Updated: 12/18/2019

Subarachnoid Hemorrhage

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Snapshot
  • A 45-year-old woman presents to the emergency room with a severe headache of acute onset. Her headache is significantly more severe than her migraine headaches. Her symptoms began approximately 2 hours ago after she was lifting heavy weights. She denies any head trauma, nausea, or vomiting. Physical examination is unremarkable. A CT head without contrast is normal. An emergency lumbar puncture is done and demonstrates elevated red blood cells that do not diminish from tube 1 to 4.
Introduction
  • Definition
    • bleeding into the subarachnoid space, where cerebrospinal fluid (CSF) is housed
  • Epidemiology
    • risk factors
      • cigarette smoking (most important preventable risk factors)
      • hypertension
      • polycystic kidney disease
  • Etiology
    • aneurysm rupture 
      • can result from an acute trigger, such as physical exertion
      • may occur in the absence of an acute trigger, such as in sleep
  • Pathogenesis
    • rupture of an aneurysm (most commonly a saccular aneurysm) leads to the release of blood into the CSF under arterial pressure
      • rapid filling of blood within the CSF leads to increased intracranial pressure  
Presentation
  • Symptoms
    • thunderclap headache
      • a sudden and severe headache, often described as "the worst headache of my life"
    • increased intracranial pressure
      • nausea
      • vomiting
    • meningismus
      • neck stiffness
Imaging
  • CT head without contrast
    • indication
      • imaging study of choice in patients with suspected subarachnoid hemorrhage 
    • findings
      • hyperdensities in the suprasella cisterns extending peripherally
Studies
  • Lumbar puncture 
    • indication
      • when CT head without contrast is normal and there is still suspicion for a subarachnoid hemorrhage > 6 hours from symptoms onset 
    • findings
      • elevated red blood cell count that does not decrease from collecting tube 1 to 4
      • xanthochromia
Differential
  • Reversible cerebral vasoconstriction syndrome (RCVS)
    • differentiating factors
      • recurrent thunderclap headaches
      • normal neuro imaging but can demonstrate border zone infarcts or vasogenic edema
      • abnormal cerebral angiography
Treatment
  • Medical
    • nimodipine
      • indication
        • to prevent cerebral vasospasm
  • Operative
    • aneurysm repair
      • indication
        • to prevent re-rupture of the aneurysm
Complications
  • Arterial vasospasm
  • Hydrocepalus
  • Hyponatremia 
 

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(M2.NE.15.19) A 62-year-old woman presents to the emergency department after developing a severe headache and neck stiffness. The pain was of sudden onset and feels more severe than her normal headaches. Her temperature is 97.7°F (36.5°C), blood pressure is 155/89 mmHg, pulse is 92/min, respirations are 17/min, and oxygen saturation is 98% on room air. A CT scan of her head is obtained and shown in Figure A and an ECG is performed as seen in Figure B. The patient is appropriately treated and transferred to the ICU. Which of the following is most likely to develop in this patient during their stay in the ICU? Tested Concept

QID: 105019
FIGURES:
1

Hyperkalemia

14%

(2/14)

2

Hypermagnesemia

0%

(0/14)

3

Hypernatremia

29%

(4/14)

4

Hyponatremia

21%

(3/14)

5

Hypokalemia

36%

(5/14)

M 8 E

Select Answer to see Preferred Response

(M3.NE.14.48) A 77-year-old man with a history of hypertension and a 46 pack-year smoking history presents to the emergency department from an extended care facility with acute onset of headache, nausea, vomiting, and neck pain which started 6 hours ago and has persisted since. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. His temperature is 99.0°F (37.2°C), blood pressure is 164/94 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. The patient's neurological exam is unremarkable with cranial nerves II-XII grossly intact and with stable gait with a walker. He is immediately sent for a head CT which is normal. What is the most appropriate next step in management? Tested Concept

QID: 103646
1

Alteplase

0%

(0/3)

2

Ibuprofen, acetaminophen, metoclopramide, and diphenhydramine

0%

(0/3)

3

Lumbar puncture

0%

(0/3)

4

MRI

33%

(1/3)

5

Ultrasound

67%

(2/3)

M 11 E

Select Answer to see Preferred Response

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