Subarachnoid Hemorrhage


Article Author:
Endrit Ziu


Article Editor:
Fassil Mesfin


Editors In Chief:
Jesse Cole


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/9/2019 7:10:07 PM

Introduction

Subarachnoid hemorrhage is an important type of head bleed that every physician should be aware because it is important to provide fast and appropriate care each patient. Subarachnoid hemorrhage is defined as blood between the arachnoid membrane and pia membrane. Several factors compromise this syndrome. Most subarachnoid hemorrhages are traumatic in nature. Aneurysmal subarachnoid hemorrhage compromises a small portion of this patient population, but nevertheless is the most worrisome type of subarachnoid hemorrhage. History is the first clue to where the subarachnoid hemorrhage originated. Spontaneous subarachnoid hemorrhage should raise suspicion for aneurismal rupture. Most of the aneurysmal ruptures occur in patients older than 50 years old. While a severe headache during strenuous postcoital activity is a typical scenario, 30% of subarachnoid hemorrhage occurs during sleep. Occasionally subarachnoid aneurysmal hemorrhage is preceded by warning sharp, severe headache, or a sentinel headache, that happens few weeks before the rupture. It is challenging to distinguish a sentinel headache from other headaches, but an intense headache in a patient that is not prone to headaches should raise suspicion for further imaging. While subarachnoid hemorrhage is typical of aneurysmal rupture, often is also associated with intraventricular hemorrhage, intracerebral hemorrhage, and subdural hematoma. The force of rupture and location of an aneurysm determine the presence of the other types of hemorrhage.  The interesting unexplained fact is that most of the aneurysmal hemorrhage occurs during spring and autumn season. While caring for a patient with a diagnosis of subarachnoid hemorrhage, a physician should be highly suspicious and promptly evaluate the patient when changes in mental status are noted. This patient population is prone to seizures as well as to hydrocephalus and vasospasm, both potentially devastating factors [1].[2][3]

Etiology

Trauma causes the highest incidence of subarachnoid hemorrhage. Non-traumatic subarachnoid hemorrhage is mostly due to vascular malformation. Aneurysmal hemorrhage is the biggest player in this subgroup. To a lesser extent, patients experience subarachnoid hemorrhage after using certain drugs like cocaine. After practitioners complete evaluation in these cases, about 10% do not have a clear identifying factors. Determining the precise etiology of the hemorrhage is very important, as practitioners can tailor treatment to the cause of hemorrhage. Response to treatment varies, for example, for subarachnoid hemorrhage stemming from a vasospasm.[4][5]

Epidemiology

The incidence of subarachnoid hemorrhage in the United States is between 10 to 14 for 100,000 population per year. Incidence is slightly higher in women, 1.3 compared to man. It is more prevalent in black and Hispanic populations than in white populations. Around the world, Japan and Finland have higher cases of subarachnoid hemorrhage, but the reason is unknown. Several factors are associated with subarachnoid hemorrhage, hypertension, cigarette smoking, excessive alcohol consumption, gender, age, genetic syndromes like Ehlers-Danlos, and polycystic kidney disease. Among the above-stated factors, history of a previously ruptured intracerebral aneurysm is very highly associated with new subarachnoid hemorrhage. The second highest association is between smoking and subarachnoid hemorrhage.

Pathophysiology

Am initial inciting event releases blood into the subarachnoid space. Blood close to the brain surface is an irritant, and many complications of subarachnoid hemorrhage are due to irritant effect of blood on the brain. Responses include seizures, vasospasm, and confusion. Subarachnoid hemorrhage has effects outside the brain. Two prominent features of this disease are neurogenic pulmonary edema and neurogenic stunned myocardium. Blood products eventually circulate with cerebral spinal fluid and in many cases impede normal fluid clearance in arachnoid granulations. When these events happen resulting hydrocephalus ensues. If hydrocephalus is not treated in timely fashion fluid collection in the ventricular system will eventually create enough pressure to cause brain herniation syndromes and possible death. Neurosurgical intervention should be the priority when hydrocephalus is identified.

History and Physical

A typical presenting symptom is a thunderclap headache. During a medical interview, patients usually call it the “worst headache of my life.” This problem should prompt further imaging. A headache often is associated with nausea, vomiting, and diplopia. Quite often signs of meningismus are present due to irritant blood spreading into the fourth ventricle and further down the spinal cord irritating nerves and causing neck and back pain. Cranial nerve deficits can occur. Practitioners should perform a detailed exam. The presence of focal deficit increases the grade of subarachnoid hemorrhage and changes the perspective of post-event recovery. Patients with a high-grade subarachnoid hemorrhage quite often present in a state of coma that calls for a quick evaluation and urgent treatment, as the coma can be reversible. In addition to subarachnoid hemorrhage patients could have intraocular hemorrhage, initially described and named after French ophthalmologist Albert Terson. When the physician identifies Terson syndrome, an ophthalmology service should be consulted to help with the care of the patient. Eighty percent of patients that develop Terson syndrome do not require further interventions other than regular follow ups.

Evaluation

Initial evaluation of a patient suspected of having a subarachnoid hemorrhage should include head CT. A CT angiography should be added if a subarachnoid hemorrhage is identified. If the initial CT is negative, but a physician has a very high suspicion for hemorrhage, a lumbar puncture should be performed and sent for laboratory evaluation of xanthochromia presence. Sometimes xanthochromia presence can be assessed at the bedside due to visible cerebrospinal fluid color change. A CT angiography diagnosis of an aneurysm or confirmation of negative CT angiography should be followed by cerebral angiography or digital subtraction angiography (DSA). A few factors should be considered in patients who are allergic to contrast or have decreased renal function. These patient populations need pre-procedure treatment to decrease the chances of an adverse reaction. Time-of-flight magnetic resonance angiography (TOF-MRA) is another acceptable mode of imaging that will not require contrast injection but due to the long time that is necessary to obtain complete examination is not always a feasible alternative in very sick patients with subarachnoid hemorrhage.[6][7][8]

Treatment / Management

Treatment of subarachnoid hemorrhage patients should occur in the intensive care unit. On initial presentation, Hunt and Hess, as well as World Federation of Neurological Surgeons scores, should be determined. If there is the presence of hydrocephalus, the placement of an external ventricular drain should be considered. Level one evidence supports the use of nimodipine and maintenance euvolemia as important factors to improve outcome. Tight control of blood pressure until an aneurysm is also secured is necessary. Blood pressure should be less than 160 mmHg and more optimally within 140-mmHg range. Seizure prophylaxis should be initiated, as 20% of these patients will seize within the first 24 hours post bleed. Seizure, while an aneurysm is unsecured, will worsen patient outcome. Avoid hyponatremia and hypovolemia and initiate fluids as soon as intravascular access is obtained. Normal saline has shown slight benefits when compared to other fluids like Ringer's lactate solution. Monitor pulmonary status. Often the patient has been intubated in the field by emergency services, but if the patient has been not intubated and the Glasgow coma scale (GCS) score is less than eight, initiate steps to secure an airway. Consider an arterial line to have better control of patient hemodynamic status. Early intervention to secure an aneurysm will allow relaxing blood pressure goals and improving cerebral perfusion pressure which is severely compromised in these patients. Use of prothrombotic agents like aminocaproic acid is surgeon dependent and will need to be considered if an aneurysm cannot be secured within a short time [9].[10][11][12]

Enhancing Healthcare Team Outcomes

The majority of patients with subarachnoid hemorrhage present to the emergency department. Thus, it is vital that the emergency department physician and nurse practitioner know the workup for these patients. Because of the very high mortality, a multidisciplinary team that includes a radiologist, neurosurgeon, neurologist, intensivist and ICU nurses is recommended. Unfortunately, despite optimal case, the majority of patients die within 30 days. Even those who survive are left with severe complications that are disabling. [13][14] (Level V)


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Subarachnoid Hemorrhage - Questions

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A young female suffers a subarachnoid bleed. The consultant wonders if it might be due to a congenital multi-organ system pathology. What part of the body should be imaged?



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What is the initial test of choice in suspected subarachnoid hemorrhage?



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Lumbar puncture in a patient with suspected subarachnoid hemorrhage is most sensitive during what time period?



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A 33-year-old female describes the most intense headache of her life and undergoes a lumbar puncture. The number of red blood cells in successive tubes starts to decrease. What does this result most likely indicate?



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What is a common detrimental complication of subarachnoid hemorrhage that occurs 2 to 4 days after the initial bleed?



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Which diagnosis is most likely for a man who is found to have blood in his cerebrospinal fluid upon undergoing lumbar puncture for the evaluation of a headache?



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What is the most common cause of subarachnoid hemorrhage?



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In a patient with a subarachnoid hemorrhage, what is the chief reason for the development of hydrocephalus?



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A patient undergoes a lumbar puncture for a severe headache and is found to have blood in the cerebrospinal fluid. Which of the following is most likely?



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What is the major risk in a patient who has suffered a subarachnoid hemorrhage from a ruptured aneurysm?



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An adult patient presents with the worst headache of her life. A noncontrast CT of the head is negative. A lumbar puncture produces four bloody tubes, each with RBC counts greater than 100,000/mm3. What is the next step in management?



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A 42-year-old woman complains of the sudden onset of a severe headache after a brief period of unconsciousness. Exam reveals a stiff neck, photophobia, and dilated pupil. There was no trauma. Which type of vascular event has most likely occurred?



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What is the MOST common cause of nontraumatic subarachnoid hemorrhage?



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A patient complains of nausea, vomiting, and thunder-clap headache. What is the most likely diagnosis?



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A 22-year-old patient presents with a severe headache and vomiting. The patient is drowsy but arousable, has mild nuchal rigidity, and no focal deficit. Which of the following is least necessary?



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A previously healthy patient initially complained of a severe headache and then loses consciousness. An intracerebral hematoma or subarachnoid hemorrhage is suspected. Which statement regarding assessment is most accurate?



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A patient is seen in the emergency department with a severe headache and vomiting. The patient is drowsy but arousable, has mild nuchal rigidity, but no focal deficit. Which of the following intervention takes the least precedence initially?



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A previously healthy patient initially complains of a severe headache and subsequently experiences loss of consciousness. He is in the Emergency department for work-up within 90 minutes. A subarachnoid hemorrhage is suspected. Which of the following choices is TRUE about investigations in this patient?



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A 32-year-old male presents with a headache that started one day ago. He was shoveling snow and experienced a sudden pain in the frontal region. The pain is constant, not like his usual migraines. He states his neck has been stiff. Vital signs are normal and the exam is remarkable for mild photophobia. Neck flexion causes mild discomfort. What is the next step in management?

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    Contributed by Scott Dulebohn, MD
Attributed To: Contributed by Scott Dulebohn, MD



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A 54 year old male had sudden onset of a severe right sided headache when getting up from the dinner table. Exam and CT are normal. Select the appropriate next step.



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A 62 year old female presents with a severe headache. Lumbar puncture shows 6000 RBCs in tube1 and 6300 RBCs in tube 4. There are 7 WBCs in each tube. The CSF shows xanthochromia and the opening pressure is 25 cm H2O. An unenhanced head CT is unremarkable. Select the best next step.



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A 38-year-old female is involved in a motor vehicle accident and had loss of consciousness. The patient is transported to the emergency department and regains consciousness but cannot remember the accident or the events leading up to it. She has a laceration of his scalp, neck stiffness, and photophobia. She has an MRI that shows no mass effects but lumbar puncture is not possible as the patient is uncooperative, irritable, and confused. Two days later lumbar puncture is performed. Which of the following would be seen on CSF analysis?



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A 49 year old female informs the physician that she has the worst headache of her life. It was sudden and excruciating. What would be a reasonable initial diagnosis?



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A 42-year-old female is admitted to the neurologic intensive care unit with a grade III subarachnoid hemorrhage. What would be an appropriate medication to reduce the effects of vasospasm?



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A patient has a modified Fisher scale grade 3 subarachnoid hemorrhage (SAH). What will be the most likely finding on a head CT?



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A patient who is 3 days status post clipping of an aneurysm and 4 days from the SAH has a significant change in mental status. The patient is on nimodipine and electrolytes are WNL. The screening transcranial Doppler indicates a small increase in velocities of the cerebral arteries suggesting the presence of vasospasm. CT shows no edema, ventriculomegaly, stroke, or recurrent hemorrhage. The doctor wants to confirm that the reason is vasospasm before inserting a swan-Ganz catheter and starting aggressive hypervolemic and possible hypertensive treatment. Which of the following radiographic studies could be considered in evaluating the arteries for narrowing?



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A female with a long history of tension headaches developed the worst headache in her life prompting a visit to the ER. Which of the following conditions is the most likely diagnosis?



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Which of the following statements about subarachnoid hemorrhage (SAH) is correct?



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Which of the following statements about aminocaproic acid and subarachnoid hemorrhage (SAH) is correct?



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Which one of the following medications is indicated in patients who are diagnosed with subarachnoid hemorrhage?



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A patient has a lumbar puncture due to concern about a subacute subarachnoid hemorrhage (SAH). There is a possibility that the tap was traumatic. Which CSF finding would make SAH most likely?



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A patient has a cerebral angiogram that reveals a subarachnoid hemorrhage of the perimesencephalic cisterns alone. What would it show?



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Which historical aspect is of most importance in diagnosis of subarachnoid hemorrhage (SAH)?



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A 42-year-old female had a sudden onset of a posterior headache bilaterally that radiated to the frontal region. After 2 days the patient presented to the emergency department where CT showed blood in the suprasellar cistern. CT angiography did not demonstrate an aneurysm. Select the most likely diagnosis.



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MRI of the brain shows a subarachnoid hemorrhage with resulting clot in the Sylvian fissure. What is the most likely cause?



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Subarachnoid hemorrhage is most commonly caused by which of the following?



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When do neonatal subarachnoid hemorrhage induced seizure usually appear?



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Which of the following is not true about subarachnoid hemorrhage?



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What is the most common cause of subarachnoid hemorrhage?



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Which of the following is not true of subarachnoid hemorrhage?



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Which of the following is false regarding aneurysmal subarachnoid hemorrhage?



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If subarachnoid hemorrhage is predominantly seen within the Sylvian fissure, where the most likely location of the aneurysm?



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A 60 year old female patient presenting with sudden severe occipital headache and nausea and then loss of consciousness with otherwise normal vital signs and neurological exam most likely has:



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Which is not a risk factor for nontraumatic subarachnoid hemorrhage (SAH)?



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Which is true regarding lumbar puncture (LP) to evaluate a patient for subarachnoid hemorrhage (SAH)?



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Which is the imaging study of choice to evaluate a patient for subarachnoid hemorrhage?



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When is the sensitivity greatest for CT looking for a subarachnoid hemorrhage (SAH)?



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Which is least important in the ICU management of a patient with subarachnoid hemorrhage (SAH)?



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Which is not true regarding morbidity and mortality in subarachnoid hemorrhage (SAH)?



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Which surgical treatment could be indicated for the patient with subarachnoid hemorrhage (SAH)?



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Which may be seen before a nontraumatic subarachnoid hemorrhage (SAH)?



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Which is not true regarding vasospasm following subarachnoid hemorrhage (SAH)?



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A patient presents with a severe headache and a subarachnoid hemorrhage of the perimesencephalic cisterns. What is expect on the cerebral angiogram?



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A 30-year-old female presents with a moderate to severe headache. Exam is normal except for neck stiffness. CT of the brain shows blood in the interpeduncular cistern. CT angiogram and four-vessel angiogram are normal. Cervical spine MRI with and without gadolinium is normal. What is the next step in management?



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What must be ruled out in a patient who has intense headaches with neurological signs?



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How is subarachnoid hemorrhage diagnosed?



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A young female presents with an excruciating headache, which she states is the worst thing she has ever experienced. In the emergency department, she becomes lethargic and unresponsive. She undergoes an immediate CT scan of the head which turns out to be negative. What is the next step in her management?



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A 27-year-old male presents to the emergency room after falling off of his porch and landing onto his back. After the fall, a very sudden onset headache developed. The patient describes this headache as the worst of his life. Since the fall, the patient has also experienced vomiting. Given that he may have a subarachnoid hemorrhage a non-contrast CT of his head is done. The CT comes back negative, but to completely rule out a subarachnoid hemorrhage, a lumbar puncture is done. If the patient does have a subarachnoid hemorrhage, what finding would be expected from analysis of his cerebrospinal fluid (CSF)?



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A 22-year-old otherwise healthy male presents with a non-traumatic headache for the past 30 minutes. The headache started suddenly and he describes it as the worst he has ever had. He has associated nausea and has had two episodes of vomiting since onset. He admits to smoking a pack of cigarettes a day for the past 2 years and denies any family history of sudden death or cerebral aneurysm. His father has high blood pressure. His vital signs reveal a heart rate of 110 beats/min, blood pressure 165/95 mmHg, respirations 18 breaths/min, and oxygen saturation 100% on room air. On exam, the patient appears uncomfortable and refuses to remove the blanket from over his head. Eventually, he agrees to remove the blanket, and his pupils are round and reactive to light, and he is oriented to person, place and time. His neck range of motion is limited in flexion. His cardiac rhythm is regular, and the rate is tachycardic. Lungs are clear to auscultation bilaterally. Cranial nerves are intact, and strength is 5 out of 5 bilaterally. He is unable to ambulate or cooperate with cerebellar testing because of pain. What is the initial diagnostic test of choice?



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Subarachnoid Hemorrhage - References

References

Initial misdiagnosis and outcome after subarachnoid hemorrhage., Kowalski RG,Claassen J,Kreiter KT,Bates JE,Ostapkovich ND,Connolly ES,Mayer SA,, JAMA, 2004 Feb 18     [PubMed]
Surgical risk as related to time of intervention in the repair of intracranial aneurysms., Hunt WE,Hess RM,, Journal of neurosurgery, 1968 Jan     [PubMed]
Ikawa F,Michihata N,Matsushige T,Abiko M,Ishii D,Oshita J,Okazaki T,Sakamoto S,Kurogi R,Iihara K,Nishimura K,Morita A,Fushimi K,Yasunaga H,Kurisu K, In-hospital mortality and poor outcome after surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage using nationwide databases: a systematic review and meta-analysis. Neurosurgical review. 2019 Apr 2;     [PubMed]
Gallas S,Tuilier T,Ebrahiminia V,Bartoluci P,Hodel J,Gaston A, Intracranial aneurysms in Sickle Cell Disease: Aneurysms characteristics and modalities of endovascular approach to treat these patients. Journal of neuroradiology. Journal de neuroradiologie. 2019 Mar 20;     [PubMed]
Marcolini E,Hine J, Approach to the Diagnosis and Management of Subarachnoid Hemorrhage. The western journal of emergency medicine. 2019 Mar;     [PubMed]
Kuroda H,Mochizuki T,Shimizu S,Kumabe T, Rupture of Thrombosed Cerebral Aneurysm During Antithrombotic Therapy for Ischemic Stroke: Case Report and Literature Review. World neurosurgery. 2019 Mar 18;     [PubMed]
Kumar A,Niknam K,Lumba-Brown A,Woodruff M,Bledsoe JR,Kohn MA,Perry JJ,Govindarajan P, Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians. Neurocritical care. 2019 Feb 21;     [PubMed]
Li K,Barras CD,Chandra RV,Kok HK,Maingard JT,Carter NS,Russell JH,Lai L,Brooks M,Asadi H, A review on the management of cerebral vasospasm following aneurysmal subarachnoid haemorrhage. World neurosurgery. 2019 Mar 18;     [PubMed]
Dodson V,Majmundar N,El-Ghanem M,Amuluru K,Gupta G,Nuoman R,Wainwright J,Kaur G,Cole C,Santarelli J,Chandy D,Bowers C,Gandhi C,Al-Mufti F, Intracranial Administration of Nicardipine After Aneurysmal Subarachnoid Hemorrhage: A Review of the Literature. World neurosurgery. 2019 Jan 29;     [PubMed]
Acciarresi M,Altavilla R,Mosconi MG,Caso V, Management of intracranial haemorrhage, unruptured aneurysms and arteriovenous malformations during and after pregnancy. Current opinion in neurology. 2019 Feb;     [PubMed]
Chu K,Windsor C,Fox J,Howell T,Keijzers G,Eley R,Kinnear F,Furyk J,Thom O,Brown NJ,Brown AFT, Factors influencing variation in investigations after a negative CT brain scan in suspected subarachnoid haemorrhage: a qualitative study. Emergency medicine journal : EMJ. 2019 Feb;     [PubMed]
Darkwah Oppong M,Gümüs M,Pierscianek D,Herten A,Kneist A,Wrede K,Barthel L,Forsting M,Sure U,Jabbarli R, Aneurysm rebleeding before therapy: a predictable disaster? Journal of neurosurgery. 2018 Nov 1;     [PubMed]
Pratt AK,Chang JJ,Sederstrom NO, A Fate Worse Than Death: Prognostication of Devastating Brain Injury. Critical care medicine. 2019 Apr;     [PubMed]
Zheng K,Zhong M,Zhao B,Chen SY,Tan XX,Li ZQ,Xiong Y,Duan CZ, Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Risk Factors Affecting Clinical Outcomes in Intracranial Aneurysm Patients in a Multi-Center Study. Frontiers in neurology. 2019;     [PubMed]

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