We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage.
Mark Iscoe, MD
Brian Gilberti, MD
Bree Tse, MD
Tags: Critical Care, Neurology, Subarachnoid Hemorrhage
Non-contrast head CT showing SAH (Case courtesy of Dr. David Cuete, Radiopaedia.org, rID: 22770)
Hunt-Hess grade and mortality (from Lantigua et al. 2015.)
1. Mild Headache
2. Severe headache or cranial nerve deficit
3. Confusion, lethargy, or lateralized weakness
Ottawa Subarachnoid Hemorrhage Rule, and appropriate population for rule application (from Perry et al. 2017)
Apply to patients who are:
≥ 15 years old
Have new, severe, atraumatic headache that reached maximum intensity within 1 hour of osnet
Do not apply to patients who have:
New neurologic deficits
Previous diagnosis of intracranial aneurysm, SAH, or brain tumor
History of similar headaches (≥ 3 episodes over ≥ 6 months)
SAH cannot be ruled out if the patient meets any of the following criteria:
* Age ≥ 40
Symptom of neck pain or stiffness
Witnessed loss of consciousness
Onset during exertion
“Thunderclap headache” (defined as instantly peaking pain)
Limited neck flexion on examination (defined as inability to touch chin to chest or raise head 3 cm off the bed if supine)
Special Thanks To:
* Dr. Mark Iscoe, MD (Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue)
Bellolio MF, Hess EP, Gilani WI, et al. External validation of the Ottawa subarachnoid hemorrhage clinical decision rule in patients with acute headache. Am J Emerg Med. 2015;33(2):244-9.
Carstairs SD, Tanen DA, Duncan TD, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Acad Emerg Med. 2006;13(5):486-492.
Connolly ES, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-1737.
Czuczman AD, Thomas LE, Boulanger AB, et al. Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap. Acad Emerg Med. 2013;20(3):247-256.