Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage

Abstract

Subarachnoid hemorrhage (SAH) is a devastating neurologic condition with a high mortality and long term neurological morbidity in 50% of survivors. In addition, SAH commonly affects young patients causing substantial loss of productive life years and resulting in significant long term healthcare costs. Early recognition of the signs and symptoms of SAH is absolutely critical to earlier intervention, and delays in diagnosis can have devastating consequences. To avoid such delays in SAH diagnosis, the medical provider should recognize its signs and symptoms. Neuroimgaging, cerebrospinal fluid examination and angiography (invasive or non-invasive) facilitate early diagnosis of SAH. The purpose of this review is not to provide an exhaustive critique of the available literature, rather, it is to provide an overview that will better enable a provider to recognize and initiate the workup of patients with SAH.

Keywords::

• aneurysm
• cerebral angiography
• computed tomography
• intracerebral hemorrhage
• MRI
• subarachnoid hemorrhage
• thunderclap headache

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The most common presenting feature of subarachnoid hemorrhage (SAH) is a severe headache that reaches maximal intensity within seconds (thunderclap headache), though altered or loss of consciousness, focal deficits and visual and constitutional symptoms are not uncommon.

• Any patient with a suspected SAH should have an emergent non-contrast CT scan of the head, which has a high sensitivity and specificity when obtained soon after symptom onset.

• MRI scans of the head may be useful when there is a delay of several days from symptom onset to presentation.

• Catheter angiography digital subtraction angiography remains the gold standard for diagnosing an underlying aneurysm responsible for SAH, though continued improvements in computed tomography angiography and MR angiography technology may supplant digital subtraction angiography within the next several years.

• Lumbar puncture and CSF analysis remain a valuable tool in assessing those with suspected SAH, but with negative imaging.

• Multiple grading systems for SAH exist, though the most common are the Hunt and Hess scale, the World Federation of Neurosurgical Societies scale and the modified Fisher scale.

Notes

Data taken from [6,7].