The detection of nontraumatic subarachnoid hemorrhage: still a diagnostic challenge

Nontraumatic subarachnoid hemorrhage is one of the most elusive diagnoses in emergency medicine; it is a potentially lethal disease that is often considered and rarely found. The current practice as determined by the American College of Emergency Physicians 1996 Clinical Policy on Headache is a noncontrast head computed tomography (CT) followed by diagnostic lumbar puncture (LP) to exclude subarachnoid hemorrhage. Whereas the guideline does not consider pretest probability of subarachnoid hemorrhage in determining which patients require LP after negative head CT, patients' acceptance of LP, technical aspects of performing a LP in patients with nonideal anatomy, and risks associated with LP must all be considered when choosing to proceed with invasive testing. This article outlines the use of current testing modalities including CT, magnetic resonance imaging, angiography and LP to provide an up-to-date understanding of diagnostic testing for subarachnoid hemorrhage.