Abstract
Headache is one of the most common reasons for presentation to the emergency department (ED), seen in up to 2% of patients.1 Most are benign, but it is imperative to understand and discern the life-threatening causes of headache when they present. Headache caused by a subarachnoid hemorrhage (SAH) from a ruptured aneurysm is one of the most deadly, with a median case-fatality of 27–44%.2 Fortunately, it is also rare, comprising only 1% of all headaches presenting to the ED.3 On initial presentation, the one-year mortality of untreated SAH is up to 65%.4 With appropriate diagnosis and treatment, mortality can be reduced to 18%.5 The implications are profound: Our careful assessment leading to the detection of a SAH as the cause of headache can significantly decrease our patients’ mortality. If this were an easy task, the 12% reported rate of missed diagnosis would not exist.6 We have multiple tools and strategies to evaluate the patient with severe headache and must understand the strengths and limitations of each tool. Herein we will describe the available strategies, as well as the ED management of the patient with SAH.
Highlights
A 50-year-old female was preparing her children for school when she experienced a headache severe enough to make her lie down on the sofa
Antiplatelet agents should be reversed with platelet infusion, and desmopressin should be considered.[40]
If the patient with subarachnoid hematoma (SAH) is taking any Factor Xa inhibitor, including unfractionated heparin or fondaparinux, prothrombin complex concentrate (PCC) is recommended as a first-line agent for reversal, unless Andexanet alpha is indicated and available
Summary
Headache caused by a subarachnoid hemorrhage (SAH) from a ruptured aneurysm is one of the most deadly, with a median case-fatality of 27-44%.2 It is rare, comprising only 1% of all headaches presenting to the ED.[3] On initial presentation, the one-year mortality of untreated SAH is up to 65%.4. The implications are profound: Our careful assessment leading to the detection of a SAH as the cause of headache can significantly decrease our patients’ mortality. If this were an easy task, the 12% reported rate of missed diagnosis would not exist.[6] We have multiple tools and strategies to evaluate the patient with severe headache and must understand the strengths and limitations of each tool. We will describe the available strategies, as well as the ED management of the patient with SAH. [West J Emerg Med. 2019;20(2)203-211.]
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