Emergency Diagnosis of Subarachnoid Hemorrhage: An Evidence-Based Debate

• Published in: The Journal of emergency medicine 2013-05, Vol.44 (5), p.1045-1053
• Main Authors: Farzad, Ali, MD, Radin, Bethany, DO, Oh, Jason S., MD, Teague, Heidi M., MD, Euerle, Brian D., MD, Nable, J.V., MD, Liferidge, Aisha T., MD, Windsor, T. Andrew, MD, Witting, Michael D., MD
• Format: Article
• Language: English
• Subjects: Brain - pathology; computed tomography; Diagnostic Imaging - methods; Emergency; Emergency Medicine; Emergency Service, Hospital; Evidence-Based Medicine; Humans; Intracranial Aneurysm - diagnosis; magnetic resonance imaging; Sensitivity and Specificity; Spinal Puncture; subarachnoid hemorrhage; Subarachnoid Hemorrhage - diagnosis
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2012.10.001

Abstract Background The diagnosis of subarachnoid hemorrhage is of paramount concern in patients presenting to the Emergency Department (ED) with acute headache. Computed tomography followed by lumbar puncture is a time-honored practice, but recent technologic advances in magnetic resonance imaging with magnetic resonance angiography and computed tomography with computed tomography angiography can present alternatives for clinicians and patients. Objective The aim of this article was to compare diagnostic strategies for ED patients in whom subarachnoid hemorrhage is suspected. Methods We analyze and discuss current protocols, in addition to summarizing the advantages and disadvantages of each method. Results Through our residency's journal club, we organized an evidence-based debate that pitted proponents of the three subarachnoid hemorrhage diagnostic strategies against one another. Proponents of each strategy described its advantages and disadvantages. Briefly, computed tomography/lumbar puncture is time honored and effective, but is limited by complications and indeterminate lumbar puncture results. Magnetic resonance imaging with magnetic resonance angiography might be more effective in late presentations and can visualize aneurysms, yet has limited availability. Computed tomography with computed tomography angiography offers rapid diagnosis and is considered the most sensitive for diagnosing aneurysms, but has the highest radiation exposure. Conclusions Each of the three strategies used to diagnose subarachnoid hemorrhage has advantages and disadvantages with which clinicians should be familiar. Patient factors (e.g., age, body habitus, and risk factors), presentation factors (e.g., time from headache onset and severity of presentation), and institutional factors (availability of magnetic resonance imaging with magnetic resonance angiography) can influence the choice of protocol.