Subarachnoid Hemorrhage


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


  • 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


  1. peter s

    am I right in thinking we should grab an attending prior to the detailed neuro exam if the history is concerning for SAH?

    • Zack

      If the patient is ill appearing, severe distress, grossly unstable vitals, etc, it is important to immediately get your attending. If the patient is stable, do a thorough neuro exam before you present (should only take 1-2minutes).

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