Paucis Verbis card: Subarachnoid hemorrhage high-risk characteristics

SAHIn 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

By |2021-10-17T09:15:59-07:00Dec 17, 2010|ALiEM Cards, Neurology|

Trick of the Trade: OKN drum to test psychogenic coma

3D Character and Question MarkOccasionally, emergency physicians see patients who present because they are unresponsive despite normal vital signs and an otherwise normal exam. You detect no drugs or alcohol on board. You suspect a psychiatric or malingering etiology, but aren’t sure. They seem non-responsive to voice and minimally responsive to very painful stimuli. Is this a case of psychogenic coma or true coma (with bilateral hemispheric dysfunction)?

What test can you do to reassure yourself that this may indeed be psychogenic coma?


By |2019-01-28T23:37:29-08:00Jul 14, 2010|Neurology, Tricks of the Trade|

PV Card: Dermatomal and Myotomal Maps

There are some things in life which I just can’t memorize and dermatomal/myotomal maps are one of them. Weird cases of peripheral neurologic symptoms have presented to the ED in the setting of trauma and no trauma. So purely for selfish reasons, I’m making my own map to have on file.

This installment of the Paucis Verbis (In a Few Words) e-card series reviews Sensory and Motor Function Testing by Levels.

PV Card: Dermatomal and Myotomal Maps

Go to ALiEM (PV) Cards for more resources.
By |2021-10-08T09:42:25-07:00May 28, 2010|ALiEM Cards, Neurology, Orthopedic|

Paucis Verbis card: Skipping the CT prior to LP for meningitis

LumbarPunctureWith increasing awareness of CT’s irradiation risk, I thought I would review a classic 2001 article from the New England Journal of Medicine. Head CT’s previously were commonly performed prior to all lumbar punctures (LP) to rule-out meningitis. When can you safely go straight to an LP without imaging?

Caveat: This review only applies to those patients in whom you suspect meningitis. This does not apply to those being worked up for subarachnoid hemorrhage.


By |2021-10-19T19:36:53-07:00Apr 23, 2010|ALiEM Cards, Neurology, Radiology|

Paucis Verbis card: Aneurysmal subarachnoid hemorrhage

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.


  1. Edlow J, Malek A, Ogilvy C. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med. 2008;34(3):237-251. [PubMed]
By |2021-10-19T19:03:54-07:00Mar 5, 2010|ALiEM Cards, Neurology|

Paucis Verbis card: NIH Stroke Scale

StrokePatients 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.

Score 0No stroke
Score 1-4Minor stroke
Score 5-15Moderate stroke
Score 16-20Moderate-severe stroke
Score 21+Severe stroke

PV Card: NIH Stroke Scale

Go to ALiEM (PV) Cards for more resources.

By |2021-10-19T19:07:03-07:00Feb 26, 2010|ALiEM Cards, Neurology|
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