Intended for healthcare professionals


Decision rules in diagnosing subarachnoid haemorrhage

BMJ 2010; 341 doi: (Published 28 October 2010) Cite this as: BMJ 2010;341:c5586
  1. Gabriel J E Rinkel, professor of neurology
  1. 1Utrecht Stroke Centre, Department of Neurology, the Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, 3508 GA Utrecht, Netherlands
  1. g.j.e.rinkel{at}

Preliminary evidence shows theoretical promise, but validation and implementation must follow

Subarachnoid haemorrhage from a ruptured aneurysm often affects relatively young people and has a poor prognosis. The improvement and greater availability of diagnosis and treatment have coincided with an improvement in the case fatality rate.1 Nonetheless, about a third of patients still die within the initial weeks after the haemorrhage. In the linked cohort study (doi:10.1136/bmj.c5204),2 Perry and colleagues assessed whether the probability of subarachnoid haemorrhage could be identified on the basis of clinical characteristics.

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An important determinant of outcome is early rebleeding. After rebleeding, 75% of patients die or remain dependent for activities of daily living.3 Accurate and prompt diagnosis is essential to prevent rebleeding. This is usually straightforward in patients who present with focal deficits or a depressed level of consciousness but is challenging in those who present with acute headache only. Most cases of acute headache are caused by a non-catastrophic event rather than a ruptured aneurysm. The greater availability of diagnostic methods, in particular computed tomography scanning, means that many patients with benign causes of headache will undergo unnecessary procedures …

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