Subarachnoid Hemorrhage – Diagnosis and Treatment
Diagnosis
Diagnosing subarachnoid hemorrhage (SAH) starts with looking for classic symptoms. A sudden, severe headache—often called a “thunderclap headache”—is a major warning sign.
Other symptoms can include nausea, vomiting, neck pain or stiffness (nuchal rigidity), dizziness, loss of consciousness, and focal neurological deficits.
People with a family history of aneurysm or known risk factors like high blood pressure (hypertension) receive close monitoring if these signs show up. Doctors usually begin with a CT scan of the head.
| Procedure | What It Detects |
|---|---|
| CT scan | Brain bleeding, especially soon after symptoms begin |
| CT angiography | Detailed blood vessels, aneurysms, abnormalities |
| MRI/MR angiography | Brain tissue, hidden bleeds, detailed vessel images |
| Lumbar puncture | Blood in cerebrospinal fluid when imaging is unclear |
| Cerebral angiography | Exact source of bleeding, blood vessel issues |
This non-invasive test is fast and usually spots bleeding in the brain, especially within six hours of symptom onset.
Sometimes, doctors pair the CT scan with contrast dye, a method called CT angiography, to get a detailed view of blood vessels and find aneurysms or other abnormalities.
If the CT scan does not reveal bleeding but suspicion remains high, doctors may perform a lumbar puncture (also called a spinal tap). In this test, a needle goes into the lower back to collect cerebrospinal fluid (CSF).
If blood appears in the CSF, that supports the diagnosis of SAH. This step is especially important when CT scans do not show clear results.
Doctors sometimes use MRI scans and MR angiography, especially if the CT scan is inconclusive or performed many hours after symptoms began. These tests can show changes the CT scan might miss and reveal hidden aneurysms.
For some patients, doctors perform a cerebral angiogram if earlier tests are not clear or to find the precise source of bleeding.
In this procedure, a catheter is threaded through the blood vessels to the brain, and dye is injected for detailed X-ray images.
Doctors also use tools like the Fisher grading scale and Glasgow Coma Scale to determine severity and make treatment decisions.
Treatment
Treatment for subarachnoid hemorrhage begins in the emergency department. The main goals are to stabilize the patient, stop the bleeding, and reduce the risk of further problems.
Staff immediately monitor breathing, blood pressure, and brain function. If doctors find a ruptured brain aneurysm, they act quickly. Two main procedures address the aneurysm:
| Procedure | Purpose | How it Works |
|---|---|---|
| Surgical Clipping | Blocks blood flow to the aneurysm | A metal clip is placed on the aneurysm. |
| Endovascular Coiling | Clots and seals the aneurysm | Coils are placed inside the aneurysm via catheter. |
Doctors may use new devices like stents or balloons to help block the aneurysm more effectively. Both techniques aim to prevent the aneurysm from bleeding again.
Managing complications is another key part of treatment. Vasospasm, where blood vessels in the brain become narrow and reduce blood flow, can lead to further brain damage or stroke.
Doctors commonly use a type of calcium channel blocker for three weeks to help keep blood vessels open and lower the risk of vasospasm.
Sometimes, they increase blood pressure with fluids or other medicines to help keep blood moving to the brain.
Another risk is hydrocephalus, which is when fluid builds up inside the brain. If this happens, doctors may place a drain in the head or lower back to remove the extra fluid and lower brain pressure.
A comprehensive stroke center team provides supportive care. The team checks sodium, sugar levels, and general brain health, working to keep all levels within a safe range. They watch for seizures and give medicine if needed.
After the first treatments, patients often need regular check-ups and therapy to regain physical strength, speech, or movement skills that may have been affected. The healthcare team discusses prevention of future strokes or bleeding.
Getting Ready for Your Visit
Steps You Can Take Before Seeing the Doctor
To help the healthcare provider understand your condition, prepare a list of details about your health.
- Write down your symptoms. Include everything you notice, even if it does not seem linked to the problem.
- Make a note of important life events. Think about recent stress, changes, or family history of health conditions.
- Bring a list of your medicines. Include the names and amounts of all medications, vitamins, and supplements you take.
- Prepare questions to ask. Good topics might include possible causes, recommended tests, and next steps.
Use this table to organize your questions:
| Possible Questions for Provider |
|---|
| What may be causing my symptoms? |
| What other reasons could explain my symptoms? |
| What exams or tests are needed? |
| Is this likely to be short-term or last a long time? |
| What treatment is best? |
| Are there other options for care? |
| How do I manage any other health problems with this? |
| Do I need to follow any special instructions? |
| Do I need to see a specialist? |
Do not hesitate to bring up other concerns too.
Questions the Medical Team May Ask
The healthcare team will try to learn as much as possible about your health and recent symptoms. Common questions they might ask include:
- When did you begin to feel unwell?
- Are your symptoms steady or do they come and go?
- How strong or severe are your symptoms?
- Have you noticed anything that makes your symptoms better?
- Is there anything that seems to make things worse?
