CASE HISTORY

Patient was admitted complaining of intractable headache of 7 days duration. In 1914 patient had had dyspepsia and a laparotomy was performed. After this he remained fit and until 2 years ago when his health began to fail, and 9 months ago he began to have severe headaches over the left parietal region. In October 1937 the headache and general debility became so severe that he remained off work until Feb 1938. At about this time he began to have some frequency of micturition. After starting work in Feb 1938 he remained fairly well until 7 days before admission when he complained of a severe headache across the vertex of the skull. This was associated with deafness, disturbances of vision and difficulty in moving his feet properly. He went to bed and remained there until admission. On examination, he was suffering from severe headache and was not very clear mentally. Pupils rather small, otherwise normal. Right disc indistinct. Heart and lungs normal. BP 160/90. Abdomen showed old scars, but was otherwise normal. Urine normal. Slight neck rigidity present. Kernig's sign positive. No other physical signs in the nervous system. 30.3.38 lumbar puncture 200mms fluid straw coloured and showed occult blood. 5.4.38 patient suddenly became unconscious with twitching of the mouth and right arm; recovered after 5 minutes but complained of severe headache. Lumbar puncture 180mms. Blood stained fluid withdrawn. 7.4.38 patient had a similar attack. On this occassion the limbs were spastic with increased reflexes with extensor plantar responses. Right disc appeared hazier than before, otherwise fundi normal. Lumbar puncture 2 hours later, pressure over 300mms. Fluid blood stained, pressure reduced to 90mms. Patient recovered from the attack, though the neck rigidity and spasticity remained. He continued to improve until 12.4.38 when he had another attack, this time associated with flaccidity of the limbs, but with extensor plantar attack his recovery was only partial and he never became fully conscious. Further lumbar puncture showed a blood stained fluid, no increased pressure, and he finally developed signs of bronchopneumonia and died. Laboratory investigations: Blood count RBC 4,800,000. Hb 84%, WBC 14,000. ECG normal. X-ray of chest normal. WR negative.

PATHOLOGY

There is a small, spherical aneurysm, marked by an arrow, arising at the junction of the right anterior cerebral artery with the anterior communicating. The bulk of the aneurism is embedded in the adjacent part of the frontal lobe. The surface of the aneurysm is covered with blood clot and there is a little further clot over the basal meninges. There is however unusually little meningeal haemorrhage. The reason for this is that the aneurysm has burst on its upper aspect and the bulk of the haemorrhage has spread into the brain substance where it can be seen to have destroyed a part of the frontal lobe.