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

July 2009



Headache is the presenting complaint in roughly 2% of ED visits.1 Of all those with headache, about 1% will have Subarachnoid Hemorrhage (SAH),2-4 meaning 99% of ED headache patients do not have SAH. This makes selecting those patients a major diagnostic challenge. Among those with sudden-onset, severe headache with normal neurologic examination, 10% to 16%5-10 have SAH. Diagnosing and accurately managing SAH remain pressing challenges for emergency clinicians. Estimates of misdiagnosis, previously as high as 32%, are now thought to be lower but still range from 5% to 15%.11-15 Patients with delayed diagnosis have worse outcomes, highlighting the importance of early recognition.12-14,16 Unfortunately, SAH claims the lives of 40% of its victims and leaves 30% with substantial neurological disability.17 The emergency clinician must be able to quickly and accurately identify SAH in order to optimize outcome. This issue of Emergency Medical Practice focuses on the challenges of diagnosing and managing SAH, using the best available evidence from the literature.

Key Words: subarachnoid hemorrhage, aneurysm, thunderclap headache, sentinel headache, lumbar puncture, xanthochromia, emergency department, head CT, CTA, angiography, MRI, nimodipine, risk factors, prehospital care, diagnosis, management, analgesia, treatment, rebleeding, vasospasm, hypertension, antiepileptic

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