- Rupture of ‘Berry’ aneurysms in the circle of Willis (commonest cause ~ 85%)
- Arteriovenous malformation
- Rupture of the mycotic aneurysms
- Connective tissue disorders
- Idiopathic ( also translated as ‘’WE STILL HAVE NO CLUE’’) ~20%
- Past H/O SAH
- Excessive alcohol consumption
- Polycystic Kidney disease
- Family history of SAH*
- Marfan’s syndrome, Ehler-Danlos syndrome type 4
- Coarctation of aorta
- Neck pain/stiffness
- Vomiting/Nausea (must increase your suspicion)
- Syncope (Yes, SAH too can present with syncopy!)
- Altered mental status
- Seizures, posturing
- Focal neurological deficits
- Dilated unequal pupils, Unilateral eye pain, papilledema.
- Fundoscopy may reveal subhyaloid hemorrhages*
- Intracerebral hemorrhage
- Cerebral venous thrombosis
- Ischemic stroke
- Coital cephalgia
- Metabolic abnormalities
- Intracranial tumor
- Primary headache syndrome (ex: Cluster headache, migraine, etc.)
- Brain imaging
- Labs: CBC, PT, APTT, Electrolytes, Creatinine, Troponin, Toxicology screen
- 12-Lead ECG
Hess and Hunt grading system
- Re-bleeding: Risk is highest in the first 24 hours.
- Hydrocephalus: About 30% develop in the first 3 days.
- Neurogenic pulmonary edema
- Aspiration pneumonia – Sepsis.
- Myocardial infarction, arrhythmias, LV dysfunction and neurogenic cardiomyopathy.
- SIADH à Hyponatremia: Most common 3days – 14days.
- Vasospasm: Most common 2days – 3 weeks following SAH.
- Airway not patent.
- Hyperventilation or hypoxia not responding to supplemental oxygen.
- Anticipated deterioration or transfer to another center.
- Always involve neurology and neurosurgery team early.
- Convey the present condition of the patient, CT finding, absence/presence of hydrocephalus, grading, present management, expected course of events and further investigations like CT angiography that might be required when talking to the specialist.
- Transfer to the appropriate center if your center doesn’t have neurosurgical facilities.
- Ask them "Is it different from their previous headaches".
- Ask for any headache preceding syncope!
- Non contrast CT is highly sensitive if done within early hours of onset of symptoms and a CSF analysis confirms the diagnosis if CT is negative.
- Reverse anticoagulants when INR > 1.4 and Antiplatelets when counts < 50,000.
Resident, Emergency medicine
Further reading and references:
1. Emergency Neurological Life Support (ENLS) guidelines for SAH: http://enlsprotocols.org/files/SAH.pdf
2. A Guideline for Healthcare Professionals From the AHA/American Stroke Association: http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839.full.pdf
3. Neurogenic Cardiomyopathy:
4. Neurogenic pulmonary edema:
5. Blood pressure control for acute ischemic and hemorrhagic stroke.
6. HOW TO BE A CLINICAL ROCK STAR MANAGING SUBARACHNOID HEMORRHAGES
7. For more radiology on SAH: http://radiopaedia.org/articles/subarachnoid-haemorrhage