The notion of "warning leaks" in subarachnoid haemorrhage: are such patients in fact admitted with a rebleed?

The Value of Cranial CT Imaging in Patients With Headache at the Emergency Department

Background: Headache is among the most prevalent complaints in patients presenting to the emergency department (ED). Clinicians are faced with the difficult task to differentiate primary (benign) from secondary headache disorders, since no international guidelines currently exist of clinical indicators for neuroimaging in headache patients.

Methods: We performed a retrospective review of 501 patients who presented at the ED with headache as a primary complaint between April 2018 and December 2018. Primary outcomes included the amount of diagnostic imaging, the different conclusions provided by diagnostic imaging, and the clinical factors associated with abnormal imaging results.

Results: About half of the patients were diagnosed with a primary headache disorder. Cranial CT imaging at the ED was performed regularly (61% of the patients) and led to the diagnosis of underlying pathology in 1 in 7.6 patients. In a multivariate model, factors significantly associated with abnormal cranial CT results were age 50 years or older, presentation within 1 h after headache onset, clinical history of aphasia, and focal neurological deficit at examination.

Conclusions: As separate clinical characteristics have limited value in detecting severe underlying headache disorders, cranial imaging is regularly performed in the ED. Clinical prediction model tools applied to headache patients may identify patients at risk of intracranial pathology prior to diagnostic imaging and reduce cranial imaging in the future.

Clinical characteristics associated with sentinel headache in patients with unruptured intracranial aneurysms

OBJECTIVE

Sentinel headache (SH) is considered as a signal of the impending rupture of an aneurysm. However, it is difficult to diagnose whether the headaches of patients are associated with unstable aneurysms. Therefore, there is some doubt about the importance of headaches in patients with unruptured intracranial aneurysms (UIAs). This study was performed to explore the existence and clinical characteristics of SH associated with aneurysms.

METHODS

Thirty-six patients with a single UIA were collected in this study. Patients were symptomatically categorized into two groups: SH and non-SH. The PHASES scores and patient and aneurysm characteristics were analyzed. Two independent MRI experts who were blinded to the patients' clinical history conducted the analysis of the SWI results.

RESULTS

There were 15 patients with sentinel headache. No significant difference was found in patient's basic information and history. The SH group had a higher PHASES score than the non-SH group (P < 0.05). In univariable analysis, abnormal SWI signals were significantly more frequent in the SH group (P < 0.01) and the inflow angle was significantly lower in the non-SH group (P < 0.05). In multivariable analysis, abnormal signals in SWI were an independent factor associated with SH (P < 0.01).

CONCLUSIONS

SH exists in patients with UIAs and may indicate a high risk of aneurysm rupture. Abnormal signals on SWI may serve as a clinical feature to identify aneurysm-related SH and be helpful for the formulation of therapeutic strategy. Aneurysm geometry may also be related to SH but need further studies in the future.

Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis

OBJECTIVES

Existing literature suggests that patients with aneurysmal subarachnoid hemorrhage (aSAH) and "sentinel" aSAH symptoms prompting healthcare evaluations prior to aSAH diagnosis are at increased risk of unfavorable neurologic outcomes and death. Accordingly, these encounters have been presumed to be unrecognized opportunities to diagnose aSAH and the worse outcomes representative of the added risks of delayed diagnoses. We sought to reinvestigate this paradigm among a contemporary cohort of patients with aSAH.

METHODS

A case-control cohort was retrospectively assembled among patients diagnosed with aSAH between January 1, 2007 and June 30, 2013 within an integrated healthcare delivery system. Patients with a discrete clinical evaluation for headache or neck pain within 14 days prior to formal aSAH diagnosis were identified as cases, and the remaining patients served as controls. Modified Rankin Scale scores at 90 days and 1 year were determined by structured chart review. Multivariable logistic regression controlling for age, sex, ethnicity, presence of intracerebral or intraventricular hemorrhage at diagnosis, and aneurysm size was used to compare adjusted outcomes. Sensitivity analyses were performed using varying definitions of favorable neurologic outcomes, a restricted control subgroup of patients with normal mental status at hospital admission, inclusion of additional cases that were diagnosed outside of the integrated health system, and exclusion of patients without evidence of subarachnoid blood on initial noncontrast cranial computed tomography (CT) at the diagnostic encounter (i.e. "CT-negative" SAH).

RESULTS

A total of 450 patients with aSAH were identified, 46 (10%) of whom had clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis (cases). In contrast to prior reports, no differences were observed among cases compared to control patients in adjusted odds of death or unfavorable neurologic status at 90 days (0.35, 95% confidence interval [CI] = 0.11-1.15; 0.59, 95% CI = 0.22-1.60, respectively) or at 1 year (0.58, 95% CI = 0.19-1.73; 0.52, 95% CI = 0.18-1.51, respectively). Likewise, neither restricting the analysis to a control subgroup of patients with normal mental status at hospital admission, varying the dichotomous definition of unfavorable neurologic outcome, inclusion of cases diagnosed outside the integrated health system, or exclusion of patients with CT-negative SAH resulted in significant adjusted outcome differences.

CONCLUSION

In a contemporary cohort of patients with aSAH, we observed no statistically significant increase in the adjusted odds of death or unfavorable neurologic outcomes among patients with clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis of aSAH. While these findings cannot exclude a smaller risk difference than previously reported, they can help refine decision analyses and testing threshold determinations for patients with possible aSAH.

Sentinel Headaches in Aneurysmal Subarachnoid Haemorrhage: What is the True Incidence? A Systematic Review

The aim of this systematic review was to determine the incidence of sentinel headache reported by patients with aneurysmal subarachnoid haemorrhage, and whether they are likely to be due to recall bias or to misdiagnosis of a previous haemorrhage. Nine studies of good quality, which reported the number of patients with aneurysmal subarachnoid haemorrhage with a history of sentinel headache, gave rates of 10% to 43%. Two case-control studies, in which the frequency of a history of sentinel headache in patients with aneurysmal subarachnoid haemorrhage was compared with that in controls with non-aneurysmal subarachnoid haemorrhage or with stroke, gave an incidence of 5% (95% confidence interval 0.5, 16) in controls, suggesting that only a small number of apparent sentinel headaches are due to recall bias. Sentinel headaches appear to be a real entity. Their true incidence may vary from near zero to about 40% according to the rate of misdiagnosis in the community under consideration.

Neuroradiologic Diagnosis of Minor Leak prior to Major SAH: Diagnosis by T1-FLAIR Mismatch

BACKGROUND AND PURPOSE

In major SAH, the only method to diagnose a preceding minor leak is to ascertain the presence of a warning headache by interview; however, poor clinical condition and recall bias can cause inaccuracy. We devised a neuroradiologic method to diagnose previous minor leak in patients with SAH and attempted to determine whether warning (sentinel) headaches were associated with minor leaks before major SAH.

MATERIALS AND METHODS

We retrospectively evaluated 127 patients who were admitted with SAH within 48 hours of ictus. Previous minor leak before major SAH was defined as T1WI-detected clearly bright hyperintense subarachnoid blood accompanied by SAH blood on FLAIR images that was distributed over a larger area than bright hyperintense subarachnoid blood on T1WI (T1-FLAIR mismatch).

RESULTS

The incidence of warning headache before SAH was 11.0% (14 of 127 patients, determined by interview). The incidence of T1-FLAIR mismatch (neuroradiologic diagnosis of minor leak before major SAH) was 33.9% (43 of 127 patients). Of the 14 patients with warning headache, 13 had a minor leak diagnosed by T1-FLAIR mismatch at the time of admission. Variables identified by multivariate analysis as significantly associated with minor leak diagnosed by T1-FLAIR mismatch included 80 years of age or older, rebleeding after admission, intracerebral hemorrhage on CT, and mRS scores of 3-6.

CONCLUSIONS

We conclude that warning headaches diagnosed by interview are not a product of recall bias but are the result of actual leaks from aneurysms.

Recognizing the signs and symptoms of aneurysmal subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a devastating neurologic condition with a high mortality and long term neurological morbidity in 50% of survivors. In addition, SAH commonly affects young patients causing substantial loss of productive life years and resulting in significant long term healthcare costs. Early recognition of the signs and symptoms of SAH is absolutely critical to earlier intervention, and delays in diagnosis can have devastating consequences. To avoid such delays in SAH diagnosis, the medical provider should recognize its signs and symptoms. Neuroimgaging, cerebrospinal fluid examination and angiography (invasive or non-invasive) facilitate early diagnosis of SAH. The purpose of this review is not to provide an exhaustive critique of the available literature, rather, it is to provide an overview that will better enable a provider to recognize and initiate the workup of patients with SAH.

An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association

Despite the global impact and advances in understanding the pathophysiology of cerebrovascular diseases, the term "stroke" is not consistently defined in clinical practice, in clinical research, or in assessments of the public health. The classic definition is mainly clinical and does not account for advances in science and technology. The Stroke Council of the American Heart Association/American Stroke Association convened a writing group to develop an expert consensus document for an updated definition of stroke for the 21st century. Central nervous system infarction is defined as brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. Central nervous system infarction occurs over a clinical spectrum: Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction by definition causes no known symptoms. Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage. The updated definition of stroke incorporates clinical and tissue criteria and can be incorporated into practice, research, and assessments of the public health.

Risk Factors for Acute Subdural Hematoma From Intracranial Aneurysm Rupture

BACKGROUND:

An acute subdural hematoma (aSDH) is a rare complication of aneurysmal subarachnoid hemorrhage (SAH) and is associated with poor clinical condition on admission and poor outcome. Risk factors for the development of an aSDH from aneurysmal rupture are unknown and may help our understanding of how an aSDH develops.

OBJECTIVE:

To identify risk factors for the development of an aSDH from intracranial aneurysm rupture.

METHODS:

Patients were selected from our prospectively collected single-center SAH database. From all 1757 patients fulfilling prespecified inclusion criteria, 63 had an aSDH. We assessed sex, age, smoking, hypertension, history of SAH, sentinel headache, location of the ruptured aneurysm, and intracerebral hemorrhage (ICH) as risk factors for an aSDH. Univariable and multivariable risk ratios with corresponding 95% confidence intervals (CIs) were calculated for characteristics with Poisson regression.

RESULTS:

Multivariable risk ratios were 1.021 (95% CI: 1.001-1.042) for each year increase in age, 2.3 (95% CI: 1.3-3.8) for posterior communicating artery aneurysms, 3.0 (95% CI: 1.5-6.0) for sentinel headache, and 5.2 (95% CI: 3.1-8.9) for ICH. None of the 95 patients (0%; 95% CI: 0%-3.8%) with a ruptured vertebrobasilar aneurysm had an aSDH, which was statistically significantly lower than at other sites (P = .02 for basilar aneurysm; P = .04 for vertebral aneurysm). None of the other studied characteristics had a statistically significant association with an aSDH.

CONCLUSION:

Increasing age, sentinel headache, ICH, and aneurysms at the posterior communicating artery are independent risk factors for an aSDH. Patients with a basilar or vertebral aneurysm have a low risk of an aSDH.

Focus on the management of thunderclap headache: from nosography to treatment

Thunderclap headache (TCH) is an excruciating headache characterized by a very sudden onset. Recognition and accurate diagnosis of TCH are important in order to rule out the various, serious underlying brain disorders that, in a high percentage of cases, are the real cause of the headache. Primary TCH, which may recur intermittently and generally has a spontaneous, benign evolution, can thus be diagnosed only when all other potential underlying causes have been excluded through accurate diagnostic work up. In this review, we focus on the management of TCH, paying particular attention to the diagnostic work up and treatment of the condition.

Massive intraventricular haemorrhage from aneurysmal rupture: patient proportions and eligibility for intraventricular fibrinolysis

Massive intraventricular haemorrhage (IVH) complicating aneurysmal subarachnoid haemorrhage (SAH) is associated with a poor prognosis. Small observational studies suggest favourable results from fibrinolysis of the intraventricular blood. We performed an observational study on IVH in a large series of patients with SAH to assess the proportion of patients that may benefit from fibrinolytic treatment. From our prospective database we retrieved patients with aneurysmal SAH admitted between January 2000 and January 2005. We calculated the proportion of patients with massive IVH and the proportion of patients that are eligible for fibrinolysis on basis of clinical and CT-scan characteristics and assessed neurological outcome in a treatment strategy without fibrinolysis. Poor neurological condition was defined as World Federation of Neurological Surgeons scale 4 and 5, poor outcome as death or dependence 3 months after SAH. Of the 573 patients admitted with aneurysmal SAH, 59 (10%; 95% confidence interval CI 8–13%) had massive IVH, of which 55 were in poor clinical condition. For these 55 patients, the case-fatality rate was 78% (95% CI 66–88%) and the proportion with poor outcome 91% (95% CI 81–97%). Of the 55 patients, 31 (56%, and 5% of all patients SAH within the study period) fulfilled our eligibility criteria and were considered suitable for intraventricular fibrinolysis. At 3 months, 30 of these 31 eligible patients (97%; 95% CI 85–100%) had a poor outcome. Massive IVH occurs in 10% of patients with aneurysmal SAH. Half of these patients may benefit from intraventricular fibrinolysis. Without fibrinolysis outcome is almost invariably poor in these patients.

[Endovascular occlusion of the intracranial aneurysms--an alternative for surgical treatment]

Aneurysms on cerebral blood vessels due to their localization, size, relationship with neurovascular structures, even today, represent besides the constant progress of the diagnostic techniques and instruments in the operating theaters, a great therapeutic challenge. Gigantic aneurysms, aneurysms localized within the cavernous sinus and aneurysms of the vertebrobasilary confluence carry a great perioperative risk of mortality and morbidity. In fact, development of the endovascular procedures for the occlusion of their lumen made possible great progress in the treatment of aneurysms of this localization. In a not so small number of cases endovascular procedure means remodeling of the lumen of the main blood vessel. Endovascular obliteration of aneurysms has a certain advantage as regards the surgical treatment of aneurysms in which, on the basis of the expected natural course and presumed operative risk, may be judged that there exists unacceptably great operative risk. We present a personal series and results in 6 patients with aneurysms of various localizations.

Patient concerns posthaemorrhagic stroke: a study of the Internet narratives of patients with ruptured arteriovenous malformation

AIMS

To identify and describe the experiences and concerns of a sample of young haemorrhagic stroke patients who experienced a ruptured arteriovenous malformation and determine whether there are gender differences.

BACKGROUND

Patients with arteriovenous malformation haemorrhage tend to be young adults, but little is known about their experiences and concerns. Some research suggest that there is a need to take gender into account when investigating their experiences and concerns.

DESIGN

A content analysis of a sample of narratives posted by survivors of an arteriovenous malformation haemorrhage on an Internet site, to determine the extent to which writers discuss similar concerns and experiences.

METHODS

The sample consists of 83 narratives. The author and a research assistant carefully considered the content of each narrative, created categories based upon this reading and then coded men and women's narratives separately, according to the topic discussed.

RESULTS

Five main categories of topics were identified: 'symptoms', 'doctors and hospitals', 'rehabilitation and recovery', 'disabilities' and 'miscellaneous reflections'. The latter category contained the sub-categories 'arteriovenous malformation website', 'thanks', 'life now' and 'feelings'. Narratives varied greatly regarding how much each topic was addressed, but there were few gender differences. Overall, most attention was paid to discussing doctors and hospitals and most writers also paid significant attention to the importance of being able to share experiences with other survivors.

CONCLUSIONS

For these narrators, the experience of being evaluated and treated for arteriovenous malformation haemorrhage is traumatic, leaves a lasting impact and men and women share similar concerns and experiences. Narrators show a need to talk about their experiences, especially with others who may share similar experiences.

RELEVANCE TO CLINICAL PRACTICE

Knowing the concerns and perspectives of a sample of arteriovenous malformation patients may help nurses anticipate the concerns of their own haemorrhagic stroke patients and help improve patients' psychosocial well-being.

Sentinel Headache and the Risk of Rebleeding After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

The clinical significance of sentinel headaches in patients with subarachnoid hemorrhage (SAH) is still unknown. We investigated whether patients with a sentinel headache (SH) have a higher rate of rebleeding after SAH.

METHODS

An SH was defined as a sudden, severe, unknown headache lasting >1 hour with or without accompanying symptoms, not leading to a diagnosis of SAH in the 4 weeks before the index SAH. Age, sex, smoking status, clinical grade, computed tomography (CT) findings, angiographic findings, placement of an external ventricular drain, and time to aneurysm obliteration were prospectively recorded. All rebleeding events were confirmed by CT. Outcome was assessed at 6 months according to the modified Rankin Scale.

RESULTS

Of 237 consecutive patients with SAH, 41 (17.3%) had an SH. Rebleeding occurred in 23 (9.7%) of all patients. Patients with an SH had a 10-fold increased odds of rebleeding compared with patients without SH. Aneurysm size and the total number of aneurysms were also significantly associated with rebleeding. There were no differences in age, sex, smoking, CT or angiographic findings, external ventricular drain placement, or time to aneurysm obliteration between groups. Patients with rebeeding had a significantly worse outcome. Logistic regression revealed the presence of an SH as an independent risk factor for rebleeding.

CONCLUSIONS

In our study, patients with SAH who had an SH constituted a special group of patients with a 10-fold odds for early rebleeding. The presence of an SH may select candidates for ultraearly aneurysm obliteration or drug treatment.

Migraine and risk of subarachnoid haemorrhage: a population-based case-control study

OBJECTIVE

Evidence exists for an association between migraine and ischaemic stroke, but there is uncertainty about whether migraine is a risk factor for subarachnoid haemorrhage (SAH).

METHODS

A multi-centre, population-based, case-control study using cases of first-ever SAH during 1995-98 and matched controls in four study centres in Australia and New Zealand. Self- or proxy-reported history, frequency and characteristics of headaches, classified according to 1988 International Headache Society diagnostic criteria.

RESULTS

206 of 432 (48%) cases and 236 of 473 (50%) controls had a history of headaches. The frequency and characteristics of headaches were similar between the two groups. No association was found in logistic regression analyses for history or frequency of headaches, or migraine headaches.

CONCLUSIONS

No evidence was found for an association between recurrent headaches and SAH. Such information is important for counselling patients and families about the significance of past and ongoing headaches in relation to this illness.

Late Recurrence of Subarachnoid Hemorrhage after Treatment for Ruptured Aneurysms: Patient Characteristics and Outcomes

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) who have been successfully treated for all detected aneurysms are at risk for recurrence of SAH. We assessed the characteristics, complications of re-treatment, and outcomes of patients with recurrent SAH as important factors in determining whether to screen patients for new aneurysms.

METHODS

We studied patients admitted between 1987 and 2002 to three hospitals in the Netherlands for recurrent SAH. Patients had received treatment previously for all aneurysms identified after initial SAH. We collected data for age, sex, risk factors, site, and number of the aneurysm(s), time between the first and the second SAH, complications of re-treatment, and outcome after recurrent SAH.

RESULTS

We identified 30 patients: 27 women and 3 men. Thirty-two aneurysms were documented; 19 were classified as de novo, 8 were classified as regrowth, and 5 had been missed in retrospect. The mean time between the first and the second SAH was 7.8 years (range, 0.25-17 yr for all aneurysms and 2.8-14 yr for de novo aneurysms). Nine patients (30%) had a family history of SAH. No specific complications were reported with reoperation in 21 patients. Ten patients (33%) died, 4 patients (14%) were severely disabled, and 16 patients (53%) had good outcomes.

CONCLUSION

Among patients admitted with recurrent SAH, there is a predominance of women and patients with familial SAH. Reoperation is not associated with specific complications. Outcome after recurrent SAH is similar to that after initial SAH.

[Subarachnoidal hemorrhage from saccular aneurysms as a cause of natural death]

INTRODUCTION

Subarachnoidal hemorrhage (SAH) is the fourth most common intracranial cause of death. Approximately 50 to 85 percent of non-traumatic SAH is caused by rupture of congenital berry aneurysm. Symptoms of rupture are typically sudden and without any heralds. In most SAH cases, the vasospasm following the rupture is the most probable cause of death. In forensic pathology, an isolated SAH episode after minor head trauma should be considered dubious, and as mode of death.

OBJECTIVE

The objective of this paper was to establish the frequency of sudden natural death caused by SAH originating from ruptured berry aneurysm and to establish the epidemiologic characteristics of the deceased, as well as pathoanatomic characteristics of ruptured aneurysms.

MATERIAL AND METHOD

A retrospective autopsy study of the material of the Institute of Forensic Medicine in Belgrade was performed over a period of eighteen years. Some risk factors were estimated: smoking habits, hypertension, alcoholism, and stress 24 hours preceding the rupture. The following pathoanatomic features of berry aneurysms were determined: localization, size, number, spread to surrounding structures and any association with atherosclerosis of brain blood vessels.

RESULTS

The analyzed sample consisted of 63 examined individuals: 33 male and 30 female. Their age ranged from 9 to 89 years, with mean age of 46.2 +/- 14.5 years. In our sample, there were 47 smokers (25 male and 22 female), 41 individuals who suffered from hypertension (22 male and 19 female), and 15 alcoholics (14 male and one female). In our sample, physical or mental stress preceded the berry aneurysm's rupture in 26 cases. Most of fatal berry aneurysms were localized in the anterior part of the circle of Willis (41 of them): 20 of them were localized in bifurcations. In 46 cases, the berry aneurysms were less than 5 mm in diameter, in 10 cases with a diameter measuring 5 to 10 mm and in 7 cases the aneurysms were larger than 10 mm in diameter. The association with macroscopically visible atherosclerotic lesions of the arteries of the circle of Willis was evident in 34 cases. Nine people had multilocular berry aneurysms. Polycystic kidney disease associated with berry aneurysms was evident in nine cases.

DISCUSSION

The difference between the number of males and females in our sample was not statistically significant (c2=0.014; p>0.10). The age of the deceased mostly ranged from 30 to 60 years. There was no significant difference between the mean age of the males and females in our sample (t=1.65; p>0.05). In our sample, statistically significant localization of fatal berry aneurysm was the anterior part of the circle of Willis (c2=5.74; p<0.05). The frequency of the berry aneurysms larger than 10 mm in diameter was less significant than those with smaller diameters (c2=31.10; p<0.001). The individuals in our sample with aneurysms smaller than 5 mm in diameter were not significantly younger than individuals with larger ones (t=0.98; p>0.05). The number of individuals in our sample with berry aneurysms associated with atherosclerotic lesions was not statistically significant (c2=0.32; p>0.1).

CONCLUSION

Sometimes, it is not possible to detect the exact localization of the ruptured berry aneurysm: the rupture may destroy the aneurysm completely. In such case, an autopsy should rule out other possible sources of intracranial bleeding, such as vascular malformations, intraventricular spreading of intracerebral hematomas, neoplasia, hematological disorders, etc.

Intracerebral aneurysms: a review with special attention to geriatric aspects

Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.

Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study

OBJECT

By pursuing a policy of very early aneurysm treatment in neurosurgical centers, in-hospital rebleeds can be virtually eliminated. Nonetheless, as many as 15% of patients with aneurysm rupture suffer ultraearly rebleeding with high mortality rates, and these individuals are beyond the reach of even the most ambitious protocol for diagnosis and referral. Only drugs given immediately after the diagnosis of subarachnoid hemorrhage (SAH) has been established at the local hospital level can, in theory, contribute to the minimization of such ultraearly rebleeding. The object of this randomized, prospective, multicenter study was to assess the efficacy of short-term antifibrinolytic treatment with tranexamic acid in preventing rebleeding.

METHODS

Only patients suffering SAH verified on computerized tomography (CT) scans within 48 hours prior to the first hospital admission were included. A 1-g dose of tranexamic acid was given intravenously as soon as diagnosis of SAH had been verified in the local hospitals (before the patients were transported), followed by doses of 1 g every 6 hours until the aneurysm was occluded; this treatment did not exceed 72 hours. In this study, 254 patients received tranexamic acid and 251 patients were randomized as controls. Age, sex, Hunt and Hess and Fisher grade distributions, as well as aneurysm locations, were congruent between the groups. Outcome was assessed at 6 months post-SAH by using the Glasgow Outcome Scale (GOS). Vasospasm and delayed ischemic neurological deficits were classified according to clinical findings as well as by transcranial Doppler (TCD) studies. All events classified as rebleeding were verified on CT scans or during surgery.

CONCLUSIONS

More than 90% of patients reached the neurosurgical center within 12 hours of their first hospital admission after SAH; 70% of all aneurysms were clipped or coils were inserted within 24 hours of the first hospital admission. Given the protocol, only one rebleed occurred later than 24 hours after the first hospital admission. Despite this strong emphasis on early intervention, however, a cluster of 27 very early rebleeds still occurred in the control group within hours of randomization into the study, and 13 of these patients died. In the tranexamic acid group, six patients rebled and two died. A reduction in the rebleeding rate from 10.8 to 2.4% and an 80% reduction in the mortality rate from early rebleeding with tranexamic acid treatment can therefore be inferred. Favorable outcome according to the GOS increased from 70.5 to 74.8%. According to TCD measurements and clinical findings, there were no indications of increased risk of either ischemic clinical manifestations or vasospasm that could be linked to tranexamic acid treatment. Neurosurgical guidelines for aneurysm rupture should extend also into the preneurosurgical phase to guarantee protection from ultraearly rebleeds. Currently available antifibrinolytic drugs can provide such protection, and at low cost. The number of potentially saved lives exceeds those lost to vasospasm.

Thunderclap headache

Thunderclap headache refers to an excruciating headache of instantaneous onset. It occurs as suddenly and unexpectedly as a "clap of thunder." Patients with thunderclap headache may have normal neurologic examination results and normal computed tomographic brain scans, even if they have serious underlying pathology. This has created confusion regarding nosology and the nature and extent of the diagnostic evaluation, which this article discusses.

Thunderclap headache

The aim is to review the background underlying the debate related to the alternative nomenclatures for and the most appropriate diagnostic evaluation of patients with thunderclap headache. The clinical profile and differential diagnosis of thunderclap headache is described, and a nosological framework and diagnostic approach to this group of patients is proposed.