Non-traumatic Subarachnoid Haemorrhage

Author: Jamie G Cooper / Editors: Gavin Lloyd, Clifford J Mann / Reviewer: Peter Kilgour, Jon Bailey / Codes: A5, R3 / Published: 21/09/2018

This session describes the management of presentations of non-traumatic subarachnoid haemorrhage in the emergency department (ED).

After completing this session you will be able to:

  • Describe the epidemiology, aetiology and pathogenesis of subarachnoid haemorrhage (SAH)
  • State the caveats in clinical presentation of SAH
  • Demonstrate knowledge of the pitfalls in diagnosis of SAH and the properties of commonly used investigations, particularly CT and LP
  • Recall the key management points to reduce complications such as rebleeding and vasospasm


  1. 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 Apr;27(4):625-9.
  2. Epidemiology of aneurysmal subarachnoid hemorrhage in Australia and New Zealand: incidence and case fatality from the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS). Stroke. 2000 Aug;31(8):1843-50.
  3. Mitchell P, Hope T, Gregson BA, Mendelow AD. Regional differences in outcome from subarachnoid haemorrhage: comparative audit. BMJ 2004 May 22;328(7450):1234-1235.
  4. Huang J, van Gelder JM. The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis. Neurosurgery 2002 discussion 1105-7; Nov;51(5):1101-1105.
  5. Stegmayr B, Eriksson M, Asplund K. Declining mortality from subarachnoid hemorrhage: changes in incidence and case fatality from 1985 through 2000. Stroke 2004 Sep;35(9):2059-2063.
  6. Hop JW, Rinkel GJ, Algra A, van Gijn J. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke 1997 Mar;28(3):660-664.
  7. 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 Jul;73(1):18-36.
  8. Mayer PL, Awad IA, Todor R, Harbaugh K, Varnavas G, et al. Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions. Stroke 1996 Sep;27(9):1558-1563.
  9. Kowalski RG, Claassen J, Kreiter KT, Bates JE, Ostapkovich ND, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 2004 Feb 18;291(7):866-869.
  10. Johnston SC, Selvin S, Gress DR. The burden, trends, and demographics of mortality from subarachnoid hemorrhage. Neurology 1998;50(5):1413-1418.
  11. Bederson JB, Connolly ES,Jr, Batjer HH, Dacey RG, Dion JE, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009 Mar;40(3):994-1025.
  12. Cioffi F, Pasqualin A, Cavazzani P, Da Pian R. Subarachnoid haemorrhage of unknown origin: clinical and tomographical aspects. Acta Neurochir. 1989;97(1-2):31-39.
  13. Rinkel GJ, Djibuti M, Algra A, van Gijn J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke 1998 Jan;29(1):251-256.
  14. Teasdale GM, Wardlaw JM, White PM, Murray G, Teasdale EM, et al. The familial risk of subarachnoid haemorrhage. Brain 2005 Jul;128 (Pt 7):1677-1685.
  15. Gieteling EW, Rinkel GJ. Characteristics of intracranial aneurysms and subarachnoid haemorrhage in patients with polycystic kidney disease. J.Neurol. 2003 Apr;250(4):418-423.
  16. Feigin VL, Rinkel GJ, Lawes CM, Algra A, Bennett DA, van Gijn J, et al. Risk factors for subarachnoid hemorrhage: an updated systematic review of epidemiological studies. Stroke 2005 Dec;36(12):2773-2780.
  17. Ruigrok YM, Buskens E, Rinkel GJ. Attributable risk of common and rare determinants of subarachnoid hemorrhage. Stroke 2001 May;32(5):1173-1175.
  18. van Gijn J, Kerr RS, Rinkel GJ. Subarachnoid haemorrhage. Lancet 2007 Jan 27;369(9558):306-318.
  19. van Gijn J, van Dongen KJ, Vermeulen M, Hijdra A. Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology 1985 Apr;35(4):493-497.
  20. Rinkel GJ, Wijdicks EF, Hasan D, Kienstra GE, Franke CL, et al. Outcome in patients with subarachnoid haemorrhage and negative angiography according to pattern of haemorrhage on computed tomography. Lancet 1991 Oct 19;338(8773):964-968.
  21. Harrod CG, Bendok BR, Batjer HH. Prediction of cerebral vasospasm in patients presenting with aneurysmal subarachnoid hemorrhage: a review. Neurosurgery 2005 discussion 633-54; Apr;56(4):633-654.
  22. Perry JJ, Stiell I, Wells GA, Spacek A. Diagnostic test utilization in the emergency department for alert headache patients with possible subarachnoid hemorrhage. CJEM 2002;4(5):333-337.
  23. Leicht MJ. Non-traumatic headache in the emergency department. Ann.Emerg.Med. 1980 Aug;9(8):404-409.
  24. 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 Dec;54(12):1506-1509.
  25. Goldstein JN, Camargo CA,Jr, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia 2006 Jun;26(6):684-690.
  26. Morgenstern LB, Luna-Gonzales H, Huber JC,Jr, Wong SS, Uthman MO, Gurian JH, et al. Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann.Emerg.Med. 1998 Sep;32(3 Pt 1):297-304.
  27. Linn FH, Rinkel GJ, Algra A, van Gijn J. Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache. Journal of Neurology, Neurosurgery & Psychiatry 1998 Nov;65(5):791-793.
  28. Kassell NF, Kongable GL, Torner JC, Adams HP,Jr, Mazuz H. Delay in referral of patients with ruptured aneurysms to neurosurgical attention. Stroke 1985 Jul-Aug;16(4):587-590.
  29. 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 Jun;22(5):354-360.
  30. Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Hohl CM, Sutherland J, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA 2013 Sep 25;310(12):1248-1255.
  31. Locker TE, Thompson C, Rylance J, Mason SM. The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department. Headache 2006 Jun;46(6):954-961.
  32. Davenport R. Acute headache in the emergency department. Journal of Neurology, Neurosurgery & Psychiatry 2002 Jun;72(Suppl 2):33-37.
  33. Weir B. Headaches from aneurysms. Cephalalgia 1994 Apr;14(2):79-87.
  34. Seymour JJ, Moscati RM, Jehle DV. Response of headaches to nonnarcotic analgesics resulting in missed intracranial hemorrhage. Am.J.Emerg.Med. 1995 Jan;13(1):43-45.
  35. Fann JR, Kukull WA, Katon WJ, Longstreth WT,Jr. Physical activity and subarachnoid haemorrhage: a population based case-control study. Journal of Neurology, Neurosurgery & Psychiatry 2000 Dec;69(6):768-772.
  36. Matsuda M, Watanabe K, Saito A, Matsumura K, Ichikawa M. Circumstances, activities, and events precipitating aneurysmal subarachnoid hemorrhage. Journal of Stroke & Cerebrovascular Diseases 2007 Jan-Feb;16(1):25-29.
  37. Al-Shahi R, White PM, Davenport RJ, Lindsay KW. Subarachnoid haemorrhage. BMJ 2006 Jul 29;333(7561):235-240.
  38. Toussaint LG,3rd, Friedman JA, Wijdicks EF, Piepgras DG, Pichelmann MA, McIver JI, et al. Survival of cardiac arrest after aneurysmal subarachnoid hemorrhage. Neurosurgery 2005 discussion 25-31; Jul;57(1):25-31.
  39. Perry JJ, Stiell IG, Wells GA, Mortensen M, Sivilotti M, Bullard M, et al. A clinical decision rule to safely rule out subarachnoid hemorrhage in acute headache patients in the emergency department. (Abstract). Acad Emerg Med 2006;13(5):Suppl 1:S9.
  40. Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Lee JS, Eisenhauer M, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ 2010;341:5204.
  41. Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke 2007 Apr;38(4):1216-1221.
  42. Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N.Engl.J.Med. 2000 Jan 6;342(1):29-36.
  43. Perry JJ, Stiell IG, Wells GA, Mortensen M, Lesuik H, Sivilotti M, et al. The sensitivity of computed tomography for the diagnosis of subarachnoid hemorrhage in ED patients with acute headache. (Abstract). Acad Emerg Med 2004;11(5):435-436.
  44. Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Emond M, Symington C, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011;343:4277.
  45. Perry JJ, Spacek A, Forbes M, Wells GA, Mortensen M, Symington C, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Ann Emerg Med 2008 Jun;51(6):707-713.
  46. Edlow JA, Malek AM, Ogilvy CS. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med 2008 Apr;34(3):237-251.
  47. Velthuis BK, Rinkel GJ, Ramos LM, Witkamp TD, van Leeuwen MS. Perimesencephalic hemorrhage. Exclusion of vertebrobasilar aneurysms with CT angiography. Stroke 1999 May;30(5):1103-1109.
  48. Ruigrok YM, Rinkel GJ, Buskens E, Velthuis BK, van Gijn J. Perimesencephalic hemorrhage and CT angiography: A decision analysis. Stroke 2000 Dec;31(12):2976-2983.
  49. “Scottish Intercollegiate Guidelines Network.”. Diagnosis and management of headache in adults;2008. view link
  50. Guidelines in Emergency Medicine Network (GEMNet). A cliinical guideline for the managment of lone acute severe headache. Dec, 2009. View link
  51. Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW, American College of Emergency P. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008 Oct;52(4):407-436.
  52. Kuntz KM, Kokmen E, Stevens JC, Miller P, Offord KP, Ho MM. Post-lumbar puncture headaches: experience in 501 consecutive procedures. Neurology 1992 Oct;42(10):1884-1887.
  53. Evans RW. Complications of lumbar puncture. Neurol.Clin. 1998 Feb;16(1):83-105.
  54. Strupp M, Brandt T, Muller A. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients. J.Neurol. 1998 Sep;245(9):589-592.
  55. Braune HJ, Huffmann GA. A prospective double-blind clinical trial, comparing the sharp Quincke needle (22G) with an “atraumatic” needle (22G) in the induction of post-lumbar puncture headache. Acta Neurol.Scand. 1992 Jul;86(1):50-54.
  56. Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Postdural puncture headache: a randomized comparison of five spinal needles in obstetric patients. Anesthesia & Analgesia 2000 Oct;91(4):916-920.
  57. Stam J. Thrombosis of the cerebral veins and sinuses. N.Engl.J.Med. 2005 Apr 28;352(17):1791-1798.
  58. Sudlow CLM, Warlow CP. Posture and fluids for preventing post-dural puncture headache. Cochrane Database of Systematic Reviews 2001(2).
  59. Shah KH, Richard KM, Nicholas S, Edlow JA. Incidence of traumatic lumbar puncture. Acad.Emerg.Med. 2003 Feb;10(2):151-154.
  60. Shah KH, Edlow JA. Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J.Emerg.Med. 2002 Jul;23(1):67-74.
  61. Graves P, Sidman R. Xanthochromia is not pathognomonic for subarachnoid hemorrhage. Acad.Emerg.Med. 2004 Feb;11(2):131-135.
  62. Vermeulen M, van Gijn J. The diagnosis of subarachnoid haemorrhage. Journal of Neurology, Neurosurgery & Psychiatry 1990 May;53(5):365-372.
  63. Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J. Xanthochromia after subarachnoid haemorrhage needs no revisitation. Journal of Neurology, Neurosurgery & Psychiatry 1989 Jul;52(7):826-828.
  64. UK National External Quality Assessment Scheme for Immunochemistry Working,Group. National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage. Ann.Clin.Biochem. 2003 Sep;40(Pt 5):481-488.
  65. 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 Jul;38(Pt 4):371-375.
  66. Gunawardena H, Beetham R, Scolding N, Lhatoo SD. Is cerebrospinal fluid spectrophotometry useful in CT scan-negative suspected subarachnoid haemorrage?. Eur.Neurol. 2004;52(4):226-229.
  67. Perry JJ, Sivilotti ML, Stiell IG, Wells GA, Raymond J, Mortensen M, et al. Should spectrophotometry be used to identify xanthochromia in the cerebrospinal fluid of alert patients suspected of having subarachnoid hemorrhage?. Stroke 2006 Oct;37(10):2467-2472.
  68. Edlow JA, Bruner KS, Horowitz GL. Xanthochromia. Arch.Pathol.Lab.Med. 2002 Apr;126(4):413-415.
  69. Sidman R, Spitalnic S, Demelis M, Durfey N, Jay G. Xanthrochromia? By what method? A comparison of visual and spectrophotometric xanthrochromia. Ann.Emerg.Med. 2005 Jul;46(1):51-55.
  70. Arora S, Swadron SP, Dissanayake V. Evaluating the sensitivity of visual xanthochromia in patients with subarachnoid haemorrhage. J Emerg Med Article in Press 24th June 2008.
  71. Cruickshank A, Beetham R, Holbrook I, Watson I, Wenham P, Keir G, et al. Spectrophotometry of cerebrospinal fluid in suspected subarachnoid haemorrhage. BMJ 2005 Jan 15;330(7483):138.
  72. Dupont SA, Wijdicks EF, Manno EM, Rabinstein AA. Thunderclap headache and normal computed tomographic results: value of cerebrospinal fluid analysis. Mayo Clin.Proc. 2008 Dec;83(12):1326-1331.
  73. Perry JJ, Spacek A, Forbes M, Wells GA, Mortensen M, Symington C, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage?. Ann.Emerg.Med. 2008 Jun;51(6):707-713.
  74. Nijjar S, Patel B, McGinn G, West M. Computed tomographic angiography as the primary diagnostic study in spontaneous subarachnoid hemorrhage. Journal of Neuroimaging 2007 Oct;17(4):295-299.
  75. Carstairs SD, Tanen DA, Duncan TD, Nordling OB, Wanebo JE, Paluska TR, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Acad.Emerg.Med. 2006 May;13(5):486-492.
  76. Mitchell P, Wilkinson ID, Hoggard N, Paley MN, Jellinek DA, Powell T, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. Journal of Neurology, Neurosurgery & Psychiatry 2001 Feb;70(2):205-211.
  77. Schull MJ. Lumbar puncture first: an alternative model for the investigation of lone acute sudden headache. Acad.Emerg.Med. 1999 Feb;6(2):131-136.
  78. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J.Neurosurg. 1968 Jan;28(1):14-20.
  79. Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset B, et al. A universal ubarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. Journal of Neurology, Neurosurgery & Psychiatry 1988 Nov;51(11):1457.
  80. Bardach NS, Zhao S, Gress DR, Lawton MT, Johnston SC. Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke 2002 Jul;33(7):1851-1856.
  81. Berman MF, Solomon RA, Mayer SA, Johnston SC, Yung PP. Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke 2003 Sep;34(9):2200-2207.
  82. Willinsky RA, Taylor SM, TerBrugge K, Farb RI, Tomlinson G, Montanera W. Neurologic complications of cerebral angiography: prospective analysis of 2,899 procedures and review of the literature. Radiology 2003 May;227(2):522-528.
  83. Kassell NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery 1983 Nov;13(5):479-481.
  84. Baharoglu MI, Germans MR, Rinkel GJ, Algra A, Vermeulen M, van Gijn J, et al. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database of Systematic Reviews 2013;8:001245.
  85. van der Schaaf I, Algra A, Wermer M, Molyneux A, Clarke M, van Gijn J, et al. Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage. Cochrane Database of Systematic Reviews 2005(4):003085.
  86. Molyneux AJ, Kerr RS, Yu LM, Clarke M, et al. International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005 Sep 3-9;366(9488):809-17.
  87. Roos YB, de Haan RJ, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M. Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in the Netherlands. Journal of Neurology, Neurosurgery & Psychiatry 2000 Mar;68(3):337-341.
  88. Hijdra A, Van Gijn J, Stefanko S, Van Dongen KJ, Vermeulen M, Van Crevel H. Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: clinicoanatomic correlations. Neurology 1986 Mar;36(3):329-333.
  89. Rabinstein AA, Weigand S, Atkinson JL, Wijdicks EF. Patterns of cerebral infarction in aneurysmal subarachnoid hemorrhage. Stroke 2005 May;36(5):992-997.
  90. Hop JW, Rinkel GJ, Algra A, van Gijn J. Initial loss of consciousness and risk of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Stroke 1999 Nov;30(11):2268-2271.
  91. Dorhout Mees SM, Rinkel GJ, Feigin VL, Algra A, van den Bergh WM, Vermeulen M, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database of Systematic Reviews 2007(3):000277.
  92. van den Bergh WM, Algra A, van Kooten F, Dirven CM, van Gijn J, Vermeulen M, et al. Magnesium sulfate in aneurysmal subarachnoid hemorrhage: a randomized controlled trial. Stroke 2005 May;36(5):1011-1015.
  93. Dorhout Mees SM, van den Bergh WM, Algra A, Rinkel GJ. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database of Systematic Reviews 2007(4):006184.
  94. Vergouwen MD, de Haan RJ, Vermeulen M, Roos YB. Effect of statin treatment on vasospasm, delayed cerebral ischemia, and functional outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis update. Stroke 2010 Jan;41(1):e47-52.
  95. Rinkel GJ, Feigin VL, Algra A, van Gijn J. Circulatory volume expansion therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database of Systematic Reviews 2004(4):000483.
  96. Guo J, Shi Z, Yang K, Tian JH, Jiang L. Endothelin receptor antagonists for subarachnoid hemorrhage. Cochrane Database of Systematic Reviews 2012;9:008354.
  97. Feigin VL, Anderson N, Rinkel GJ, Algra A, van Gijn J, Bennett DA. Corticosteroids for aneurysmal subarachnoid haemorrhage and primary intracerebral haemorrhage. Cochrane Database of Systematic Reviews 2005(3):004583.
  98. Hasan D, Vermeulen M, Wijdicks EF, Hijdra A, van Gijn J. Management problems in acute hydrocephalus after subarachnoid hemorrhage. Stroke 1989 Jun;20(6):747-753.
  99. Claiborne Johnston S, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict early stroke risk after transient ischaemic attack. Lancet 2007;369(9558):283-292.

Leave a Reply