In Wednesday’s post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada.

We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it’s difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don’t miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache.

In this 5-year multicenter study, the investigators identified clinical decision rules to help identify the higher-risk groups for a subarachnoid hemorrhage. They derived 3 models, based on recursive partitioning. Each has a negative predictive value of 100%.

Before thinking about seeing if your headache patient has any of these high-risk features, pay special attention to see if s/he would have met the inclusion and exclusion criteria of this study.

Inclusion criteria:

• Neurologically intact adults (age ≥ 16 years) with a non-traumatic headache peaking within an hour.

Exclusion criteria:

• History of ≥3 recurrent HA’s of same character/intensity
• Referred from another hospital with confirmed SAH
• Returned for reassessment of same HA which was already evaluated for SAH
• Papilledema
• New focal neurologic deficits
• Previous dx of cerebral aneurysm or SAH
• Previous dx of brain neoplasm
• Known hydrocephalus

Although none of the models are validated as of yet, the cumulative list of clinical characteristics from these 3 models may be able to help you understand who may be at higher risk:

• Age ≥ 40 years
• Witnessed loss of consciousness
• Neck pain or stiffness
• Onset of HA with exertion
• Arrival by ambulance
• Vomiting
• DBP ≥ 100 mmHg or SBP ≥ 160 mmHg

PV Card: Subarachnoid Hemorrhage – High Risk Characteristics

Atraumatic subarachnoid bleeds are most commonly caused by ruptured intracranial aneurysms.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews the current management, knowledge, and challenges in aneurysmal subarachnoid hemorrhage (SAH).

PV Card: Subarachnoid Hemorrhage

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

1. Edlow J, Malek A, Ogilvy C. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med. 2008;34(3):237-251. [PubMed]

Patients present with acute strokes to the Emergency Department. Time is of the essence to obtain a rapid neurologic exam, draw labs, get CT imaging, and consulting a neurologist especially if the patient presents within 3 hours of onset. To help the neurologist determine whether the patient should get thrombolytics, calculating a NIH Stroke Scale score is useful.w

In this installment of the Paucis Verbis (In a Few Words) e-card series, here is the NIHSS scoresheet.

PV Card: NIH Stroke Scale

Go to ALiEM (PV) Cards for more resources.

Here is another installment of the Paucis Verbis (In a Few Words) e-card series on the topic of Transient Ischemic Attacks (TIA) from EM Clinics of North America. I use this card a lot specifically for the ABCD2 risk-stratification score.

PV Card: Transient Ischemic Attacks

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

1. Ross M, Nahab F. Management of transient ischemia attacks in the twenty-first century. Emerg Med Clin North Am. 2009;27(1):51-69, viii. [PubMed]