In this Clinical Risk Alert, THEMIS’s Lead Clinical Partner, TMLEP, discusses the possibility of brain haemorrhage as a differential diagnosis in patients who present with severe headaches and vomiting without clear cause.
A Case Example
The patient, in this case, presented to A&E with constant severe headache and vomiting without history of a head injury. A diagnosis of suspected urinary tract infection was made despite test results not corroborating this. They were prescribed antibiotics and analgesia and sent to an out of hours GP.
The patient was found unconscious the next morning and was taken to A&E. A CT scan showed a large area of intracerebral haemorrhage. Unfortunately, no surgical treatment was possible and the patient sadly died.
The main learning points from this review stem from the following events:
Lack of appreciation of the severity of the focal headache
Not considering the possibility of a brain haemorrhage
- No brain scan was undertaken
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
Undertake further investigations into headaches that do not improve with analgesia and present alongside symptoms such as fever and vomiting without other obvious cause NICE Guidance CG150. Given the potential severity of conditions causing these symptoms, it is crucial to investigate further using brain scans to determine whether patients are suffering from life-threatening conditions such as meningitis or brain haemorrhage.
Other symptoms should also be highlighted as warranting further investigation if present with severe headaches, such as neurological changes, personality changes and impaired levels of consciousness.
Consider brain haemorrhage as a differential diagnosis in cases of sudden onset of severe headache that presents with vomiting and no other obvious cause, where infection can be ruled out on the basis of blood results and clinical symptoms. Whilst infection is a common cause of vomiting and headache, it is unusual for a headache to be so severe as a result of dehydration caused by something such as gastroenteritis. This should prompt clinicians to look into less obvious causes of the patient’s symptoms. This is especially important when test results do not corroborate a diagnosis of infection.
Perform CT brain scans when the cause of severe headache is uncertain and patients do not respond to analgesia. Undertaking brain imaging in such cases is paramount to diagnosing brain haemorrhage (2) and facilitating relevant treatment in a timely manner to reduce the chance of death in a condition with an already-high mortality rate of around 40% at 1 month (3).
- Ensure any diagnoses of infection or virus are backed up by clinical symptoms and test results where available. When diagnoses of infection are made in cases of severe headache, ensure that other symptoms are in accordance with what would be expected for such infection as misdiagnosing brain haemorrhage as infection can lead to failure to provide treatment for haemorrhage, ultimately resulting in severe if not fatal consequences for the patient.
This is a case of a patient who had a brain haemorrhage and was misdiagnosed with an infection, despite their clinical symptoms and test results not corroborating this diagnosis and their presentation of severe headache.
TMLEP would like to highlight the importance of being aware of the possibility of brain haemorrhage as a differential diagnosis in patients who present with severe headaches and vomiting without clear cause and stress the necessity of investigating this in a timely manner to increase the chance of optimal outcome for the patient.