Neurocritical Care

, Volume 17, Supplement 1, pp 47–53

Emergency Neurological Life Support: Subarachnoid Hemorrhage

  • Jonathan A. Edlow
  • Owen Samuels
  • Wade S. Smith
  • Scott D. Weingart
Review Article


Subarachnoid hemorrhage (SAH) is a neurological emergency because it may lead to sudden neurological decline and death and, depending on the cause, has treatment options that can return a patient to normal. Because there are interventions that can be life-saving in the first hour of onset, SAH was chosen as an Emergency Neurological Life Support protocol.


Aneurysm Ventriculostomy Hydrocephalus Protocol 


  1. 1.
    Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711–37.CrossRefPubMedGoogle Scholar
  2. 2.
    Diringer MN, Bleck TP, Claude Hemphill J Jr. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011;15:211–40.CrossRefPubMedGoogle Scholar
  3. 3.
    Edlow JA, Malek AM, Ogilvy CS. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med. 2008;34:237–51.CrossRefPubMedGoogle Scholar
  4. 4.
    Linn FH, Wijdicks EF. Causes and management of thunderclap headache: a comprehensive review. Neurologist. 2002;8:279–89.CrossRefPubMedGoogle Scholar
  5. 5.
    Schievink WI, Karemaker JM, Hageman LM, van der Werf DJ. Circumstances surrounding aneurysmal subarachnoid hemorrhage. Surg Neurol. 1989;32:266–72.CrossRefPubMedGoogle Scholar
  6. 6.
    Pope JV, Edlow JA. Favorable response to analgesics does not predict a benign etiology of headache. Headache. 2008;48:944–50.CrossRefPubMedGoogle Scholar
  7. 7.
    Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52:407–36.CrossRefPubMedGoogle Scholar
  8. 8.
    Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med. 2000;342:29–36.CrossRefPubMedGoogle Scholar
  9. 9.
    Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke J Cereb Circ. 2007;38:1216–21.CrossRefGoogle Scholar
  10. 10.
    Kowalski RG, Claassen J, Kreiter KT, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA. 2004;291:866–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Perry JJ, Stiell IG, Sivilotti ML, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204.CrossRefPubMedGoogle Scholar
  12. 12.
    Cuvinciuc V, Viguier A, Calviere L, et al. Isolated acute nontraumatic cortical subarachnoid hemorrhage. AJNR Am J Neuroradiol. 2010;31:1355–62.CrossRefPubMedGoogle Scholar
  13. 13.
    Byyny RL, Mower WR, Shum N, Gabayan GZ, Fang S, Baraff LJ. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med. 2008;51:697–703.CrossRefPubMedGoogle Scholar
  14. 14.
    Cortnum S, Sorensen P, Jorgensen J. Determining the sensitivity of computed tomography scanning in early detection of subarachnoid hemorrhage. Neurosurgery. 2010;66:900–2 (discussion 3).PubMedGoogle Scholar
  15. 15.
    Perry JJ, Stiell IG, Sivilotti ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343:d4277.CrossRefPubMedGoogle Scholar
  16. 16.
    Perry JJ, Sivilotti ML, Stiell IG, et al. Should spectrophotometry be used to identify xanthochromia in the cerebrospinal fluid of alert patients suspected of having subarachnoid hemorrhage? Stroke J Cereb Circ. 2006;37:2467–72.CrossRefGoogle Scholar
  17. 17.
    Edlow JA, Bruner KS, Horowitz GL. Xanthochromia. Arch Pathol Lab Med. 2002;126:413–5.PubMedGoogle Scholar
  18. 18.
    Linn FH, Voorbij HA, Rinkel GJ, Algra A, van Gijn J. Visual inspection versus spectrophotometry in detecting bilirubin in cerebrospinal fluid. J Neurol Neurosurg Psychiatry. 2005;76:1452–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Walton J. Subarachnoid hemorrhage. Edinburgh: E&S Livingstone, Ltd.; 1956.Google Scholar
  20. 20.
    Shah KH, Edlow JA. Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J Emerg Med. 2002;23:67–74.CrossRefPubMedGoogle Scholar
  21. 21.
    Schull MJ. Lumbar puncture first: an alternative model for the investigation of lone acute sudden headache. Acad Emerg Med. 1999;6:131–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Carstairs SD, Tanen DA, Duncan TD, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Acad Emerg Med. 2006;13:486–92.CrossRefPubMedGoogle Scholar
  23. 23.
    McCormack RF, Hutson A. Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan? Acad Emerg Med. 2010;17:444–51.CrossRefPubMedGoogle Scholar
  24. 24.
    Edlow JA. What are the unintended consequences of changing the diagnostic paradigm for subarachnoid hemorrhage after brain computed tomography to computed tomographic angiography in place of lumbar puncture? Acad Emerg Med. 2010;17:991–5. discussion 6–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Bardach NS, Zhao S, Gress DR, Lawton MT, Johnston SC. Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke J Cereb Circ. 2002;33:1851–6.CrossRefGoogle Scholar
  26. 26.
    Berman MF, Solomon RA, Mayer SA, Johnston SC, Yung PP. Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke J Cereb Circ. 2003;34:2200–7.CrossRefGoogle Scholar
  27. 27.
    Rabinstein AA, Lanzino G, Wijdicks EF. Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid haemorrhage. Lancet Neurol. 2010;9:504–19.CrossRefPubMedGoogle Scholar
  28. 28.
    Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg. 2002;97:771–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Dorhout Mees SM, Rinkel GJ, Feigin VL, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007:CD000277.Google Scholar

Copyright information

© Neurocritical Care Society 2012

Authors and Affiliations

  • Jonathan A. Edlow
    • 1
  • Owen Samuels
    • 2
  • Wade S. Smith
    • 3
  • Scott D. Weingart
    • 4
  1. 1.Department of Emergency Medicine, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Department of NeurosurgeryEmory University School of MedicineAtlantaUSA
  3. 3.ENLS Course Co-Chair, Department of NeurologyUniversity of California, San FranciscoSan FranciscoUSA
  4. 4.ENLS Course Co-Chair, Division of ED Critical CareMount Sinai School of MedicineNew YorkUSA

Personalised recommendations