Subarachnoid Hemorrhage in the Emergency Setting: Diagnostic Yield, Clinical Course, and Predictors of Functional Recovery

Abstract

Objective: Subarachnoid hemorrhage (SAH) remains a substantial neurological emergency. Data on diagnostic timing, etiologic distribution, and prognostic factors across SAH subtypes are limited in emergency department (ED)-based cohorts.
Methods: We retrospectively reviewed 110 patients presenting with suspected SAH between 2018-2024. Demographic and clinical features, imaging patterns, etiology, comorbidities, complications, and treatments were extracted. Outcomes were assessed at one month using Glasgow Coma Scale (GCS), modified Rankin Scale (mRS), and Hunt & Hess (H&H) grades.
Results: The cohort (mean age 53.2 ± 16.8 years; 60.9% male) frequently exhibited hypertension (24.5%). Leading presentations were trauma (32.7%) and headache (33.6%); sentinel headache occurred in 12.7%. Nearly all patients (89.1%) underwent non-contrast CT within 6 hours. SAH etiology was traumatic (53.6%), aneurysmal (24.5%), and spontaneous (21.8%). Mean admission GCS was 12.6 ± 3.6. Complication rates were low (rebleeding 4.5%, delayed cerebral ischemia 2.7%, vasospasm 0.9%). Traumatic SAH, despite lower admission GCS, was associated with higher rates of functional improvement (GCS 61.0%, mRS 74.6%) and fewer comorbidities compared to spontaneous/aneurysmal subtypes. Younger age (mRS and H&H analyses) and absence of comorbidities (GCS analysis) were associated with improvement, whereas patients who were fully alert at admission were less likely to meet the improvement criterion. Sentinel headache and nimodipine use clustered among non-improvers, likely reflecting disease severity. CT bleed pattern and H&H grade were not significantly associated with outcome.
Conclusions: Traumatic SAH predominated in this ED-based cohort and showed more favourable one-month recovery than spontaneous subtypes. Admission clinical severity was the factor most consistently associated with functional change, although this association is constrained by the ceiling inherent to a change-based outcome definition. Early imaging and rigorous vascular evaluation remain essential, and larger etiology-stratified studies using absolute outcome measures are warranted.

Keywords

• Subarachnoid Hemorrhage/diagnosis
• Subarachnoid Hemorrhage/etiology
• Prognosis

Ethical Statement

This retrospective observational cohort study was conducted at the Neurology Clinic of Sakarya University Faculty of Medicine Training and Research Hospital. Patients presenting to the ED with suspected SAH between January 1, 2018, and December 31, 2024, were screened. Ethical approval was obtained from the Sakarya University Clinical Research Ethics Committee on January 22, 2025 (22.1.25-94).

References

1. Ziu E, Khan Suheb MZ, Mesfin FB. Subarachnoid Hemorrhage. [Updated 2023 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441958/
2. Liu X, Cheng R, Song Y, Yang X, Niu X, Wang C, et al. Global burden of subarachnoid hemorrhage among adolescents and young adults aged 15-39 years: a trend analysis study from 1990 to 2021. PLoS One. 2024 Dec 20;19(12):e0316111. doi:10.1371/journal.pone.0316111.
3. Harrison CH, Taquet M, Harrison PJ, Watkinson PJ, Rowland MJ. Sex and age effects on risk of non-traumatic subarachnoid hemorrhage: retrospective cohort study of 124,234 cases using electronic health records. J Stroke Cerebrovasc Dis. 2023 Aug;32(8):107196. doi:10.1016/j.jstrokecerebrovasdis.2023.107196.
4. Griswold DP, Fernandez L, Rubiano AM. Traumatic Subarachnoid Hemorrhage: A Scoping Review. J Neurotrauma. 2022 Jan;39(1-2):35-48. doi:10.1089/neu.2021.0007. Patel S, Parikh A, Okorie ON. Subarachnoid hemorrhage in the emergency department. Int J Emerg Med. 2021 May 12;14(1):31. doi:10.1186/s12245-021-00353-w.
5. Carpenter CR, Hussain AM, Ward MJ, Zipfel GJ, Fowler S, Pines JM, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Acad Emerg Med. 2016 Sep;23(9):963-1003. doi:10.1111/acem.12984.
6. Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Stroke. 2016 Mar;47(3):750-5. doi:10.1161/STROKEAHA.115.011386.
7. Zinganell A, Berek K, Bsteh G, Di Pauli F, Rass V, Helbok R, et al. Subarachnoid haemorrhage or traumatic lumbar puncture. Differentiation by cerebrospinal fluid parameters in a multivariable approach. Sci Rep. 2023 Dec 15;13(1):22310. doi:10.1038/s41598-023-49693-y.
8. Hoh BL, Cheung AC, Rabinov JD, Pryor JC, Carter BS, Ogilvy CS. Results of a prospective protocol of computed tomographic angiography in place of catheter angiography as the only diagnostic and pretreatment planning study for cerebral aneurysms by a combined neurovascular team. Neurosurgery. 2004 Jun;54(6):1329-40; discussion 1340-2. doi:10.1227/01.neu.0000125325.22576.83.

9. Mohamed M, Heasly DC, Yagmurlu B, Yousem DM. Fluid-attenuated inversion recovery MR imaging and subarachnoid hemorrhage: not a panacea. AJNR Am J Neuroradiol. 2004 Apr;25(4):545-50. Erratum in: AJNR Am J Neuroradiol. 2004 May;25(5):904. Heaseley, D Cressler [corrected to Heasly, D Cressler]. Erratum in: AJNR Am J Neuroradiol. 2008 Nov;29(10):E107. Luo Y, Li M. The progressive frontier of aneurysmal subarachnoid hemorrhage: diagnosis and treatment advances. Brain Hemorrhages. 2025;6(3):128-37. doi:10.1016/j.hest.2024.09.001.
10. Frontera JA, Claassen J, Schmidt JM, Wartenberg KE, Temes R, Connolly ES Jr, et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified Fisher scale. Neurosurgery. 2006 Jul;59(1):21-7; discussion 21-7. doi:10.1227/01.neu.0000243277.86222.6c.
11. Dengler NF, Madai VI, Unteroberdörster M, Zihni E, Brune SC, Hilbert A, et al. Outcome prediction in aneurysmal subarachnoid hemorrhage: a comparison of machine learning methods and established clinico-radiological scores. Neurosurg Rev. 2021 Oct;44(5):2837-46. doi:10.1007/s10143-020-01453-6.
12. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974 Jul 13;2(7872):81-4. doi:10.1016/s0140-6736(74)91639-0.
13. Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 1957;2(5):200-15. doi:10.1177/003693305700200504.
14. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968 Jan;28(1):14-20. doi:10.3171/jns.1968.28.1.0014.
15. Claassen J, Park S. Spontaneous subarachnoid haemorrhage. Lancet. 2022;400(10355):846-62. doi:10.1016/S0140-6736(22)00938-2.
16. Rinkel GJ, Wijdicks EF, Vermeulen M, Ramos LM, Tanghe HL, Hasan D, et al. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture. AJNR Am J Neuroradiol. 1991 Sep-Oct;12(5):829-34.
17. Phelan HA, Richter AA, Scott WW, Pruitt JH, Madden CJ, Rickert KL, et al. Does isolated traumatic subarachnoid hemorrhage merit a lower intensity level of observation than other traumatic brain injury? J Neurotrauma. 2014 Oct 15;31(20):1733-6. doi:10.1089/neu.2014.3377.
18. van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain. 2001 Feb;124(Pt 2):249-78. doi:10.1093/brain/124.2.249.
19. Boswell S, Thorell W, Gogela S, Lyden E, Surdell D. Angiogram-negative subarachnoid hemorrhage: outcomes data and review of the literature. J Stroke Cerebrovasc Dis. 2013 Aug;22(6):750-7. doi:10.1016/j.jstrokecerebrovasdis.2012.02.001.
20. Konczalla J, Platz J, Schuss P, Vatter H, Seifert V, Güresir E. Non-aneurysmal non-traumatic subarachnoid hemorrhage: patient characteristics, clinical outcome and prognostic factors based on a single-center experience in 125 patients. BMC Neurol. 2014 Jul 1;14:140. doi:10.1186/1471-2377-14-140.
21. van der Schaaf IC, Velthuis BK, Gouw A, Rinkel GJ. Venous drainage in perimesencephalic hemorrhage. Stroke. 2004 Jul;35(7):1614-8. doi:10.1161/01.STR.0000131657.08655.ce.
22. Westerlaan HE, van Dijk JM, Jansen-van der Weide MC, de Groot JC, Groen RJ, Mooij JJ, et al. Intracranial aneurysms in patients with subarachnoid hemorrhage: CT angiography as a primary examination tool for diagnosis--systematic review and meta-analysis. Radiology. 2011 Jan;258(1):134-45. doi:10.1148/radiol.10092373.
23. Etminan N, Rinkel GJ. Unruptured intracranial aneurysms: development, rupture and preventive management. Nat Rev Neurol. 2016 Dec;12(12):699-713. doi:10.1038/nrneurol.2016.150. Epub 2016 Nov 3. Erratum in: Nat Rev Neurol. 2017 Feb 1;13(2):126. doi:10.1038/nrneurol.2017.14.
24. Karhunen V, Bakker MK, Ruigrok YM, Gill D, Larsson SC. Modifiable risk Factors for Intracranial Aneurysm and Aneurysmal Subarachnoid Hemorrhage: A Mendelian Randomization Study. J Am Heart Assoc. 2021 Nov 16;10(22):e022277. doi:10.1161/JAHA.121.022277.
25. Etminan N, Chang HS, Hackenberg K, de Rooij NK, Vergouwen MDI, Rinkel GJE, et al. Worldwide Incidence of Aneurysmal Subarachnoid Hemorrhage According to Region, Time Period, Blood Pressure, and Smoking Prevalence in the Population: A Systematic Review and Meta-analysis. JAMA Neurol. 2019 May 1;76(5):588-97. doi:10.1001/jamaneurol.2019.0006.
26. Witsch J, Frey HP, Patel S, Park S, Lahiri S, Schmidt JM, et al. Prognostication of long-term outcomes after subarachnoid hemorrhage: The FRESH score. Ann Neurol. 2016 Jul;80(1):46-58. doi:10.1002/ana.24675.
27. van Donkelaar CE, Bakker NA, Birks J, Veeger NJGM, Metzemaekers JDM, Molyneux AJ, et al. Prediction of Outcome After Aneurysmal Subarachnoid Hemorrhage. Stroke. 2019 Apr;50(4):837-44. doi:10.1161/STROKEAHA.118.023902.
28. Beck J, Raabe A, Szelenyi A, Berkefeld J, Gerlach R, Setzer M, et al. Sentinel headache and the risk of rebleeding after aneurysmal subarachnoid hemorrhage. Stroke. 2006 Nov;37(11):2733-7. doi:10.1161/01.STR.0000244762.51326.e7.
29. Ois A, Vivas E, Figueras-Aguirre G, Guimaraens L, Cuadrado-Godia E, Avellaneda C, et al. Misdiagnosis Worsens Prognosis in Subarachnoid Hemorrhage With Good Hunt and Hess Score. Stroke. 2019 Nov;50(11):3072-6. doi:10.1161/STROKEAHA.119.025520.
30. Feigin VL, Rinkel GJ, Algra A, Vermeulen M, van Gijn J. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2000;(2):CD000277. doi:10.1002/14651858.CD000277. Update in: Cochrane Database Syst Rev. 2002;(4):CD000277. doi:10.1002/14651858.CD000277.
31. Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, et al. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2023 Jul;54(7):e314-70. doi:10.1161/STR.0000000000000436. Epub 2023 May 22. Erratum in: Stroke. 2023 Dec;54(12):e516. doi:10.1161/STR.0000000000000449.
32. Carlson AP, Hänggi D, Wong GK, Etminan N, Mayer SA, Aldrich F, et al. Single-Dose Intraventricular Nimodipine Microparticles Versus Oral Nimodipine for Aneurysmal Subarachnoid Hemorrhage. Stroke. 2020 Apr;51(4):1142-9. doi:10.1161/STROKEAHA.119.027396.
33. van der Steen WE, Leemans EL, van den Berg R, Roos YBWEM, Marquering HA, Verbaan D, et al. Radiological scales predicting delayed cerebral ischemia in subarachnoid hemorrhage: systematic review and meta-analysis. Neuroradiology. 2019 Mar;61(3):247-56. doi:10.1007/s00234-019-02161-9.