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Subarachnoid hemorrhage presenting as chest pain

      To the Editor:—Patients presenting with chest pain continue to be a difficult challenge to the emergency doctors.
      • Lee T.H
      • Goldman L
      Evaluation of the patient with acute chest pain.
      Cardiovascular causes must be ruled out first because the history cannot distinguish between coronary artery disease and other causes of chest pain. The percentage of patients who present at the ED with acute chest pain and are admitted to the hospital is growing,
      • Goldman L
      • Cook E.F
      • Johnson P.A
      • Brand D.A
      • Rouan G.W
      • Lee T.H
      Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain.
      and costs increase as well. At the same time, discharging patients with myocardial infarction because of a missed diagnosis can have dire consequences.
      • Pope J.H
      • Aufderheide T.P
      • Ruthazer R
      • et al.
      Missed diagnoses of acute cardiac ischemia in the emergency department.
      However, chest pain sometimes could be a dilemma between different life-threatening cardiovascular diseases,
      • Nallamathu B.K
      • Eagle K.A
      When zebras run with horses the diagnostic dilemma of acute aortic dissection complicated by myocardial infarction.
      be a common symptom of noncardiac diseases,
      • Botoman V.A
      Noncardiac chest pain.
      or masquerade unfrequent neurologic diseases.
      • Combarros O
      • Vadillo A
      • Gutierrez-Perez R
      • Berciano J
      Cervical spine cord infarction simulating myocardial infarction.
      We describe a patient with spinal subarachnoid hematoma whose clinical presentation with sudden acute chest pain without any neurologic sign at onset prompted the initial diagnostic suspicion of an acute vascular emergency.
      A 74-year-old man presented to the ED with the sudden, abrupt onset of acute pain, described as very severe and tearing, associated with diaphoresis, paleness, and hypotension. The pain was felt in the center of the chest and radiated to the back. In his medical history, there was only mild hypertension. On admission, the electrocardiogram excluded acute myocardial ischemia, the blood chemistry panel did not show elevations of cardiac enzymes, whereas a chest radiograph revealed a significant aortic root dilatation. An aortic dissection was therefore suspected, but a computed tomography scan with contrast excluded this diagnosis.
      Physical and neurologic examinations resulted in normal findings. The pain propagated distally down within a few hours. The day after, he experienced paresthesias with a sock distribution in the left lower limb. Neurologic examination revealed only a Babinski sign on the left. Panspinal magnetic resonance image (MRI) showed the presence of a subarachnoid haemorrage with a hematoma at the dorsal level D9–D12. The spine was normal. Clotting disorders were carefully excluded. The subsequent clinical course was uneventful and the patient underwent complete recovery within 2 days. A further MRI examination demonstrated the complete blood reabsorption and confirmed normal spine signal. No vascular malformations were detected apart from the presence of an angioma at the level D11 within an otherwise normal vertebra. Spinal angiography was not performed because of the patient’s refusal.
      Spontaneous spinal subarachnoid hemorrhage is unusual and rarely results in spinal subarachnoid hematoma because the cerebrospinal fluid tends to dilute the blood and prevent the formation of clots. Patients with this disease could present with serious signs of myelopathy, and urgent surgical decompression is then warranted to preserve neurologic functions.
      • Toole J.F
      • Robinson M.K
      • Mercuri M
      Primary subarachnoid hemorrage.
      ,
      • Sunada I
      • Akano Y
      • Kidosaki Y
      • Shimokawa N
      • Yamamoto S
      Spontaneous spinal subarachnoid hematoma—case report.
      ,
      • Komiyama M
      • Yasui T
      • Sumimoto T
      • Fu Y
      Spontaneous spinal subarachnoid hematoma of unknown pathogenesis case reports.
      When spinal cord symptoms are present, the correct diagnosis is easily made. However, often, the clinical picture is that of local pain in the spinal column, which eventually becomes stiff. The pain can be severe and worsened by movement. It could be felt at various level along the vertebral column depending on the site of bleeding.
      • Toole J.F
      • Robinson M.K
      • Mercuri M
      Primary subarachnoid hemorrage.
      Thus, the frequent absence of remarkable spinal cord involvement and nerve root signs could delay diagnosis or lead to misdiagnoses, in particular while arising at the thoracic level and presenting with suddent thoracic pain, mimicking vascular emergencies. Slight signs of meningeal irritation, nerve roots, and spinal cord compression must be carefully searched in patients with sudden backache without proven cardiovascular causes.
      There is no doubt that triage of patients with chest pain is extremely difficult,
      • Reilly B.M
      • Evans A.T
      • Schaider J.J
      • Wang J
      Triage of patients with chest pain in the emergency department a comparative study of physicians decisions.
      and medical literature everyday adds new suggestive presentations of infrequent diseases. Nevertheless, EPs should be familiar also with unfrequent conditions to assure appropriate therapy in a timely manner. Spontaneous spinal subarachnoid hemorrhage should be considered early in the differential diagnosis either of acute spinal cord compression or, in any case of sudden back pain of unknown etiology, even in the absence of remarkable neurologic deficit.

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