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Subarachnoid Hemorrhage: Can't-Miss Diagnosis and Management

Subarachnoid hemorrhage (SAH) is a terrifying, relatively frequent cause of intracranial bleeding and has a significant degree of morbidity and mortality. SAH makes up ~10% of all strokes. SAH can be aneurysmal (more common) or non-aneurysmal. Average age of aneurysmal rupture causing SAH is ~50 years old...

Non-aneurysmal causes: trauma, AVM, vasculitis, amyloid, bleeding pathology, sympathomimetic abuse.

Biggest risks for aneurysm formation and SAH: smoking > HTN > family history (specific traits, Ehlers-Danlos, PCKD)

As disturbing as they are to patients, most cerebral aneurysms do not rupture. Their lifetime prevalence is ~5% in the US alone. About 85% of them are…

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Featured

 Migraine Headache and Subarachnoid Hemorrhage

The following are strongly and reliably associated with SAH: age >40, neck stiffness or pain, onset of headache on exertion, vomiting, witnessed loss of consciousness, and elevated BP >160/100

 Subarachnoid Hemorrhage: What is the role of LP?

Is the CT within 6 hours really 100% sensitive? No, it is not.

Articles of Interest

Subarachnoid Hemorrhage, Harold & Kumar...and the Terminator

A deadly cause of headache... We talk some serious movie references here while dropping bombs about SAH, its causes, diagnosis, and management. What about BP in SAH? No one knows, but we'll try... "Come with us if you want to live, er, pass boards."

An Evidence-Based Approach To Diagnosis And Management Of Subarachnoid Hemorrhage In The Emergency Department

Aneurysmal subarachnoid hemorrhage accounts for a small percentage of strokes, but it is a significant contributor to the morbidity rate. The diagnosis is challenging and has devastating consequences if it is missed.

Approach to the Diagnosis and Management of Subarachnoid Hemorrhage

The diagnosis of SAH should be considered in any patient with a severe and sudden onset or rapidly escalating headache. With such a large number of patients presenting to the ED with a chief complaint of headache, differentiating those with a benign cause from those with an emergent etiology such as SAH can be difficult. A negative head CT within six hours to be a “rule-out” study given the sensitivity and confidence intervals.

Controversies in the Diagnosis of Subarachnoid Hemorrhage

Subarachnoid hemorrhage is a deadly disease and can present in a variety of ways, most commonly sudden, severe headache. Multiple diagnostic regimens exist, including non-contrast CT only, CT/LP, and CT/CTA. Many of these pathways have significant controversy. Within 6 hours of headache onset, a CT only approach does have literature support for risk stratifying patients to less than 1% risk of SAH.

Listen, to what the British Doctors Say about LPs Post CT from SAH

About 5% of SAH are misdiagnosed on the first emergency department assessment (Vermeulen). This is partly because 50% of SAH present with no neurologic deficit (Weir). Dr. Jeff Perry and his team have tried to create a clinical decision tool to rule out SAH for acute headaches.

Living Well after Surviving a Subarachnoid Hemorrhage

To those who have experienced a subarachnoid hemorrhage, Dr. Cohn encourages them: “What you’re going through is normal. Recovery is long and hard. Most importantly, it’s individual.”

Sirens to Scrubs: Subarachnoid Hemorrhage

You recall that the “worst headache of my life” and “thunderclap headache” are often descriptors for a subarachnoid hemorrhage – bleeding into the space between the arachnoid and the pia mater of the brain, where all the blood supply for the brain runs. You also remember that while nearly everyone suffering from SAH will use these descriptors, only 1 in 10 patients with these symptoms will actually be diagnosed with SAH.

The Weekly Cheese: Headaches And Subarachnoid Hemorrhages

SAH is a high-mortality diagnosis with a missed diagnosis carrying a 20% mortality in the first 2 hours and 40% within a week. These days, many departments have relatively modern CT scanners that can take thin cuts of the brain. In light of this, there’s some strong evidence that a non-contrast CT scan within 6 hours of headache onset is very sensitive (97-99%) for detecting intracranial hemorrhage.

Resources

EMCrit

The age range is broad. With an average age of only 50, SAH affects younger patients more often than most other stroke types.

Core EM

We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage.

Life in the Fastlane

target BP <140 mmHg; >150 mmHg associated with re-bleeding.

Diagnosis of Subarachnoid Hemorrhage

Non-contrast head CT is an excellent test for ED headache patients in whom SAH is a concern, but like every other test that exists it is not 100% sensitive.