Don’t miss subarachnoid hemorrhage in your ED

Do you know how to assess patients for subarachnoid hemorrhage (SAH), the most deadly type of stroke? A new study has dramatic implications for ED care of these patients. Researchers found that ED patients with SAH were 40% more likely to survive their hospital stay if they were treated at facilities with high volumes of SAH patients.1

Key factors linked with better outcomes include availability of subspecialists and advanced nursing staff, a team approach to care, written stroke protocols, and access to sophisticated diagnostic equipment. There are approximately 6,700 deaths attributed to SAH each year in the United States.2

Thrombolytics must be administered within the first three hours after onset of symptoms for ischemic stroke, but there is a wider window of time for treatment of SAH patients, notes DeWitte T. Cross III, MD, associate professor of radiology and neurological surgery at St. Louis-based Washington University School of Medicine and the study’s principal investigator.

"This is a smaller group with a specific type of hemorrhage, related in most cases to aneurysm rupture," he explains. "There is time to stabilize these patients. Usually, the goal of treatment is to treat within 48 hours of the rupture."

The wider window for treatment allows more time to arrange for transfer of these patients to a high-volume SAH facility, adds Cross. To significantly improve care of SAH patients, do the following:

• Keep a high index of suspicion for SAH.

There is a whole spectrum of clinical scenarios that patients may present with, says Cross. "They may complain of severe headache, period, and be neurologically intact and responsive and stable from a cardiovascular standpoint," he says.

On the other hand, they may be comatose and require intubation, Cross says. "It just depends on the degree of bleeding and the status of the patient before the hemorrhage occurred," he says.

Patients who have a hemorrhagic stroke due to SAH often present with complaints of the "worst headache of my life," as opposed to the facial droop, slurred speech, and extremity weakness that are associated with ischemic stroke, says Cynthia Bautista, PhD, RN, neuroscience clinical nurse specialist at Yale New Haven (CT) Hospital. "The patient also may complain of pain above and behind the eye," she adds.

When blood is in the subarachnoid space, Bautista says, the patient will present with:

  • meningeal irritation, which presents as neck pain on flexion;
  • photophobia;
  • nausea and/or vomiting;
  • positive Brudzinski’s sign (when you flex the patient’s head and neck, involuntary flexion of hips/ legs occurs);
  • positive Kernig’s sign (the patient has an inability to extend leg when the thigh is flexed onto the abdomen).

• Give patients a thorough assessment.

If you suspect SAH, here is a partial listing of items to assess, advises Bautista:

  • Level of consciousness. Use the Glasgow Coma Scale to assess transient loss of consciousness, recommends Bautista. "It is the most widely recognized level of consciousness assessment tool, and it is the basis of many neurologic assessment flow sheets," she says. "It is good for serial assessments."
  • Pupil size and reaction to light. Pupils may be dilated and nonreactive, says Bautista. "The assessment of size and reactivity of pupils plays a key role in assessment of intracranial pressure changes," she says. "Change in pupil size, dilation, and nonreactivity is due to compression on cranial nerve III and could be the first sign of herniation."
  • Motor strength on all four extremities. Ask the patient to lift each extremity into the air, and then provide resistance to assess strength, advises Bautista. "If motor weakness is found, there may be possible damage to the motor strip in the frontal lobe," she says.
  • Blood pressure. Hypertension is a response to increased intracranial pressure due to bleeding and should be controlled to avoid causing additional bleeding, says Bautista.
  • Increased intracranial pressure. This pressure could present as decreased level of consciousness, seizures, hypertension, bradycardia, or widening pulse pressure, says Bautista. "Increased intracranial pressure means some kind of herniation is possible," she says.

• Ensure that appropriate tests are ordered for patients who present with severe headaches.

"If a patient with a long history of migraine headache comes in and complains of a horrible headache, you may not attribute this to something different," advises Cross. "Keep the question in mind, Could this patient presenting with severe headache be a person with a SAH?’"

• If the decision is made to transfer, include the patient’s current neurological status at the time of the ED visit.

This information can have important implications for the patient’s care at the receiving facility, explains Cross. "It’s important to know how the patient presented, because if there is a difference when they get to the second hospital, then perhaps the patient needs another intervention, such as a shunt placed or a more urgent evaluation," he says.


  1. Cross DT, Tirschwell DL, Clark MA, et al. Mortality following subarachnoid hemorrhage varies with hospital case volume in 18 states. J Neurosurg 2003; 99:810-817.
  2. Johnston SC, Selvin S, Gress DR. The burden, trends, and demographics of mortality from subarachnoid hemorrhage. Neurology 1998; 50:1,413-1,418.


For more information about caring for subarachnoid hemorrhage patients, contact:

  • Cynthia Bautista, PhD, RN, Neuroscience Clinical Nurse Specialist, Yale New Haven Hospital, 20 York St., New Haven, CT 06504. Telephone: (203) 688-3352. E-mail:
  • DeWitte T. Cross III, MD, Department of Radiology, Box 8131, Washington University Medical Center, 510 S. Kingshighway Blvd., St. Louis, MO 63110. Telephone: (314) 362-5950. Fax: (314) 362-4886. E-mail: