Subarachnoid Hemorrhage

History











* Sudden and maximal in onset* Compared to previous headaches* Family history of aneurysm* Associated Symptoms* Photophobia* Visual Changes* Neck Stiffness











Exam











* Full neuro examination* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sensation* Gait











Testing Plan











* Non-contrast head CT* Excellent sensitivity <6 hours from onset* Lumbar puncture* >100 RBCs in tube 4* Can be difficult to interpret after a traumatic lumbar puncture* Xanthochromia











Treatment Plan











* Prevent rebleeding* Keep SBP <140* Nicardipine* Reverse any anticoagulants* Vitamin K* Prothrombin complex concentrate* Fresh frozen plasma* Prevent vasospasm* Nimodipine PO* Prevent delayed ischemia* Avoid hyperthermia* Avoid hyper/hypoglycemia* Prevent seizures* Levetiracetam (aka Keppra)











Additional Reading











* Ottawa Subarachnoid Hemorrhage (MDCalc)