- 1) Sudden onset - 2) Maximal at onset (*w/in 10 min*) - 3) Diff in quality from prev HAs - 2 other imp questions to ask: - Any PMHx of Polycystic Kidney Disease? - Any FHx of aneurysm or bleed? - The "worst HA of pt's life" is not a very specific or useful point on Hx! - Don't expect to see strong meningeal signs (e.g. Kernigs/Brudzinski's), but on e good test is: - Ask pt to turn head to side: if worsens HA, this may imply meningeal irrit ation! ###CT Head - CT sensitivity decreases w/ time! - Is reassuring only if *totally normal* w/in 6 hrs of Sx onset - But note that the Steele study behind this idea is pretty flawed; - Need to r/o hydrocephalus: look for dilated *temporal* ventricular horns! - Look for subtle bleeds on "suprapenducular fossa" and tips of occipital horns - A tiny white dot here is all you need to see to worry about blood! ###DDx of Rare HA Causes (& Considerations) - A) Pituitary apoplexy - B) Cervical artery dissection - Lancinating/knife-like pain going up face or neck - Recent minor neck trauma (chiropractor visit, yoga, head-banging) - Connective tissue dieases - FHx of stroke - C) Cerebral venous thrombosis - Think about this if H/A is totally unremitting (doesn't respond to anythin g) and has either: - a) Hypercoagulable state (pregnant or recent post-partum, multiple previou s DVTs, malginancy, hormonal therapy) - b) Head & neck infection ###Diagnostic Algorithm For Suspected SAH - i) CT Head w/o contrast - ii) Negative or equivocal CT: LP - Incompletely clearing RBCs or xanthochromia: this is a +ve test! - iii) Suspected traumatic LP: repeat LP! - iv) If LP is clearly -ve: SAH ruled out! ###Rx For SAH - 1) Pain control - 2) Nimodipine - 3) Seizure prophylaxis - 4) Blood pressure Rx w/ IV agents (get pt normotensive fast!) ###Ottawa SAH Rule - In alert pts >15 y.o w/ new severe non-traumatic HA maximum w/ 1 hr, investiga te *if any of*: - Age >40 - Complaint of neck pain or stiffness - Witnessed loss of consciousness - Onset during exertion (sexual intercourse, running, etc) - Thunderclap quality (sudden & maximal onset) - Limited neck flexion on exam - Note that this rule doesn't really add much or help: the more reasonable appro ach is to just **fully work up all pts with a thunderclap quality HA (& this inc ludes an LP!)** ###Pitfalls In Our Usual Approach - 1) Not the worst H/A in pt's life - 2) PEx looked completely normal (this is not reassuring in potential subarachn oid cases!) - 3) The pain got better w/ Tylenol/Advil/etc - Response to Rx has no effect on the potential diagnosis! (And don't forget that usually subarachnoids get better temporarily once the initial sentinel ble ed is finished!) - 4) The CT was negative - If you're really suspicious, need to do an LP even if CT clean! - 5) The LP tubes show decreasing RBCs from tube 1-4 - The trend in RBCs doesn't really matter! - RBCs <100 are very unlikely to be subarachnoid, but above this it becomes hard to be really reassured (esp if RBCs >=1000 have to assume it's positive) - 6) Maybe we can just skip the LP and do a CT angiogram? - Can't reliably establish rupture w/ CTA, only an LP! - CTAs can show small aneurysms and if an *unruptured* aneurysm is <10mm it' s *very* unlikely to rupture in future or cause prbs, but really worries pts!