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Diagnosis of subarachnoid hemorrhage

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Abstract

The ideal therapy and neurocritical care for patients with aneurysmal subarachnoid hemorrhage (SAH) follows from an early and accurate diagnosis. However, approximately 30% of patients with SAH are misdiagnosed at their initial visit to a physician. This article explores the reasons for this alarming error rate: failure to understand the full spectrum of presentation of SAH and failure to know the limitations of the major diagnostic tests (computed tomography of the brain and lumbar puncture [LP]). I suggest a strategy for selecting which patients with headache require evaluation beyond history and physical examination and how that evaluation should proceed. Other diagnostic issues are also discussed, such as use of magnetic resonance scanning and angiography for diagnosis, distinguishing the traumatic LP from true SAH, the concept of warning bleeds, and the LP-first diagnostic strategy.

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References

  1. Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage [see comments]. N Engl J Med 2000;342(1):29–36.

    Article  PubMed  CAS  Google Scholar 

  2. Evans R. Diagnostic testing for the evaluation of headaches. Neurol Clin 1996;14(1):1–26.

    Article  PubMed  CAS  Google Scholar 

  3. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, Johnston KL, Cipolle RJ, Barber DL. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 1997;54(12):1506–1509.

    PubMed  CAS  Google Scholar 

  4. Frishberg BM. The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations [see comments]. Neurology 1994;44(7):1191–1197.

    PubMed  CAS  Google Scholar 

  5. Schievink WI. Intracranial aneurysms [see comments] [published erratum appears in N Engl J Med 1997;24;336(17):1267]. N Engl J Med 1997;336(1):28–40.

    Article  PubMed  CAS  Google Scholar 

  6. Mattioli C, Beretta L, Gerevini S, et al. Traumatic subarachnoid hemorrhage on the computerized tomography scan obtained at admission: a multicenter assessment of the accuracy of diagnosis and the potential impact on patient outcome. J Neurosurg 2003;98(1):37–42.

    PubMed  Google Scholar 

  7. Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke 1994;25(11):2315–2328.

    PubMed  CAS  Google Scholar 

  8. Linn FH, Rinkel GJ, Algra A, van Gijn J. Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke 1996;27(4):625–629.

    PubMed  CAS  Google Scholar 

  9. Sivenius J, Tuomilehto J, Immonen-Raiha P, et al. Continuous 15-year decrease in incidence and mortality of stroke in Finland. The FINSTROKE Study. Stroke 2004;420–425.

  10. Leicht M. Non-traumatic headache in the emergency department. Ann Emerg Med 1980;9(8):404–409.

    Article  PubMed  CAS  Google Scholar 

  11. Dhopesh V, Anwar R, Herring C. A retrospective assessment of emergency department patients with complaints of headache. Headache 1979;19:37–42.

    Article  PubMed  CAS  Google Scholar 

  12. Morgenstern LB, Luna-Gonzales H, Huber JC, Jr., et al. Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 1998;32(3 pt 1):297–304.

    PubMed  CAS  Google Scholar 

  13. Linn FH, Wijdicks EF, van der Graaf Y, Weerdesteyn-van Vliet FA, Bartelds AI, van Gijn J. Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet 1994;344(8922):590–593.

    Article  PubMed  CAS  Google Scholar 

  14. Landtblom AM, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia 2002;22(5):354–360.

    Article  PubMed  Google Scholar 

  15. Adams HP, Jr., Jergenson DD, Kassell NF, Sahs AL. Pitfalls in the recognition of subarachnoid hemorrhage. Jama 1980;244(8):794–796.

    Article  PubMed  Google Scholar 

  16. Kassell N, Kongable G, Torner J, Adams H, Mazuz H. Delay in referral of patients with ruptured aneurysms to neurosurgical attention. Stroke 1985;16(4):587–590.

    PubMed  CAS  Google Scholar 

  17. Kassell NF, Torner JC, Haley EC, Jr., Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 1990;73(1):18–36.

    Article  PubMed  CAS  Google Scholar 

  18. 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):1558–1563.

    PubMed  CAS  Google Scholar 

  19. Neil-Dwyer G, Lang D. ‘Brain attack’—aneurysmal subarachnoid haemorrhage: death due to delayed diagnosis. J R Coll Physicians (London) 1997;31(1):49–52.

    CAS  Google Scholar 

  20. Edlow JA. Diagnosis of subarachnoid hemorrhage in the emergency department. Emerg Med Clin North Am 2003;21(1):73–87.

    Article  PubMed  Google Scholar 

  21. Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. Relation to age, income, race, and other sociodemographic factors. JAMA 1992;267(1):64–69.

    Article  PubMed  CAS  Google Scholar 

  22. Karcz A, Holbrook J, Burke M, et al. Massachusetts emergency medicine closed malpractice claims: 1988–1990. Ann Emerg Med 1993;22(3):553–559.

    Article  PubMed  CAS  Google Scholar 

  23. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968;28:14–20.

    PubMed  CAS  Google Scholar 

  24. Rosenorn J, Eskesen V, Schmidt K, et al. Clinical features and outcome in 1076 patients wtih ruptured intracranial saccular aneurysms: a prospective consecutive study. Br J Neurosurg 1987;1:33–46.

    PubMed  CAS  Google Scholar 

  25. Weir B. Headaches from aneurysms. Cephalgia 1993;14:79–87.

    Article  Google Scholar 

  26. Liedo A, Calandre L, Martinez-Menendez B, Perez-Sempere A, Portera-Sanchez A. Acute headache of recent onset and subarachnoid hemorrhage: a prospective study. Headache 1994;34(4):172–174.

    Article  Google Scholar 

  27. Seymour JJ, Moscati RM, Jehle D. Response of headache to non-narcotic analgesics resulting in missed intracranial hemorrhage. A J Emerg Med 1995;13(1):43–65.

    Article  CAS  Google Scholar 

  28. Limmroth V, Cutrer FM, Moskowitz MA. Neurotransmitters and neuropeptides in headache. Curr Opin Neurol 1996;9(3):206–210.

    Article  PubMed  CAS  Google Scholar 

  29. Moskowitz MA, Henrikson BM, Markowitz S. Experimental studies on the sensory innervation of the cerebral blood vessels. Cephalalgia 1986;6(Suppl 4):63–66.

    PubMed  Google Scholar 

  30. Schievink WI, Karemaker JM, Hageman LM, van der Werf DJM. Circumstances surrounding anerysmal subarachnoid hemorrhage. Surg Neurol 1989;32:266–272.

    Article  PubMed  CAS  Google Scholar 

  31. Linn F, Rinkel G, Algra A, van Gijn J. Headache characteristics in subarachnoid hemorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 1998;65:791–793.

    PubMed  CAS  Google Scholar 

  32. Sarner M, Rose F. Clinical presentation of ruptured intracranial aneurysm. J Neurol Neurosurg Pschiat 1967;30:67–70.

    Google Scholar 

  33. Walton J. Subarachnoid Hemorrhage. Edinburgh: E & S Livingstone, 1956.

    Google Scholar 

  34. Raps EC, Rogers JD, Galetta SL, et al. The clinical spectrum of unruptured intracranial aneurysm. Arch Neurol 1993;50:265–268.

    PubMed  CAS  Google Scholar 

  35. Anonymous. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalgia 1988;8(Suppl 7):1–73.

  36. Schattner A. Pain in the neck [letter]. Lancet 1996;348(9024):411,412.

    Article  PubMed  CAS  Google Scholar 

  37. Reijneveld JC, Wermer M, Boonman Z, van Gijn J, Rinkel GJ. Acute confusional state as presenting feature in aneurysmal subarachnoid hemorrhage: frequency and characteristics. J Neurol 2000;247(2):112–116.

    Article  PubMed  CAS  Google Scholar 

  38. Abbot RJ, van Hille P. Thunderclap headache and unruptured aneurysm. Lancet 1986;ii:1459.

    Article  Google Scholar 

  39. Findlay JM. Current management of aneurysmal subarachnoid hemorrhage guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci 1997;24(2):161–170.

    PubMed  CAS  Google Scholar 

  40. Edlow JA, Wyer PC. How good is a negative cranial computed tomographic scan result in excluding subarachnoid hemorrhage? Ann Emerg Med 2000;36(5):507–516.

    PubMed  CAS  Google Scholar 

  41. Edlow, Wyer. Feedback: computed tomography for subarachnoid hemorrhage. Which review should we believe regarding the diagnostic power of computed tomography for ruling out subarachnoid hemorrhage? Ann Emerg Med 2001;37(6):679,680; discussion 80–85.

    Article  Google Scholar 

  42. Hoffman JR. Computed tomography for subarachnoid hemorrhage: what should we make of the “evidence”? Ann Emerg Med 2001;37(3):345–349.

    Article  PubMed  CAS  Google Scholar 

  43. Vos PE, Zwienenberg M, O’Hannian KL, Muizelaar JP. Subarachnoid haemorrhage following rupture of an ophthalmic artery aneurysm presenting as traumatic brain injury. Clin Neurol Neurosurg 2000;102(1):29–32.

    Article  PubMed  CAS  Google Scholar 

  44. Sakas DE, Dias LS, Beale D. Subarachnoid haemorrhage presenting as head injury. BMJ 1995;310(6988):1186,1187.

    PubMed  CAS  Google Scholar 

  45. Sharp S, Stone J, Beach R. Contrast agent neurotoxicity presenting as subarachnoid hemorrhage [see comments]. Neurology 1999;52(7):1503–1505.

    PubMed  CAS  Google Scholar 

  46. Velden J, Milz P, Winkler F, Seelos K, Hamann GF. Nonionic contrast neurotoxicity after coronary angiography mimicking subarachnoid hemorrhage. Eur Neurol 2003;49(4):249–251.

    Article  PubMed  Google Scholar 

  47. Chatterjee T, Gowardman JR, Goh TD. Pneumococcal meningitis masquerading as subarachnoid haemorrhage. Med J Aust 2003;178(10):505–507.

    PubMed  Google Scholar 

  48. Mendelsohn DB, Moss ML, Chason DP, Muphree S, Casey S. Acute purulent leptomeningitis mimicking subarachnoid hemorrhage on CT. J Comput Assist Tomogr 1994; 18(1):126–128.

    Article  PubMed  CAS  Google Scholar 

  49. Huang D, Abe T, Ochiai S, et al. False positive appearance of subarachnoid hemorrhage on CT with bilateral subdural hematomas. Radiat Med 1999;17(6):439–442.

    PubMed  CAS  Google Scholar 

  50. Voris H. Subarachnoid hemorrhage. Illinois Med J 1949;95:160–167.

    CAS  Google Scholar 

  51. Wolfe H. Spontaneous subarachnoid hemorrhage. Br J Surg 1955;50:319–325.

    Google Scholar 

  52. Richardson J, Hyland H. Intracranial aneurysms. Medicine (Baltimore) 1941;20:1–83.

    Google Scholar 

  53. Weir B. Diagnostic aspects of subarachnoid hemorrhage. In: Weir B, ed. Subarachnoid Hemorrhage: Causes and Cures. New York: Oxford University Press, 1998, pp. 144–176.

    Google Scholar 

  54. Roost KT, Pimstone NR, Diamond I, Schmid R. The formation of cerebrospinal fluid xanthochromia after subarachnoid hemorrhage. Neurology 1972;22:973–977.

    PubMed  CAS  Google Scholar 

  55. Fishman R. Chapter 8: Composition of the Cerebrospinal Fluid. Second ed. Philadelphia: WB Saunders, 1992.

    Google Scholar 

  56. Beetham R, Fahie-Wilson MN, Park D. What is the role of CSF spectrophotometry in the diagnosis of subarachnoid haemorrhage? Ann Clin Biochem 1998;35 (pt 1):1–4.

    PubMed  Google Scholar 

  57. Vermeulen M. Subarachnoid haemorrhage: diagnosis and treatment. J Neurol 1996;243:496–501.

    Article  PubMed  CAS  Google Scholar 

  58. van Gijn J. Slip-ups in diagnosis of subarachnoid haemorrhage. Lancet 1997;349(9064):1492.

    Article  PubMed  Google Scholar 

  59. Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J. Xanthochromia after subarachnoid haemorrhage needs no revisitation. J Neurol Neurosurg Psychiatry 1989;52(7):826–828.

    PubMed  CAS  Google Scholar 

  60. Edlow JA, Bruner KS, Horwitz GL. Xanthochromia. Arch Pathol Lab Med 2002;126(4):413–415.

    PubMed  Google Scholar 

  61. Mendelow AD, Cartlidge N. Xanthochromia in subarachroid haemorrhage. J Neurol Neurosurg Psychiatry 1990;53(3):270,271.

    Article  PubMed  CAS  Google Scholar 

  62. Gerber CJ, Crawford P, Mendelow AD, Gholkar A, Sengupta RP. Lumbar puncture should not be delayed in subarachnoid haemorrhage [letter; comment]. BMJ 1998;317(7151):148.

    PubMed  CAS  Google Scholar 

  63. Eskey CJ, Ogilvy CS. Fluoroscopy-guided lumbar puncture: decreased frequency of traumatic tap and implications for the assessment of CT-negative acute subarachnoid hemorrhage. AJNR Am J Neuroradiol 2001;22(3):571–576.

    PubMed  CAS  Google Scholar 

  64. Shah KH, Richard KM, Nicholas S, Edlow JA. Incidence of traumatic lumbar puncture. Acad Emerg Med 2003;10(2):151–154.

    Article  PubMed  Google Scholar 

  65. Shah KH, Edlow JA. Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J Emerg Med 2002;23(1):67–74.

    Article  PubMed  Google Scholar 

  66. Tourtellotte W, Somers J, Parker J, Itabashi H, De Jong R. A study of traumatic lumbar punctures. Neurology 1958; 8: 129–134.

    PubMed  CAS  Google Scholar 

  67. Buruma OJS, Janson HLF, den Bergh FAJTM, Bots GTH. Blood-stained cerebrospinal fluid: traumatic puncture or haemorrhage. J Neurol Neurosurg Psychiatry 1981;44:144–147.

    PubMed  CAS  Google Scholar 

  68. Beetham R, Fahie-Wilson MN, Holbrook I, et al. CSF spectrophotometry in the diagnosis of subarachnoid haemorrhage. J Clin Pathol 2002;55(6):479,480; author reply 80.

    PubMed  CAS  Google Scholar 

  69. Soderstrom CE. Diagnostic significance of CSF spectrophotometry and computerized tomography in cerebrovascular disease: a comparative study in 231 cases. Stroke 1977;8(5):606–612.

    PubMed  CAS  Google Scholar 

  70. Wenham PR, Hanson T, Ashby JP. Interference in spectrophotometric analysis of cerebrospinal fluid by haemolysis induced by transport through a pneumatic tube system. Ann Clin Biochem 2001;38(Pt 4):371–375.

    Article  PubMed  CAS  Google Scholar 

  71. Mitchell P, Wilkinson ID, Hoggard N, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. J Neurol Neurosurg Psychiatry 2001;70(2):205–211.

    Article  PubMed  CAS  Google Scholar 

  72. Noguchi K, Ogawa T, Inugami A, et al. Acute subarachnoid hemorrhage: MR imaging with fluid-attenuated inversion recovery pulse sequences. Radiology 1995;196(3):773–777.

    PubMed  CAS  Google Scholar 

  73. Rumboldt Z, Kalousek M, Castillo M. Hyperacute subarachnoid hemorrhage on T2-weighted MR images. AJNR 2003;24(3):472–475.

    PubMed  Google Scholar 

  74. Woodcock RJ, Jr., Short J, Do HM, Jensen ME, Kallmes DF. Imaging of acute subarachnoid hemorrhage with a fluid-attenuated inversion recovery sequence in an animal model: comparison with non-contrast-enhanced CT. AJNR 2001;22(9):1698–1703.

    PubMed  Google Scholar 

  75. Wiesmann M, Mayer TE, Yousry I, Medele R, Hamann GF, Bruckmann H. Detection of hyperacute subarachnoid hemorrhage of the brain by using magnetic resonance imaging. J Neurosurg 2002;96(4):684–689.

    PubMed  Google Scholar 

  76. Dechambre SD, Duprez T, Grandin CB, Lecouvet FE, Peeters A, Cosnard G. High signal in cerebrospinal fluid mimicking subarachnoid haemorrhage on FLAIR following acute stroke and intravenous contrast medium. Neuroradiology 2000;42(8):608–611.

    Article  PubMed  CAS  Google Scholar 

  77. Schull M. Lumbar puncture first: an alternative model for the investigation of lone acute sudden headache. Acad Emerg Med 1999;6(2):131–136.

    PubMed  CAS  Google Scholar 

  78. Patel MK, Clarke MA. Lumbar puncture and subarachnoid haemorrhage. Postgrad Med J 1986;62(733):1021–1024.

    PubMed  CAS  Google Scholar 

  79. French JK, Glasgow GL. Lumbar puncture in subarachnoid haemorrhage: yes or no? N Z Med J 1985;98(779):383,384.

    PubMed  CAS  Google Scholar 

  80. Duffy GP. Lumbar puncture in spontaneous subarachnoid hemorrhage. BMJ 1982;285:1163–1166.

    PubMed  CAS  Google Scholar 

  81. Hillman J. Should computered tomography scanning replace lumbar puncture in the diagnostic process in suspected subarachnoid hemorrhage? Surg Neurol 1986;26:547–550.

    Article  PubMed  CAS  Google Scholar 

  82. Bassi P, Bandera R, Loiero M, Tognoni G, Mangoni A. Warning signs in subarachnoid hemorrhage: a cooperative study. Acta Neurol Scand 1991;84(4):277–281.

    PubMed  CAS  Google Scholar 

  83. Duffy GP. The warning leak in spontaneous subarachnoid haemorrhage. Med J Aust 1983;1:514–516.

    PubMed  CAS  Google Scholar 

  84. Edner G, Ronne-Engstrom E. Can early admission reduce aneurysmal rebleeds? A prospective study on aneurysmal incidence, aneurysmal rebleeds, admission and treatment delays in a defined region. Br J Neurosurg 1991;5(6):601–608.

    PubMed  CAS  Google Scholar 

  85. Hauerberg J, Andersen BB, Eskesen V, Rosenorn J, Schmidt K. Importance of the recognition of a warning leak as a sign of a ruptured intracranial aneurysm. Acta Neurologica Scandinavica 1991;83(1):61–64.

    Article  PubMed  CAS  Google Scholar 

  86. Jakobsson KE, Saveland H, Hillman J, et al. Warning leak and management outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 1996;85(6):995–999.

    PubMed  CAS  Google Scholar 

  87. Mayberg MR. Warning leaks and subarachnoid hemorrhage. West J Med 1990;153(5):549,550.

    PubMed  CAS  Google Scholar 

  88. Okawara SH. Warning signs prior to rupture of an intracranial aneurysm. J Neurosurg 1973;38:575–580.

    PubMed  CAS  Google Scholar 

  89. Ostergaard JR. Headache as a warning symptom of impending aneurysmal subarachnoid haemorrhage. Cephalalgia 1991;11(1):53–55.

    Article  PubMed  CAS  Google Scholar 

  90. Verweij RD, Wijdicks EF, van Gijn J. Warning headache in aneurysmal subarachnoid hemorrhage. A case-control study. Arch Neurol 1988;45(9):1019,1120.

    PubMed  CAS  Google Scholar 

  91. Gillingham FJ. The management of ruptured intracranial aneurysm. Ann R Coll Surg, (English) 1958;23:89–117.

    CAS  Google Scholar 

  92. Linn FH, Rinkel GJ, Algra A, van Gijn J. The notion of “warning leaks” in subarachnoid haemorrhage: are such patients in fact admitted with a rebleed? J Neurol Neurosurg Psychiatry 2000;68(3):332–336.

    Article  PubMed  CAS  Google Scholar 

  93. Leblanc R. The minor leak preceding subarachnoid hemorrhage. J Neurosurg 1987;66(1):35–39.

    PubMed  CAS  Google Scholar 

  94. Harling DW, Peatfield RC, van Hille PT, Abbot RJ. Thunderclap headache: is it migraine? Cephalgia 1989;9:87–90.

    Article  CAS  Google Scholar 

  95. Markus HS. A prospective follow-up of thunderclap headache mimicking subarachnoid hemorrhage. J Neurol Neurosurg Psychiatry 1991;54:1117–1125.

    Article  PubMed  CAS  Google Scholar 

  96. Wijdicks EFM, Kerkhoff H, vanGijn J. Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid hemorrhage. Lancet 1988;ii:68,69.

    Article  Google Scholar 

  97. Ball MJ. Pathogenesis of the “sentinel” headache preceding berry aneurysm rupture. Canadian Med Assoc J 1975;112(1):78,79.

    CAS  Google Scholar 

  98. Fridriksson S, Hillman J, Landtblom AM, Boive J. Education of referring doctors about sudden onset headache in subarachnoid hemorrhage. A prospective study. Acta Neurol Scand 2001;103(4):238–242.

    Article  PubMed  CAS  Google Scholar 

  99. Imaizumi T, Chiba M, Honma T, Niwa J. Detection of hemosiderin deposition by T2*-weighted MRI after subarachnoid hemorrhage. Stroke 2003;34(7):1693–1698.

    Article  PubMed  CAS  Google Scholar 

  100. Johnson MR, Good CD, Penny WD, Barnes PR, Scadding JW. Lesson of the week: playing the odds in clinical decision making: lessons from berry aneurysms undetected by magnetic resonance angiography. Bmj 2001;322(7298):1347–1349.

    Article  PubMed  CAS  Google Scholar 

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  1. Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Place, CC-2, 02215, Boston, MA

    Jonathan A. Edlow

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Edlow, J.A. Diagnosis of subarachnoid hemorrhage. Neurocrit Care 2, 99–109 (2005). https://doi.org/10.1385/NCC:2:2:099

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