What caused this aneurysm?

October 10, 2006 10:55 PM

WWII Medical Mystery Filter: Why did this young woman have an aneurysm?

During World War II, a young woman in the UK is hit in the head by a boom at a munitions factory, but the 21-year-old woman seems to be okay. (No details available on what this means.) About two weeks later, she and her younger sister go on a trip to the seashore by themselves. While there, she gets her period and complains that she feels very ill and that her period is very heavy. The younger sister persuades her to stay just one more day.

The next day, they take the train back home. The young woman gets into the shower and calls her mother, who gasps at the amount of blood and rushes her to hospital. Tragically, the young woman dies in hospital. Doctors say the cause is an aneurysm.

Over the years, family members assumed the aneurysm was caused by the blow to the head. The younger sister has spent 60 years blaming herself for persuading her older sister to spend one more day at the beach.

Can a blow to the head result in an aneurysm that would lead to bleeding that would be mistaken for a period? It's possible that something else caused the aneurysm. And it's possible the doctors used aneurysm and the family assumed it was related to the head injury.. Perhaps doctors even used aneurysm vaguely. It does seem a little odd that an aneurysm would take place over a few days, but I am not a doctor.

posted by acoutu to health & fitness (22 answers total)

It seems like the most important question is where was the aneurysm? You don't make it quite clear--was it in her brain or below the waist? If the aneurysm was in her head, it was probably the accident that caused it, or it could have been there all along--brain aneurysms are not uncommon. It's very possible that the head injury could have weakened a blood vessel in her brain, and that it didn't rupture until a few days later.

It sounds like you're saying that it was a uterine vessel that ruptured. IANAD, but I've never heard of a period-realted aneurysm. What vessel would have burst?

I do know that aneurysm ruptures are sudden, unpredictable events. Aneurysms are nearly impossible to detect until they rupture. There is no way anyone involved could have known that this accident was going to occur. Even if the elder sister had come home a day earlier, she surely wouldn't have gone to the hospital until the bleeding started in earnest in the shower next day, anyway.

No matter what the cause, the most important thing is that the sister, if she is still alive, forgives herself for something she IN NO WAY caused, and, in all probablility could never have prevented.
posted by folara at 11:44 PM on October 10, 2006

Well, I'm not sure that the doctors said what kind of aneurysm it was. I don't have a lot of details and there aren't many forthcoming. However, I think the family interpreted aneurysm as something related to being hit in the head. And, although I'm not a doctor, I just can't see how that would be related. A uterine aneurysm would seem more likely to me, but isn't that a sudden, unpredictable event, not something that takes place over a couple of days? Granted, perhaps it coincided with her period.

I wonder if doctors would use aneurysm to describe a uterine vessel rupture...maybe stemming from an abortion, pregnancy or STD? The part where they go off to the seashore during the war makes me wonder about such things. Aneurysm would be a lot more palatable given the times.

I absolutely agree that the younger sister is not to blame, but I'm not sure she's ever going to come to peace with it.
posted by acoutu at 11:51 PM on October 10, 2006

First of all, I am not a doctor, but I am a medical writer and I've just been reading a lot about cardiovascular medicine, specifically about abdominal aortic aneurysm. Abdominal pain could definitely be a symptom, especially in one so young, but death is generally quite quick -- you basically bleed out internally. However, such an event would be completely unrelated to head trauma.

What you are describing sounds more like the symptoms of ectopic pregnancy or a botched abortion, frankly. I can see "aneurysm" being used as a euphemism, especially if the young woman was unmarried. Or, it was a tragic coincidence -- she was hit, then died of something completely unrelated.
With such a strange and vague story and collection of symptoms, I don't see how you can ever really resolve this without access to the original medical records, which may or may not have been altered to protect the woman. That poor sister. How could she have known, in any event?
posted by melissa may at 11:58 PM on October 10, 2006

(Sorry acoutu, as I was composing I didn't see the first answer or your reply. And I hope that someone else -- specifically a doctor -- can be more helpful to you. What a sad, sad story.)
posted by melissa may at 12:02 AM on October 11, 2006

Quick data point about aneurysms. I have a distant relative who died from a brain aneurysm and it's reallly one of those things where you're fine and then you pitch over dead. Usually there is a weakened blood vessel wall, and then all of the sudden it bursts. This is probably something you already know, but the idea of an aneurysm taking place over days doesn't jjibe with what I know.
posted by jessamyn at 5:14 AM on October 11, 2006

I think Melissa is on the right track with the ectopic pregnancy.
posted by Mister_A at 6:51 AM on October 11, 2006

Yes the one story that I've heard (from a friend who witnessed this happening to thier father) about an aneurysm involved the victim being abosolutely fine one moment and on-the-floor dead the next.
posted by ob at 7:20 AM on October 11, 2006

Very probably she did not have an aneurysm, or if she did it was a secondary effect of the real underlying problem: a subdural hematoma caused by the blow to the head.

The connection with a heavy period is that as the hematoma grows larger blood presure increases to force blood into brain tissues against the growing pressure of the hematoma, and high blood pressure caused the heavy period.
posted by jamjam at 8:21 AM on October 11, 2006

The story doesn't make sense as told - there's some piece of information missing.

Head trauma doesn't cause cerebral aneurysms, nor is it known to cause them to rupture. The known risk factors include high blood pressure and smoking; these are weak risk factors, and many folks with aneurysms don't have them. Folks with autosomal dominant polycystic kidney disease, a genetic disorder, also get cerebral aneurysms, but that disorder is quite rare.

An aortic aneurysm would not cause metrorrhagia (excessive uterine bleeding). When you bleed out from one of those, it happens into the thorax or the abdomen.

I don't buy jamjam's explanation, either. Subdural intracranial hematomas also are generally non-traumatic in origin. Subarachnoid or epidural intracranial hematomas can be due to trauma. They can lead to high blood pressure, usually during their terminal phases, but this is accompanied by coma. Also, high blood pressure by itself doesn't cause uterine bleeding unless there's something structurally wrong in the uterus - menstruation is not a hose.
posted by ikkyu2 at 1:31 PM on October 11, 2006

My guess, by the way, is that the blow to the head was entirely unrelated to the subsequent story. Blows to the head are extremely common, and frequently related to me by patients, regarding stories in which they could have played no causal role.
posted by ikkyu2 at 1:34 PM on October 11, 2006

With regard to jessamyn's comment: not everyone with a cerebral aneurysm pitches over dead. In the days of 2% autopsy rates, it's hard to know for sure, but we think maybe 1/3 of aneurysmal ruptures result in immediate death or coma. Perhaps another 1/3 result in severe neurologic impairment - sufficient to cause emergency medical services to be summoned immediately - and the remaining 1/3 of folks experience a severe headache and maybe some double vision. (Google "Hunt and Hess grade" for more on this topic.)

One of the more interesting tales was that of Soma Weiss, a physician known as a master diagnostician at the Brigham and Women's hospital in Boston. He was giving a lecture in 1942, stopped, said "I believe I have ruptured a berry aneurysm," and fell over unconscious. This, his last diagnosis, was correct; the decision was made not to transport him to a different hospital for surgery, and he rebled and died a few days later. Dr Weiss lives on in the eponymic Mallory-Weiss tear and the Charcot-Weiss-Baker syndrome.
posted by ikkyu2 at 1:47 PM on October 11, 2006

Thanks. So it's sounding like the blow to the head was unrelated. I do know that the young woman's mother later died of a brain aneurysm, but that was sudden and I can't see how it was related. One of the young woman's other sisters had kidney disease, but, again, the one who bled out was thought to be healthy.

My guess, before I posted this, was that an ectopic pregnancy or botched abortion were to blame. (Although I did read that some STDs, like syphillis, can cause such problems.) Is that seeming likely, given that we've pretty much ruled out the aneurysm and possibly the hematoma?
posted by acoutu at 2:34 PM on October 11, 2006

If the woman's sister had kidney disease and the mother had an aneursym, there is a very good chance that the patient could have had polycystic kidney disease (specifically, autosomal-dominant polycystic kidney disease). There is a strong association between berry aneursyms (of the cerebral vasculature) and ADPKD.

Then again, they could be completely unrelated.

There is very little chance that any aneurysm (that I can think of) would cause excessive menstrual bleeding. My money is on a ruptured ectopic (which may or may not cause vaginal bleeding).
posted by i_am_a_Jedi at 3:09 PM on October 11, 2006

From the Wikipedia article Subdural hematoma:

Causes

Subdural hematomas are most often caused by head injury, when rapidly changing velocities within the skull may stretch and tear small bridging veins. Subdural hematomas due to head injury are described as traumatic. Much more common than epidural hemorrhages, subdural hemorrhages generally result from shearing injuries due to rotational or linear forces (University of Vermont; Wagner, 2004).

From the eMedicine article Subdural Hematoma:

Suspect acute subdural hematoma (SDH) whenever the patient has experienced a mechanism of moderately severe to severe blunt head trauma
[...]

Chronic SDH is more difficult to anticipate, and about half of such cases offer no history of head trauma. Patients often present with progressive symptoms such as unexplained headache, personality changes, signs of increased ICP, or hemiparesis/plegia.

Since the young woman's hospitalization occurred around two weeks after her head trauma, that would just place her into the category of chronic SDH, according to the eMedicine article, if that's what was wrong and we attribute it to her accident.

I mistakenly thought it was plausible that a hematoma would cause high blood pressure which would in turn cause a heavy period. I could find no support for this view online, but the eMedicine article did have an intriguing sentence as far as this case is concerned:

Any degree or type of coagulopathy should heighten suspicion of SDH

Heavy menstrual bleeding of the sort this woman experienced is a sign of coagulopathy.

But this young woman worked in a WWII munitions factory, where there would have been ample opportunity for exposure to mercury compounds, if not an inevitability of such exposure. According to the eMedicine article Mecury :

Inorganic mercury causes cerebral infarctions as well as systemic features, such as pneumonia, renal cortical necrosis, and disseminated intravascular coagulopathy.
[my emphasis]

So I would say it still seems reasonable to me to guess she suffered a subdural hematoma from that blow to the head, very possibly potentiated by occupational exposure to mercury.
posted by jamjam at 4:20 PM on October 11, 2006

Jamjam, thanks for all the information. Is a subdural hematoma something that could have been stopped by medical intervention around 1939 to 1944?
posted by acoutu at 6:39 PM on October 11, 2006

Is a subdural hematoma something that could have been stopped by medical intervention around 1939 to 1944?

Yes, it could have been, if diagnosed. But I still don't think it's very likely. Jamjam's cited some work about acute SDH: he may not realize that moderate head trauma is defined as loss of consciousness greater than 1 hour; severe head trauma greater than 24 hours. That's not what was described here. And chronic subdurals are a disease of the elderly, period.

DIC can certainly happen from mercury exposure, but before that, you tend to see the more classic symptoms, such as the skin lesions, the psychiatric symptoms, the alopecia and so on.

It's certainly true that an ectopic pregnancy or botched surgical abortion would not have been acceptable in polite society as a cause of death at that time.
posted by ikkyu2 at 7:20 PM on October 11, 2006

I'm not sure what happened after the young woman was hit in the head. I don't know if she became unconscious or not. However, I'm not aware of any descriptions of skin lesions, alopecia or pyschiatric symptoms. (Not that I have received full information -- and it has been 65 years or so since the incident.)

Given that the young woman and her sister were on holiday, I would think that the younger sister might have noticed something was up if they other had disappeared for a few hours to have an abortion. So perhaps ectopic pregnancy is the most likely scenario. Of course, the younger sister may have edited details.
posted by acoutu at 8:45 PM on October 11, 2006

I have to agree with the neurologist... chronic SDH is extremely unlikely in a younger individual.

With DIC, you are typically not up walking and talking and taking a shower. You are severely sick.

While it is true that heavy menstrual bleeding can be a sign of a coagulopathy (in a female, the most likely cause will be a von Willebrand's disease), she would have had heavy bleeding her whole post-pubertal life. So again, an inheritable coagulopathy is highly unlikely.

You must remember that then, as is the case today, the manner and cause of death is often not fully disclosed to protect the family from embarassment (for a current corollary, google 'autoerotic asphyxiation'... there's a bit of controversy: suicide vs. accident).
posted by i_am_a_Jedi at 8:54 PM on October 11, 2006

I agree about the protection of the family, especially given the times. (And the fact that I've worded my question and comments to provide further protection, given the age of the younger sister today.) I tried looking up ectopic pregnancy and botched abortions for the WWII period, but I couldn't tell whether death was guaranteed or whether going to the doctor earlier would help.

This is such a sad story, but the mystery part of it is intriguing for me.
posted by acoutu at 9:30 PM on October 11, 2006

Have you considered that the heavy bleeding/feeling of illness might have been neither a botched abortion, nor an ectopic pregnancy, but simply a miscarriage? "Aneurysm" might indeed have been a euphemism used by the doctor or other medical staff, or by family members, all of whom simply wished to cover up the fact that the unmarried woman was pregnant.

I'd also like to point out that family members often misunderstand facts about their loved ones' health care, sometimes to the point of confusion that makes them wrongly blame themselves or each other. This sounds like a classic case.

It's sad to think that the woman's sister has blamed herself for all these years. Of course without access to the medical charts, we can't know what the young woman died of...but this situation can only encourage all of us to search for better communication and information in our heath care.

Use doctors who take the time to talk to you and present options in a clear way. If you switch doctors because you're unsatisfied with the doctor's communication skills, tell him/her AND their supervisor. When a health care professional explains something especially well, tell them AND their supervisor how much you appreciate it. Get informed about your health care issues NOT through Wikipedia or Google searches, but through reliable websites like MedlinePlus. And if your hospital has a medical or consumer health library, use it.

Finally: talk to your family members, even the young ones, about your health concerns. Don't conceal important facts, and if something is an unknown, tell them so. You never know what your loved ones are assuming.
posted by gillyflower at 11:02 PM on October 18, 2006

Can you bleed to death from a miscarriage?
posted by acoutu at 2:26 PM on November 17, 2006

Can you bleed to death from a miscarriage?

Heavens, yes. In fact if you have an incomplete miscarriage and don't get a D&C, you're quite likely to.
posted by ikkyu2 at 1:13 AM on May 15, 2007