###Signs & Symptoms

- **3 most imp qualities of SAH on Hx**:

- 1) Sudden onset
- 2) Maximal at onset (*w/in 10 min*)
- 3) Diff in quality from prev HAs
- 2 other imp questions to ask:
- Any PMHx of Polycystic Kidney Disease?
- Any FHx of aneurysm or bleed?
- The "worst HA of pt's life" is not a very specific or useful point on Hx!
- Don't expect to see strong meningeal signs (e.g. Kernigs/Brudzinski's), but on
e good test is:
- Ask pt to turn head to side: if worsens HA, this may imply meningeal irrit
ation!
###CT Head
- CT sensitivity decreases w/ time!
- Is reassuring only if *totally normal* w/in 6 hrs of Sx onset
- But note that the Steele study behind this idea is pretty flawed;
- Need to r/o hydrocephalus: look for dilated *temporal* ventricular horns!
- Look for subtle bleeds on "suprapenducular fossa" and tips of occipital horns
- A tiny white dot here is all you need to see to worry about blood!
###DDx of Rare HA Causes (& Considerations)
- A) Pituitary apoplexy
- B) Cervical artery dissection
- Lancinating/knife-like pain going up face or neck
- Recent minor neck trauma (chiropractor visit, yoga, head-banging)
- Connective tissue dieases
- FHx of stroke
- C) Cerebral venous thrombosis
- Think about this if H/A is totally unremitting (doesn't respond to anythin
g) and has either:
- a) Hypercoagulable state (pregnant or recent post-partum, multiple previou
s DVTs, malginancy, hormonal therapy)
- b) Head & neck infection
###Diagnostic Algorithm For Suspected SAH
- i) CT Head w/o contrast
- ii) Negative or equivocal CT: LP
- Incompletely clearing RBCs or xanthochromia: this is a +ve test!
- iii) Suspected traumatic LP: repeat LP!
- iv) If LP is clearly -ve: SAH ruled out!
###Rx For SAH
- 1) Pain control
- 2) Nimodipine
- 3) Seizure prophylaxis
- 4) Blood pressure Rx w/ IV agents (get pt normotensive fast!)
###Ottawa SAH Rule
- In alert pts >15 y.o w/ new severe non-traumatic HA maximum w/ 1 hr, investiga
te *if any of*:
- Age >40
- Complaint of neck pain or stiffness
- Witnessed loss of consciousness
- Onset during exertion (sexual intercourse, running, etc)
- Thunderclap quality (sudden & maximal onset)
- Limited neck flexion on exam
- Note that this rule doesn't really add much or help: the more reasonable appro
ach is to just **fully work up all pts with a thunderclap quality HA (& this inc
ludes an LP!)**
###Pitfalls In Our Usual Approach
- 1) Not the worst H/A in pt's life
- 2) PEx looked completely normal (this is not reassuring in potential subarachn
oid cases!)
- 3) The pain got better w/ Tylenol/Advil/etc
- Response to Rx has no effect on the potential diagnosis! (And don't forget
that usually subarachnoids get better temporarily once the initial sentinel ble
ed is finished!)
- 4) The CT was negative
- If you're really suspicious, need to do an LP even if CT clean!
- 5) The LP tubes show decreasing RBCs from tube 1-4
- The trend in RBCs doesn't really matter!
- RBCs <100 are very unlikely to be subarachnoid, but above this it becomes
hard to be really reassured (esp if RBCs >=1000 have to assume it's positive)
- 6) Maybe we can just skip the LP and do a CT angiogram?
- Can't reliably establish rupture w/ CTA, only an LP!
- CTAs can show small aneurysms and if an *unruptured* aneurysm is <10mm it'
s *very* unlikely to rupture in future or cause prbs, but really worries pts!