Journal of the Accident and Medical Practitioners Association (JAMPA) 2004; Vol. 1 (No. 1)
 Accident and Medical Practitioners Association, New Zealand
___________________________________________________________________________
Intracranial Bleeding/Subarachnoid Haemorrhage
Secondary to a Ruptured Aneurysm:
Recognition, Investigation and Management
Elaine Jeffrey, MBChB
Locum MOSS/GP
About the author
Dr Elaine Jeffrey, MBChB, works as a locum Medical Office Special Scale (MOSS)/GP
throughout New Zealand. Her principal areas of interest are emergency department work,
general medicine and paediatrics.
Address for correspondence: Dr Elaine Jeffrey, MBChB, P.O. Box 678 Rangiora, New
Zealand.
E-mail: pjem@xtra.co.nz
Issues this article will address

Aetiology and presenting symptoms of subarachnoid haemorrhage

The concept of the ‘warning leak’

Current guidelines for investigation and management of severe headache

Familial links and screening in subarachnoid haemorrhage
2
Salient Points
___________________________________________________________________________
  Aetiology
of Subarachnoid
Haemorrage
Many patients
present to general
practitioners or emergency departments with

Warning
Leak
headaches
of Headaches
varying severity and a broad spectrum of associated symptoms.
  Investigation
and Management
of Headaches
The annual incidence
of subarachnoid
haemorrhage (SAH) is 6 to 16 per 100,000

population,
being attributable
to ruptured aneurysms.
Familial
Links15%
in Subarachnoid
Haemorrhage
The spectrum
ofmembers
symptoms
SAH iswith
vast,subarachnoid
ranging fromhaemorrhage.
new/unusual headaches to
  Screening
family
ofof
patients
loss of consciousness.
___________________________________________________________________________
 ‘Warning leak’ (prodromal) symptoms occur in 20-40% of SAH cases. Improved
recognition of these warning symptoms would improve the outcome for patients.

All patients presenting with severe headaches require an accurate history and full
examination. If the diagnosis is unclear, computed tomography (CT) should be
undertaken promptly, particularly if abnormal neurology is present.

Delays in diagnosis of SAH and referral of patients to neurosurgical centres lead to
poorer overall outcomes.

Familial links in SAH exist. First-degree relatives of patients with SAH are 3 to 7
times more likely to have the condition.

Screening of first-degree relatives of SAH patients has been recommended. Family
members should be advised to seek medical advice if they develop new-onset
headaches.
Key words: Headache · Subarachnoid haemorrhage · Warning leak headaches ·
Thunderclap headaches
3
Introduction
The ‘thunderclap’ headache is something all clinicians have been taught to be wary of in case
the patient is experiencing a subarachnoid haemorrhage (SAH). Although secondary
intracranial haemorrhage (due to vascular malformations or aneurysms) is rare when
considered alongside the overall incidence of intracranial bleeding, it is, tragically, the most
common cause in the younger age group. However, such patients do not always present in
‘typical text book’ fashion.
Illustrative Case Histories
The following two cases histories involve young males, both of whom suffered SAH but had
vastly different outcomes.
CASE DESCRIPTIONS
The first patient, a 53-year-old male, woke from sleep with a sudden severe, frontal
headache, vomiting, photophobia and feeling disoriented. A known migraine sufferer, he
had noticed more frequent headaches recently but none this severe. There was a history of
hypertension and hypercholesterolaemia for which he was taking celiprolol and simvastatin,
respectively. He was a non-smoker.
The only positive finding on initial examination was neck pain but no stiffness. Morphine
and antiemetics had little effect, so the next morning transfer was arranged for computed
tomography (CT). This revealed a SAH involving the 4th ventricle and right occipital horn.
He underwent clipping of a right middle cerebral artery aneurysm and progressed well with
no neurological deficit.
The second patient was 46 years of age. He suddenly collapsed while at a party. His eyes
rolled back and he seemed not to be breathing, so mouth-to-mouth resuscitation was
performed briefly. No seizure activity was noted. He had had a “few rums and some red
wine” but no other drugs. He had no past medical history but smoked 30g tobacco per week.
4
On examination, he was restless, agitated, vomiting, had a Glasgow Coma Score (GCS) of
9/15, heart rate 60 beats/min, BP 140/80 mm Hg, HS dual, abdomen soft, respiratory rate
20/min with deep sighing respirations and widespread crackles throughout his chest. His
right side was not moving and had decreased tone and reflexes. His pupils, though equal,
were sluggish.
After intubation, he was transferred for CT which confirmed extensive left frontal
haemorrhage with intraventricular blood, moderate hydrocephalus, and involvement of the
subarachnoid space, basal cisterns and sylvian fissures. An aneurysmal site was noted in the
left anterior communicating artery. Unfortunately, he never regained consciousness and
died later that night.
Incidence, Aetiology and Presenting Symptoms of Subarachnoid
Haemorrhage
The annual incidence of SAH is 6 to16 per 100,000 population, 15% being attributable to
ruptured aneurysms and young adults accounting for around 18% of cases.[1-5] It is almost
twice as common in females. Hypertension increases the risk and is associated with the
presence of multiple aneurysms. Smoking also significantly increases the risk. The
prevalence of SAH is greater in patients with polycystic kidney disease, and in those with a
family history of SAH and atherosclerosis.[3,4,6,7]
Headaches account for 1 to 2% of all emergency department presentations and up to 4% of all
general practice presentations. The spectrum of symptoms of SAH is vast, ranging from little
more than a new/unusual headache to loss of consciousness. Those presenting to emergency
departments tend to have more severe symptoms. All patients presenting with new/unusual
headaches should undergo careful evaluation for more serious causes of headache.[8,9]
The concept of ‘warning leak’ symptoms is well recognised. A prospective study by
Jakobsson et al.[10] found that 19.9% of patients with SAH had symptoms suggesting a
‘warning leak’ but 40.5% did not have their symptoms recognised as such. The authors
suggested that improved recognition of ‘warning leaks’ would improve outcome.[10] In other
studies, Fridriksson et al.[11] noted that 40% of patients had prodromal symptoms with 12%
5
not being recognised initially, while Tolias et al.[5] found that 20% of patients had ‘warning
leak’ symptoms when seen by a general practitioner but were not referred for investigation at
the time. On the basis of these findings, it was suggested that closely linked teaching between
GPs and neurosurgeons may improve recognition of warning symptoms,[11] and that the
threshold for investigating these patients needs to be lowered.[5] In a review of the pitfalls
that can be encountered when diagnosing SAH, Edlow et al.[8] concluded that most warning
headaches signal SAH, and not recognising this leads to diagnostic delays and a worsening of
the clinical state when it is finally diagnosed. However, Linn et al.[12,13] consider that the
concept of ‘warning leaks/headaches’ is not as significant as others have suggested, and that
the clinical and radiological features of SAH are the same regardless of preceding headaches.
Current Guidelines for Investigation and Management of Severe Headache
Patients presenting with severe headache require an accurate history and full examination,
including head/eyes/ears/nose/throat (HEENT) and neurology signs. If no clear diagnosis is
evident, they should then undergo CT and/or lumbar puncture for cerebrospinal fluid (CSF)
analysis.[14] In a study that compared the efficiency of CT and CSF analysis for excluding
SAH in patients with ‘worst headaches’, CT-confirmed SAH was found in 17% of patients
but among those with a negative imaging result, CSF analysis detected SAH in only 2.5% of
cases.[15] It was concluded, therefore, that CT is sufficient to exclude SAH in 97.5% of
patients presenting to emergency departments with ‘worst headaches’.[14,15]
However, a clinical policy statement by the American College of Emergency Physicians
recommends CSF analysis in the presence of a normal CT but ongoing high clinical suspicion
of SAH. They suggest that the response to analgesia does not provide a guide to the aetiology
of severe headache, and recommend that all patients with headache and any abnormal
neurology proceed to CT. In particular, all patients over 50 years of age with new-onset
headache require urgent CT. Those with headache but normal neurology should also be
considered for CT. The guidelines further recommend that all patients with normal CT,
normal opening pressure on lumbar puncture, and normal CSF findings can be discharged
from the emergency department to GP follow-up. In the absence of abnormal neurology, a
lumbar puncture can be performed without prior CT, but it should be noted that lumbar
puncture alone is not sufficient to assess all causes of sudden severe headache.[16]
6
The Need to Avoid Delays in Diagnosis of SAH
In a study of the timing of presentation to hospital in relation to outcome, the severity of the
clinical condition was found to be worse in those presenting within 6 hours of onset of their
symptoms, and this group of patients had a poorer outcome overall.[17] Neil-Dwyer et al.[18]
found that 51% of patients who had been diagnosed with SAH experienced diagnostic delays
in either the prehospital or in-hospital settings, and these 65% of these patients had further
bleeding before finally being diagnosed. These delays contributed to poorer overall
outcomes.[18]
Importance of Rapid Referral for Treatment
Avoiding delays in referral to neurosurgical centres is important with respect to treatment and
outcome. In recent years, the outcome for patients with aneurysmal SAH has improved,
especially for those with less severe symptoms, and this improvement has been attributed to
better referral guidelines and surgical management.[19] More recently, there has been a move
towards medical management of SAH, but at present, studies have shown that this contributes
to considerable worsening of morbidity and mortality.[20,21]
Familial Links and Screening for Subarachnoid Haemorrhage
Although there is a familial link in SAH, screening is a contentious issue. As first-degree
relatives of patients with SAH have been found to be 3 to 7 times more likely to have the
condition, Bromberg et al.[22] recommend screening of family members. In other studies, an
increased risk has been noted where two or more relatives have had SAH, with siblings more
at risk than children.[23] A greater risk from a positive maternal versus paternal history has
been noted by Okamoto et al.[24] and these authors strongly recommend screening of firstdegree relatives.
Others are less supportive of screening, as the overall prevalence of aneurysms is only about
2%, most being small and less likely to rupture.[7] One meta-analysis found that clipping of
unruptured aneurysms carries a significant morbidity and mortality risk,[25] while another
7
study found considerable evidence of decreased functioning/disablement following elective
clipping of aneurysms and that surgery only increased life expectancy by 2.5 years.[26]
Lessons from the Case Histories
Case one of the illustrative histories presented above highlights some important issues. This
patient is representative of many patients with a past history of migraines seen in either
emergency departments or general practice. Often this new headache is treated as a more
severe form of the previous headaches. It is important to remain vigilant and look closely at
the patient’s history. If the headache or history differs in any way from the ‘usual’ headache
for that patient, it is crucial to consider the need for early referral for investigation and
management in order to maximise the outcome.
The second patient presented immediately after the onset of his symptoms. His clinical status
at the time pointed strongly to a poor outcome and it is unlikely anything would have
changed this. However, many peripheral hospitals transfer patients to the closest tertiary
hospital for CT, regardless of whether a neurosurgical team is available at that hospital or not.
This results in a further delay if the CT is positive while the transfer is being made. When
time is of the essence, this is certainly not in the best interests of the patient. In such cases,
direct transfer to a neurosurgical unit would seem more appropriate.
With both these cases, each family had only one relative with SAH. Given the risks and
limited benefits of surgery, screening would not be advised. However, all first-degree
relatives of these men should be advised to seek medical advice if they develop new-onset
headaches.
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