Spontaneous Subarachnoid Hemorrhage: A Best-Practice Approach to Identification and Management in the ED - Stroke EXTRA Supplement (Stroke CME)

Table of Contents

 

About This Issue

Emergency clinicians must have a high index of suspicion and a judicious approach to evaluating the chief complaint (ie, headache) of patients with suspected subarachnoid hemorrhage, as accurate initial diagnosis and management are critical to optimizing outcomes. Emergency clinicians must be able to identify SAH and determine the etiology quickly and accurately, and they should be aware of the secondary complications that affect both the central nervous system and other major organs. The diagnosis is challenging and has devastating consequences if missed. This review evaluates the literature and current evidence, including controversies and recent guidelines, to support a best-practice approach to the diagnosis and treatment of patients with spontaneous subarachnoid hemorrhage.

What are the typical and atypical presentations of SAH?

What is the optimal diagnostic approach to a patient with suspected SAH?

What are the major advantages and limitations in available diagnostic modalities?

Which clinical severity scales and clinical decision rules can aid in management of SAH?

What is the initial focus of management and treatment decisions in the ED?

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Incidence
   2. Etiology
   3. Pathophysiology of Aneurysms
7. Subarachnoid Hemorrhage Clinical Severity Scales
8. Differential Diagnosis
9. Prehospital Care
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Clinical Decision Rules
11. Diagnostic Studies
    1. Noncontrast Computed Tomography
    2. Lumbar Puncture
       1. Interpreting the Lumbar Puncture
       2. Obtaining Opening Pressure
       3. Red Blood Cell Analysis
       4. Xanthochromia
          • Assessing Xanthochromia: Visual Analysis Versus Spectrophotometry
       5. Primary Computed Tomographic Angiography
    3. Primary Magnetic Resonance Imaging
    4. Cardiopulmonary Testing
    5. Clinical Decision Making
12. Emergency Department Management
    1. Initial Management and General Care
    2. Cerebrovascular Imaging
    3. Monitoring and Prevention of Complications
       1. Rebleeding
       2. Blood Pressure Management
       3. Prevention of Vasospasm
       4. Seizure Prophylaxis
       5. Acute Clinical Deterioration
       6. Definitive Aneurysm Repair
    4. Prognosis
13. Special Circumstances
    1. Nonaneurysmal Perimesencephalic Hemorrhage
    2. Pregnant and Postpartum Women
    3. Anticoagulated Patients
14. Controversies and Cutting Edge
    1. Computed Tomographic Angiography Versus Lumbar Puncture
    2. Lumbar Puncture-First Strategy
    3. Role of Warning Headache
15. Disposition
16. Summary
17. Case Conclusions
18. Clinical Pathway for Emergency Evaluation of Suspected Subarachnoid Hemorrhage
19. Tables and Figures
20. References

Abstract

Emergency clinicians must have a high in-dex of suspicion and a judicious approach to evaluating the chief complaint (ie, headache) of patients with suspected subarachnoid hemorrhage, as accurate initial diagnosis and management are critical to optimizing outcomes. Aneurysmal subarachnoid hemorrhage ac-counts for a small percentage of strokes, but contributes significantly to the morbidity rate in stroke. The diagnosis is challenging and has devastating consequences if missed. This review evaluates the literature and current evidence, including controversies and recent guidelines, to support a best-practice approach to the diagnosis and treatment of patients with spontaneous subarachnoid hemorrhage.

Case Presentations

When you begin your shift in the ED, your first patient is a middle-aged woman clutching her head in her hands, complaining of the sudden onset of the “worst headache of her life.” You are concerned for subarachnoid hemorrhage. You treat her pain with 1 g of acetaminophen and obtain a noncontrast head CT. She now states that her headache has improved and that she needs to go pick up her kids. Pending the results of the CT scan, what else needs to be done to determine her disposition? Is additional workup needed?

While you are considering options, another patient with a history of migraine arrives complaining of a sudden-onset, severe headache that has lasted 12 hours. Is this her usual migraine, or could this be something more significant such as a spontaneous subarachn oid hemorrhage? She states that she usually sees flashing lights prior to headache onset, but this time she had no aura. You obtain a head CT, which is normal. You also perform a lumbar puncture, which shows some clearing of red blood cells from tube 1 to tube 4. You consider that it may have been a traumatic tap, but how can you be certain? Just as you are pondering this, the lab calls to say there is xanthochromia, so you diagnose spontaneous subarachnoid hemorrhage. While awaiting neurosurgical consultation, what else should be done to treat this patient in the ED?

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Clinical Pathway for Emergency Evaluation of Suspected Subarachnoid Hemorrhage

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Edlow JA, Malek AM, Ogilvy CS. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med. 2008;34(3):237-251. (Review)
2. Fukuda T, Hasue M, Ito H. Does traumatic subarachnoid hemorrhage caused by diffuse brain injury cause delayed ischemic brain damage? Comparison with subarachnoid hemorrhage caused by ruptured intracranial aneurysms. Neurosurgery. 1998;43(5):1040-1049. (Retrospective; 99 patients, 114 patients)
3. * Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006;354(4):387-396. (Review) DOI: 10.1056/NEJMra052732
4. Carvi y Nievas MN, Archavlis E. Atypical causes of nontraumatic intracranial subarachnoid hemorrhage. Clin Neurol Neurosurg. 2009;111(4):354-358. (Retrospective; 820 patients)
5. * Godwin SA, Cherkas DS, Panagos PD, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2019;74(4):e41-e74. (Practice guidelines, systematic review) DOI: 10.1016/j.annemergmed.2019.07.009
6. * Connolly ES Jr, 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. (Practice guidelines) DOI: 10.1161/STR.0b013e3182587839
7. * Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15(2):211-240. (Practice guidelines) DOI: 10.1007/s12028-011-9605-9
8. * Bederson JB, Connolly ES Jr, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40(3):994-1025. (Practice guidelines, systematic review) DOI: 10.1161/STROKEAHA.108.191395

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Keywords: spontaneous subarachnoid hemorrhage, SAH, cerebrospinal fluid, CSF, headache, thunderclap headache, aneurysm, Hunt and Hess, Fisher scale, Ottawa Subarachnoid Hemorrhage Rule, computed tomography, CT, lumbar puncture, LP, xanthochromia, computed tomographic angiography, CTA, rebleeding, blood pressure, vasospasm