The diagnosis of subarachnoid hemorrhage (SAH) usually depends
on a high index of clinical suspicion combined with radiologic
confirmation via urgent computed tomography (CT) scan without
contrast. Traditionally, a negative CT scan is followed with lumbar
puncture (LP). However, noncontrast CT followed by CT angiography
(CTA) of the brain can rule out SAH with greater than 99%
sensitivity.[2]Compared with the traditional recommendation of CT
followed by LP, CT/CTA may offer a less invasive and more
informative diagnostic approach for emergency department patients
complaining of acute-onset headache and with no significant risk
factors for SAH. A disadvantage of foregoing LP is that spinal
fluid analysis may point toward an alternative diagnosis.After the
diagnosis of SAH is established, further imaging should be
performed to characterize the source of the hemorrhage. This effort
can include standard angiography, CT angiography, and magnetic
resonance (MR) angiography.Laboratory studies for SAH should
include the following: Serum chemistry panel - To establish a
baseline for detection of future complications Complete blood count
- For evaluation of possible infection or hematologic abnormality
Prothrombin time (PT) and activated partial thromboplastin time
(aPTT) - For evaluation of possible coagulopathy Blood
typing/screening - To prepare for possible intraoperative
transfusions Cardiac enzymes - For evaluation of possible
myocardial ischemia Arterial blood gas (ABG) - Necessary in
patients with pulmonary compromiseSerum cardiac troponin
measurement is important in patients with subarachnoid hemorrhage,
even in those without underlying cardiac conditions. It was
initially thought to be useful only as a predictor for the
occurrence of pulmonary and cardiac complications.[15]However,
correlation was subsequently found between troponin levels and
neurologic complications and outcome.[16]All patients with SAH
should have a baseline chest radiograph to serve as a reference
point for evaluation of possible pulmonary complications. All
patients with SAH should also have an electrocardiogram (ECG) on
admission. Patients with SAH can have myocardial ischemia due to
the increased level of circulating catecholamines or to autonomic
stimulation from the brain. Myocardial infarction is a rare
complication. However, suspicion of SAH is a contraindication to
thrombolytic and anticoagulant therapy.Because most of the ECG
abnormalities that occur with SAH are benign and reversible,
differentiating true myocardial ischemia from benign changes is
important. Two-dimensional echocardiography often is more sensitive
in detecting myocardial ischemia than is ECG and thus is useful in
the setting of SAH.Other imaging studies may be indicated. MRI is
performed if no lesion is found on angiography, and transcranial
Doppler studies are useful in the detection and monitoring of
arterial vasospasm.Computed TomographyCT without contrast is the
most sensitive imaging study in SAH (see the images below). When
carried out within 6 hours of headache onset, CT has 100%
sensitivity and specificity. Sensitivity is 93% within 24 hours of
onset,[17]80% at 3 days, and 50% at 1 week.[18]Sensitivity is less
on older second- or first-generation scanners, but most North
American hospitals have been using third-generation scanners since
the mid 1980s. Thin (3 mm) cuts are necessary to properly identify
the presence of smaller hemorrhages.CT scan reveals subarachnoid
hemorrhage in the right sylvian fissure; no evidence of
hydrocephalus is apparent.CT scan reveals subarachnoid hemorrhage
in the sylvian fissure, right more than left.A 47-year-old woman
presented with headache and vomiting; her CT scan in the emergency
department revealed subarachnoid hemorrhage.Brain CT scan showing
subtle finding of blood at the area of the circle of Willis
consistent with acute subarachnoid hemorrhage. Image courtesy of
Dana Stearns, MD, Massachusetts General Hospital.Findings may be
negative in 10-15% of patients with SAH. A falsely negative CT scan
can result from severe anemia or small-volume subarachnoid
hemorrhage.The location of blood within the subarachnoid space
correlates directly with the location of the aneurysm in 70% of
cases. In general, blood localized to the basal cisterns, the
sylvian fissure, or the intrahemispheric fissure indicates rupture
of a saccular aneurysm. Blood lying over the convexities or within
the superficial parenchyma of the brain often is indicative of
arteriovenous malformation (AVM) or mycotic aneurysm
rupture.Intraparenchymal hemorrhage may occur with middle
communicating artery and posterior communicating artery aneurysms.
Interhemispheric and intraventricular hemorrhages may occur with
anterior communicating artery aneurysms.A contrast-enhanced CT scan
may reveal an AVM. However, this study should not be performed
before a noncontrast CT scan because the contrast may interfere
with the visualization of subarachnoid blood.Degree and location of
SAH are significant prognostic factors. The Fisher grading system
is used to classify SAH, as follows: Grade 1 - No subarachnoid
blood seen on CT scan Grade 2 - Diffuse or vertical layers of SAH
less than 1 mm thick Grade 3 - Diffuse clot and/or vertical layer
greater than 1 mm thick Grade 4 - Intracerebral or intraventricular
clot with diffuse or no subarachnoid bloodCT scan allows for the
detection of ventricular size and, thus, evaluation and
surveillance of mass effect and hydrocephalus. On CT scan,
hydrocephalus is evident as trapped temporal horns and "Mickey
Mouse" appearance of the ventricular system.Infusion CT scanSome
centers have obtained good results with infusion CT scanning. This
scan employs a contrast dye and can be performed immediately after
a noncontrast CT scan. Reformatted image data can be viewed and
rotated in 2-dimensional displays. Infusion CT scanning has been
reported to detect aneurysms larger than 3 mm with a sensitivity of
97%, which may provide sufficient anatomic detail to allow for
surgical management in the absence of angiography.Lumbar PunctureLP
is traditionally performed as a follow-up test when a CT scan has
shown no SAH and has excluded possible contraindications to LP such
as significant intracranial mass effect, elevated ICP, obstructive
hydrocephalus, or obvious intracranial bleed. LP should not be
performed if the CT scan demonstrates an SAH because of the (small)
risk of further intracranial bleeding associated with a drop in
ICP.An LP is performed to evaluate the cerebrospinal fluid for the
presence of red blood cells (RBCs) and xanthochromia. LP may be
negative if performed less than 2 hours after an SAH occurs; LP is
most sensitive 12 hours after onset of symptoms. CSF samples taken
within 24 hours of the ictus usually show a WBC-to-RBC ratio that
is consistent with the normal circulating WBC-to-RBC ratio of
approximately 1:1000. After 24 hours, CSF samples may demonstrate a
polymorphonuclear and mononuclear polycytosis secondary to chemical
meningitis caused by the degradation products of subarachnoid
blood.RBCs in the CSF can reflect a traumatic LP rather than SAH;
however, SAH often can be distinguished from traumatic LP by
comparing the RBC count of the first and last tubes of CSF. In
traumatic LP, the RBC count in the last tube is usually lower,
whereas in SAH the RBC typically remains consistently elevated.
Nevertheless, cases of SAH in which the RBC count is lower have
been reported.No consensus is found in the literature on the lower
limit of the RBC count in the CSF that signifies a positive tap.
However, most counts range from a few hundred to a million or more
cells per cubic millimeter. The most reliable method of
differentiating SAH from a traumatic tap is to spin down the CSF
and examine the supernatant fluid for the presence of
xanthochromia, a pink or yellow coloration caused by the breakdown
of RBCs and subsequent release of heme pigments.Xanthochromia
typically will not appear until 2-4 hours after the ictus. In
nearly 100% of patients with an SAH, xanthochromia is present 12
hours after the bleed and remains for approximately 2 weeks.
Xanthochromia is present 3 weeks after the bleed in 70% of
patients, and it is still detectable at 4 weeks in 40% of patients.
Spectrophotometry is much more sensitive than the naked eye in
detecting xanthochromia. Nevertheless, many laboratories rely on
visual inspection.Some authors have suggested that the D-dimer
assay can be used to discriminate SAH from traumatic LP. Results
have been conflicting, however, and further data are
needed.Patients with negative CT and LP findings have a favorable
prognosis. However, LP findings can be negative in approximately
10-15% of patients with SAH. In the past, LP findings were thought
to be positive in 5-15% of all SAH presentations that are not
evident on the CT scan. This number may be no longer valid with the
advent of newer generations of CT scans. A small retrospective
review of patients who presented to the ED and underwent
fifth-generation CT scans and LP showed no cases of a positive LIP
after a negative CT scan.[19]Cerebral
AngiographyDigital-subtraction cerebral angiography has been the
criterion standard for the detection of cerebral aneurysms (see the
images below). It is particularly useful in cases of diagnostic
uncertainty (after CT scan and LP) and in patients with septic
endocarditis and SAH to search for the presence of mycotic
aneurysms.In cases where the diagnosis of SAH has been determined,
the timing of cerebral angiography will depend on surgical
considerations. Cerebral angiography can provide the following
important surgical information in the setting of SAH:
Cerebrovascular anatomy Aneurysm location and source of bleeding
Aneurysm size and shape, as well as orientation of the aneurysm
dome and neck Relation of the aneurysm to the parent artery and
perforating arteries Presence of multiple or mirror aneurysms
(identically placed aneurysms in both the left and right
circulations)A trial balloon occlusion of the parent artery can be
performed and may help to guide preoperative surgical
planning.Cerebral angiogram reveals a middle cerebral artery
aneurysm.Cerebral angiogram reveals a middle cerebral artery
aneurysm.Cerebral angiogram (lateral view) reveals a large aneurysm
arising from the left anterior choroidal artery.Cerebral angiogram
(anteroposterior view) reveals a large aneurysm arising from the
left anterior choroidal artery.Negative angiographic findings do
not rule out aneurysm. Approximately 10-20% of patients with
clinically diagnosed SAH (on CT and/or lumbar puncture) have
negative angiographic findings. A repeat angiogram is usually
required in 10-21 days in such cases.A negative study finding can
result from aneurysm obliteration secondary to clotting. Hemorrhage
secondary to a ruptured AVM or spinal cord aneurysm may be present
despite a negative finding on cerebral angiogram. Perimesencephalic
venous hemorrhage also should be consideredFollow-up angiography is
useful after surgical intervention. The postoperative study can
confirm aneurysmal obliteration and to evaluate for possible
cerebral vasospasm. The management of moribund patients with CT
scan evidence of a large SAH and focal hematoma is controversial.
Performing angiography may result in a life-threatening delay in
treatment.CT AngiographyAlthough digital-subtraction cerebral
angiography has been the criterion standard for the detection of
cerebral aneurysms, multidetector CT angiography (MD-CTA) of the
intracranial vessels is now routinely performed, and it is becoming
fully integrated into the imaging and treatment algorithm of
patients presenting with acute subarachnoid hemorrhage in many
centers in the United Kingdom and Europe.[20]The popularity of
MD-CTA derives from its noninvasiveness and a sensitivity and
specificity comparable to that of cerebral angiography.[21, 22]This
technique is beneficial in very unstable patients who cannot
undergo angiography or in emergent settings prior to operative
intervention for clot evacuation.[21]Magnetic Resonance ImagingMRI
is performed if no lesion is found on angiography. Its sensitivity
in detecting blood is considered equal or inferior to that of CT
scan. The higher cost, lower availability, and longer study time
make it less optimal for detecting SAH. In addition, MRI is not
sensitive for SAH within the first 48 hours.MRI is a useful tool to
diagnose AVMs that are not detected by cerebral angiography or
spinal AVMs causing SAH. It can also be useful for diagnosing and
monitoring unruptured cerebral aneurysms. MRI can detect aneurysms
5 mm or larger with a high sensitivity and is useful for monitoring
the status of small, unruptured aneurysms. MRI can be used to
evaluate the degree of intramural thrombus in giant aneurysms.One
study found that cranial MRI including the brain and craniocervical
region does not provide additional benefit for the detection of
bleeding sources in patients with perimesencephalic and
nonperimesencephalic SAH. However, MRI should be considered on a
case-by-case basis because rare bleeding sources are possible in
cases of nonperimesencephalic SAH.[23]Magnetic Resonance
AngiographyThe role of magnetic resonance angiography (MRA) in the
detection of SAH currently is under investigation; however, many
authors believe that MRA eventually will replace conventional
transfemoral cerebral angiography. Given the current limitations of
MRA, which include lower sensitivity than cerebral angiography in
the detection of small aneurysms and failure to detect posterior
inferior communicating artery and anterior communicating artery
aneurysms in one series, most authors feel that the risk/benefit
ratio still favors conventional angiography.ElectrocardiographyAll
patients with SAH should have a baseline chest radiograph to serve
as a reference point for evaluation of possible pulmonary
complications. All patients with SAH should have an
electrocardiogram (ECG) on admission. Patients with SAH can have
myocardial ischemia due to the increased level of circulating
catecholamines or to autonomic stimulation from the brain.
Myocardial infarction is a rare complication.ECG abnormalities
frequently detected in patients with SAH include the following:
Nonspecific ST and T wave changes Decreased PR intervals Increased
QRS intervals Increased QT intervals Presence of U waves
Dysrhythmias, including premature ventricular contractions (PVCs),
supraventricular tachycardia (SVT), and bradyarrhythmias