient was able to move all four limbs. There were no obvious external injuries. Brain imaging a week ago was normal. Cerebrospinal fluid (CSF) analysis was planned to be performed the following day.

CT brain was advised to rule out any organic cause of seizures (new symptom), which revealed it to be subarachnoid hemorrhage [Figure 3]. Neurosurgical consult was needed, and CT brain angiogram was advised to rule out any vascular abnormalities. Routine laboratory parameters were normal, except for leukocytosis (total leukocyte count – 16,400). Prothrombin time and INR were in normal range. The patient was started on nitroglycerin drip for high blood pressures along with injection tranexamic acid and tablet nimodipine.
Figure 3: Computed tomography brain — Arrows indicating subarachnoid hemorrhage (1 week postwarning headache)

Click here to view

The patient had a fall in GCS during the next 6 h (E2V3M6) and was transferred to a higher center for neurosurgical intervention. CT angiogram revealed anterior communicating artery rupture, which was treated with endovascular balloon-assisted coiling. The patient made a good recovery and was self-ambulatory within a week.

  Discussion Top

Patients may present with mild headache in consistence with a minor bleed (warning leak) before a major and full-blown SAH can develop, known as a sentinel headache or warning headache. The majority of these minor hemorrhages occur within 2–8 weeks before overt SAH. The headache associated with a warning leak is usually milder than that associated with a major rupture, but it may last for a few days.[2] Nausea and vomiting may occur, but meningismus is uncommon after a sentinel hemorrhage. The importance of recognizing a warning leak cannot be overemphasized. A high index of suspicion is warranted because diagnosis of the warning leak or sentinel hemorrhage before a catastrophic rupture may be lifesaving.[3]

Cranial CT scan is the first-choice investigation in suspected SAH, but the sensitivity is related to the time elapsed from the bleeding, detecting blood in 95% within 24 h, in 74% on the 3rd day, in 50% after 1 week, in 30% after 2 weeks, and absence of abnormal findings after 3 weeks. Thin-slice cranial CT should be performed, because small blood collections may not be evident with thicker slices.[4] Brain MRI showed nearly the same sensitivity in acute phase (94%) and higher sensitivity in subacute phase (100%).[5]

CSF examination with spectrophotometry, performed after 12 h, showed a higher sensitivity, with evidence of xanthochromia in 100% of SAH within 14 days, in 70% in the 3rd week, and in 40% in the fourth. Because of its risks, lumbar puncture (LP) should be performed only after cranial CT.[6]

In our case, brain imaging in the 1st week was not able to pick up on any warning leak and a CSF analysis should have been done in the first instance.

Usually, the characteristic clinical features of SAH such as the presence of neurological signs and symptoms, consciousness impairment, and neck stiffness are not present in SH. Underestimation or misdiagnosis of SH depends on incorrect evaluation of the headache characteristics (unusual, severe, abrupt, and thunderclap), overestimation of cranial CT sensitivity (false negative increasing over the elapsing time), failure to perform LP in patients with negative CT, incorrect evaluation of CSF findings (xanthochromia may be absent in the first 12 h), and failure to differentiate traumatic tap from true SA.[7] Seizures may occur in up to 20% of patients after SAH, most commonly in the first 24 h and more commonly in SAH associated with intracerebral hemorrhage, hypertension, and middle cerebral and anterior communicating artery aneurysms.

The important risk factors for the development of cerebral aneurysms are hypertension, smoking, chronic alcohol use, family history of intracranial aneurysms in first-degree relatives, and female sex. The incidence of aneurysmal rupture is higher in the African American and Hispanic population compared with Whites. Autosomal dominant polycystic kidney disease has a prevalence rate 2–4 times higher than the general population. Connective tissue disorders such as Marfan syndrome are weakly associated [Table 1].[8]
Table 1: Risk factors for intracerebral aneurysms

Click here to view

  Conclusion Top

This case report highlights the need for considering, the diagnosis of sentinel headache in all cases of a severe, suddenonset (thunderclap) headache. And timely performing all the appropriate diagnostic examinations, including LP if necessary, could prevent missing subsequent fatal consequences.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ingall T, Asplund K, Mähönen M, Bonita R. A multinational comparison of subarachnoid hemorrhage epidemiology in the WHO MONICA stroke study. Stroke 2000;31:1054-61.  Back to cited text no. 1
Juvela S. Minor leak before rupture of an intracranial aneurysm and subarachnoid hemorrhage of unknown etiology. Neurosurgery 1992;30:7-11.  Back to cited text no. 2
Jakobsson KE, Säveland H, Hillman J, Edner G, Zygmunt S, Brandt L, et al. Warning leak and management outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 1996;85:995-9.  Back to cited text no. 3
Evans RW. Diagnostic testing for the evaluation of headaches. Neurol Clin 1996;14:1-26.  Back to cited text no. 4
Mitchell P, Wilkinson ID, Hoggard N, Paley MN, Jellinek DA, Powell T, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. J Neurol Neurosurg Psychiatry 2001;70:205-11.  Back to cited text no. 5
Duffy GP. Lumbar puncture in spontaneous subarachnoid haemorrhage. Br Med J (Clin Res Ed) 1982;285:1163-4.  Back to cited text no. 6
Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29-36.  Back to cited text no. 7
Brisman JL, Song JK, Newell DW. Cerebral aneurysms. N Engl J Med 2006;355:928-39.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Case Report
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded152    
    Comments [Add]    

Recommend this journal