Subarachnoid Hemorrhage

  • Joshua S. Catapano
  • Michael T. LawtonEmail author


Subarachnoid hemorrhage (SAH) is blood in the subarachnoid space that is most commonly caused by trauma but, on occasion, can occur spontaneously without injury. Nontraumatic SAH is a rare cause of stroke that is often due to a ruptured intracranial aneurysm. Ruptured intracranial aneurysms cause great morbidity and mortality, leading to life-altering effects. An aneurysmal subarachnoid hemorrhage (aSAH) must be treated by open surgery (most often via clipping) or endovascularly (most often via coiling). After the initial treatment, physiological complications often develop including vasospasm, delayed cerebral ischemia, seizures, and hydrocephalus, among other pathologies inherent to critically ill patients. All of these manifestations are treated in a multimodal manner by multiple specialties. Although with the advent of modern medicine aSAH management and outcomes have improved, future research is necessary to determine the best management regimen for each patient.


Subarachnoid hemorrhage Aneurysm Treatment Coiling Clipping Angiography Endovascular Headache Intracranial Stroke 



Aneurysmal subarachnoid hemorrhage


Barrow Ruptured Aneurysm Trial


Computed tomography


Delayed cerebral ischemia


International Subarachnoid Aneurysm Trial


Subarachnoid hemorrhage



The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

Suggested Readings and References

  1. 1.
    Rincon F, Rossenwasser RH, Dumont A. The epidemiology of admissions of nontraumatic subarachnoid hemorrhage in the United States. Neurosurgery. 2013;73(2):217–22; discussion 2–3. Scholar
  2. 2.
    van Gijn J, Kerr RS, Rinkel GJ. Subarachnoid haemorrhage. Lancet. 2007;369(9558):306–18. Scholar
  3. 3.
    Elhadi AM, Zabramski JM, Almefty KK, Mendes GA, Nakaji P, McDougall CG, et al. Spontaneous subarachnoid hemorrhage of unknown origin: hospital course and long-term clinical and angiographic follow-up. J Neurosurg. 2015;122(3):663–70. Scholar
  4. 4.
    Lawton MT, Vates GE. Subarachnoid hemorrhage. N Engl J Med. 2017;377(3):257–66. Scholar
  5. 5.
    Brown RD Jr, Broderick JP. Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neurol. 2014;13(4):393–404. Scholar
  6. 6.
    Jellinger K. Pathology of intracerebral hemorrhage. Zentralbl Neurochir. 1977;38(1):29–42.PubMedGoogle Scholar
  7. 7.
    Jakubowski J, Kendall B. Coincidental aneurysms with tumours of pituitary origin. J Neurol Neurosurg Psychiatry. 1978;41(11):972–9.CrossRefGoogle Scholar
  8. 8.
    Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL. The international cooperative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg. 1990;73(1):18–36. Scholar
  9. 9.
    Chason JL, Hindman WM. Berry aneurysms of the circle of Willis; results of a planned autopsy study. Neurology. 1958;8(1):41–4.CrossRefGoogle Scholar
  10. 10.
    International Study of Unruptured Intracranial Aneurysms I. Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med. 1998;339(24):1725–33.
  11. 11.
    Juvela S, Hillbom M, Numminen H, Koskinen P. Cigarette smoking and alcohol consumption as risk factors for aneurysmal subarachnoid hemorrhage. Stroke. 1993;24(5):639–46.CrossRefGoogle Scholar
  12. 12.
    Shiue I, Arima H, Hankey GJ, Anderson CS, Group A. Modifiable lifestyle behaviours account for most cases of subarachnoid haemorrhage: a population-based case-control study in Australasia. J Neurol Sci. 2012;313(1–2):92–4. Scholar
  13. 13.
    Knekt P, Reunanen A, Aho K, Heliovaara M, Rissanen A, Aromaa A, et al. Risk factors for subarachnoid hemorrhage in a longitudinal population study. J Clin Epidemiol. 1991;44(9):933–9.CrossRefGoogle Scholar
  14. 14.
    Longstreth WT Jr, Nelson LM, Koepsell TD, van Belle G. Cigarette smoking, alcohol use, and subarachnoid hemorrhage. Stroke. 1992;23(9):1242–9.CrossRefGoogle Scholar
  15. 15.
    Bor AS, Koffijberg H, Wermer MJ, Rinkel GJ. Optimal screening strategy for familial intracranial aneurysms: a cost-effectiveness analysis. Neurology. 2010;74(21):1671–9. Scholar
  16. 16.
    Broderick JP, Brown RD Jr, Sauerbeck L, Hornung R, Huston J 3rd, Woo D, et al. Greater rupture risk for familial as compared to sporadic unruptured intracranial aneurysms. Stroke. 2009;40(6):1952–7. Scholar
  17. 17.
    Lall RR, Eddleman CS, Bendok BR, Batjer HH. Unruptured intracranial aneurysms and the assessment of rupture risk based on anatomical and morphological factors: sifting through the sands of data. Neurosurg Focus. 2009;26(5):E2. Scholar
  18. 18.
    Kaye AH. Subarachnoid hemorrhage. In: Kaye AH, editor. Essential neurosurgery. 3rd ed. Malden, MA: Blackwell Publishing; 2005. p. 312.Google Scholar
  19. 19.
    Klatsky AL, Armstrong MA, Friedman GD. Alcohol use and subsequent cerebrovascular disease hospitalizations. Stroke. 1989;20(6):741–6.CrossRefGoogle Scholar
  20. 20.
    Bonita R. Cigarette smoking, hypertension and the risk of subarachnoid hemorrhage: a population-based case-control study. Stroke. 1986;17(5):831–5.CrossRefGoogle Scholar
  21. 21.
    Longstreth WT, Nelson LM, Koepsell TD, van Belle G. Subarachnoid hemorrhage and hormonal factors in women. A population-based case-control study. Ann Intern Med. 1994;121(3):168–73.CrossRefGoogle Scholar
  22. 22.
    Johnston SC, Colford JM Jr, Gress DR. Oral contraceptives and the risk of subarachnoid hemorrhage: a meta-analysis. Neurology. 1998;51(2):411–8.CrossRefGoogle Scholar
  23. 23.
    Broderick JP, Viscoli CM, Brott T, Kernan WN, Brass LM, Feldmann E, et al. Major risk factors for aneurysmal subarachnoid hemorrhage in the young are modifiable. Stroke. 2003;34(6):1375–81. Scholar
  24. 24.
    Zacharia BE, Hickman ZL, Grobelny BT, DeRosa P, Kotchetkov I, Ducruet AF, et al. Epidemiology of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am. 2010;21(2):221–33. Scholar
  25. 25.
    de Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry. 2007;78(12):1365–72. Scholar
  26. 26.
    Korja M, Lehto H, Juvela S, Kaprio J. Incidence of subarachnoid hemorrhage is decreasing together with decreasing smoking rates. Neurology. 2016;87(11):1118–23. Scholar
  27. 27.
    Bassi P, Bandera R, Loiero M, Tognoni G, Mangoni A. Warning signs in subarachnoid hemorrhage: a cooperative study. Acta Neurol Scand. 1991;84(4):277–81.CrossRefGoogle Scholar
  28. 28.
    Polmear A. Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review. Cephalalgia. 2003;23(10):935–41. Scholar
  29. 29.
    Matsuda M, Watanabe K, Saito A, Matsumura K, Ichikawa M. Circumstances, activities, and events precipitating aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis. 2007;16(1):25–9. Scholar
  30. 30.
    Meurer WJ, Walsh B, Vilke GM, Coyne CJ. Clinical guidelines for the emergency department evaluation of subarachnoid hemorrhage. J Emerg Med. 2016;50(4):696–701. Scholar
  31. 31.
    Hunt WE, Meagher JN, Hess RM. Intracranial aneurysm. A nine-year study. Ohio State Med J. 1966;62(11):1168–71.PubMedGoogle Scholar
  32. 32.
    Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28(1):14–20. Scholar
  33. 33.
    Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol. 2009;8(7):635–42. Scholar
  34. 34.
    Edlow JA. Diagnosing headache in the emergency department: what is more important? Being right, or not being wrong? Eur J Neurol. 2008;15(12):1257–8. Scholar
  35. 35.
    Kowalski RG, Claassen J, Kreiter KT, Bates JE, Ostapkovich ND, Connolly ES, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA. 2004;291(7):866–9. Scholar
  36. 36.
    Petridis AK, Kamp MA, Cornelius JF, Beez T, Beseoglu K, Turowski B, et al. Aneurysmal subarachnoid hemorrhage. Dtsch Arztebl Int. 2017;114(13):226–36. Scholar
  37. 37.
    Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43(6):1711–37. Scholar
  38. 38.
    Martin SC, Teo MK, Young AM, Godber IM, Mandalia SS, St George EJ, et al. Defending a traditional practice in the modern era: the use of lumbar puncture in the investigation of subarachnoid haemorrhage. Br J Neurosurg. 2015;29(6):799–803. Scholar
  39. 39.
    Cortnum S, Sorensen P, Jorgensen J. Determining the sensitivity of computed tomography scanning in early detection of subarachnoid hemorrhage. Neurosurgery. 2010;66(5):900–2; discussion 3. Scholar
  40. 40.
    Sayer D, Bloom B, Fernando K, Jones S, Benton S, Dev S, et al. An observational study of 2,248 patients presenting with headache, suggestive of subarachnoid hemorrhage, who received lumbar punctures following normal computed tomography of the head. Acad Emerg Med. 2015;22(11):1267–73. Scholar
  41. 41.
    Czuczman AD, Thomas LE, Boulanger AB, Peak DA, Senecal EL, Brown DF, et al. Interpreting red blood cells in lumbar puncture: distinguishing true subarachnoid hemorrhage from traumatic tap. Acad Emerg Med. 2013;20(3):247–56. Scholar
  42. 42.
    Shimoda M, Hoshikawa K, Shiramizu H, Oda S, Matsumae M. Problems with diagnosis by fluid-attenuated inversion recovery magnetic resonance imaging in patients with acute aneurysmal subarachnoid hemorrhage. Neurol Med Chir (Tokyo). 2010;50(7):530–7.CrossRefGoogle Scholar
  43. 43.
    Agid R, Andersson T, Almqvist H, Willinsky RA, Lee SK, terBrugge KG, et al. Negative CT angiography findings in patients with spontaneous subarachnoid hemorrhage: when is digital subtraction angiography still needed? AJNR Am J Neuroradiol. 2010;31(4):696–705. Scholar
  44. 44.
    Jane JA, Winn HR, Richardson AE. The natural history of intracranial aneurysms: rebleeding rates during the acute and long term period and implication for surgical management. Clin Neurosurg. 1977;24:176–84.CrossRefGoogle Scholar
  45. 45.
    Kassell NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery. 1983;13(5):479–81.CrossRefGoogle Scholar
  46. 46.
    Naidech AM, Janjua N, Kreiter KT, Ostapkovich ND, Fitzsimmons BF, Parra A, et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62(3):410–6. Scholar
  47. 47.
    Ortega-Gutierrez S, Thomas J, Reccius A, Agarwal S, Lantigua H, Li M, et al. Effectiveness and safety of nicardipine and labetalol infusion for blood pressure management in patients with intracerebral and subarachnoid hemorrhage. Neurocrit Care. 2013;18(1):13–9. Scholar
  48. 48.
    Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg. 2002;97(4):771–8. Scholar
  49. 49.
    Starke RM, Kim GH, Fernandez A, Komotar RJ, Hickman ZL, Otten ML, et al. Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke. 2008;39(9):2617–21. Scholar
  50. 50.
    Gilmore E, Choi HA, Hirsch LJ, Claassen J. Seizures and CNS hemorrhage: spontaneous intracerebral and aneurysmal subarachnoid hemorrhage. Neurologist. 2010;16(3):165–75. Scholar
  51. 51.
    Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267–74.CrossRefGoogle Scholar
  52. 52.
    Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366(9488):809–17. Scholar
  53. 53.
    Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, et al. The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg. 2013;119(1):146–57.
  54. 54.
    Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, et al. The Barrow Ruptured Aneurysm Trial: 6-year results. J Neurosurg. 2015;123(3):609–17.
  55. 55.
    Boogaarts HD, van Amerongen MJ, de Vries J, Westert GP, Verbeek AL, Grotenhuis JA, et al. Caseload as a factor for outcome in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg. 2014;120(3):605–11. Scholar
  56. 56.
    Rosenwasser RH, Chalouhi N, Tjoumakaris S, Jabbour P. Open vs endovascular approach to intracranial aneurysms. Neurosurgery. 2014;61(Suppl 1):121–9. Scholar
  57. 57.
    Dorsch NW, King MT. A review of cerebral vasospasm in aneurysmal subarachnoid haemorrhage part I: incidence and effects. J Clin Neurosci. 1994;1(1):19–26.CrossRefGoogle Scholar
  58. 58.
    Boulouis G, Labeyrie MA, Raymond J, Rodriguez-Regent C, Lukaszewicz AC, Bresson D, et al. Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Eur Radiol. 2017;27(8):3333–42. Scholar
  59. 59.
    Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KT. Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm. Br J Anaesth. 2012;109(3):315–29. Scholar
  60. 60.
    Lucke-Wold BP, Logsdon AF, Manoranjan B, Turner RC, McConnell E, Vates GE, et al. Aneurysmal subarachnoid hemorrhage and neuroinflammation: a comprehensive review. Int J Mol Sci. 2016;17(4):497. Scholar
  61. 61.
    Dorhout Mees SM, Rinkel GJ, Feigin VL, Algra A, van den Bergh WM, Vermeulen M, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007;(3):CD000277.
  62. 62.
    Lennihan L, Mayer SA, Fink ME, Beckford A, Paik MC, Zhang H, et al. Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2000;31(2):383–91.Google Scholar
  63. 63.
    Zwienenberg-Lee M, Hartman J, Rudisill N, Madden LK, Smith K, Eskridge J, et al. Effect of prophylactic transluminal balloon angioplasty on cerebral vasospasm and outcome in patients with Fisher grade III subarachnoid hemorrhage: results of a phase II multicenter, randomized, clinical trial. Stroke. 2008;39(6):1759–65. Scholar
  64. 64.
    Rajshekhar V, Harbaugh RE. Results of routine ventriculostomy with external ventricular drainage for acute hydrocephalus following subarachnoid haemorrhage. Acta Neurochir. 1992;115(1–2):8–14.CrossRefGoogle Scholar
  65. 65.
    Ransom ER, Mocco J, Komotar RJ, Sahni D, Chang J, Hahn DK, et al. External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: effect on preoperative grading and prognosis. Neurocrit Care. 2007;6(3):174–80. Scholar
  66. 66.
    Milhorat TH. Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery. 1987;20(1):15. Scholar
  67. 67.
    Hasan D, Vermeulen M, Wijdicks EF, Hijdra A, van Gijn J. Management problems in acute hydrocephalus after subarachnoid hemorrhage. Stroke. 1989;20(6):747–53.CrossRefGoogle Scholar
  68. 68.
    Samuels O, Webb A, Culler S, Martin K, Barrow D. Impact of a dedicated neurocritical care team in treating patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2011;14(3):334–40. Scholar
  69. 69.
    Nyquist P, Jichici D, Bautista C, Burns J, Chhangani S, DeFilippis M, et al. Prophylaxis of venous thrombosis in neurocritical care patients: an executive summary of evidence-based guidelines: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Crit Care Med. 2017;45(3):476–9. Scholar
  70. 70.
    Springer MV, Schmidt JM, Wartenberg KE, Frontera JA, Badjatia N, Mayer SA. Predictors of global cognitive impairment 1 year after subarachnoid hemorrhage. Neurosurgery. 2009;65(6):1043–50; discussion 50–1. Scholar
  71. 71.
    Lin N, Zenonos G, Kim AH, Nalbach SV, Du R, Frerichs KU, et al. Angiogram-negative subarachnoid hemorrhage: relationship between bleeding pattern and clinical outcome. Neurocrit Care. 2012;16(3):389–98. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryBarrow Neurological Institute, St. Joseph’s Hospital and Medical CenterPhoenixUSA

Personalised recommendations