American Journal of Emergency Medicine xxx (2015) xxx–xxx Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Case Report The worst amnesia of your life Abstract Subarachnoid hemorrhage (SAH) is a medical emergency that can be life threatening or lead to severe disability even if recognized and managed early. Majority of spontaneous SAHs arise from a ruptured saccular aneurysm. However, up to 15% of SAHs do not have a bleeding source and are termed nonaneurysmal SAHs. Although sudden, severe headache is classically associated with aneurysmal SAHs, nonaneurysmal SAHs tend to have a more gradual onset headache and can even present with transient amnesia in about one-third of patients. Here, we report a case of prolonged transient amnesia secondary to SAH with acute hydrocephalus in a postpartum 38-year-old woman with a history of essential thrombocytosis on aspirin. Subarachnoid hemorrhage (SAH) is a medical emergency that can be life threatening or lead to severe disability. Most spontaneous SAHs arise from a ruptured saccular aneurysm. However, up to 15% of SAHs do not have a bleeding source and are termed nonaneurysmal SAHs (NASAHs)[1]. Nonaneurysmal SAHs are thought to be from a venous source [2,3] and hence have a more favorable prognosis than aneurysmal SAHs, which are from an arterial source. Sudden severe headache is classically associated with aneurysmal SAH, but NASAH tends to have a more gradual onset headache and can present with transient amnesia in about one-third of patients [4]. A 38-year-old woman presented to the emergency department with a chief concern of memory loss for 2 days. Her last memory of events was 2 days before presentation. Her sister brought her to the emergency department for evaluation because she appeared “confused” and had no recollection of their phone conversation from the day before presentation. Her medical history included essential thrombocytosis on daily aspirin. She delivered her first baby vaginally 3 months before presentation without any complications. There was no history of seizures or migraines. On review of systems, she endorsed a mild headache without focal weakness, slurred speech, or vision changes. She reported no recent head trauma. She denied alcohol, tobacco, or illicit drug use. At presentation, her vital signs were as follows: pulse of 62 beats per minute, blood pressure of 127/80 mm Hg, respiratory rate of 16 respirations per minute, temperature of 98.7°F, and oxygen saturation of 100% on room air. On physical examination, she was alert and oriented with clear and fluent speech, and no focal neurological deficits; but she had mild neck rigidity. There was no proptosis, and the remainder of her examination was within normal limits. Laboratory examination was unremarkable except for a platelet count of 871 × 10 9/L. A noncontrast computed tomography (CT) of the brain revealed subarachnoid hemorrhage in the suprasellar cistern, third and fourth ventricle, and bilateral sylvian fissures, with acute hydrocephalus (Figure A-D). The patient was transferred to another facility for a higher level of care. She received a ventricular drain for increased intracranial pressure and was found to have no source for the bleed. The patient ultimately did well and was discharged home without any neurologic deficits. Our patient’s presentation led to a broad differential diagnosis, ranging from transient global amnesia (TGA), to cerebral venous thrombosis (CVT), and to an acute intracranial bleed. Transient global amnesia is a syndrome that presents with temporary anterograde amnesia. This inability to form new memories gradually recovers, and the patient returns to normal except for the amnestic gap during the attack. The pathophysiology of TGA is unclear but has been associated with strokes [5]. The arguments against a simple case of TGA in our patient included the patient’s young age, the presence of a headache, neck rigidity on examination, and duration of amnesia greater than 24 hours, all of which are uncommon in classic TGA [6]. The patient’s postpartum state, coupled with her increased risk of venous slugging from thrombocytosis, put CVT high on the differential diagnosis. Postpartum patients are at increased risk of thrombotic complications until at least 12 weeks after delivery [7]. However, the patient had no proptosis or cranial nerve deficits to support a diagnosis of CVT. The other consideration was SAH given her neck rigidity and headache, even though this was not the worst headache of her life. Although the CT scan revealed a SAH, CT angiography of the head did not show a source for the bleed. Subarachnoid hemorrhages that do not have a bleeding source are termed NASAH. Usually, this diagnosis is not given until second imaging is done because an initial false-negative angiography is possible due to vascular thrombosis or vasospasm [8]. There are 2 types of NASAH. Majority of patients with NASAH have perimesencephalic hemorrhage, where blood is localized to the cisterns around the midbrain and the center of bleeding is anterior to the midbrain [2]. The remaining patients with NASAH have a bleeding pattern that is not perimesencephalic and are termed nonaneurysmal nonperimesencephalic SAH. Our patient’s pattern of hemorrhage had features of a perimesencephalic hemorrhage with blood in the suprasellar cistern. Regardless of the distinction, NASAHs have a more favorable prognosis than aneurysmal SAHs. Moreover, patients tend to have a milder headache and can present with transient amnesia [4]. Subarachnoid hemorrhage may not always present in the classic way with “the worst headache of my life.” An entity called NASAH can have a more subtle presentation, including transient amnesia. Our case is particularly interesting because the patient’s history was more concerning for a thrombotic event rather than hemorrhage given her hypercoagulable state. Muneer Hameer MD New York Medical College, Metropolitan Hospital Center Department of Emergency Medicine, New York, NY ⁎Corresponding author at: New York Medical College Metropolitan Hospital Center, Department of Emergency Medicine 1901 First Ave 2A31, New York, NY 10028. Tel.: +1 2124236684 E-mail address: muneer.hameer@gmail.com 0735-6757/© 2015 Elsevier Inc. All rights reserved. Please cite this article as: Hameer M, et al, The worst amnesia of your life, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.069 2 M. Hameer et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx Figure. Noncontrast CT of the brain showing subarachnoid hemorrhage. A, Transverse CT of the head showing blood in the fourth ventricle. B, Transverse CT of the head showing blood in the suprasellar cistern. C, Transverse CT of the head showing blood in bilateral sylvian fissures. D, Transverse CT showing acute hydrocephalus with transependymal edema of the occipital horn. Aashish Valvani MD New York Medical College, Metropolitan Hospital Center Department of Internal Medicine New York, NY Hossein Kalantari MD New York Medical College, Metropolitan Hospital Center Department of Emergency Medicine New York, NY Getaw Worku Hassen MD, PhD New York Medical College, Metropolitan Hospital Center Department of Emergency Medicine, New York, NY http://dx.doi.org/10.1016/j.ajem.2015.03.069 References [1] Konczallla J, Platz J, Schuss P, Vatter H, Seifer V, Guresir E. 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