Journal of the Accident and Medical Practitioners Association (JAMPA) 2004; Vol. 1 (No.

1)
Accident and Medical Practitioners Association, New ealand
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!ntracranial "leedin#$%u&arachnoid 'ae(orrha#e
%econdar) to a *u+tured Aneur)s(,
*eco#nition, !n-esti#ation and Mana#e(ent
Elaine Jeffrey, MBChB
Locum MOSS/GP
A&out the author
Dr Elaine Jeffrey, MBChB, works as a locum Medical Office Special Scale (MOSS)/GP
hrou!hou "ew #eala$d% &er pri$cipal areas of i$eres are emer!e$c' deparme$ work,
!e$eral medici$e a$d paediarics%
Address for corres+ondence, Dr Elaine Jeffrey, MBChB, P%O% Bo( )*+ ,a$!iora, "ew
#eala$d%
E-mail: p-em.(ra%co%$/
!ssues this article will address
0eiolo!' a$d prese$i$! s'mpoms of su1arach$oid haemorrha!e
2he co$cep of he 3war$i$! leak4
Curre$ !uideli$es for i$5esi!aio$ a$d ma$a!eme$ of se5ere headache
6amilial li$ks a$d scree$i$! i$ su1arach$oid haemorrha!e

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0eiolo!' of Su1arach$oid &aemorra!e
7ar$i$! Leak &eadaches
8$5esi!aio$ a$d Ma$a!eme$ of &eadaches
6amilial Li$ks i$ Su1arach$oid &aemorrha!e
Scree$i$! famil' mem1ers of paie$s wih su1arach$oid haemorrha!e%
...........................................................................
/e) words, &eadache 9 Su1arach$oid haemorrha!e 9 7ar$i$! leak headaches 9 2hu$derclap
headaches
:
%alient Points
Ma$' paie$s prese$ o !e$eral praciio$ers or emer!e$c' deparme$s wih
headaches of 5ar'i$! se5eri' a$d a 1road specrum of associaed s'mpoms%
2he a$$ual i$cide$ce of su1arach$oid haemorrha!e (S0&) is ) o ;) per ;<<,<<<
populaio$, ;=> 1ei$! ari1ua1le o rupured a$eur'sms%
2he specrum of s'mpoms of S0& is 5as, ra$!i$! from $ew/u$usual headaches o
loss of co$scious$ess%
37ar$i$! leak4 (prodromal) s'mpoms occur i$ :<?@<> of S0& cases% 8mpro5ed
reco!$iio$ of hese war$i$! s'mpoms would impro5e he oucome for paie$s%
0ll paie$s prese$i$! wih se5ere headaches reAuire a$ accurae hisor' a$d full
e(ami$aio$% 8f he dia!$osis is u$clear, compued omo!raph' (C2) should 1e
u$derake$ prompl', paricularl' if a1$ormal $eurolo!' is prese$%
Dela's i$ dia!$osis of S0& a$d referral of paie$s o $eurosur!ical ce$res lead o
poorer o5erall oucomes%
6amilial li$ks i$ S0& e(is% 6irs?de!ree relai5es of paie$s wih S0& are B o *
imes more likel' o ha5e he co$diio$%
Scree$i$! of firs?de!ree relai5es of S0& paie$s has 1ee$ recomme$ded% 6amil'
mem1ers should 1e ad5ised o seek medical ad5ice if he' de5elop $ew?o$se
headaches%
!ntroduction
2he 3hu$derclap4 headache is somehi$! all cli$icia$s ha5e 1ee$ au!h o 1e war' of i$ case
he paie$ is e(perie$ci$! a su1arach$oid haemorrha!e (S0&)% 0lhou!h seco$dar'
i$racra$ial haemorrha!e (due o 5ascular malformaio$s or a$eur'sms) is rare whe$
co$sidered alo$!side he o5erall i$cide$ce of i$racra$ial 1leedi$!, i is, ra!icall', he mos
commo$ cause i$ he 'ou$!er a!e !roup% &owe5er, such paie$s do $o alwa's prese$ i$
3'pical e( 1ook4 fashio$%
!llustrati-e 0ase 'istories
2he followi$! wo cases hisories i$5ol5e 'ou$! males, 1oh of whom suffered S0& 1u had
5asl' differe$ oucomes%
0A%1 21%0*!P3!4N%
2he firs paie$, a =B?'ear?old male, woke from sleep wih a sudde$ se5ere, fro$al
headache, 5omii$!, phoopho1ia a$d feeli$! disorie$ed% 0 k$ow$ mi!rai$e sufferer, he
had $oiced more freAue$ headaches rece$l' 1u $o$e his se5ere% 2here was a hisor' of
h'pere$sio$ a$d h'percholeserolaemia for which he was aki$! celiprolol a$d sim5asai$,
respeci5el'% &e was a $o$?smoker%

2he o$l' posii5e fi$di$! o$ i$iial e(ami$aio$ was $eck pai$ 1u $o siff$ess% Morphi$e
a$d a$iemeics had lile effec, so he $e( mor$i$! ra$sfer was arra$!ed for compued
omo!raph' (C2)% 2his re5ealed a S0& i$5ol5i$! he @h 5e$ricle a$d ri!h occipial hor$%
&e u$derwe$ clippi$! of a ri!h middle cere1ral arer' a$eur'sm a$d pro!ressed well wih
$o $eurolo!ical defici%
2he seco$d paie$ was @) 'ears of a!e% &e sudde$l' collapsed while a a par'% &is e'es
rolled 1ack a$d he seemed $o o 1e 1reahi$!, so mouh?o?mouh resusciaio$ was
performed 1riefl'% "o sei/ure aci5i' was $oed% &e had had a Cfew rums a$d some red
wi$eD 1u $o oher dru!s% &e had $o pas medical hisor' 1u smoked B<! o1acco per week%
B
O$ e(ami$aio$, he was resless, a!iaed, 5omii$!, had a Glas!ow Coma Score (GCS) of
E/;=, hear rae )< 1eas/mi$, BP ;@</+< mm &!, &S dual, a1dome$ sof, respiraor' rae
:</mi$ wih deep si!hi$! respiraio$s a$d widespread crackles hrou!hou his ches% &is
ri!h side was $o mo5i$! a$d had decreased o$e a$d refle(es% &is pupils, hou!h eAual,
were slu!!ish%
0fer i$u1aio$, he was ra$sferred for C2 which co$firmed e(e$si5e lef fro$al
haemorrha!e wih i$ra5e$ricular 1lood, moderae h'drocephalus, a$d i$5ol5eme$ of he
su1arach$oid space, 1asal ciser$s a$d s'l5ia$ fissures% 0$ a$eur'smal sie was $oed i$ he
lef a$erior commu$icai$! arer'% F$foru$ael', he $e5er re!ai$ed co$scious$ess a$d
died laer ha $i!h%
!ncidence, Aetiolo#) and Presentin# %)(+to(s of %u&arachnoid
'ae(orrha#e
2he a$$ual i$cide$ce of S0& is ) o;) per ;<<,<<< populaio$, ;=> 1ei$! ari1ua1le o
rupured a$eur'sms a$d 'ou$! aduls accou$i$! for arou$d ;+> of cases%G;?=H 8 is almos
wice as commo$ i$ females% &'pere$sio$ i$creases he risk a$d is associaed wih he
prese$ce of muliple a$eur'sms% Smoki$! also si!$ifica$l' i$creases he risk% 2he
pre5ale$ce of S0& is !reaer i$ paie$s wih pol'c'sic kid$e' disease, a$d i$ hose wih a
famil' hisor' of S0& a$d aherosclerosis%GB,@,),*H
&eadaches accou$ for ; o :> of all emer!e$c' deparme$ prese$aio$s a$d up o @> of all
!e$eral pracice prese$aio$s% 2he specrum of s'mpoms of S0& is 5as, ra$!i$! from lile
more ha$ a $ew/u$usual headache o loss of co$scious$ess% 2hose prese$i$! o emer!e$c'
deparme$s e$d o ha5e more se5ere s'mpoms% 0ll paie$s prese$i$! wih $ew/u$usual
headaches should u$der!o careful e5aluaio$ for more serious causes of headache%G+,EH
2he co$cep of 3war$i$! leak4 s'mpoms is well reco!$ised% 0 prospeci5e sud' 1'
Iako1sso$ e al%G;<H fou$d ha ;E%E> of paie$s wih S0& had s'mpoms su!!esi$! a
3war$i$! leak4 1u @<%=> did $o ha5e heir s'mpoms reco!$ised as such% 2he auhors
su!!esed ha impro5ed reco!$iio$ of 3war$i$! leaks4 would impro5e oucome%G;<H 8$ oher
sudies, 6ridriksso$ e al%G;;H $oed ha @<> of paie$s had prodromal s'mpoms wih ;:>
@
$o 1ei$! reco!$ised i$iiall', while 2olias e al%G=H fou$d ha :<> of paie$s had 3war$i$!
leak4 s'mpoms whe$ see$ 1' a !e$eral praciio$er 1u were $o referred for i$5esi!aio$ a
he ime% O$ he 1asis of hese fi$di$!s, i was su!!esed ha closel' li$ked eachi$! 1ewee$
GPs a$d $eurosur!eo$s ma' impro5e reco!$iio$ of war$i$! s'mpoms,G;;H a$d ha he
hreshold for i$5esi!ai$! hese paie$s $eeds o 1e lowered%G=H 8$ a re5iew of he pifalls
ha ca$ 1e e$cou$ered whe$ dia!$osi$! S0&, Jdlow e al%G+H co$cluded ha mos war$i$!
headaches si!$al S0&, a$d $o reco!$isi$! his leads o dia!$osic dela's a$d a worse$i$! of
he cli$ical sae whe$ i is fi$all' dia!$osed% &owe5er, Li$$ e al%G;:,;BH co$sider ha he
co$cep of 3war$i$! leaks/headaches4 is $o as si!$ifica$ as ohers ha5e su!!esed, a$d ha
he cli$ical a$d radiolo!ical feaures of S0& are he same re!ardless of precedi$! headaches%
0urrent 5uidelines for !n-esti#ation and Mana#e(ent of %e-ere 'eadache
Paie$s prese$i$! wih se5ere headache reAuire a$ accurae hisor' a$d full e(ami$aio$,
i$cludi$! head/e'es/ears/$ose/hroa (&JJ"2) a$d $eurolo!' si!$s% 8f $o clear dia!$osis is
e5ide$, he' should he$ u$der!o C2 a$d/or lum1ar pu$cure for cere1rospi$al fluid (CS6)
a$al'sis%G;@H 8$ a sud' ha compared he efficie$c' of C2 a$d CS6 a$al'sis for e(cludi$!
S0& i$ paie$s wih 3wors headaches4, C2?co$firmed S0& was fou$d i$ ;*> of paie$s
1u amo$! hose wih a $e!ai5e ima!i$! resul, CS6 a$al'sis deeced S0& i$ o$l' :%=> of
cases%G;=H 8 was co$cluded, herefore, ha C2 is sufficie$ o e(clude S0& i$ E*%=> of
paie$s prese$i$! o emer!e$c' deparme$s wih 3wors headaches4%G;@,;=H
&owe5er, a cli$ical polic' saeme$ 1' he 0merica$ Colle!e of Jmer!e$c' Ph'sicia$s
recomme$ds CS6 a$al'sis i$ he prese$ce of a $ormal C2 1u o$!oi$! hi!h cli$ical suspicio$
of S0&% 2he' su!!es ha he respo$se o a$al!esia does $o pro5ide a !uide o he aeiolo!'
of se5ere headache, a$d recomme$d ha all paie$s wih headache a$d a$' a1$ormal
$eurolo!' proceed o C2% 8$ paricular, all paie$s o5er =< 'ears of a!e wih $ew?o$se
headache reAuire ur!e$ C2% 2hose wih headache 1u $ormal $eurolo!' should also 1e
co$sidered for C2% 2he !uideli$es furher recomme$d ha all paie$s wih $ormal C2,
$ormal ope$i$! pressure o$ lum1ar pu$cure, a$d $ormal CS6 fi$di$!s ca$ 1e dischar!ed
from he emer!e$c' deparme$ o GP follow?up% 8$ he a1se$ce of a1$ormal $eurolo!', a
lum1ar pu$cure ca$ 1e performed wihou prior C2, 1u i should 1e $oed ha lum1ar
pu$cure alo$e is $o sufficie$ o assess all causes of sudde$ se5ere headache%G;)H
=
The Need to Avoid Delays in Diagnosis of SAH
8$ a sud' of he imi$! of prese$aio$ o hospial i$ relaio$ o oucome, he se5eri' of he
cli$ical co$diio$ was fou$d o 1e worse i$ hose prese$i$! wihi$ ) hours of o$se of heir
s'mpoms, a$d his !roup of paie$s had a poorer oucome o5erall%G;*H "eil?Dw'er e al%G;+H
fou$d ha =;> of paie$s who had 1ee$ dia!$osed wih S0& e(perie$ced dia!$osic dela's
i$ eiher he prehospial or i$?hospial sei$!s, a$d hese )=> of hese paie$s had furher
1leedi$! 1efore fi$all' 1ei$! dia!$osed% 2hese dela's co$ri1ued o poorer o5erall
oucomes%G;+H
Importance of Rapid Referral for Treatment
05oidi$! dela's i$ referral o $eurosur!ical ce$res is impora$ wih respec o reame$ a$d
oucome% 8$ rece$ 'ears, he oucome for paie$s wih a$eur'smal S0& has impro5ed,
especiall' for hose wih less se5ere s'mpoms, a$d his impro5eme$ has 1ee$ ari1ued o
1eer referral !uideli$es a$d sur!ical ma$a!eme$%G;EH More rece$l', here has 1ee$ a mo5e
owards medical ma$a!eme$ of S0&, 1u a prese$, sudies ha5e show$ ha his co$ri1ues
o co$sidera1le worse$i$! of mor1idi' a$d morali'%G:<,:;H
6a(ilial 7in8s and %creenin# for %u&arachnoid 'ae(orrha#e
0lhou!h here is a familial li$k i$ S0&, scree$i$! is a co$e$ious issue% 0s firs?de!ree
relai5es of paie$s wih S0& ha5e 1ee$ fou$d o 1e B o * imes more likel' o ha5e he
co$diio$, Brom1er! e al%G::H recomme$d scree$i$! of famil' mem1ers% 8$ oher sudies, a$
i$creased risk has 1ee$ $oed where wo or more relai5es ha5e had S0&, wih si1li$!s more
a risk ha$ childre$%G:BH 0 !reaer risk from a posii5e maer$al versus paer$al hisor' has
1ee$ $oed 1' Okamoo e al%G:@H a$d hese auhors sro$!l' recomme$d scree$i$! of firs?
de!ree relai5es%
Ohers are less suppori5e of scree$i$!, as he o5erall pre5ale$ce of a$eur'sms is o$l' a1ou
:>, mos 1ei$! small a$d less likel' o rupure%G*H O$e mea?a$al'sis fou$d ha clippi$! of
u$rupured a$eur'sms carries a si!$ifica$ mor1idi' a$d morali' risk,G:=H while a$oher
)
sud' fou$d co$sidera1le e5ide$ce of decreased fu$cio$i$!/disa1leme$ followi$! eleci5e
clippi$! of a$eur'sms a$d ha sur!er' o$l' i$creased life e(peca$c' 1' :%= 'ears%G:)H

7essons fro( the 0ase 'istories
Case o$e of he illusrai5e hisories prese$ed a1o5e hi!hli!hs some impora$ issues% 2his
paie$ is represe$ai5e of ma$' paie$s wih a pas hisor' of mi!rai$es see$ i$ eiher
emer!e$c' deparme$s or !e$eral pracice% Ofe$ his $ew headache is reaed as a more
se5ere form of he pre5ious headaches% 8 is impora$ o remai$ 5i!ila$ a$d look closel' a
he paie$4s hisor'% 8f he headache or hisor' differs i$ a$' wa' from he 3usual4 headache
for ha paie$, i is crucial o co$sider he $eed for earl' referral for i$5esi!aio$ a$d
ma$a!eme$ i$ order o ma(imise he oucome%
2he seco$d paie$ prese$ed immediael' afer he o$se of his s'mpoms% &is cli$ical saus
a he ime poi$ed sro$!l' o a poor oucome a$d i is u$likel' a$'hi$! would ha5e
cha$!ed his% &owe5er, ma$' peripheral hospials ra$sfer paie$s o he closes eriar'
hospial for C2, re!ardless of wheher a $eurosur!ical eam is a5aila1le a ha hospial or $o%
2his resuls i$ a furher dela' if he C2 is posii5e while he ra$sfer is 1ei$! made% 7he$
ime is of he esse$ce, his is cerai$l' $o i$ he 1es i$eress of he paie$% 8$ such cases,
direc ra$sfer o a $eurosur!ical u$i would seem more appropriae%
7ih 1oh hese cases, each famil' had o$l' o$e relai5e wih S0&% Gi5e$ he risks a$d
limied 1e$efis of sur!er', scree$i$! would $o 1e ad5ised% &owe5er, all firs?de!ree
relai5es of hese me$ should 1e ad5ised o seek medical ad5ice if he' de5elop $ew?o$se
headaches%
*eferences
;% Bederso$ IB, 0wad 80, 7ie1ers DO, Piep!ras D, &ale' JC Ir, Bro 2, e al%
,ecomme$daio$s for he ma$a!eme$ of paie$s wih u$rupured i$racra$ial
a$eur'sms% Stroke :<<<KB;(;;)L:*@:?=<%
:% 8$er$aio$al Su1arach$oid 0$eur'sm 2rial (8S02) Colla1orai5e Group% 8$er$aio$al
su1arach$oid a$eur'sm rial (8S02) of $eurolo!ical clippi$! 5ersus e$do5ascular coili$!
*
i$ :;@B paie$s wih rupured i$racra$ial a$eur'smsL a ra$domised rial% Lancet
:<<:KB)<L;:)*?*@%
B% O!u$!1o B, Gre!so$ B, Black1ur$ 0, Bar$es I, Mi5ar ,, Se$!upa ,, e al% 0$eur'smal
su1arach$oid haemorrha!e i$ 'ou$! aduls% J Neurosurg :<<BKE+(;)L@B?E%
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su1arach$oid haemorrha!eL he 2romso sud'% J Neurol Neurosurg Psychiatry
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=% 2olias CM, Chokse' MS% 7ill i$creased aware$ess amo$! ph'sicia$s of he si!$ifica$ce
of sudde$ a!o$isi$! headache affec he oucome of su1arach$oid hemorrha!eO Co5e$r'
a$d 7arwickshire sud'L audi of su1arach$oid hemorrha!e (esa1lishi$! hisorical
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:<<;K;;L;+;?E+%
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+
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su1arach$oid haemorrha!e% %MJ ;EE=KB;;L:++?E%
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:<<BKB@(:)L@::?)%
:=% ,aa'makers 27, ,i$kel GI, Lim1ur! M, 0l!ra 0% Morali' a$d mor1idi' of sur!er'
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