Talk:Subarachnoid hemorrhage

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Good article Subarachnoid hemorrhage has been listed as one of the Natural sciences good articles under the good article criteria. If you can improve it further, please do. If it no longer meets these criteria, you can delist it, or ask for a reassessment.
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[edit] Why

Why would a subarachnoid hemorrhage lead to myocardial damage and/or rhythm problems? Bart 194.151.165.92 13:24, 12 February 2007 (UTC)

It's likely due to the massive catecholamine response to the aneurysm. Global and regional myocardial dysfunction is common as well as arythmias. Permanant damage is however uncommon. This is probably because most of these patients are young without significant underlying heart disease.

The mortality figures given on this page seem way out of date however i don't have time at the moment to reference accurate ones. The current mortality is about 30%. Mortality by Hunt and Hess class 1 - 0-5% 2 - 2-10% 3 - 8-15% 4 - 60-70% 5 - 70-100%

[edit] van Gijn et al

I'm presently reading the Jan 07 Lancet seminar by Jan van Gijn et al. Hope to update this article soon. JFW | T@lk 19:08, 13 March 2007 (UTC)

[edit] Ref

This was dropped in the article:

  • Watson ID, Beetham R, Keir G, Cruickshank AM, Holbrook IB, Fahie-Wilson MN, White PA, Patel D, Egner W. Cerebrospinal fluid spectrophotometry of bilirubin, not the Xanthochromic Index, for the detection of CT-negative sub-arachnoid haemorrhage. J Clin Neurosci 2006. PMID 16647856.

I can't see which statement it was meant to support, but I will review it in due course. JFW | T@lk 20:06, 13 March 2007 (UTC)

[edit] Confused

I had asubarachnoid hemorrhage last year and was told that I had a anurysm with it. During the last year and half I have had an automobile accident and was told that the surgery that was done was weird.

How am I going to find out if I did or didn't have anrysm?

I am so confused now. —The preceding unsigned comment was added by Linda Keigher (talk • contribs) 18:28, 6 May 2007 (UTC).

Start by not asking a bunch of complete strangers on the internet. Go speak to your own physician, who should be able to find out on what basis the diagnosis of an aneurysm was made (e.g. CT angiogram).
Who told you the surgery was "weird"? That is a rather heavy accusation for what was probably intended as a life-saving procedure. Again, your own physician is the person who can clarify this best. JFW | T@lk 09:37, 30 July 2007 (UTC)

[edit] Hypopituitarism

Hypopit quite common and cause for lots of trouble JAMA. JFW | T@lk 19:24, 29 September 2007 (UTC)

[edit] Suggestions

Very nice article, I hear there's thoughts of turning it into a GA at least. Here are some possible ways to improve the article:

  • To make the article more layperson friendly, explaining technical terms or substituting more common words could help (e.g. "neurosurgical investigations" -> "surgery"). I can't figure out how, but there must be a more lay friendly way to say "Glasgow Coma Score calculations deteriorate."
    • Agree. The sentence in question could be rephrased as: "[...] the level of consciousness decreases (as shown by lower GCS scores)". JFW | T@lk 16:48, 13 March 2008 (UTC)
  • Some of the article reads like a how-to manual for doctors, e.g the diagnosis section. For example, "...careful consideration of differentials should be completed (e.g. evaluation of meningitis, migraine headaches and/or central venous thrombosis)." We should try to reword this to avoid sounding like it's advice.
    • The word "should" should be banned in medical articles; the best alternative is a good source on which this differential diagnosis is based. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • In the same vein of writing for doctors, less use of the word "patients" and "cases" might be helpful.
    • I'm not sure if there's much point in finding alternatives here. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • This is not necessarily contradictory, but seems like it is, it might help to explain the difference:
  • one in ten people with [thunderclap headache] turn out to have a subarachnoid hemorrhage.
  • Only 25% of patients admitted to the emergency department with a thunderclap headache are suffering from a SAH
    • The former statistic is mentioned in VanGijn and should remain. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • I've fact tagged every numerical statistic without a ref.
    • Most of them are based on VanGijn, and I have untagged these instances. JFW | T@lk 16:48, 13 March 2008 (UTC)
      • Can we cite that ref explicitly for those sentences then? I know you don't have to, but it would help if someone moves the sentences or adds something from a different ref in between, and others won't make my mistake of thinking it's unverified. delldot on a public computer talk 02:13, 14 March 2008 (UTC)
  • " A further 10% of cases is due to non-aneurysmal perimesencephalic hemorrhage, in which the blood is limited to the area of the midbrain.[citation needed] No aneurysms are generally found." I assume the second sentence is referring to non-aneurysmal perimesencephalic hemorrhage, but wasn't sure enough to clarify it myself.
  • We might consider turning the grading scales into a table, since each gets a 1-4 or 5 grade. What do folks think of this idea?
    • The problem would be that people would think that Hunt-Hess 2 is the same as WFNS 2 - quod non. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • What are "broad-based aneurysms"?
    • No idea; something to look up. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • I think the treatment section goes into too much detail about the aneurysm clipping/coiling. Could some of this info be transferred to aneurysm?
    • Perhaps cerebral aneurysm. On the other hand, asymptomatic aneurysms usually are not clipped/coiled, so the information should be available in this article too. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • The Follow-up section is so short, maybe it should be integrated into the rest of the treatment section.
    • It is part of the treatment; I would not oppose integration. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • Maybe we should convert the lists under Complications to prose and explain what acute, subacute, and chronic mean.
    • Agree, but wikilinks may be all that is needed. JFW | T@lk 16:48, 13 March 2008 (UTC)
  • May want to get rid of the support group link in the EL section.

I can work on these things, just plopping them here for the mean time so others can consider them too. delldot talk 13:30, 13 March 2008 (UTC)

A couple more things
  • is focal neurology the same as focal neurologic deficit? We should put an explanation or create the stub.
    • Y Done - turned into a redirect. Both are terms for the same concept, namely loss of neurological function to a discrete lesion. JFW | T@lk 08:39, 14 March 2008 (UTC)
  • Can we get an explanation of the grading scales? Is it safe to assume the higher the number, the worse off you are? delldot on a public computer talk 02:34, 14 March 2008 (UTC)
    • Yes, we should make that clearer. Not being a neurosurgeon I don't know about the practical applicability of these scores. But I do know that Hunt & Hess is still very much in use. JFW | T@lk 08:39, 14 March 2008 (UTC)

[edit] Hypertension

Having high blood pressure doesn't actually seem to worsen risk of SAH: doi:10.1161/STROKEAHA.107.504019 JFW | T@lk 08:39, 14 March 2008 (UTC)

[edit] Triple H

The "triple H" treatment for the prevention of vasospasm cannot be left undiscussed. The classic reference is PMID 7133349. JFW | T@lk 09:40, 14 March 2008 (UTC)

de:Subarachnoidalblutung is featured. It contains some interesting images that could be adapted for use in this article. JFW | T@lk 09:40, 14 March 2008 (UTC)
Ooh! Nice. I'll ask German speakers I know if they can help translate parts. delldot on a public computer talk 09:55, 14 March 2008 (UTC)

[edit] German translations

Thanks to Yummifruitbat, we now have a translation for the images de:Bild:SabCT comment.png/de:SabCT.JPG and de:Bild:SabAngio Comment.png/de:Bild:SabAngio.JPG from de:Subarachnoidalblutung! I'm copying YFB's post to my talk page here:

First image:
Computed Tomography: massive subarachnoid haemorrhage with ruptured large aneurysm of the arteria basilaris.
The computed tomography image represents a section through the skull at the level of a hat brim. The section through the skull is thus near the skull base.
Imagine the patient lying on their back with their feet towards the viewer. This means that the front of the skull is shown at the top of the image and the right and left sides are interchanged. Therefore, for example, the structure numbered [2] is situated in the right hemisphere of the patient's brain.
The skull bone, shown in white, surrounds the brain and its blood vessels. At the front, the frontal sinus is depicted in black.
The aneurysm [1] is in this case very large. The blood from the ruptured aneurysm has spread to the surrounding cisterns ([2] = cisterna valleculae cerebri, which appears relatively clear, however, on the left-hand side [3]). The blood has spread far into the small subarachnoid space. Signs of the significant findings are the evidence of blood in the interhemisphere fissure [4] and on individual convolutions of the brain (Gyri) [6] of the right brain hemisphere (right hemisphere, frontal lobe). There is also a haemorrhage in the fourth ventricle [5].
The lateral ventricles [7] are free of blood.


One part of this I'm not sure about is the sentence "Signs of the significant findings..." - apart from the fact that that doesn't make particularly nice English, I'm also not sure whether "significant" should be "serious" or "grave" given the context - the word "erheblich[en]" could mean any of those.


Second image:
Angiography: massive subarachnoid haemorrhage with ruptured large aneurysm of the arteria basilaris.
This digital subtraction angiogram shows the same case as in the CT image above.
The aneurysm [1] is located in the region of the arteria basilaris [2]. This cerebral artery arises from the arteriae vertebrales [3], into which the contrast medium was injected. Further along its course, the arteria basilaris splits into the two arteriae cerebri posteriores [4], which in this case are inconspicuous.


Again, there's a bit of ambiguity here as that final "inconspicuous" ("unauffällig") could also mean "without pathological findings" in medical terminology. Hopefully you'll be able to use your better-informed medical judgement to decide what phrasing to use!

I'll work on getting these copied to commons and added into the article today. delldot talk 14:14, 15 March 2008 (UTC)

I've done the first one, cut down the wording a little in the caption. Does it look OK? It's quite long for a caption on en. If folks like it we can do the other one the same way, otherwise we can tweak further. delldot talk 15:43, 15 March 2008 (UTC)

Looks very pretty, although I personally prefer images to be positioned on the right. JFW | T@lk 22:17, 15 March 2008 (UTC)

I can't get it on the right without squishing the text that floats around it in a thin column. Feel free to tweak it as you see fit though. delldot talk 08:53, 17 March 2008 (UTC)
The second one is done too. I changed one of the artery names, are the names correct? delldot talk 04:26, 18 March 2008 (UTC)

I rejigged the images a bit - I also can't figure out how to improve whitespace around the table, but it will have to do for now. In the second one I made some changes to the caption, and ditched the angiogram without numbers. JFW | T@lk 13:04, 18 March 2008 (UTC)

[edit] Refs

Any strong objections to citing the van Gign ref explicitly in sentences that use it? I bet the GA reviewer will want sources for these sentences (or any that have statistics). I know it can get repetitive, but I prefer to have the citation made explicit for each sentence that uses it. It makes the article more flexible, since people can move the sentence or add another in between it and the citation without losing the ref. Plus, it will make it more checkable for a reader that wants to check the info but doesn't necessarily know where the info's from. delldot talk 15:43, 15 March 2008 (UTC)

I've not had any trouble with this during my last GA effort, rhabdomyolysis. I don't know what the guidelines say, and I remain open to persuation. JFW | T@lk 22:17, 15 March 2008 (UTC)
Persuasion, huh?  ;-) Here are my persuasive arguments. Refs at the end of each sentence:
  • Make it easier to tell what comes from a reference and what doesn't in the future: If someone adds something unreferenced later, it may be harder to tell which is referenced and which isn't. (more at Wikipedia:Guide for nominating good articles#Inline citations)
  • Make parts more "portable": If each sentence is referenced, someone can move material or add a sentence from another reference between two facts from van Gijn and we can still tell where each fact is from.
  • Set a good example for other writers: If someone sees a GA with statistics that don't have references, they may think it's OK not to reference them.
  • Help readers check a particular fact: If someone who reads the article wants to find the source for a particular statistic, having the reference explicit will make them easier (in case they don't know to check the ref at the end of the paragraph, or if a sentence is moved in the future). Similarly, if someone comes along and changes a number, it'll be easier to check which it is.
  • Even if the GA criteria let you put the ref at the end of the paragraph, the FA criteria are more strict, and we're likely to get trouble for it at FAC if we decide to eventually take it there.
What are the arguments in favor of keeping them unreferenced? delldot talk 00:18, 16 March 2008 (UTC)
My only real counterargument is "clutter". But I agree with most of your points. JFW | T@lk 13:03, 18 March 2008 (UTC)

[edit] Stuff to consider

doi:10.1161/STROKEAHA.107.498345 - another scoring system.

Initial misdiagnosis JFW | T@lk 23:15, 18 March 2008 (UTC)

Recent advances 2005 - doi:10.1161/01.STR.0000200558.38774.d5 JFW | T@lk 23:16, 18 March 2008 (UTC)
Still need to look at the abovementioned papers. JAMA is hard to ignore. JFW | T@lk 10:11, 22 May 2008 (UTC)

[edit] Original Research

The stuff in the section on which procedure is better (clipping vs. endovascular coiling) contradicts information I saw on other web resources. I don't know which is correct, but the article should either cite both opinions or at least state whose opinion this is. Mkop (talk) 02:13, 2 April 2008 (UTC)

I know. I am hesitant to attack this without some further reading; the author of the content was a neurosurgeon who, like you have indicated, seemed to have made up his mind about the most suitable approach. Given that I am not a neurosurgeon and haven't worked with any lately, I'll need to go through the sources in question and see whether the conclusions drawn from them are justified. Could you supply some further sources to clarify this? JFW | T@lk 23:25, 2 April 2008 (UTC)

[edit] Comments

A couple questions and suggestions:

  • What is "non-specific" vomiting? Can that be explained?
  • "seizure makes bleeding from an aneurysm more likely" Does this literally mean that if you seize, an aneurysm you have is more likely to bleed? Or should it read something more like "seizure is associated with an increased risk of bleeding from an aneurysm"?
  • Can we change "nuchal rigidity" to "stiff neck"? Or otherwise reword it?

Just some thoughts, I'll be back with more later. delldot on a public computer talk 11:01, 21 May 2008 (UTC)

Thanks for coming back to this. I'd love to get this baby up to GA, and I'm sure this can be done over the next few weeks.
  1. There is no such thing as "non-specific vomiting", but vomiting is not a specific finding in SAH as many people with headaches vomit (especially migraines!) I'll fix it.
  2. Seizures are more likely if the SAH is due to aneurysm. I'll fix it.
  3. We ought to mention both neck stiffness / inability to flex the neck forward and the technical term "nuchal rigidity". JFW | T@lk 11:38, 21 May 2008 (UTC)
You speed demon you! Awesome work. :-) delldot talk 12:20, 21 May 2008 (UTC)
Speed demon! Lucifer on amphetamines! JFW | T@lk 10:11, 22 May 2008 (UTC)

[edit] More comments

A couple more, these are not going to be as easy to fix, they're more just ideas for the future:

  • "The risk of SAH for someone who has never smoked is slightly over half that for someone who has been a smoker in the past." It would be great if we could get a statistic for current smokers, I bet it's even higher.
  • Also under epidemiology, it'd be great to get an incidence.
  • "Cocaine abuse and sickle cell anemia and, rarely, anticoagulant therapy and problems with blood clotting can also result in SAH." - can we explain how? I'm picturing cocaine use causing aneurysms to rupture because of increased pressure, but not sure how the others would cause bleeding.

I can hopefully add some of this in when I'm working on adding stuff later. delldot talk 13:25, 21 May 2008 (UTC)

The smoking stats are from Feigin's meta-analysis. It is pretty hard to phrase their conclusions into something that is both relevant and easy to understand. I'll read it closely and try.
I've found a paper about incidence and will cite it.
Wrt the 1993 Rinkel study, I will need to read the paper to find out the proposed mechanisms for those risk factors. JFW | T@lk 05:55, 22 May 2008 (UTC)
Great! Here's a couple more, mainly just questions:
  • Should we have a mention of the diagnosis in the lead, or is the mention of symptoms enough?
  • Should we move the "Causes" section to below "Signs and symptoms" as WP:MEDMOS has it? Of course, MEDMOS recommends that "Classification" go above signs and symptoms, but in this case I don't think it's a great idea because that section relies on info you need from other sections.
  • What about 3 separate tables for each of the classification scales? delldot on a public computer talk 05:59, 22 May 2008 (UTC)
I think it is reasonable to discuss the main diagnostic modalities in the lead. After all, the lead is meant to be a summary of the article.
Wrt causes, I am personally much more of the persuation that "causes" should be listed after "diagnosis". But that is perhaps my professional deformity: once the diagnostic process is complete, one should have picked up one of the causes.
I am very bad at making tables look nice. If you feel up to it, it would probably be for the benefit of the article. JFW | T@lk 10:11, 22 May 2008 (UTC)
How about I do it and see what we think? delldot on a public computer talk 11:07, 22 May 2008 (UTC)

[edit] More thoughts

I've been making some bold edits, removing unsourced material I think is either dubious or too detailed. I'm a little concerned that the article goes into too much detail about the clipping and coiling business, and I think it would be better to just summarize here and point the reader to those articles for more detail.

One more minor point:

  • More words to explain: "centrifugated", "spectrophotometric"

delldot on a public computer talk 07:31, 22 May 2008 (UTC)

Centrifuges are common knowledge. I agree we may need to explain spectrophotometry. JFW | T@lk 10:11, 22 May 2008 (UTC)

More still (sorry!)

  • What do you think of moving the complications from under treatment to under prognosis? The one sentence that deals with treatment of the complications could stay in the general measures section (which I just moved it from).
  • I think there's a lot more that could be said under prognosis, in the paragraph that mentions long term headaches. AFAIK, symptoms are similar to those of severe head trauma, with emotional, cognitive and physical effects that may last a long time. (Would these things fit under prognosis?).
  • If we can find an incidence by continent statistic, I can make a bar graph or map in inkscape to illustrate it. Or, if we have incidence statistics by age group, I could do a bar graph like this one. delldot on a public computer talk 08:38, 22 May 2008 (UTC)
Much of the treatment of SAH is actually aimed at preventing complications. This is the reason why I have tried to discuss complications in the context of measures taken against them. "Prognosis" should be reserved for numerical data on long-term outcomes (e.g. death, disability, chronic complications).
I couldn't find a good source for chronic headaches, although I have met plenty of SAH patients who mention this prominently.
A bar graph could be fashioned from the 2005 De Rooij study. That would be very nice, actually. JFW | T@lk 10:11, 22 May 2008 (UTC)
Ah, sorry about the rearranging then. Feel free to rv me. OK, I'll work on the graph. :-) delldot on a public computer talk 11:04, 22 May 2008 (UTC)
What do you think? Any suggestions for improvement? I wasn't sure how to deal with the CI or the standard deviation/range thing so I just kind of didn't. Maybe I should add those little lines above the bars to show the range? delldot talk 02:25, 25 May 2008 (UTC)
Beautiful. I think SDs would just confuse the matter, so let's keep it as it is. JFW | T@lk 06:27, 25 May 2008 (UTC)

[edit] When to scan

I'm not actually sure whether to include this paper from the "Rational Clinical Examination" series, because it sounds like a "how-to" manual: http://jama.ama-assn.org/cgi/content/full/296/10/1274. JFW | T@lk 10:30, 22 May 2008 (UTC)

[edit] Headache

Searching PubMed for "headache + SAH" gave a rubbish yield. Thankfully, I then trawled PubMed for publications by Neil Kitchen (of Saturday fame) and found http://jnnp.bmj.com/cgi/content/full/72/6/772. At nine months, 80% report headaches. I didn't want to cite the paper yet because it has numerous other conclusions wrt outcomes, and is restricted to those who had a good neurosurgical recovery. JFW | T@lk 10:56, 22 May 2008 (UTC)

Dunno if we should add the controversial and outdated concept of "sentinel headaches" or "warning leaks". PMID 10675215 demonstrates their non-existence, but many people seem to believe in it. JFW | T@lk 11:22, 22 May 2008 (UTC)

[edit] Hydrocephalus

PMID 10549928 may be helpful here. JFW | T@lk 11:20, 22 May 2008 (UTC)

[edit] My turn

Presently we have covered all the major issues, using 28 references. The challenge is to "dot the i's and cross the t's" without bloating the reference apparatus. I'm keen to remain very selective in what we cite. Let me do a section-by-section breakdown of what we need at present:

  • Signs and symptoms - (1) how do we deal with traumatic SAH - is the present "afterthought" the right way forward? (2) any images for this section? N Not done Further images might help, though.
  • Diagnosis - is there any way of knowing, beyond a normal CT and LP, whether someone has indeed suffered an SAH? does it matter? (studies may be absent). N Not done Not widely discussed.
  • Causes - as above, do we know why cocaine and sickle cell disease etc can cause SAH? Y Done We don't.
  • Classification - Delldot - could you turn these lists into pretty tables?
  • Well, there it is, I'm not sure I really like it. It's bigger, so it breaks the text up even more. We can tweak or revert it. delldot on a public computer talk 07:36, 23 May 2008 (UTC)
  • Thanks for the effort. I agree that it somehow doesn't really work. A single table would probably have been nicer than three in a row. JFW | T@lk 08:45, 23 May 2008 (UTC)
  • Well, could do something like this, but it would dip way down into the next section. Probably better off as it was before. delldot on a public computer talk 08:50, 23 May 2008 (UTC)
  • That looks a lot better, though. JFW | T@lk 06:27, 25 May 2008 (UTC)
  • With the headers removed, it looks fine. Y Done
  • Pathophysiology - this section is presently absent, because there isn't an awful lot to discuss. Perhaps we should discuss Laplace's law with reference to the risk of rupture from an expanding aneurysm. N Not done Don't think there's much to discuss that is not already covered elsewhere
  • Treatment
    1. shall we merge "other complications" and "general measures", because we risk duplicating certain things Y Done
    2. can we tidy up the section on "clipping vs coiling" Y Done
    3. we need discussion of hyponatraemia and hydrocephalus with references references Y Done
    4. we need a solid study on outcomes with regards to mobility Y Done
    5. we should mention the outcomes wrt headache, fatigue and neuropsychological deficts (probably in "prognosis" though) Y Done
  • Prognosis - as above.
    1. PMID 17569871 is a meta-analysis of four trials and seems to be ideal. Y Done
    2. ISAT has some data on seizures, and there's PMID 18325027. N Not done Not sure of the relevance.
  • We need a history section - PMID 11337350 discusses Guglielmi and his detachable coil. I'm sure we can find out about Dandy somewhere. We are already citing the pivotal reports on nimodipine and 3H, so those can be double-cited to provide historical context. PMID 11175986 is a historical review but I have no acccess.
    So's PMID 6387987 but ditto. I can't get 11175986 either. delldot on a public computer talk 08:56, 23 May 2008 (UTC)
    I have ordered PMID 11175986 (may turn out to cost me some money...). Otherwise this section is pretty much {{done}} and acceptable. Y Done

I have left a message on a UK-based doctors' forum with a request for a neurosurgeon to review "treatment#prevention of rebleeding". But then even that forum doesn't attract many neurosurgeons. JFW | T@lk 11:49, 22 May 2008 (UTC)

A colleague directed me to the website of the ISAT trial, which controversially suggested that coiling was associated with better long-term outcomes than clipping. It is the largest study of its kind (and the principal investigator, Mr Richard Kerr of Oxford, is a co-author of the Van Gijn review). In 2005, when the first paper came out, it drew significant criticism from neurosurgical societies. (The cynic in us would imagine that much of this is possibly territorial.) The good thing is that the Lancet and Stroke papers are readily available on the website. We can therefore place the criticisms in context. JFW | T@lk 13:41, 22 May 2008 (UTC)
I think the main/most valid criticism of ISAT is that it's a fairly selected patient population, and the findings are not necessarily generalizable to the majority of patients seen in clinical practice. However, it's fairly strong evidence that selected patients may do better with coiling. MastCell Talk 19:11, 22 May 2008 (UTC)
I need to print out the papers and read them over a good glass of wine. JFW | T@lk 21:48, 22 May 2008 (UTC)

[edit] Cerebrovascular inflammation following subarachnoid hemorrhage

Quickly searching PubMed found this: PMID 11949877

Not sure how much use it is considering it was published 2001/2002 but i'll leave that to the more experienced of you. Regards, CycloneNimrodTalk? 12:48, 25 May 2008 (UTC)

It is not something that my sources have been particularly interested in (i.e. mainly Van Gijn 2007). It is a piece of speculation on the exact background of vasospasm.
I've seen both rebleeding and vasospasm kill people. It's horrible. JFW | T@lk 16:33, 25 May 2008 (UTC)

[edit] Preparing for GAC

Thanks to Cyclonenim (talk · contribs), Stevenfruitsmaak (talk · contribs) and Wouterstomp (talk · contribs) for expert input, especially disentangling woolly sentences and cutting redundant words. I take the absence of other comments on this page as an indication that there are no major content problems. Obviously I will try to have this page reviewed by an external source, as is my personal habit. But there is no reason why that should hold up GA candidacy. Similarly, I am waiting for a reprint of the historical source linked above, but I don't expect major expansions from that. JFW | T@lk 18:02, 25 May 2008 (UTC)

[edit] Sections

I note that there are several deviations from WP:MEDMOS, but I feel that "classification" in this case is only relevant after the diagnosis has been established, and similarly that "screening" only makes sense in the context of epidemiology. JFW | T@lk 18:06, 25 May 2008 (UTC)

I think complications are missing, might be split off from prognosis. Hearing loss should be added. --Steven Fruitsmaak (Reply) 18:15, 25 May 2008 (UTC)
Thanks for including the additional grading scale and the content about seizures. I don't think I agree with a separate section on complications, because essentially the whole "treatment" paragraph also deals with complications (such as vasospasm). As I've indicated, I have tried to keep acute complications in the "treatment" paragraph while addressing long-term non-modifiable outcomes in the "prognosis" section.
I have also moved "classification" back to earlier in the article. I might not have been clear about this, but many treatment decisions are influenced by the grading of SAH. It would therefore make more sense to place this somewhere between "diagnosis" and "treatment".
I haven't seen much about hearing loss, at least not as much as in bacterial meningitis. JFW | T@lk 20:40, 25 May 2008 (UTC)
Complications: makes more sense to mention them separately, but then before treatment, imho. I don't see why acute complications should be mixed with treatment of them, and chronic complications should be mixed with prognosis.
Classification: might guide treatment to some extent (although the article doesn't go into great detail there), but still the classification section is not interesting to the general audience -and probably not for the general physician or medical student either. We could just say "treatment depends on the classification (see below)". I don't see how reading the classification paragraph would be necessary to understand treatment.
--Steven Fruitsmaak (Reply) 21:25, 25 May 2008 (UTC)

Complications: we're going to be disagreeing about this one, and we'd better come up with an agreement before the GAC-person comes along! I think I was quite clear that acute complications are mostly addressed through preventative treatment (e.g. nimodipine for vasospasm), but that long-term sequelae are unpredictable. I will support a paragraph called "complications" if necessary, but I am personally much more in favour of merging the sequelae into the "prognosis" section.

Classification: on the neurosurgical ward, their handover will include time of haemorrhage, clinical state, and some form of classification or grading. In professional correspondence, the grading is mentioned. Unfortunately I could not derive from my sources how the grading would influence treatment, but one could imagine that grading was only of any benefit if it actually influenced management! JFW | T@lk 21:47, 25 May 2008 (UTC)

That doesn't prevent us from introducing the complications first, then explaining treatment. As far as long-term complications vs prognosis... (Dutch) de vlag dekt de lading niet! --Steven Fruitsmaak (Reply) 22:00, 25 May 2008 (UTC)
Basically, you admit its not of major influence. I would add its not exciting nor necessary to understand all the rest. --Steven Fruitsmaak (Reply) 22:00, 25 May 2008 (UTC)

Most long-term complications are recognised after initial emergency management. I think the temporal relationship is very important here. If someone is comatose on intensive care, few people will be interested at that point whether they'll have a touch of hypopituitarism a few months down the line. I leave it to you if you think there needs to be a section on long-term complications distinct from "prognosis", but it needs to be after "treatment".

I did not admit that the clinical scoring systems are not of clinical importance! I am simply not sure how they influence treatment decisions (haven't worked on the neurosurgery ward since 2002), but I am pretty certain that they do. JFW | T@lk 07:49, 26 May 2008 (UTC)

[edit] GAC

Thanks to the three wise men. Off to GAC with you![1] JFW | T@lk 20:59, 25 May 2008 (UTC)

Best of luck, I severely doubt this will fail. The article is of excellent standard thanks to the hard work put in by everyone involved. Well done. Regards, CycloneNimrodTalk? 21:39, 25 May 2008 (UTC)
Thanks Cyclonenim! JFW | T@lk 21:47, 25 May 2008 (UTC)

[edit] GOS

Found GOS grading here, worth adding if I can find a decent peer review instead of a Google books source? Regards, CycloneNimrodTalk? 22:06, 25 May 2008 (UTC)

It seems this book is referring to the paper in which the WFNS score was introduced (Teasdale et al), which we are presently citing. Still, the Modified Rankin Scale is more detailed, and the ISAT study uses the MRS. I'm not fully convinced that we need to mention these in too much detail. JFW | T@lk 07:55, 26 May 2008 (UTC)

[edit] Couple of things

  • Patients with a large hematoma, depressed level of consciousness or focal neurological symptoms may be candidates for urgent surgical removal of the blood or occlusion of the bleeding site. The remainder are admitted to the hospital and stabilized more extensively, and undergo an transfemoral angiogram or CT angiogram later. - sounds a bit funny as I read it - the bolded bit makes it sound like the first bunch aren't admitted to hosptial. I know/obvious. I suspect it can be removed. Do you think 'managed conservatively' is too jargony?
  • Y Done Regards, CycloneNimrodTalk? 11:32, 26 May 2008 (UTC)
  • When I wrote that, I intended it to distinguish between taking them straight to theatre for a craniotomy vs going to the ward. I agree with the solution. JFW | T@lk 12:32, 26 May 2008 (UTC)
  • Also, may be good to list some non-sedating analgesics, or class anyway (i.e. I guess NSAIDS are a no-no...) Cheers, Casliber (talk · contribs) 11:21, 26 May 2008 (UTC)
  • Y Done Van Gijn lists codeine phosphate. I have personally seen horrible things happen with tramadol. JFW | T@lk 12:32, 26 May 2008 (UTC)
  • Tramadol is an opiate, right? I haven't seen any documented side effects that would play a role on SAH? Regards, CycloneNimrodTalk? 12:46, 26 May 2008 (UTC)
  • In this case, the patient became sedated, and it became impossible to monitor the GCS properly. As a result, the rebleed was identified late. JFW | T@lk 10:45, 30 May 2008 (UTC)
  • The decision as to which modality is to be preferred.. - aargh. Sounds ungainly but an alternative doesn't immediately spring to mind --> 'The decision as to which intervention is undertaken (?)'...
Y Done - "The decision as to which treatment is undertaken is typically made by..." Regards, CycloneNimrodTalk? 11:32, 26 May 2008 (UTC)
  • Neurocognitive symptoms, such as fatigue, mood disturbances, and other related symptoms are common in people who have suffered a subarachnoid hemorrhage. - the sentence doesn't clarify that these are sequelae down the track. I'd place the last two paras of the Prognosis section in a sequelae/ long-term sequelae subsection.
  • Y Done moved to "Long-term outcomes" subsection. Regards, CycloneNimrodTalk? 13:06, 26 May 2008 (UTC)

Looks pretty good otherwise, good to go :) Cheers, Casliber (talk · contribs) 12:53, 26 May 2008 (UTC)

[edit] External peer review

A stroke physician I know (who once edited as Dokane (talk · contribs)) has been so kind as to review the article. Here are his comments:

  • IIIrd nerve best sign is complete ptosis
  • IIIrd nerve palsy classical with posterior communicating artery
  • Also mention about hyponatraemia with SAH due to renal Na loss and not SIADH
  • All CT negative need LP if SAH suspected
  • Mention exact drug regimen for Nimodipine
  • Kick in the head doesnt really get the exact feeling = I say hit round head with a baseball bat. Thats more it

I must say that I haven't found a good reference for the mechanism of hyponatraemia in SAH. We don't usually do dosing regimens. I'm not sure which phrase best describes thunderclap headache; I suspect we'll be sticking with the OHCM phrasing for now. JFW | T@lk 18:43, 26 May 2008 (UTC)

PMID 16936387 talks of hyponatraemia with SAH. It's free, though. On the other hand, if anyone has access to the Clinical Endocrinology journal, here's another option: PMID 16487432 Other options are PMID 7299468 (which speaks about SIADH) and PMID 2301918 However, i'm limited with what I can do with no access to these journals! Regards, CycloneNimrodTalk? 20:40, 26 May 2008 (UTC)
The 2006 Dublin study sounds perfect, doi:10.1111/j.1365-2265.2006.02432.x for anyone who cares to dig it up from the library. From that study, 56.6% developed hyponatremia, and 19.6% had sodium below 130. SIADH was the most common problem, followed by hypovolaemic hyponatraemia, cerebral salt wasting syndrome and some other rarities. JFW | T@lk 22:54, 26 May 2008 (UTC)
Can't get electronic access even at our hospital library. Whoever has a well-equipped library is free to share the main conclusions of that paper. I'm also quite interested to hear how they differentiated between SIADH and CSW. Last I heard was the fractional excretion of uric acid! JFW | T@lk 15:48, 27 May 2008 (UTC)
The definitions used are: SIADH: (Janicic and Verbalis criteria) euvolaemic hyponatraemia, with inappropriate urine concentration, low urine volume and natriuresis, with exclusion of hypocortisolaemia and hypothyroidism. CSW: hypovolaemic hyponatraemia, as evident by low central venous pressure, with diuresis and natriuresis. --WS (talk) 19:15, 29 May 2008 (UTC)
Wouter, do you think this is relevant enough to mention in the article? It seems an extremely common problem. OTOH, we would also need to elaborate on the acute ruined posterior pituitary and diabetes insipidus. JFW | T@lk 10:41, 30 May 2008 (UTC)

[edit] GA review

Excellent article, virtually faultless. Three very minor points, optional

  1. Perhaps in line one indicate that the alt spellings are US/Brit Eng respectively
    Y Done by someone who wasn't me, probably Cyclone. delldot talk 18:29, 27 May 2008 (UTC)
  2. would the tables on severity look better all the same width?
    Y Done What do you think? delldot talk 18:29, 27 May 2008 (UTC)
  3. does the info in the last severity table need to be tabulated, esp as last column is same for all entries?
    Y Done You like? delldot talk 18:29, 27 May 2008 (UTC)

jimfbleak (talk) 07:23, 27 May 2008 (UTC)

Thanks Jim! Looks like Cyclonenim clarified AE/BE. I will look into the tables, although this is not my forte and perhaps we need Delldot's wisdom some more. JFW | T@lk 09:29, 27 May 2008 (UTC)

[edit] Clarification

"The risk of SAH for someone who has never smoked is slightly over half that for someone who has been a smoker in the past."

Really? Are you sure this is written right? I could swear the risk is reduced for someone who has never smoked; otherwise we may have just discovered a new benefit to smoking... Regards, CycloneNimrod talk?contribs? 11:50, 3 June 2008 (UTC)

This needs correcting. I must say that the source on which this statement is based is very cryptical. Oh, and smoking decreases risk of ulcerative colitis, but don't tell anyone. JFW | T@lk 14:31, 3 June 2008 (UTC)
Am I reading this wrong? It looks to me like it's saying having been a smoker increases your risk by about a factor of two. delldot on a public computer talk 05:48, 4 June 2008 (UTC)
"The risk of SAH for someone who has never smoked" - implies non smoker, "is slightly over half that for someone" - has double the risk of, "that for someone who has been a smoker in the past" - than a smoker. Regards, CycloneNimrod talk?contribs? 06:54, 4 June 2008 (UTC)

[edit] Associations of 'berry aneurysms'

Berry aneurysms are associated with polycystic kidneys, coarctation of the aorta and Ehlers-Danlos syndrome (e.g. hypermobile joints and increased skin elasticity) — from OHCM. I'm not sure where or if I should place this in the article? Regards, CycloneNimrod talk?contribs? 14:23, 3 June 2008 (UTC)

The NEJM review mentions a few others, such as pseudoxanthoma elasticum. To be perfectly frank, I think only ADPKD has got a reasonable evidence base for association, and I'm a bit hesitant to broaden the list too much. JFW | T@lk 14:30, 3 June 2008 (UTC)

[edit] Going for featured status

It's been almost a year since I worked an article up to featured status, but it was great. I'm very tempted to let this article incubate for a few more weeks, but then push for FAC. Are there any concerns at the moment that definitely need to be addressed? JFW | T@lk 14:30, 3 June 2008 (UTC)

WTHN, really. It's not lacking any major facts (or many that are minor for that matter) and with a few more weeks of general fixes to wording, links etc. there isn't really a reason it couldn't be submitted for FAC. Regards, CycloneNimrod talk?contribs? 14:37, 3 June 2008 (UTC)

WTHN indeed. Would like to hear Wouter's opinion on the hyponatraemia study (above). JFW | T@lk 21:37, 3 June 2008 (UTC)

Do you have anything in particular (other than WS's hyponatraemia) to correct before sending it off to the FAC? Regards, CycloneNimrod talk?contribs? 22:49, 6 June 2008 (UTC)

I think we might get in trouble for the frequent use of "patients" and for "many experts believe" under Other complications. By the way, this book has a chapter on SAH that discusses complications (e.g. cardiac, pulmonary, and gastrointestinal) if we want more on that. delldot talk 19:33, 8 June 2008 (UTC)

[edit] This is spinal tap

Ah, I was wondering when this controversy would spill over onto Wikipedia. All recent English reviews regard lumbar puncture as mandatory. There is a school of thought that CT is sensitive enough (which is implied by Suarez et al but as far as I can remember they do not spell this out), and a school of thought that there is simply no statistical sense (doi:10.1136/bmj.333.7564.396-b). I want to avoid the discussion, as it is a current controversy that has not been settled. In practice, it seems LP is still necessary to eliminate other causes of headache, especially when there is concurrent meningism and fever. JFW | T@lk 08:34, 5 June 2008 (UTC)

Ok, I'll point the doc who added this to this discussion. delldot on a public computer talk 08:40, 5 June 2008 (UTC)
I found it quite interesting that the majority of people who support lumbar puncture usage in every negative result are neurologists, neurosurgeons and neuroradiologists, people who work long-term with the patient. On the other hand, the author of doi:10.1136/bmj.333.7564.396-b is an emergency physician, someone who works in an environment where speed is of the essence and where 'promiscuity' with the patient is common. Regards, CycloneNimrod talk?contribs? 10:55, 5 June 2008 (UTC)
There's nothing like a good old ad hominem. JFW | T@lk 22:25, 5 June 2008 (UTC)

Tonight I have had another look at Suarez et al. Sure enough, they don't support Dr Naegele's claim in any form. The nice flowchart specifically demands lumbar puncture and provides advice on how to deal with equivocal results. JFW | T@lk 22:25, 5 June 2008 (UTC)

Interesting, so even the opposers to LP are demanding it? Also, if there is a particular treatment regime that consensus agrees upon, if you draw my attention to it i'll try and make up a flowchart for the article itself. Regards, CycloneNimrod talk?contribs? 13:48, 6 June 2008 (UTC)

No, Suarez doesn't say anywhere that they are opposed to LP. I don't think we can use the flowchart from that article without getting into copyright problems. JFW | T@lk 14:10, 6 June 2008 (UTC)

Fair dues to the Suarez point, then. As for the flowchart, I wasn't referring to copying the one from Suarez et al, I was referring to creating a new one from information in the article? I'm not even sure if that's allowed, though. Regards, CycloneNimrod talk?contribs? 14:49, 6 June 2008 (UTC)

I'm not sure what should be on the flowchart. The diagnostic process is fairly straightforward: unusual/sudden-onset headache needs urgent CT brain. If CT brain shows SAH, go to neurosurgeon. If CT brain doesn't show SAH, then do LP. If LP also normal, stop worrying. If LP xanthochromic, still go to neurosurgeon.

One point we are not covering is the possibility of uninterpretable LP results. This is not as uncommon as one might wish, but laboratories sometimes give very guarded responses to xanthochromia requests. Suarez et al suggest that these people should undergo a CT angiogram anyway. On what data this is based, I do not know. I think it is rather too technical to discuss in this article. JFW | T@lk 16:05, 6 June 2008 (UTC)

Fair enough. This article gives a good outline of the usage of LP in SAH, particularly in the context of xanthochromia. It's a shame that it's not an ideal candidate for inclusion per WP:MEDRS. Perhaps some of the cited sources at the bottom may be of more use. Although I agree, from reading this short article alone, it quickly becomes evident that the topic is not as simple as one may wish and is probably not ideal for inclusion on those grounds alone. Regards, CycloneNimrod talk?contribs? 16:20, 6 June 2008 (UTC)
I've found another non-free yet more recent study (May 08) on LP — PMID 18482910 details revised national guidelines which I believe should be mentioned at some stage in the article. Regards, CycloneNimrod talk?contribs? 20:39, 6 June 2008 (UTC)

The Ann Clin Biochem paper is excellent, and is actually free. doi:10.1258/acb.2008.007257. In my humble view, it is criminal to publish guidelines and then lock them in a non-free resource. That would obviate the whole point in disseminating a guideline! JFW | T@lk 11:59, 8 June 2008 (UTC)

[edit] Mayberg et al

PMID 7955232 is stating guidelines for the treatment of aneurysmal subarachnoid haemorrhage. It's not a free text so I can't check it out really but if someone else with access to the circulation journal would then that'd be marvelous. Although, i'm a little sceptical of a 1994 paper with a vascular background; opposed to a neurological standpoint.

In addition, i've been in touch with a Dr. George Jallo who is a paediatric neurosurgeon from John Hopkins. I've asked if he has any images available to the public domain regarding SAH and he's said that he'll get in touch sometime after Tuesday since he's currently away. Hopefully we'll get a few more images for the article this way. Regards, CycloneNimrod talk?contribs? 13:56, 6 June 2008 (UTC)

Thanks for trying to get some more images, given that the CommonsDelinker has been wreaking havoc on this page. Could you also persuade Dr Jallo to proofread this article and correct any errors? When it comes to medical articles, I personally find external peer review a sine qua non.
With regards to the 1994 guideline (http://stroke.ahajournals.org/content/vol25/issue11/ - clearly not available online) - it is not likely to reflect current practice as it predates all our reviews (Van Gijn, Suarez). It has struck me how many high-quality studies have been conducted over the 1990s, many of which contradict previous nostrums about SAH (e.g. the mistaken belief that SAH is more common in middle age than in the elderly). I will see if I can find that paper, but unless anyone disagrees I don't think it would lead to major changes in the article. JFW | T@lk 14:10, 6 June 2008 (UTC)
I'll ask if he'll take a look at the article when he replies with, hopefully, some images. As for the 1994 guideline, I'm aware it's likely to be quite outdated and may not lead to many breakthroughs but every little helps I suppose. Regards, CycloneNimrod talk?contribs? 14:19, 6 June 2008 (UTC)

I'll have to get it from the library, then. JFW | T@lk 15:53, 6 June 2008 (UTC)

I can obtain it online if you think you need it. --WS (talk) 21:55, 6 June 2008 (UTC)
Do you think there is anything mentioned that is particularly worth mentioning? Regards, CycloneNimrod talk?contribs? 22:19, 6 June 2008 (UTC)

Wouter, could I have a copy? All other content from Stroke in 1994 is freely available, so I don't understand why they haven't digitised that paper. JFW | T@lk 11:59, 8 June 2008 (UTC)

[edit] Images

Received two CT slices from Dr. Jallo, both showing SAH. I was hoping for an image of an aneurysm before rupture but unfortunately I didn't get one. The two images are shown here and can be placed where ever people see fit — I don't have a clue, personally. Regards, CycloneNimrod talk?contribs? 15:44, 10 June 2008 (UTC)

Oh, and i've hinted at him to try and take a look but that's really down to him and his workload, I suppose. I'm grateful for any help at all. Regards, CycloneNimrod talk?contribs? 15:45, 10 June 2008 (UTC)