Episode 181.0: Subarachnoid Hemorrhage

Mar 4, 2021

Mark Iscoe, a Senior EM resident from Washington, D.C., soon to embark on a clinical informatics fellowship at Yale, dives into the critical realm of subarachnoid hemorrhage. The discussion highlights the complexity of diagnosis, emphasizing the importance of advanced CT imaging and timely intervention. Iscoe explains the Hunt and Hess grading scale, illustrating how it informs treatment decisions and mortality risks. He also covers management strategies, including blood pressure regulation and the use of tranexamic acid to enhance patient outcomes in this high-stakes scenario.

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ANECDOTE

A Severe SAH Case

Dr. Mark Iscoe shared a case of a young woman with altered mental status who rapidly deteriorated and required intubation before diagnosis.
This highlights the unpredictable and severe presentations of subarachnoid hemorrhage.

INSIGHT

SAH Often Mimics Benign Headache

Up to half of subarachnoid hemorrhage patients present neurologically intact, mimicking benign headaches.
This similarity leads to about 5% of cases being initially missed in the ED.

ADVICE

Apply Ottawa SAH Rule

Use the Ottawa subarachnoid hemorrhage rule in alert patients ≥15 with new severe headache peaking within an hour.
If none of the six criteria are present, SAH can likely be ruled out.

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We discuss EM presentation, diagnosis, and management of subarachnoid hemorrhage.

Hosts:
Mark Iscoe, MD
Brian Gilberti, MD
Bree Tse, MD

Download One Comment Tags: Critical Care, Neurology, Subarachnoid Hemorrhage

Show Notes

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.)

Hunt-Hess grade	Mortality (%)
1. Mild Headache	3.5
2. Severe headache or cranial nerve deficit	3.2
3. Confusion, lethargy, or lateralized weakness	9.4
4. Stupor	23.6
5. Coma	70.5

Ottawa Subarachnoid Hemorrhage Rule, and appropriate population for rule application (from Perry et al. 2017)

Apply to patients who are:

Alert
≥ 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)

___________________________

References:

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.

Dugas C, Jamal Z, Bollu PC. Xanthochromia. [Updated 2020 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526048/

Goldstein JN, Camargo CA, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006;26(6):684-90.

Kumar A, Niknam K, Lumba-brown A, et al. Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians. Neurocrit Care. 2019.

Lantigua H, Ortega-Gutierrez S, Schmidt JM, et al. Subarachnoid hemorrhage: who dies, and why? Crit Care. 2015;19:309.

Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage. Lancet. 2017;389(10069):655-666.

Mayer PL, Awad IA, Todor R, et al. Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions. Stroke. 1996;27(9):1558-63.

Meurer WJ, Walsh B, Vilke GM, Coyne CJ. Clinical guidelines for the emergency department evaluation of subarachnoid hemorrhage. J Emerg Med. 2016;50(4):696-701.

Perry JJ, Spacek A, Forbes M, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Ann Emerg Med. 2008;51(6):707-713

Perry JJ, Stiell IG, Sivilotti MLA, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204.

Perry JJ, Stiell IG, Sivilotti MLA, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343(jul18 1):d4277-d4277.

Perry JJ, Stiell IG, Sivilotti ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013;310(12):1248-55.

Perry JJ, Sivilotti MLA, Sutherland J, et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ. 2017;189(45):E1379-E1385.

Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke. 2007;38(4):1216-21.