Diagnostic Considerations

Missing SAH obviously carries major medicolegal consequences.^[14]In the emergency department, clinicians should err on the side of "overtapping" patients.

A good history of the current headache is essential, even in known migraineurs, and if the presentation has any unusual aspects (eg, worst ever headache, episode of loss of consciousness, first ever episode of diplopia), obtain a CT scan of the head and perform a lumbar puncture even if the CT scan is negative for blood. Do not forget to measure opening pressure and adequately check for xanthochromia.

Differential Diagnoses

Aseptic Meningitis
Cluster Headache in Emergency Medicine
Encephalitis
First Adult Seizure
Hypertensive Emergencies in Emergency Medicine
Intracranial Hemorrhage
Ischemic Stroke in Emergency Medicine
Meningitis
Migraine Headache
Transient Ischemic Attack

Workup

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Media Gallery

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.
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.
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.

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Author

Tibor Becske, MD REX Neurosurgery and Spine Specialists, REX Neuroendovascular Surgery

Tibor Becske, MD is a member of the following medical societies: Society of NeuroInterventional Surgery, Society of Vascular and Interventional Neurology

Disclosure: Received reimbursement of expenses and proctoring honoraria from ev3 for independent contractor.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

Additional Contributors

George I Jallo, MD Professor of Neurosurgery, Pediatrics, and Oncology, Director, Clinical Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine

George I Jallo, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, American Society of Pediatric Neurosurgeons

Disclosure: Nothing to disclose.

Acknowledgements

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center

Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment