PRIMARY CARE

Review Article

Primary Care A VOIDING P ITFALLS IN THE D IAGNOSIS OF S UBARACHNOID H EMORRHAGE

JONATHAN A. EDLOW, M.D.,
AND

LOUIS R. CAPLAN, M.D.

gery to repair aneurysms reduces short-term complications (primarily recurrent bleeding and vasospasm) and improves outcomes,11 accurate early diagnosis is critical. Despite the widespread availability of neuroimaging equipment, misdiagnosis of subarachnoid hemorrhage remains common,12,13 and it is an important cause of litigation related to emergency medicine.14 This review is intended to provide primary care and emergency physicians with a strategy for identifying patients who should be evaluated for subarachnoid hemorrhage and establishing the diagnosis.
SCOPE OF THE PROBLEM OF MISDIAGNOSIS

For it happens in this, as the physicians say it happens in hectic fever, that in the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated in the beginning, it becomes easy to detect but difficult to cure. Niccol Machiavelli, The Prince

ATIENTS with headache account for 1 to 2 percent of visits to the emergency department1-4 and up to 4 percent of visits to physicians offices.5 Most have primary headache disorders, such as migraine and tension-type headaches. Only a few patients have treatable secondary causes that threaten life, limb, brain, or vision,1,3-5 such as subarachnoid hemorrhage (Table 1). Roughly 80 percent of patients with nontraumatic subarachnoid hemorrhage have ruptured saccular aneurysms, which occur in 30,000 patients annually in the United States.6 Among the remaining 20 percent, about half have nonaneurysmal perimesencephalic hemorrhages.7,8 The initial diagnostic approach is the same for both groups. Among all patients with headache who presented to emergency departments, retrospective studies1,3,4 have found that approximately 1 percent had subarachnoid hemorrhage. One prospective study 9 put that figure at 4 percent. Two prospective studies found that if only patients with the worst headache of their lives and a normal neurologic examination were considered, 12 percent of such patients had subarachnoid hemorrhage.9,10 This proportion increased to 25 percent when patients whose examinations were abnormal were included.10 The initial hemorrhage may be fatal, may result in devastating neurologic outcomes, or may produce relatively minor symptoms. Because early definitive sur-

From the Departments of Emergency Medicine (J.A.E.) and Neurology (L.R.C.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. Address reprint requests to Dr. Edlow at the Department of Emergency Medicine, Finard 202, 330 Brookline Ave., Boston, MA 02215, or at jonathan_edlow@hms.harvard.edu. 2000, Massachusetts Medical Society.

The typical patient with subarachnoid hemorrhage has a sudden onset of severe headache (frequently described as being the worst headache of his or her life) that develops during exertion. Transient loss of consciousness or buckling of the legs often accompanies the headache. Vomiting soon follows. The physical examination may show retinal hemorrhages (Fig. 1), nuchal rigidity, restlessness, a diminished level of consciousness, and focal neurologic signs (Table 2). Patients with these classic findings present little diagnostic difficulty. However, in the absence of such symptoms and signs, clinicians often miss the diagnosis, as several studies have demonstrated. During the 1980s, 23 to 37 percent of all patients referred to the University of Iowa with subarachnoid hemorrhage were given an incorrect diagnosis on their first visit to a physician.15,16 These patients tended to be less ill than those given a correct diagnosis and to have normal neurologic examinations. Among patients treated at four Connecticut neurosurgical units in the 1990s, 25 percent of patients with subarachnoid hemorrhage initially received an incorrect diagnosis; most of them were in good clinical condition at presentation.13 The condition of half the 54 patients with an incorrect diagnosis worsened, usually as a result of recurrent bleeding, before definitive treatment was begun. Of the 163 patients given a correct diagnosis, the condition of only 2.5 percent worsened. Among patients who were in good clinical condition when first seen, 91 percent of patients with a correct diagnosis had good or excellent outcomes at six weeks, as compared with 53 percent of patients with an incorrect diagnosis. British investigators also found that half of a series of patients with subarachnoid hemorrhage initially received an incorrect diagnosis; 65 percent had recurrent bleeding before a correct diagnosis was given.12 Table 3 shows the results of these four studies in which a substantial proportion of patients were givVo l u m e 3 4 2 Nu m b e r 1

29

Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.

The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

TABLE 1. CAUSES OF HEADACHE THAT REQUIRE SPECIFIC THERAPY.*

Subarachnoid hemorrhage Meningitis Encephalitis Cervicocranial-artery dissection Temporal arteritis Acute angle-closure glaucoma Hypertensive emergency Carbon monoxide poisoning Pseudotumor cerebri Cerebral venous and dural sinus thrombosis Acute stroke (hemorrhagic or ischemic) Mass lesion Tumor Abscess Intracranial hematoma (parenchymal, subdural, or epidural) Parameningeal infection *These causes are diseases or conditions that are treatable and that, if untreated, threaten life, limb, brain, or vision.
FINDING

TABLE 2. PHYSICAL FINDINGS IN PATIENTS WITH SUBARACHNOID HEMORRHAGE.

LIKELY LOCATION ANEURYSM

OF

Nuchal rigidity Diminished level of consciousness

Papilledema Retinal and subhyaloid hemorrhage Third-nerve palsy Sixth-nerve palsy Bilateral weakness in legs or abulia Nystagmus or ataxia Aphasia, hemiparesis, or left-sided visual neglect

Any Any (could result from possible complications of aneurysmal rupture: hydrocephalus, hematoma, or ischemia) Any Any Posterior communicating artery Posterior fossa* Anterior communicating artery Posterior fossa Middle cerebral artery

*Sixth-nerve palsy may also be associated with nonspecific changes related to increased intracranial pressure.

rhage were excluded because of a delay of more than three days before referral.20 Three facts are clear. First, physicians consistently misdiagnose subarachnoid hemorrhage. Second, the patients with the greatest likelihood of benefiting from surgery are the ones who most often receive an incorrect diagnosis. Third, early complications develop in patients with an incorrect diagnosis, resulting in worse outcomes more often in these patients than in those initially given a correct diagnosis. Misdiagnosis stems from three recurring, correctable patterns of diagnostic error: failure to appreciate the spectrum of clinical presentation, failure to understand the limitations of computed tomography (CT), and failure to perform and correctly interpret the results of lumbar puncture (Table 4).
THE SPECTRUM OF PRESENTATION
Warning Headache

Figure 1. Subhyaloid Hemorrhage. The retina of the right eye of a patient with aneurysmal subarachnoid hemorrhage has small, flame-shaped hemorrhages (arrowheads) and a large subhyaloid hemorrhage (arrow) temporal to the optic disk. At the inferior margin of the subhyaloid hemorrhage, the blood forms layers in a gravity-dependent fashion. Ocular hemorrhages in patients with subarachnoid hemorrhage can be flame-shaped, subhyaloid, or vitreous and are thought to result from an acute increase in intracranial pressure that causes obstruction of venous outflow from the eye. These hemorrhages may be the only clue to the underlying cause in unconscious patients with subarachnoid hemorrhage. (Provided by Dr. John J. Weiter.)

en an incorrect diagnosis. Frequent misdiagnosis has also been documented in the Netherlands,17 Portugal,18 and Australia.19 In the International Cooperative Study on the Timing of Aneurysm Surgery, involving 68 centers in 14 countries, nearly half the eligible patients with aneurysmal subarachnoid hemor30
Ja n u a r y 6 , 2 0 0 0

Between 20 and 50 percent of patients with documented subarachnoid hemorrhage report a distinct, unusually severe headache in the days or weeks before the index episode of bleeding, referred to as a warning headache.21-28 These so-called thunderclap headaches develop in seconds, achieve maximal intensity in minutes, and last hours to days. The differential diagnosis includes subarachnoid hemorrhage29-31; acute expansion, dissection, or thrombosis of unruptured aneurysms32; cerebral venous sinus thrombosis33; brief headaches during exertion and sexual intercourse34; and benign thunderclap headache.31 All patients with thunderclap headache should be evaluated for subarachnoid hemorrhage.
Deviations from the Classic Presentation

Roughly half of all patients with subarachnoid hemorrhage have episodes of minor bleeding, often

Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.

P R I M A RY C A R E

TABLE 3. FREQUENCY

OF

MISDIAGNOSIS

OF

SUBARACHNOID HEMORRHAGE.*
MAYER
ET AL.13

VARIABLE

NEIL-DWYER AND LANG12

KASSELL ET AL.15

ADAMS
ET AL.16

ALL STUDIES

Overall Patients with incorrect diagnosis no./total no. (%) Delay in diagnosis days Median Range

69/136 (51) 54/217 (25) 56/150 (37) 41/182 (23) 220/685 (32) 814 1180 37 130 3.6 050 47 127 6 0180
no. (%)

no. of patients

Specific misdiagnoses No diagnosis or headache of unknown cause Migraine, cluster, or tension headache Meningitis or encephalitis Systemic infection (influenza, gastroenteritis, or viral syndrome) Stroke or cerebral ischemia Hypertensive crisis Cardiac causes (myocardial infarction, arrhythmia, and syncope) Sinus-related condition Neck problem (disk-related or arthritis) Psychiatric diagnosis (including malingering and alcohol intoxication) Trauma-related condition Back pain Other *Some patients had more than one diagnosis.

45 9 4 6 1 0 0 0 3 1 0 0 0

7 13 8 0 7 4 0 4 0 2 2 0 8

0 17 8 7 7 5 11 6 4 4 0 1 16

0 8 3 10 2 7 3 3 4 3 1 0 8

52 (24) 47 (21) 23 (10) 23 (10) 17 (8) 16 (7) 14 (6) 13 (6) 11 (5) 10 (5) 3 (1) 1 (<1) 32 (15)

The numbers in parentheses denote the percentages of patients with the particular misdiagnoses among all patients with an incorrect diagnosis.

with atypical features.35,36 Among 500 patients with subarachnoid hemorrhage in one series, the condition developed in 34 percent during nonstrenuous activities and in 12 percent during sleep.37 The headache may be in any location, may be localized or generalized, may be mild,38 may resolve spontaneously, or may be relieved by nonnarcotic analgesics.39 Patients with such less severe headaches are incorrectly given a diagnosis of a more common condition possibly migraine, tension-type, or sinus-related headaches.12,13,15-17 Even these less severe types of headache tend to develop abruptly and have a distinctive quality. When vomiting is prominent, especially if accompanied by low-grade fever, viral syndrome, viral meningitis, influenza, or gastroenteritis is often diagnosed.12,13,15-17 Patients with prominent neck pain may be given a diagnosis of cervical sprain or arthritis,12,15,16,40 and those with blood irritating the lumbar theca may be given a diagnosis of sciatica.15,38 Patients who are confused, agitated, or restless and who are unable to give cogent histories may receive primary psychiatric diagnoses.12,13,15-17,38 According to the International Headache Society, a first episode of severe headache cannot be classified as migraine or tension-type headache; diagnostic criteria require multiple episodes with specific characteristics (more than 9 episodes for tension-type headache and more than 4 episodes for migraine without aura).41 Although patients with primary headache dis-

orders must have their first headache at some point, the diagnosis cannot be made definitively at that time. The first or worst headache requires evaluation, as do qualitatively different headaches in patients with established headache patterns, even if the headache is not the worst ever. In patients with unruptured aneurysms, seizures, mass effect, cranial neuropathy, or brain ischemia from passage of a clot into the territory distal to the aneurysm may also develop.32 Typically, aneurysmal thirdnerve palsy dilates the pupil, whereas microvascular infarction does not, although there are exceptions.42 Patients with partial lesions that spare the pupil must be evaluated for the presence of aneurysms.
Secondary Head Injury, High Blood Pressure, and Abnormal Electrocardiographic Findings

Diagnostic ambiguity arises in patients with subarachnoid hemorrhage who lose consciousness, fall, and sustain head injuries.13,16,43 Blood seen on CT scanning may be incorrectly attributed to trauma, the most common cause of blood in the subarachnoid space. Some patients may have high blood pressure, with or without alterations in consciousness.20 Excessive focus on blood pressure may lead to the incorrect diagnosis of primary hypertensive emergency.13,15,16 Up to 91 percent of patients with subarachnoid hemorrhage have cardiac arrhythmias,44 and electrocardiographic patterns mimicking myocardial
Vo l u m e 3 4 2 Nu m b e r 1

31

Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.

The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

TABLE 4. REASONS FOR MISDIAGNOSIS OF SUBARACHNOID HEMORRHAGE.

Failure to appreciate the spectrum of presentations of subarachnoid hemorrhage Failure to evaluate patients with warning headaches (severe, abrupt, unusual headaches) Failure to recognize that headache can improve spontaneously or with nonnarcotic analgesic drugs Overreliance on the classic presentation, leading to the following incorrect diagnoses: Viral syndrome, viral meningitis, or gastroenteritis Migraine or tension-type headache Sinus-related headache Neck pain (rarely, back pain) Psychiatric disorders Focus on secondary head injury (resulting from syncope) Focus on electrocardiographic abnormalities Focus on high blood pressure Lack of knowledge of presentations of unruptured aneurysm Failure to understand the limitations of computed tomography Loss of sensitivity with increasing time between onset of headache and scanning False negative results in cases of small-volume bleeding (spectrum bias) Interpretation factors (e.g., variations in expertise of physician reading the scan) Technical factors (e.g., variations in thickness of slices taken at the base of the brain, motion artifact) False negative results for blood with a hematocrit of less than 30 percent Failure to perform lumbar puncture and correctly interpret cerebrospinal fluid findings Failure to perform lumbar puncture in patients with negative, equivocal, or suboptimal results on computed tomography Failure to recognize that xanthochromia may be absent very early (<12 hours after hemorrhage) and very late (>2 weeks after hemorrhage) Failure to realize that visual inspection for the presence of xanthochromia is less sensitive than spectrophotometry Failure to distinguish properly between traumatic tap and true subarachnoid hemorrhage

ischemia or infarction are seen, resulting in the erroneous diagnosis of a primary cardiac disorder.15-17 Despite these caveats, most patients with subarachnoid hemorrhage have abrupt onset of severe, unique headache or neck pain. Many will have abnormal findings on neurologic examination, if only subtle meningismus or ocular findings. An understanding of this wide spectrum of clinical presentation, coupled with a careful history taking and physical examination that actively targets these diagnostic clues, is the best strategy for identifying patients who should be evaluated for subarachnoid hemorrhage.
LIMITATIONS OF CT SCANNING

B Figure 2. Subarachnoid Hemorrhage on CT Scan. A 34-year-old woman presented to the emergency department with headache. While sitting at her desk three hours earlier, she had had a syncopal episode, followed immediately by a moderate-intensity, unusual, localized headache in the left frontal and temporal areas. She was awake and alert and had no meningeal, ophthalmologic, or neurologic signs. The CT scan without contrast material showed blood in the subarachnoid space. In Panel A, blood fills the basal cisterns and extends into the sylvian fissures bilaterally and the interhemispheric fissure anteriorly. In Panel B, the blood in the more rostral sylvian fissures is more difficult to see. Both images show enlarged lateral, third, and fourth ventricles, indicating the presence of communicating hydrocephalus.

The first diagnostic study should be noncontrast CT (Fig. 2).6-8,11,45 Technique is important. Very thin cuts (3 mm in thickness) through the base of the brain are recommended, because thicker cuts (10 mm) miss small collections of blood.46 The plane of scanning should be parallel to the hard palate.46 Blood and adjacent bone, which both appear white, can be difficult to distinguish from one another, especially in small hemorrhages. Because the increased density of blood on CT is a function of the hemoglobin con32
Ja n u a r y 6 , 2 0 0 0

Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.

P R I M A RY C A R E

centration,46 blood with a hemoglobin concentration below 10 g per deciliter may appear isodense.47 Artifacts of motion in the scans of restless patients can render such scans technically suboptimal and obscure the diagnosis. The sensitivity of CT decreases over time from the onset of symptoms; the dynamics of cerebrospinal fluid and spontaneous lysis can result in the rapid clearing of subarachnoid blood.48 In the International Cooperative Study of the Timing of Aneurysm Surgery, over 3500 patients with aneurysmal subarachnoid hemorrhage underwent scanning with the type of CT equipment in use between 1980 and 1983. Ninety-two percent of the scans were positive on the day of rupture, but this percentage declined to 86 percent one day later, 76 percent two days later, and 58 percent five days later.20 In another study, 85 percent of scans were positive five days after rupture and 50 percent at one week.49 Four studies have evaluated modern, third-generation CT scanners.9,48,50,51 Retrospective studies of patients admitted to the hospital with subarachnoid hemorrhage indicate that 100 percent of patients who underwent scanning in the first 12 hours (80 of 80)50 and 93 percent of patients studied within the first 24 hours (134 of 144)51 after the onset of headache had positive findings on CT scanning. Prospective studies of outpatients found a sensitivity of 98 percent (117 of 119) for scanning performed in the first 12 hours48 and 93 percent (14 of 15) for scanning performed in the first 24 hours.9 In three of these studies,9,48,50 expert neuroradiologists interpreted the CT scans, but in many hospitals such experts are not available. The fourth study,51 in which the readings of the initial radiologist were used, found a sensitivity of 93 percent for scanning performed within 24 hours after the onset of symptoms. Skill in correctly identifying hemorrhage on CT varies widely among emergency physicians, neurologists, and general radiologists.52 Less experienced physicians undoubtedly miss subtle abnormalities. Spectrum bias is another issue; alert patients are more likely to seek care later and have normal CT scans than those with diminished mental status.20 In the International Cooperative Study, 15 percent of 638 alert patients had normal scans.53 Patients with small hemorrhages, who are the most likely to receive an incorrect clinical diagnosis, are also more likely to have negative results on CT.48 Although magnetic resonance technology is continually advancing and can detect aneurysms, standard magnetic resonance imaging is inferior to CT for the detection of acute subarachnoid hemorrhage.54 Magnetic resonance imaging with fluid-attenuated inversion recovery shows promise,55 but CT remains the imaging method of choice because of its wider availability, lower cost, and greater convenience for ill patients and because there is wider experience with its interpretation.56

LUMBAR PUNCTURE AND INTERPRETATION OF FINDINGS

Lumbar puncture should be performed in a patient whose clinical presentation suggests subarachnoid hemorrhage and whose CT scan is negative, equivocal, or technically inadequate.6-8,45,48 This recommendation, however, is often not followed in practice.9 Lumbar puncture as a first strategy, postulated to be cost effective in carefully selected patients who have completely normal physical examinations,57 may be safe but has not been studied clinically. Duffy reported that of 55 patients who underwent lumbar puncture as the initial means of diagnosing subarachnoid hemorrhage, the condition of 7 deteriorated immediately thereafter.58 Hillman described four alert patients with subarachnoid hemorrhage whose neurologic condition deteriorated after lumbar puncture.59 In both studies, all the patients whose condition deteriorated had either clots on CT or a dilated pupil. Patients with possible bacterial meningitis should be treated with antibiotics while awaiting imaging. Even when lumbar punctures are performed, errors are sometimes made in interpreting cerebrospinal fluid findings. The cerebrospinal fluid pressure should always be measured. High intracranial pressure is an important clue in the occasional patient with cerebral venous sinus thrombosis33 or pseudotumor cerebri and may help distinguish bleeding due to traumatic lumbar puncture from true subarachnoid hemorrhage.60 Traumatic taps occur in up to 20 percent of lumbar punctures61 and must be distinguished from true hemorrhage. Depending on the method of detection, between 0.5 and 6.0 percent of the population has incidental intracranial aneurysms.11 Misinterpretation of a traumatic tap in a patient with an incidental aneurysm can precipitate potentially risky diagnostic and therapeutic interventions, so distinguishing traumatic taps from true hemorrhages is critical. Neither the impression of the operator nor the time-honored threetube method, in which one looks for a diminishing erythrocyte count in three successive tubes of cerebrospinal fluid, is entirely reliable in identifying a traumatic tap.7,62 A finding of crenated erythrocytes is also without value.7 Erythrophages are found inconsistently in the cerebrospinal fluid62,63 and may take days to develop.7 The use of D-dimer levels in cerebrospinal fluid to differentiate true hemorrhage from traumatic tap has proved inconsistent.9,63,64 If clear fluid is obtained on a second puncture one interspace higher than the initial tap, then it is likely that the first puncture was traumatic.60 After aneurysmal hemorrhage, erythrocytes rapidly disseminate throughout the subarachnoid space, where they persist for days or weeks and then are gradually lysed.56,60 Released hemoglobin is metabolized to the pigmented molecules oxyhemoglobin (reddish
Vo l u m e 3 4 2 Nu m b e r 1

33

Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.

The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

pink) and bilirubin (yellow), resulting in xanthochromia. Oxyhemoglobin can be detected within hours. The formation of bilirubin, an enzyme-dependent process, is diagnostically more reliable but requires up to 12 hours to occur.60,65 Timing is therefore important in interpreting the results of a lumbar puncture; cerebrospinal fluid should be centrifuged and examined promptly so that erythrocytes resulting from bleeding during lumbar puncture do not undergo lysis in vitro, producing xanthochromia from oxyhemoglobin. Most authorities agree that the presence of xanthochromia is the primary criterion for a diagnosis of subarachnoid hemorrhage in patients with negative CT scans.7,8,61 Others contend that the presence of erythrocytes, even in the absence of xanthochromia, is more accurate.66 These divergent opinions may be explained by the various methods of detecting xanthochromia. Those who believed that xanthochromia is most important used spectrophotometry, whereas those who believed that erythrocytes are most important used visual inspection, which can miss discoloration in up to 50 percent of specimens.67 In a study by Vermeulen et al., all 111 patients with subarachnoid hemorrhage who underwent lumbar puncture between 12 hours and 2 weeks after the onset of symptoms had xanthochromic cerebrospinal fluid, as determined by spectrophotometry.68 Vermeulen et al., along with others, recommend waiting 12 hours after the onset of headache, so that a traumatic first attempt undertaken earlier does not lead to xanthochromia and diagnostic confusion when a subsequent puncture is performed.7,8,57,68,69 The disadvantages of delaying lumbar puncture for 12 hours are primarily logistic (e.g., the prolongation of a patients emergency department stay). In addition, there is the potential for ultra-early rebleeding that is, within the first 12 hours after hemorrhage.70 We do not advocate delayed lumbar puncture in patients with negative CT scans. Patients with persistently bloody cerebrospinal fluid without xanthochromia (as determined by any method in patients presenting in the first 12 hours after the onset of headache and as determined visually in patients presenting after 12 hours) should undergo vascular imaging when the level of clinical suspicion of subarachnoid hemorrhage is high. This approach also applies to patients with xanthochromic cerebrospinal fluid. If CT or lumbar puncture indicates the presence of subarachnoid hemorrhage, consultation with a specialist and vascular imaging are indicated. What if the evaluation is negative? Is vascular imaging indicated in such patients? Day and Raskin reported on a patient with explosive headache and negative results on CT and lumbar puncture who, on angiography, had an unruptured internal-carotid-artery aneurysm and vasospasm.71 The aneurysm was clipped, and the patient recovered. Raps et al. described seven other patients
34
Ja n u a r y 6 , 2 0 0 0

OF

TABLE 5. FACTORS INDICATING A HIGH RISK ANEURYSMAL SUBARACHNOID HEMORRHAGE.

Clinical history Onset of headache: abrupt, maximal at onset, thunderclap headache Severity of headache: usually worst of life or very severe Qualitative characteristics: first headache ever of this intensity, unique or different in patients with prior headaches Associated signs and symptoms Loss of consciousness* Diplopia* Seizure* Focal neurologic signs* Epidemiologic factors Cigarette smoking Hypertension Alcohol consumption (especially after a recent binge) Personal or family history of subarachnoid hemorrhage* Polycystic kidney disease* Heritable connective-tissue diseases EhlersDanlos syndrome (type IV) Pseudoxanthoma elasticum Fibromuscular dysplasia* Other Sickle cell anemia Alpha1-antitrypsin deficiency Physical findings Retinal or subhyaloid hemorrhage* Nuchal rigidity* Any unequivocal neurologic finding (focal or generalized)* *Patients with this risk factor are at very high risk for aneurysm; clinicians should consider a consultation with a specialist and noninvasive vascular imaging for such patients, even when the results of computed tomography and lumbar puncture are negative.

with unruptured aneurysms and thunderclap headaches.32 On the other hand, in a retrospective evaluation of 71 patients with thunderclap headaches whose results on CT and lumbar puncture were negative, none of the patients had subarachnoid hemorrhage during an average follow-up period of 3.3 years.72 Nearly half were later given a diagnosis of migraine or tension headache. Furthermore, in three prospective studies in which a total of 117 patients with thunderclap headaches and negative findings on CT and lumbar puncture were followed for over one year, none of the patients had hemorrhage or died suddenly.10,30,73
CONCLUSIONS

The data described above strongly support two conclusions. First, most warning headaches are, in reality, indications of unrecognized subarachnoid hemorrhages that can be diagnosed by appropriate methods. Second, properly performed and interpreted CT and lumbar puncture in patients with acute, severe headache will identify the vast majority of patients with subarachnoid hemorrhage. Symptomatic treatment of the headache, discharge, and outpatient follow-up are a safe practice in patients whose results

Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.

P R I M A RY C A R E

are normal. Important exceptions are patients presenting more than two weeks after the onset of symptoms, who often have negative CT findings and may have normal cerebrospinal fluid. Also, some patients whose diagnostic-test results are ambiguous or who are at unusually high risk for aneurysm (Table 5) should undergo neurologic or neurosurgical consultation and vascular imaging by magnetic resonance, CT, or conventional catheter angiography.
REFERENCES
1. Dhopesh V, Anwar R , Herring C. A retrospective assessment of emergency department patients with complaint of headache. Headache 1979; 19:37-42. 2. Evans RW. Diagnostic testing for the evaluation of headaches. Neurol Clin 1996;14:1-26. 3. Leicht MJ. Non-traumatic headache in the emergency department. Ann Emerg Med 1980;9:404-9. 4. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, Johnston KL, Cipolle RJ, Barber DL. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 1997;54: 1506-9. 5. Frishberg BM. The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations. Neurology 1994;44: 1191-7. 6. Mayberg MR , Batjer HH, Dacey R , et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994;25:2315-28. 7. Vermeulen M. Subarachnoid haemorrhage: diagnosis and treatment. J Neurol 1996;243:496-501. 8. Vermeulen M, van Gijn J. The diagnosis of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1990;53:365-72. 9. Morgenstern LB, Luna-Gonzales H, Huber JC Jr, et al. Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 1998;32:297-304. 10. Linn FH, Wijdicks EF, van der Graff Y, Weerdesteyn-van Vliet FA, Bartelds AI, van Gijn J. Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet 1994;344:590-3. 11. Schievink WI. Intracranial aneurysms. N Engl J Med 1997;336:28-40. [Erratum, N Engl J Med 1997;336:1267.] 12. Neil-Dwyer G, Lang D. Brain attack aneurysmal subarachnoid haemorrhage: death due to delayed diagnosis. J R Coll Physicians Lond 1997;31:49-52. 13. Mayer PL, Awad IA, Todor R, et al. Misdiagnosis of symptomatic cerebral aneurysm: prevalence and correlation with outcome at four institutions. Stroke 1996;27:1558-63. 14. Karcz A, Holbrook J, Burke MC, et al. Massachusetts emergency medicine closed malpractice claims: 1988-1990. Ann Emerg Med 1993;22:553-9. 15. Kassell NF, Kongable GL, Torner JC, Adams HP Jr, Mazuz H. Delay in referral of patients with ruptured aneurysms to neurosurgical attention. Stroke 1985;16:587-90. 16. Adams HP Jr, Jergenson DD, Kassell NF, Sahs AL. Pitfalls in the recognition of subarachnoid hemorrhage. JAMA 1980;244:794-6. 17. Schievink WI, van der Werf DJ, Hageman LM, Dreissen JJ. Referral pattern of patients with aneurysmal subarachnoid hemorrhage. Surg Neurol 1988;29:367-71. 18. Ferro J, Lopes J, Melo T, et al. Investigation into the causes of delayed diagnosis of subarachnoid hemorrhage. Cerebrovasc Dis 1991;1:160-4. 19. Sved PD, Morgan MK, Weber NC. Delayed referral of patients with aneurysmal subarachnoid haemorrhage. Med J Aust 1995;162:310-1. 20. Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. 1. Overall management results. J Neurosurg 1990;73:18-36. 21. Okawara SH. Warning signs prior to rupture of an intracranial aneurysm. J Neurosurg 1973;38:575-80. 22. Duffy GP. The warning leak in spontaneous subarachnoid haemorrhage. Med J Aust 1983;1:514-6. 23. Leblanc R. The minor leak preceding subarachnoid hemorrhage. J Neurosurg 1987;66:35-9. 24. Verweij RD, Wijdicks EF, van Gijn J. Warning headache in aneurysmal subarachnoid hemorrhage: a case-control study. Arch Neurol 1988;45: 1019-20. 25. Bassi P, Bandera R , Loiero M, Tognoni G, Mangoni A. Warning signs

in subarachnoid hemorrhage: a cooperative study. Acta Neurol Scand 1991;84:277-81. 26. Hauerberg J, Andersen BB, Eskesen V, Rosenorn J, Schmidt K. Importance of the recognition of a warning leak as a sign of a ruptured intracranial aneurysm. Acta Neurol Scand 1991;83:61-4. 27. Juvela S. Minor leak before rupture of an intracranial aneurysm and subarachnoid hemorrhage of unknown etiology. Neurosurgery 1992;30:711. 28. Jakobsson KE, Saveland H, Hillman J, et al. Warning leak and management outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 1996;85:995-9. 29. Ball MJ. Pathogenesis of the sentinel headache preceding berry aneurysm rupture. CMAJ 1975;112:78-9. 30. Harling DW, Peatfield RC, Van Hille PT, Abbott RJ. Thunderclap headache: is it migraine? Cephalalgia 1989;9:87-90. 31. Linn FH, Rinkel GJ, Algra A, van Gijn J. Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 1998;65:791-3. 32. Raps EC, Rogers JD, Galetta SL, et al. The clinical spectrum of unruptured intracranial aneurysms. Arch Neurol 1993;50:265-8. 33. de Bruijn SF, Stam J, Kappelle LJ. Thunderclap headache as first symptom of cerebral venous sinus thrombosis. Lancet 1996;348:1623-5. 34. Pascual J, Iglesias F, Oterino A, Vazquez-Barquero A, Berciano J. Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 1996;46:1520-4. 35. Rosenorn J, Eskesen V, Schmidt K, et al. Clinical features and outcome in 1076 patients with ruptured intracranial saccular aneurysms: a prospective consecutive study. Br J Neurosurg 1987;1:33-45. 36. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968;28:14-20. 37. Schievink WI, Karemaker JM, Hageman LM, van der Werf DJM. Circumstances surrounding aneurysmal subarachnoid hemorrhage. Surg Neurol 1989;32:266-72. 38. Weir B. Headaches from aneurysms. Cephalalgia 1993;14:79-87. 39. Seymour JJ, Moscati RM, Jehle DV. Response of headaches to nonnarcotic analgesics resulting in missed intracranial hemorrhage. Am J Emerg Med 1995;13:43-5. 40. Schattner A. Pain in the neck. Lancet 1996;348:411-2. 41. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8:Suppl 7:1-96. 42. Kasner SE, Liu GT, Galetta SL. Neuro-ophthalmologic aspects of aneurysms. Neuroimaging Clin North Am 1997;7:679-92. 43. Sakas DE, Dias LS, Beale D. Subarachnoid haemorrhage presenting as head injury. BMJ 1995;310:1186-7. 44. Andreoli A, di Pasquale G, Pinelli G, Grazi P, Tognetti F, Testa C. Subarachnoid hemorrhage: frequency and severity of cardiac arrhythmias: a survey of 70 cases studied in the acute phase. Stroke 1987;18:55864. 45. Findlay JM. Current management of aneurysmal subarachnoid hemorrhage guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci 1997;24:161-70. 46. Latchaw RE, Silva P, Falcone SF. The role of CT following aneurysmal rupture. Neuroimaging Clin North Am 1997;7:693-708. 47. Smith WP Jr, Batnitzky S, Rengachary SS. Acute isodense subdural hematomas: a problem in anemic patients. AJR Am J Roentgenol 1981; 136:543-6. 48. van der Wee N, Rinkel GJ, Hasan D, van Gijn J. Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan? J Neurol Neurosurg Psychiatry 1995;58:357-9. 49. van Gijn J, van Dongen KJ. The time course of aneurysmal haemorrhage on computed tomograms. Neuroradiology 1982;23:153-6. 50. Sidman R, Connolly E, Lemke T. Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal. Acad Emerg Med 1996;3:827-31. 51. Sames TA, Storrow AB, Finkelstein JA, Magoon MR. Sensitivity of new-generation computed tomography in subarachnoid hemorrhage. Acad Emerg Med 1996;3:16-20. 52. Schriger D, Kalafut M, Starkman S, Krueger M, Saver J. Cranial computed tomography interpretation in acute stroke: physician accuracy in determining eligibility for thrombolytic therapy. JAMA 1998;279:1293-7. 53. Adams HP Jr, Kassell NF, Torner JC, Sahs AL. CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study. Neurology 1983;33:981-8. 54. Atlas SW. Magnetic resonance imaging of intracranial aneurysms. Neuroimaging Clin North Am 1997;7:709-20. 55. Noguchi K, Ogawa T, Inugami A, et al. Acute subarachnoid hemorrhage: MR imaging with fluid-attenuated inversion recovery pulse sequences. Radiology 1995;196:773-7. 56. Weir B. Diagnostic aspects of subarachnoid hemorrhage. In: Weir B,

Vo l u m e 3 4 2

Nu m b e r 1

35

Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.

The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne

ed. Subarachnoid hemorrhage: causes and cures. New York: Oxford University Press, 1998:144-76. 57. Schull MJ. Lumbar puncture first: an alternative model for the investigation of lone acute sudden headache. Acad Emerg Med 1999;6:1316. 58. Duffy GP. Lumbar puncture in spontaneous subarachnoid haemorrhage. BMJ 1982;285:1163-4. 59. Hillman J. Should computed tomography scanning replace lumbar puncture in the diagnostic process in suspected subarachnoid hemorrhage? Surg Neurol 1986;26:547-50. 60. Composition of the cerebrospinal fluid. In: Fishman RA. Cerebrospinal fluid in diseases of the nervous system. Philadelphia: W.B. Saunders, 1992:183-252. 61. Xanthochromia. Lancet 1989;2:658-9. 62. Buruma OJS, Janson HLF, Den Bergh FAJTM, Bots GTH. Bloodstained cerebrospinal fluid: traumatic puncture or haemorrhage? J Neurol Neurosurg Psychiatry 1981;44:144-7. 63. Page KB, Howell SJ, Smith CM, et al. Bilirubin, ferritin, D-dimers and erythrophages in the cerebrospinal fluid of patients with suspected subarachnoid haemorrhage but negative computed tomography scans. J Clin Pathol 1994;47:986-9. 64. Lang DT, Berberian LB, Lee S, Ault M. Rapid differentiation of subarachnoid hemorrhage from traumatic lumbar puncture using the D-dimer assay. Am J Clin Pathol 1990;93:403-5. 65. Roost KT, Pimstone NR, Diamond I, Schmid R. The formation of

cerebrospinal fluid xanthochromia after subarachnoid hemorrhage: enzymatic conversion of hemoglobin to bilirubin by the arachnoid and choroid plexus. Neurology 1972;22:973-7. 66. MacDonald A, Mendelow AD. Xanthochromia revisited: a re-evaluation of lumbar puncture and CT scanning in the diagnosis of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1988;51:342-4. 67. Soderstrom CE. Diagnostic significance of CSF spectrophotometry and computer tomography in cerebrovascular disease: a comparative study in 231 cases. Stroke 1977;8:606-12. 68. Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J. Xanthochromia after subarachnoid haemorrhage needs no revisitation. J Neurol Neurosurg Psychiatry 1989;52:826-8. 69. van Gijn J. Slip-ups in diagnosis of subarachnoid haemorrhage. Lancet 1997;349:1492. 70. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Ultraearly rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg 1996;84:35-42. 71. Day JW, Raskin NH. Thunderclap headache: symptom of unruptured cerebral aneurysm. Lancet 1986;2:1247-8. 72. Wijdicks EFM, Kerkhoff H, van Gijn J. Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid haemorrhage. Lancet 1988;2:68-70. 73. Markus HS. A prospective follow up of thunderclap headache mimicking subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1991;54: 1117-8.

RECEIVE THE JOURNALS TABLE OF CONTENTS EACH WEEK BY E-MAIL To receive the table of contents of the New England Journal of Medicine by e-mail every Wednesday evening, send an e-mail message to: listserv@massmed.org Leave the subject line blank, and type the following as the body of your message: subscribe TOC-L You can also sign up through our Web site at: http://www.nejm.org

36

Ja n u a r y 6 , 2 0 0 0 Downloaded from www.nejm.org at UNIVERSITY OF NEW MEXICO on January 14, 2004. Copyright 2000 Massachusetts Medical Society. All rights reserved.