A case of subarachnoid hemorrhage that a fire department first reported as an inhalation burn injury.

Dear Editor,

The typical presentations in cases of subarachnoid hemorrhage (SAH) caused by cerebral aneurysm rupture include headache, vomiting, giddiness, or unconsciousness.[1] We herein report a case of SAH, in which the first call from a fire department reported an inhalation burn injury.

The patient was a 53-year-old homeless man who had been living under a bridge that was hit by a fire. At the scene, the exposed surface of his face and upper extremities was sooty. He had second-degree burns, mainly to his nose. He was able to answer that he felt no pain but could not respond to the other questions and enter the ambulance by himself. On the way to our institution, however, he became restless. After arriving at our department, he was transferred to a bed on a stretcher. As he did not have any relative and had not depended on public assistance, the details of his past and family history were unclear. He attempted to sit up and could not respond to verbal stimulation. He was, therefore, restrained by the medical staff, and a sedative drug was administered. A computed tomography (CT) examination revealed an SAH, mainly in the basilar cistern, and an anterior interhemispheric fissure [Figure 1]. CT angiography showed an aneurysm at the anterior communicating artery. Aneurysmal neck clipping was performed on the same day, and the patient was transferred to a nursing care facility.

Figure 1

Head computed tomography on arrival. The computed tomography examination revealed subarachnoid hemorrhage, mainly in a basilar cistern and an anterior interhemispheric fissure

The suspected clinical course is as follows. The patient first suffered from a cerebral aneurysmal rupture. He then became disoriented and caused the fire, which resulted in the burns to his body. During the transportation or after his arrival at the hospital, the cerebral aneurysm is thought to have re-ruptured.

In the present case of SAH, the main clinical symptom was restlessness rather than a loss of consciousness or headache. In 2000, Reijneveld conducted a retrospective study to determine the frequency at which SAH induced an acute confusional state (ACS). They studied 646 SAH patients and found that nine patients (1.4%) presented in an ACS.[2] They concluded that the keys to the early diagnosis of SAH in the neurological assessment of patients presenting with an ACS were a preceding loss of consciousness or severe headache. However, the possibility of SAH cannot be denied in cases with no preceding period of loss of consciousness or headache, since two patients who presented in an ACS showed no such symptoms. Meanwhile, Downes et al. reported that most ACS (89%) cases were induced by alcohol/illicit drug abuse or psychiatric illness.[3] However, some of the cases were caused by endogenous diseases, including SAH. Thus, it is possible that an incorrect initial diagnosis may lead to worse clinical outcomes if the patients in whom an ACS is induced by SAH are treated as alcohol/illicit drug abusers or psychiatric patients.[45]

In conclusion, when treating patients present in an ACS, it is necessary to first rule out endogenous diseases using sedation and then to consider other diagnostic possibilities such as illicit drug abuse or psychiatric illness.

Financial support and sponsorship

Youichi Yanagawa received a research fund from the Ministry of Education, Culture, Sports, Science, and Technology - Supported Program for the Strategic Research Foundation at Private Universities, 2015–2019, concerning the constitution of total researching system for comprehensive disaster, medical management, corresponding to wide-scale disaster.

Conflicts of interest

There are no conflicts of interest.