The nose knows: an unusual presentation of a cerebral aneurysm

Cerebral aneurysms most commonly present with subarachnoid hemorrhage (SAH), a catastrophic event. However, 11-15% of unruptured aneurysms are symptomatic, with presentations including seizures, unilateral cranial nerve deficits, visual loss, headache, and ischemia. Of patients presenting with seizures, the semiology described includes speech arrest, "feelings of dread," localized pins and needles, and tonic clonic episodes. We report the case of a patient who presented to the emergency department (ED) with complex partial seizures secondary to a cerebral aneurysm.

A 54-year-old woman presented to the ED after an episode where she had noticed a "bad smell" and sensations of nausea and dizziness. This was the third episode she had experienced in 2 weeks, and other than migraine, she had no significant medical or family history. Physical examination was normal, but a computed tomography (CT) scan of the brain revealed a 15-mm aneurysm of the right middle cerebral artery. The patient was subsequently transferred for urgent neurosurgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The emergency physician should strongly consider the use of head CT in the evaluation of adults presenting with a first unprovoked seizure, as rarely they can be caused by urgent pathologies including cerebral aneurysms. If a patient is found to have a possible symptomatic unruptured aneurysm, they should be referred for urgent neurosurgical consultation, as these lesions have an increased risk of rupture.