Clinical lessons and risk factors from 403 fatal cases of subarachnoid haemorrhage

Intracranial aneurysm rupture continues to cause high mortality and morbidity. Determining the aetiology, identifying the risk factors and improving diagnostic accuracy are ongoing challenges. We retrospectively reviewed consecutive autopsies over 30 years (1977–2006) in Auckland, New Zealand, and identified 403 cases of subarachnoid haemorrhage to examine these challenges within a fatal case population. Females (67%) outnumbered males. Ruptured posterior circulation aneurysms were frequent (25%). Left ventricular hypertrophy was documented in 45% of cases, with fatty metamorphosis of the liver also prominent (16%). About 6.5% had additional unruptured aneurysm/s. Most patients were sedentary at onset (39% being asleep); 6% were involved in significant physical exertion; 69% were found dead or collapsed; the remaining patients reported headache (27%) or atypical primary symptoms (4%). Warning headache over recent days to months occurred in 38%, among whom misdiagnosis was notable. Our findings regarding warning headache patterns and the range of atypical presentations are aimed at improving clinician discernment in managing this condition.