A 56-year-old woman is brought to the emergency department by her partner. She had initially complained of a severe headache before collapsing unconscious on the floor at home. She has no significant past medical history but smokes 30 cigarettes a day. She has now regained consciousness and is complaining of neck stiffness. Her initial assessment
is carried out using the system shown below.
Eye opening Best motor response Best verbal response
1 None 1 None 1 None
2 To pain 2 Extension to pain 2 Incomprehensible sounds
3 To speech 3 Flexion to pain 3 Inappropriate words
4 Spontaneous 4 Withdraws from pain 4 Confused
5 Localizes to pain 5 Orientated
6 Obeys commands
• What system has been used to assess the patient?
• What is the likely diagnosis?
• What are the possible underlying causes?
The Glasgow Coma Score (GCS) is composed of three parameters: verbal commands, eye opening and motor responses. The patient is assessed on their ‘best’ response. The scores are summed to give an overall value from 3 (being the worst) to 15 (being the best). In this case the GCS is 13. While the score is useful in absolute terms, such as defining coma (GCS 8), the main value of the GCS is being able to monitor the ongoing neurological status of a patient by repeated assessment every 15 min. A fall in the score of 2 or more should prompt an urgent review of the patient, as this indicates a potentially significant deterioration in their condition.
The most likely diagnosis in this case is of a subarachnoid haemorrhage. The classical symptoms are of a severe ‘thunderclap’ headache affecting the back of the head that reaches maximal intensity within a few seconds.
Causes of bleeding into the subarachnoid space !
• 85 per cent: saccular aneurysms in the cerebral vasculature – ‘berry’ aneurysms
• 15 per cent: non-aneursymal subarachnoid haemorrhage:
• arterial dissection
• arteriovenous malformation
• cocaine abuse
• septic aneurysm
The initial management involves stabilizing the patient and arranging the following:
• blood tests: full blood count, renal function, coagulation screen and group and save
• computerized tomography (CT) of the brain: to look for evidence of subarachnoid blood and hydrocephalus
• lumbar puncture: if the CT scan does not show any pathology, then cerebral spinal fluid should be sent for spectrophotometric analysis to look for the presence of oxyhaemoglobin and bilirubin.
Differential diagnoses include transient ischaemic attacks, migraine or epilepsy. Patients confirmed to have a subarachnoid haemorrhage should be referred to a neurosurgical unit for further assessment (cerebral angiography) and treatment (embolization).
• The Glasgow Coma Score ranges from 3 to 15.
• A fall of 2 points or more should prompt an immediate reassessment