Ostermayer: Remove See Also link to non-existent Thunderclap headache page

2026-04-28T04:32:53Z

Remove See Also link to non-existent Thunderclap headache page

← Older revision		Revision as of 04:32, 28 April 2026
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	*[[Intracerebral hemorrhage]]		*[[Intracerebral hemorrhage]]
	*[[Headache]]		*[[Headache]]
	*[[Thunderclap headache]]
	*[[Lumbar puncture]]		*[[Lumbar puncture]]

Ostermayer: Remove non-existent Category:Neurosurgery

2026-04-28T04:22:16Z

Remove non-existent Category:Neurosurgery

← Older revision		Revision as of 04:22, 28 April 2026
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	[[Category:Neurology]]		[[Category:Neurology]]
	[[Category:Critical Care]]		[[Category:Critical Care]]
	~~[[Category:Neurosurgery]]~~

Ostermayer: Create Aneurysmal SAH page (split from Subarachnoid hemorrhage); aneurysmal/spontaneous content

2026-04-28T04:17:56Z

Create Aneurysmal SAH page (split from Subarachnoid hemorrhage); aneurysmal/spontaneous content

New page

''Spontaneous (non-traumatic) subarachnoid hemorrhage, most commonly due to ruptured cerebral aneurysm. For trauma-related SAH, see [[Traumatic subarachnoid hemorrhage]].''

==Background==
*Bleeding into the subarachnoid space (between arachnoid and pia mater) from a non-traumatic source
*Ruptured cerebral aneurysm accounts for ~85% of nontraumatic SAH
**Most common locations: anterior communicating artery (30%), posterior communicating artery (25%), MCA bifurcation (20%)
*Other causes: arteriovenous malformation, perimesencephalic (benign, ~10%), vasculitis, coagulopathy, drug use
*Mortality: ~50% overall (25% die before reaching hospital, 25% die within 30 days)
*Risk factors:
**[[Hypertension]] (most important modifiable risk factor)
**Smoking, heavy alcohol use
**Family history of SAH or aneurysm (first-degree relative)
**Polycystic kidney disease, Ehlers-Danlos, connective tissue disorders
**Prior SAH (risk of rebleeding)
**Sympathomimetic drug use ([[cocaine]], [[amphetamines]])
*Peak incidence: age 40-60; female predominance (1.6:1)

==Clinical Features==
*"Worst headache of my life" — sudden onset, maximal at onset (thunderclap headache)
*'''Sentinel headache''': warning leak days-weeks before major rupture (present in ~30-50%)
*Meningismus (neck stiffness, photophobia) — may take 6-12 hours to develop
*Loss of consciousness at onset (~50%)
*Nausea, vomiting (common)
*Focal neurologic deficits (CN III palsy → posterior communicating artery aneurysm)
*Seizures (~10% at onset)
*Terson syndrome: intraocular hemorrhage (subhyaloid/vitreous) associated with severe SAH
*'''May present as syncope, cardiac arrest, or altered mental status without headache'''

===Hunt-Hess Grading===
*Grade I: asymptomatic or mild headache
*Grade II: moderate-severe headache, nuchal rigidity, CN palsy
*Grade III: drowsiness, confusion, mild focal deficit
*Grade IV: stupor, moderate-severe hemiparesis
*Grade V: coma, decerebrate posturing

==Differential Diagnosis==
*[[Traumatic subarachnoid hemorrhage]]
*Primary [[headache]] (migraine, tension, cluster)
*[[Meningitis]] / [[encephalitis]]
*[[Intracerebral hemorrhage]]
*[[Cerebral venous sinus thrombosis]]
*[[Hypertensive emergency]]
*Reversible cerebral vasoconstriction syndrome (RCVS)
*[[Cervical artery dissection]]
*[[Pituitary apoplexy]]

{{Headache DDX}}

==Evaluation==
===Non-Contrast CT Head===
*First-line test
*Sensitivity ~98% within 6 hours of onset, ~93% at 12 hours, decreasing to ~50% by day 5-7<ref name="perry2011">Perry JJ, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage. ''BMJ''. 2011;343:d4277. PMID 21768192</ref>
*Fisher grade: amount of blood predicts vasospasm risk
*Modern thin-cut CT with experienced radiologist within 6 hours may approach 100% sensitivity

===Lumbar Puncture===
*Required if CT negative and clinical suspicion remains
*Classic finding: xanthochromia (yellow discoloration from bilirubin in CSF)
**Takes 6-12 hours to develop — LP performed <6 hours after onset may miss xanthochromia
*'''Elevated RBCs that do NOT clear''' across sequential tubes (vs traumatic tap which clears)
*Elevated opening pressure
*Traumatic tap vs SAH: controversial; visual xanthochromia and clinical context are most important

===Ottawa SAH Rule===
*For alert patients >15 years with new severe nontraumatic headache reaching maximum intensity within 1 hour
*100% sensitivity (validation study) — if none present, SAH effectively ruled out<ref name="perry2013">Perry JJ, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. ''JAMA''. 2013;310(12):1248-1255. PMID 24065011</ref>:
**Age ≥40
**Neck pain or stiffness
**Witnessed loss of consciousness
**Onset during exertion
**Thunderclap headache (instant peak)
**Limited neck flexion on exam

===CT Angiography (CTA)===
*Obtain with initial CT if SAH confirmed or high suspicion
*Identifies aneurysm location and morphology for surgical/endovascular planning
*Sensitivity >95% for aneurysms >3 mm

===Labs===
*CBC, BMP, coagulation studies (PT/INR, PTT)
*Type and screen
*Troponin (neurogenic myocardial stunning)
*Finger stick glucose

==Management==
===ED Management===
*ABCs, IV access, continuous monitoring
*Blood pressure control:
**Target SBP <160 mmHg until aneurysm secured (reduce rebleeding risk)
**Nicardipine infusion (5-15 mg/hr, titrate q5min) — preferred
**Labetalol 10-20 mg IV q10-20min
**Avoid nitroprusside (increases ICP)
*Seizure management: benzodiazepines acutely; prophylactic AEDs controversial
*Treat headache: acetaminophen; short-acting opioids cautiously
**Avoid ketorolac (platelet inhibition)
*Aminocaproic acid (tranexamic acid): may reduce rebleeding risk before aneurysm secured — 4g IV loading dose (discuss with neurosurgery)
*Reverse anticoagulation if applicable

===Definitive Treatment===
*Neurosurgery/neurointerventional consultation emergently
*Aneurysm securing (within 24 hours ideally):
**Endovascular coiling (preferred for most aneurysms) OR
**Surgical clipping
*ICU admission

===Complications (Post-Hemorrhage)===
*'''Rebleeding''': highest risk in first 24 hours (~4%); '''most devastating complication'''
*Vasospasm: occurs days 3-14 (peak day 7); monitor with daily TCDs
**Treat with nimodipine 60 mg PO/NG q4h x 21 days (improves outcomes; does not prevent vasospasm)
**Triple-H therapy (hypertension, hypervolemia, hemodilution) — only after aneurysm secured
*Hydrocephalus: acute (requires EVD) or chronic (VP shunt)
*Hyponatremia: cerebral salt wasting vs SIADH
*Neurogenic cardiac dysfunction: Takotsubo-like, neurogenic pulmonary edema

==Disposition==
*All confirmed aneurysmal SAH: emergent neurosurgical consultation and ICU admission
*Transfer to neurosurgical center if local capabilities unavailable
*SAH ruled out (negative CT + negative LP): may discharge with headache precautions and PCP follow-up

== Calculators ==
{{Ottawa SAH Calculator}}
{{Fisher Scale Calculator}}

==See Also==
*[[Subarachnoid hemorrhage]]
*[[Traumatic subarachnoid hemorrhage]]
*[[Intracerebral hemorrhage]]
*[[Headache]]
*[[Thunderclap headache]]
*[[Lumbar puncture]]

==References==
<references/>
*Connolly ES Jr, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline from the AHA/ASA. ''Stroke''. 2012;43(6):1711-1737. PMID 22556195
*Edlow JA, et al. Diagnosis of subarachnoid hemorrhage. ''Stroke''. 2023;54(4):1058-1072. PMID 36848423
*van Gijn J, et al. Subarachnoid haemorrhage. ''Lancet''. 2007;369(9558):306-318. PMID 17258671

[[Category:Neurology]]
[[Category:Critical Care]]
[[Category:Neurosurgery]]

Aneurysmal subarachnoid hemorrhage - Revision history

Ostermayer: Remove See Also link to non-existent Thunderclap headache page

Ostermayer: Remove non-existent Category:Neurosurgery

Ostermayer: Create Aneurysmal SAH page (split from Subarachnoid hemorrhage); aneurysmal/spontaneous content