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

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

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. Etiology And Pathophysiology
    1. Incidence
    2. Etiology
    3. Pathophysiology Of Aneurysms
    4. Subarachnoid Hemorrhage Clinical Severity Scales
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Whom To Evaluate?
    2. History
    3. Physical Examination
    4. Clinical Decision Rules
  9. Diagnostic Studies
    1. Noncontrast Computed Tomography
    2. Lumbar Puncture
      1. Interpreting The Lumbar Puncture
      2. Opening Pressure
      3. Red Blood Cell Analysis
      4. Xanthochromia
        • Assessing Xanthochromia: Visual Analysis Versus Spectrophotometry
    3. Cardiopulmonary Testing
    4. Clinical Decision Making
    5. Role Of Primary Computed Tomography Angiography In Subarachnoid Hemorrhage
    6. Role Of Primary Magnetic Resonance Imaging In Diagnosis Of Subarachnoid Hemorrhage
  10. Management
    1. Initial Management
    2. General Care Measures
    3. Cerebrovascular Imaging
    4. Monitoring And Preventing Complications
      1. Rebleeding
      2. Blood Pressure Management
      3. Preventing Vasospasm
      4. Seizure Prophylaxis
      5. Acute Clinical Deterioration
      6. Definitive Aneurysm Repair
    5. Prognosis
  11. Special Circumstances
    1. Pregnant And Postpartum Women
    2. Anticoagulated Patients
  12. Controversies And Cutting Edge
    1. Computed Tomography Angiography
    2. Lumbar Puncture–First Strategy
    3. Role Of Warning Headache
  13. Disposition
  14. Summary
  15. Cost-Effective Strategies
  16. Risk Management Pitfalls For Subarachnoid Hemorrhage
  17. Case Conclusion
  18. Clinical Pathway For Emergency Evaluation Of Suspected Subarachnoid Hemorrhage
  19. Tables and Figures
    1. Table 1. 2008 ACEP Clinical Policy On Acute Headache (Subarachnoid Hemorrhage)
    2. Table 2. 2012 AHA Guidelines For Management Of Aneurysmal Subarachnoid Hemorrhage
    3. Table 3. Subarachnoid Hemorrhage Grading Scales
    4. Table 4. Differential Diagnosis Of Sudden-Onset Nontraumatic Headache
    5. Table 5. Key Questions For Patients With Acute Headache
    6. Table 6. Associated Findings That May Distract From Diagnosis Of Subarachnoid Hemorrhage
    7. Table 7. Physical Examination Findings Associated With Aneurysmal Subarachnoid Hemorrhage
    8. Table 8. Ottawa Subarachnoid Hemorrhage Rules
    9. Table 9. Limitations Of Computed Tomography
    10. Table 10. Limitations Of Lumbar Puncture
    11. Table 11. Non-SAH Causes Of Xanthochromia
    12. Table 12. Emergency Department Management Of Subarachnoid Hemorrhage
    13. Figure 1. Subarachnoid Hemorrhage On Noncontrast Head Computed Tomography
    14. Figure 2. Perimesencephalic Hemorrhage On Noncontrast Head Computed Tomography
    15. Figure 3. Causes Of Spontaneous Subarachnoid Hemorrhage
    16. Figure 4. Traumatic Subarachnoid Hemorrhage On Noncontrast Head Computed Tomography
    17. Figure 5. Detection Of Aneurysm By Computed Tomography Angiography OF The Head
  20. References


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. Accurate initial diagnosis and management are critical to the outcome of the disease. The emergency clinician must have a high index of suspicion and a judicious approach to evaluating the chief complaint of patients with spontaneous subarachnoid hemorrhage (ie, headache). This review evaluates the literature and current evidence, including controversies and recent American Heart Association guidelines, to support a best-practice approach to the diagnosis and treatment of patients with spontaneous subarachnoid hemorrhage.

Case Presentations

You walk into a crowded evening shift in the ED, and your first patient is a middle-aged woman clutching her head in her hands, complaining of the "worst headache of her life." You are worried about a subarachnoid hemorrhage. After treating her pain, you order a noncontrast head CT, which is negative. She now says that her headache is better and that she needs to go home to pick up her kids. Does she really need a lumbar puncture? She eventually agrees to stay for a lumbar puncture, which is also negative. Can she go home now? Does she need any additional workup?

While you are thinking about this, another patient with a history of migraine arrives complaining of suddenonset, severe headache that has lasted 12 hours. Is this headache her usual migraine or could this be a spontaneous subarachnoid hemorrhage? After further history is obtained, you are concerned about a subarachnoid hemorrhage and you obtain a CT, which is normal. You perform a lumbar puncture, which shows some clearing of red blood cells from tube 1 to tube 4. You think it may have been a traumatic tap, but how can you be sure? Just as you are pondering this, the lab calls to say there is xanthochromia. You make the diagnosis of spontaneous subarachnoid hemorrhage. After calling for neurosurgical consultation, what else should you do in the ED to treat this patient?


Subarachnoid hemorrhage (SAH) is the extravasation of blood into the cerebrospinal fluid (CSF). It is usually a diffuse process that results from rupture of corticomeningeal vessels and from hemorrhagic contusions of the brain.1 Trauma is the most common cause of all SAH; however, the majority (85%) of nontraumatic, or spontaneous SAH (sSAH), the focus of this article, are related to aneurysm rupture.2-4 Aneurysmal SAH (aSAH) and other forms of sSAH can pose diagnostic challenges in the emergency department (ED).

Distinguishing traumatic SAH from sSAH may be difficult in some cases because the trauma may have been unwitnessed; however, this distinction is important. See Figure 1 for the typical appearance of a sSAH on noncontrast head computed tomography (CT). The emergency clinician must be able to quickly and accurately identify and categorize SAH, and should be aware of the secondary complications that affect both the central nervous system and other major organs. Initial management and treatment decisions should be made to minimize effects of the initial neurologic injury. This issue of Emergency Medicine Practice focuses on the diagnostic challenges, the initial management and treatment options, and some of the more severe complications of sSAH, using the best available evidence from the literature.

Critical Appraisal Of The Literature

The overall incidence of sSAH is relatively low and, therefore, the availability of high-quality evidence is limited. A literature search was performed using Ovid MEDLINE® and PubMed from 1950 to May 2014. Search terms included 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, and combinations of these keywords. The search was limited to the English language and human studies. More than 500 articles were reviewed, which provided background for further literature review. During the literature review process, the highest value was placed on clinical trials, larger prospective cohort studies, and meta-analyses of clinical trials. Secondary evidence was collected from retrospective studies, case-control studies, and other metaanalyses. Finally, expert consensus statements and case reports were reviewed. The Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse ( were also consulted.

The most relevant guidelines for emergency clinicians are the 2008 American College of Emergency Physicians (ACEP) Clinical Policy on acute headache (see Table 1),5 the 2012 American Heart Association (AHA) Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage,6 (see Table 2) and the 2011 Neurocritical Care Society (NCS) Guidelines on the critical care management of patients with aSAH.7

Risk Management Pitfalls For Subarachnoid Hemorrhage

  1. “I thought it was a migraine, so I did not order a head CT.” A head CT should be considered even in patients with a primary headache disorder, like migraine, if the characteristics of the headache are substantially different from their usual symptoms.
  2. “Her symptoms were suggestive of the flu.” Emergency clinicians should be aware of the wide spectrum of clinical symptoms that may present as SAH. Patients may have nonspecific symptoms, including neck pain, myalgia, and mild headache, which may be misdiagnosed as a viral syndrome. Consider CT and, if negative, LP.
  3. “His symptoms improved with antiemetics and analgesics.” Patients with SAH may have symptoms that completely resolve with pain medications and sometimes even without treatment. The decision to work up a patient for SAH should not be solely influenced by response to pain medications.
  4. “He was from a nursing home, delirious, and had a urinary tract infection, so I thought it was urosepsis.” Patients with delirium or a change in mental status should be carefully evaluated, as SAH may be in the differential. Studies have shown that psychiatric diagnoses and delirium are common misdiagnoses for SAH.
  5. “Her pain was atypical and she had chest pain with an abnormal ECG.” Patients with SAH may have an abnormal ECG and/or positive cardiac markers due to effects of a catecholamine surge from brain injury. Focusing on these cardiac findings may distract the emergency clinician from diagnosing the underlying etiology, which may be SAH.
  6. “The head CT was negative and the patient clinically improved and wanted to go home.” CT may be negative in 2% to 7% of patients with SAH, and sensitivity is highly time-dependent. In a patient with suspected SAH, LP is required to rule out the diagnosis, regardless of other circumstances. However, patients’ autonomy is important and should be respected as long as they are informed.
  7. “The patient did not mention taking anticoagulants, so I did not check anticoagulation tests.” Basic laboratory tests (including prothrombin time and partial thromboplastin time) should be checked in all patients with intracranial hemorrhage. Some patients may not be able to provide an accurate history. When patients on therapeutic anticoagulants are diagnosed with SAH, the clotting deficiency should be reversed quickly with intravenous vitamin K and clotting factor.
  8. “The number of RBCs decreased from the first tube to the fourth tube so I presumed it was a traumatic tap.” There is no cutoff for the minimum number of RBCs required to diagnose SAH, and it has been reported with even a few hundred cells. Despite serial clearing of red cells, if there is ambiguity between a traumatic tap and possible SAH, further neuroimaging and neurosurgical consultation should be obtained to rule out the diagnosis. Also, remember that the number of RBCs diminishes with time after onset of headache.
  9. “I did not transfer the patient because…” Any patient whose condition is diagnosed as SAH should be transferred to a facility with neurosurgical, endovascular, and advanced neuroimaging capabilities. Data show better outcomes for patients treated quickly at these specialized centers.
  10. “I diagnosed the SAH and the patient was waiting to transfer when she became disoriented.” Patients with SAH should have careful cardiorespiratory monitoring and serial neurological examinations. They are at risk for developing complications such as rebleeding, vasospasm, and hydrocephalus. Intubation may need to be performed if the patient is unable to protect the airway. Repeated head CT should be considered, because clinical deterioration from acute hydrocephalus can be reversed with treatment.

Tables and Figures

Table 1. 2008 ACEP Clinical Policy On Acute Headache (Subarachnoid Hemorrhage)


Table 2. 2012 AHA Guidelines For Management Of Aneurysmal Subarachnoid Hemorrhage


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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Publication Information

Imoigele Aisiku, MD, MBA; Jonathan A. Edlow, MD, FACEP; Joshua Goldstein, MD; Lisa E. Thomas, MD

Publication Date

October 1, 2014

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