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SubarachnoidHemorrhageWorkup
Author:TiborBecske,MDChiefEditor:HelmiLLutsep,MDmore...
Updated:Apr29,2014

ApproachConsiderations
Thediagnosisofsubarachnoidhemorrhage(SAH)usuallydependsonahighindexofclinicalsuspicioncombined
withradiologicconfirmationviaurgentcomputedtomography(CT)scanwithoutcontrast.Traditionally,anegative
CTscanisfollowedwithlumbarpuncture(LP).However,noncontrastCTfollowedbyCTangiography(CTA)ofthe
braincanruleoutSAHwithgreaterthan99%sensitivity. [2]
ComparedwiththetraditionalrecommendationofCTfollowedbyLP,CT/CTAmayofferalessinvasiveandmore
informativediagnosticapproachforemergencydepartmentpatientscomplainingofacuteonsetheadacheandwith
nosignificantriskfactorsforSAH.AdisadvantageofforegoingLPisthatspinalfluidanalysismaypointtowardan
alternativediagnosis.
AfterthediagnosisofSAHisestablished,furtherimagingshouldbeperformedtocharacterizethesourceofthe
hemorrhage.Thiseffortcanincludestandardangiography,CTangiography,andmagneticresonance(MR)
angiography.
LaboratorystudiesforSAHshouldincludethefollowing:
SerumchemistrypanelToestablishabaselinefordetectionoffuturecomplications
CompletebloodcountForevaluationofpossibleinfectionorhematologicabnormality
Prothrombintime(PT)andactivatedpartialthromboplastintime(aPTT)Forevaluationofpossible
coagulopathy
Bloodtyping/screeningToprepareforpossibleintraoperativetransfusions
CardiacenzymesForevaluationofpossiblemyocardialischemia
Arterialbloodgas(ABG)Necessaryinpatientswithpulmonarycompromise
Serumcardiactroponinmeasurementisimportantinpatientswithsubarachnoidhemorrhage,eveninthosewithout
underlyingcardiacconditions.Itwasinitiallythoughttobeusefulonlyasapredictorfortheoccurrenceofpulmonary
andcardiaccomplications. [15]However,correlationwassubsequentlyfoundbetweentroponinlevelsandneurologic
complicationsandoutcome. [16]
AllpatientswithSAHshouldhaveabaselinechestradiographtoserveasareferencepointforevaluationof
possiblepulmonarycomplications.AllpatientswithSAHshouldalsohaveanelectrocardiogram(ECG)on
admission.PatientswithSAHcanhavemyocardialischemiaduetotheincreasedlevelofcirculating
catecholaminesortoautonomicstimulationfromthebrain.Myocardialinfarctionisararecomplication.However,
suspicionofSAHisacontraindicationtothrombolyticandanticoagulanttherapy.
BecausemostoftheECGabnormalitiesthatoccurwithSAHarebenignandreversible,differentiatingtrue
myocardialischemiafrombenignchangesisimportant.Twodimensionalechocardiographyoftenismoresensitive
indetectingmyocardialischemiathanisECGandthusisusefulinthesettingofSAH.
Otherimagingstudiesmaybeindicated.MRIisperformedifnolesionisfoundonangiography,andtranscranial
Dopplerstudiesareusefulinthedetectionandmonitoringofarterialvasospasm.

ComputedTomography
CTwithoutcontrastisthemostsensitiveimagingstudyinSAH(seetheimagesbelow).Whencarriedoutwithin6
hoursofheadacheonset,CThas100%sensitivityandspecificity.Sensitivityis93%within24hoursofonset, [17]
80%at3days,and50%at1week. [18]Sensitivityislessonoldersecondorfirstgenerationscanners,butmost
NorthAmericanhospitalshavebeenusingthirdgenerationscannerssincethemid1980s.Thin(3mm)cutsare
necessarytoproperlyidentifythepresenceofsmallerhemorrhages.

CTscanrevealssubarachnoidhemorrhageintherightsylvianfissurenoevidenceofhydrocephalusisapparent.

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CTscanrevealssubarachnoidhemorrhageinthesylvianfissure,rightmorethanleft.

A47yearoldwomanpresentedwithheadacheandvomitingherCTscanintheemergencydepartmentrevealedsubarachnoid
hemorrhage.

BrainCTscanshowingsubtlefindingofbloodattheareaofthecircleofWillisconsistentwithacutesubarachnoidhemorrhage.
ImagecourtesyofDanaStearns,MD,MassachusettsGeneralHospital.

Findingsmaybenegativein1015%ofpatientswithSAH.AfalselynegativeCTscancanresultfromsevere
anemiaorsmallvolumesubarachnoidhemorrhage.
Thelocationofbloodwithinthesubarachnoidspacecorrelatesdirectlywiththelocationoftheaneurysmin70%of
cases.Ingeneral,bloodlocalizedtothebasalcisterns,thesylvianfissure,ortheintrahemisphericfissureindicates
ruptureofasaccularaneurysm.Bloodlyingovertheconvexitiesorwithinthesuperficialparenchymaofthebrain
oftenisindicativeofarteriovenousmalformation(AVM)ormycoticaneurysmrupture.
Intraparenchymalhemorrhagemayoccurwithmiddlecommunicatingarteryandposteriorcommunicatingartery
aneurysms.Interhemisphericandintraventricularhemorrhagesmayoccurwithanteriorcommunicatingartery
aneurysms.
AcontrastenhancedCTscanmayrevealanAVM.However,thisstudyshouldnotbeperformedbeforea
noncontrastCTscanbecausethecontrastmayinterferewiththevisualizationofsubarachnoidblood.
DegreeandlocationofSAHaresignificantprognosticfactors.TheFishergradingsystemisusedtoclassifySAH,
asfollows:
Grade1NosubarachnoidbloodseenonCTscan
Grade2DiffuseorverticallayersofSAHlessthan1mmthick
Grade3Diffuseclotand/orverticallayergreaterthan1mmthick
Grade4Intracerebralorintraventricularclotwithdiffuseornosubarachnoidblood
CTscanallowsforthedetectionofventricularsizeand,thus,evaluationandsurveillanceofmasseffectand
hydrocephalus.OnCTscan,hydrocephalusisevidentastrappedtemporalhornsand"MickeyMouse"appearance
oftheventricularsystem.

InfusionCTscan
SomecentershaveobtainedgoodresultswithinfusionCTscanning.Thisscanemploysacontrastdyeandcanbe
performedimmediatelyafteranoncontrastCTscan.Reformattedimagedatacanbeviewedandrotatedin2
dimensionaldisplays.InfusionCTscanninghasbeenreportedtodetectaneurysmslargerthan3mmwitha
sensitivityof97%,whichmayprovidesufficientanatomicdetailtoallowforsurgicalmanagementintheabsenceof
angiography.

LumbarPuncture
LPistraditionallyperformedasafollowuptestwhenaCTscanhasshownnoSAHandhasexcludedpossible
contraindicationstoLPsuchassignificantintracranialmasseffect,elevatedICP,obstructivehydrocephalus,or
obviousintracranialbleed.LPshouldnotbeperformediftheCTscandemonstratesanSAHbecauseofthe(small)

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riskoffurtherintracranialbleedingassociatedwithadropinICP.
AnLPisperformedtoevaluatethecerebrospinalfluidforthepresenceofredbloodcells(RBCs)and
xanthochromia.LPmaybenegativeifperformedlessthan2hoursafteranSAHoccursLPismostsensitive12
hoursafteronsetofsymptoms.CSFsamplestakenwithin24hoursoftheictususuallyshowaWBCtoRBCratio
thatisconsistentwiththenormalcirculatingWBCtoRBCratioofapproximately1:1000.After24hours,CSF
samplesmaydemonstrateapolymorphonuclearandmononuclearpolycytosissecondarytochemicalmeningitis
causedbythedegradationproductsofsubarachnoidblood.
RBCsintheCSFcanreflectatraumaticLPratherthanSAHhowever,SAHoftencanbedistinguishedfrom
traumaticLPbycomparingtheRBCcountofthefirstandlasttubesofCSF.IntraumaticLP,theRBCcountinthe
lasttubeisusuallylower,whereasinSAHtheRBCtypicallyremainsconsistentlyelevated.Nevertheless,casesof
SAHinwhichtheRBCcountislowerhavebeenreported.
NoconsensusisfoundintheliteratureonthelowerlimitoftheRBCcountintheCSFthatsignifiesapositivetap.
However,mostcountsrangefromafewhundredtoamillionormorecellspercubicmillimeter.Themostreliable
methodofdifferentiatingSAHfromatraumatictapistospindowntheCSFandexaminethesupernatantfluidfor
thepresenceofxanthochromia,apinkoryellowcolorationcausedbythebreakdownofRBCsandsubsequent
releaseofhemepigments.
Xanthochromiatypicallywillnotappearuntil24hoursaftertheictus.Innearly100%ofpatientswithanSAH,
xanthochromiaispresent12hoursafterthebleedandremainsforapproximately2weeks.Xanthochromiais
present3weeksafterthebleedin70%ofpatients,anditisstilldetectableat4weeksin40%ofpatients.
Spectrophotometryismuchmoresensitivethanthenakedeyeindetectingxanthochromia.Nevertheless,many
laboratoriesrelyonvisualinspection.
SomeauthorshavesuggestedthattheDdimerassaycanbeusedtodiscriminateSAHfromtraumaticLP.Results
havebeenconflicting,however,andfurtherdataareneeded.
PatientswithnegativeCTandLPfindingshaveafavorableprognosis.However,LPfindingscanbenegativein
approximately1015%ofpatientswithSAH.Inthepast,LPfindingswerethoughttobepositivein515%ofall
SAHpresentationsthatarenotevidentontheCTscan.Thisnumbermaybenolongervalidwiththeadventof
newergenerationsofCTscans.AsmallretrospectivereviewofpatientswhopresentedtotheEDandunderwent
fifthgenerationCTscansandLPshowednocasesofapositiveLIPafteranegativeCTscan. [19]

CerebralAngiography
Digitalsubtractioncerebralangiographyhasbeenthecriterionstandardforthedetectionofcerebralaneurysms(see
theimagesbelow).Itisparticularlyusefulincasesofdiagnosticuncertainty(afterCTscanandLP)andinpatients
withsepticendocarditisandSAHtosearchforthepresenceofmycoticaneurysms.
IncaseswherethediagnosisofSAHhasbeendetermined,thetimingofcerebralangiographywilldependon
surgicalconsiderations.Cerebralangiographycanprovidethefollowingimportantsurgicalinformationinthesetting
ofSAH:
Cerebrovascularanatomy
Aneurysmlocationandsourceofbleeding
Aneurysmsizeandshape,aswellasorientationoftheaneurysmdomeandneck
Relationoftheaneurysmtotheparentarteryandperforatingarteries
Presenceofmultipleormirroraneurysms(identicallyplacedaneurysmsinboththeleftandrightcirculations)
Atrialballoonocclusionoftheparentarterycanbeperformedandmayhelptoguidepreoperativesurgicalplanning.

Cerebralangiogramrevealsamiddlecerebralarteryaneurysm.

Cerebralangiogramrevealsamiddlecerebralarteryaneurysm.

Cerebralangiogram(lateralview)revealsalargeaneurysmarisingfromtheleftanteriorchoroidalartery.

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Cerebralangiogram(anteroposteriorview)revealsalargeaneurysmarisingfromtheleftanteriorchoroidalartery.

Negativeangiographicfindingsdonotruleoutaneurysm.Approximately1020%ofpatientswithclinicallydiagnosed
SAH(onCTand/orlumbarpuncture)havenegativeangiographicfindings.Arepeatangiogramisusuallyrequiredin
1021daysinsuchcases.
Anegativestudyfindingcanresultfromaneurysmobliterationsecondarytoclotting.Hemorrhagesecondarytoa
rupturedAVMorspinalcordaneurysmmaybepresentdespiteanegativefindingoncerebralangiogram.
Perimesencephalicvenoushemorrhagealsoshouldbeconsidered
Followupangiographyisusefulaftersurgicalintervention.Thepostoperativestudycanconfirmaneurysmal
obliterationandtoevaluateforpossiblecerebralvasospasm.ThemanagementofmoribundpatientswithCTscan
evidenceofalargeSAHandfocalhematomaiscontroversial.Performingangiographymayresultinalife
threateningdelayintreatment.

CTAngiography
Althoughdigitalsubtractioncerebralangiographyhasbeenthecriterionstandardforthedetectionofcerebral
aneurysms,multidetectorCTangiography(MDCTA)oftheintracranialvesselsisnowroutinelyperformed,anditis
becomingfullyintegratedintotheimagingandtreatmentalgorithmofpatientspresentingwithacutesubarachnoid
hemorrhageinmanycentersintheUnitedKingdomandEurope. [20]
ThepopularityofMDCTAderivesfromitsnoninvasivenessandasensitivityandspecificitycomparabletothatof
cerebralangiography. [21,22]Thistechniqueisbeneficialinveryunstablepatientswhocannotundergoangiography
orinemergentsettingspriortooperativeinterventionforclotevacuation. [21]

MagneticResonanceImaging
MRIisperformedifnolesionisfoundonangiography.Itssensitivityindetectingbloodisconsideredequalor
inferiortothatofCTscan.Thehighercost,loweravailability,andlongerstudytimemakeitlessoptimalfor
detectingSAH.Inaddition,MRIisnotsensitiveforSAHwithinthefirst48hours.
MRIisausefultooltodiagnoseAVMsthatarenotdetectedbycerebralangiographyorspinalAVMscausingSAH.
Itcanalsobeusefulfordiagnosingandmonitoringunrupturedcerebralaneurysms.MRIcandetectaneurysms5
mmorlargerwithahighsensitivityandisusefulformonitoringthestatusofsmall,unrupturedaneurysms.MRIcan
beusedtoevaluatethedegreeofintramuralthrombusingiantaneurysms.
OnestudyfoundthatcranialMRIincludingthebrainandcraniocervicalregiondoesnotprovideadditionalbenefitfor
thedetectionofbleedingsourcesinpatientswithperimesencephalicandnonperimesencephalicSAH.However,
MRIshouldbeconsideredonacasebycasebasisbecauserarebleedingsourcesarepossibleincasesof
nonperimesencephalicSAH. [23]

MagneticResonanceAngiography
Theroleofmagneticresonanceangiography(MRA)inthedetectionofSAHcurrentlyisunderinvestigation
however,manyauthorsbelievethatMRAeventuallywillreplaceconventionaltransfemoralcerebralangiography.
GiventhecurrentlimitationsofMRA,whichincludelowersensitivitythancerebralangiographyinthedetectionof
smallaneurysmsandfailuretodetectposteriorinferiorcommunicatingarteryandanteriorcommunicatingartery
aneurysmsinoneseries,mostauthorsfeelthattherisk/benefitratiostillfavorsconventionalangiography.

Electrocardiography
AllpatientswithSAHshouldhaveabaselinechestradiographtoserveasareferencepointforevaluationof
possiblepulmonarycomplications.AllpatientswithSAHshouldhaveanelectrocardiogram(ECG)onadmission.
PatientswithSAHcanhavemyocardialischemiaduetotheincreasedlevelofcirculatingcatecholaminesorto
autonomicstimulationfromthebrain.Myocardialinfarctionisararecomplication.
ECGabnormalitiesfrequentlydetectedinpatientswithSAHincludethefollowing:
NonspecificSTandTwavechanges
DecreasedPRintervals
IncreasedQRSintervals
IncreasedQTintervals
PresenceofUwaves
Dysrhythmias,includingprematureventricularcontractions(PVCs),supraventriculartachycardia(SVT),and
bradyarrhythmias

ContributorInformationandDisclosures
Author
TiborBecske,MDClinicalAssistantProfessor,DepartmentsofRadiologyandNeurology,LangoneMedical
Center,NewYorkUniversitySchoolofMedicineAssistantAttendingPhysician,DepartmentsofRadiologyand
Neurology,BellevueHospitalCenter

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TiborBecske,MDisamemberofthefollowingmedicalsocieties:SocietyofNeuroInterventionalSurgeryand
SocietyofVascularandInterventionalNeurology
Disclosure:ev3reimbursementofexpensesandproctoringhonorariaIndependentcontractor
Coauthor(s)
GeorgeIJallo,MDProfessorofNeurosurgery,Pediatrics,andOncology,Director,ClinicalPediatric
Neurosurgery,DepartmentofNeurosurgery,JohnsHopkinsUniversitySchoolofMedicine
GeorgeIJallo,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationofNeurological
Surgeons,AmericanMedicalAssociation,andAmericanSocietyofPediatricNeurosurgeons
Disclosure:Codman(Johnson&Johnson)Grant/researchfundsConsultingMedtronicGrant/researchfunds
Consulting
ChiefEditor
HelmiLLutsep,MDProfessorandViceChair,DepartmentofNeurology,OregonHealthandScience
UniversitySchoolofMedicineAssociateDirector,OregonStrokeCenter
HelmiLLutsep,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurologyand
AmericanStrokeAssociation
Disclosure:StrykerNeurovascularConsultingfeeReviewpanelmembership
AdditionalContributors
StephenABerman,MD,PhD,MBAProfessorofNeurology,UniversityofCentralFloridaCollegeofMedicine
StephenABerman,MD,PhD,MBAisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanAcademyofNeurology,andPhiBetaKappa
Disclosure:Nothingtodisclose.
HowardSKirshner,MDProfessorofNeurology,PsychiatryandHearingandSpeechSciences,ViceChairman,
DepartmentofNeurology,VanderbiltUniversitySchoolofMedicineDirector,VanderbiltStrokeCenterProgram
Director,StrokeService,VanderbiltStallworthRehabilitationHospitalConsultingStaff,Departmentof
Neurology,NashvilleVeteransAffairsMedicalCenter
HowardSKirshner,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofNeurology,AmericanHeartAssociation,AmericanMedicalAssociation,AmericanNeurological
Association,AmericanSocietyofNeurorehabilitation,NationalStrokeAssociation,PhiBetaKappa,and
TennesseeMedicalAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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