Misdiagnosis of acute subarachnoid hemorrhage in the era of multimodal diagnostic options

Published:March 10, 2019DOI:



      Patients suffering from aneurysmatic Subarachnoid Hemorrhage (SAH) may present with a variety of symptoms. The aim of this study is to evaluate the spectrum of misdiagnoses and to analyze the significance of delay of correct diagnosis on the clinical outcome.


      The data was collected prospectively from 2003 to 2013. Patients diagnosed with disease different from aneurysmal SAH by the initially treating physician, and admitted to our department with a delay of at least 24 h after the beginning of the symptoms, were included in this study. We analyzed the various diagnoses that were ascertained instead of SAH and which medical specialty had provided them.


      Overall 704 patients were treated with acute SAH. The inclusion criteria were matched in 76 patients (13.7%). Eleven specialties were involved in the initial patients' treatment. The time interval between initial symptoms and neurosurgical admission varied enormously. Statistically, higher Hunt & Hess score did not lead to an earlier diagnosis (p = 0.56) nor did localisation of the aneurysm (p = 0.75). Lower Fisher score was led to delayed diagnosis (p = 0.02). Delay of diagnosis was not significantly associated with the outcome (p = 0.08) whereas Hunt & Hess grade on admission was a strong predictor for bad outcome (p = 0.00001) as was cerebral vasospasm on the first angiogram (p < 0.05).


      A straightforward diagnosis of SAH despite diffuse and unspecific symptoms is crucial for the successful treatment of these patients, especially with high grade SAH.
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        • Zhao B.
        • Yang H.
        • Zheng K.
        • Li Z.
        • Xiong Y.
        • Tan X.
        • et al.
        AMPAS study group. Predictors of good functional outcomes and mortality in patients with severe rebleeding after aneurysmal subarachnoid hemorrhage.
        Clin Neurol Neurosurg. 2016 May; 144: 28-32
        • Starke R.M.
        • Connolly Jr., E.S.
        Rebleeding after aneurysmal subarachnoid hemorrhage.
        Neurocrit Care. 2011 Sep; 15: 241-246
        • Zhao B.
        • Fan Y.
        • Xiong Y.
        • Yin R.
        • Zheng K.
        • Li Z.
        • et al.
        AMPAS study group. Aneurysm rebleeding after poor-grade aneurysmal subarachnoid hemorrhage: predictors and impact on clinical outcomes.
        J Neurol Sci. 2016 Dec 15; 371: 62-66
        • Sehba F.A.
        • Bederson J.B.
        Mechanisms of acute brain injury after subarachnoid hemorrhage.
        Neurol Res. 2006 Jun; 28: 381-398
        • Frontera J.A.
        • Provencio J.J.
        • Sehba F.A.
        • McIntyre T.M.
        • Nowacki A.S.
        • Gordon E.
        • et al.
        The role of platelet activation and inflammation in early brain injury following subarachnoid hemorrhage.
        Neurocrit Care. 2017 Feb; 26: 48-57
        • Caner B.
        • Hou J.
        • Altay O.
        • Fujii M.
        • Zhang J.H.
        Transition of research focus from vasospasm to early brain injury after subarachnoid hemorrhage.
        J Neurochem. 2012 Nov; 123 Suppl 2: 12-21
        • Topkoru B.
        • Egemen E.
        • Solaroglu I.
        • Zhang H.
        Early brain injury or vasospasm?.
        An overview of Common Mechanisms Curr Drug Targets. 2017; 18: 1424-1429
        • Rabinstein A.A.
        • Lanzino G.
        • Wijdicks E.F.
        Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid haemorrhage.
        Lancet Neurol. 2010 May; 9: 504-519
        • Rinkel G.J.
        • Algra A.
        Long-term outcomes of patients with aneurysmal subarachnoid haemorrhage.
        Lancet Neurol. 2011 Apr; 10: 349-356
        • Schmieder K.
        • Heuser L.
        • Skodda S.
        The management of non traumatic subarachnoid hemorrhage in adults.
        Dtsch Arztebl. 2007; 104: A 2649-54
        • van Lieshout J.H.
        • Bruland I.
        • Fischer I.
        • Cornelius J.F.
        • Kamp M.A.
        • Turowski B.
        • et al.
        Increased mortality of patients with aneurysmatic subarachnoid hemorrhage caused by prolonged transport time to a high-volume neurosurgical unit.
        Am J Emerg Med. 2017 Jan; 35: 45-50
        • Edlow J.A.
        • Malek A.M.
        • Ogilvy C.S.
        Aneurysmal subarachnoid hemorrhage: update for emergency physicians.
        J Emerg Med. 2008 Apr; 34: 237-251
        • Bäuerle J.
        • Gross N.J.
        • Egger K.
        • Neubauer J.
        • Niesen W.D.
        • Buttler K.J.
        • et al.
        Terson's syndrome: diagnostic comparison of ocular sonography and CT.
        J Neuroimaging. 2016 Mar-Apr; 26: 247-252
        • Chatterjee S.
        ECG changes in subarachnoid haemorrhage: a synopsis.
        Neth Heart J. 2011 Jan; 19: 31-34
        • Zaroff J.G.
        • Rordorf G.A.
        • Newell J.B.
        • Ogilvy C.S.
        • Levinson J.R.
        Cardiac outcome in patients with subarachnoid hemorrhage and electrocardiographic abnormalities.
        Neurosurgery. 1999 Jan; 44 ([discussion 39-40]): 34-39
        • Lewandowski P.
        Subarachnoid haemorrhage imitating acute coronary syndrome as a cause of out-of-hospital cardiac arrest - case report.
        Anaesthesiol Intensive Ther. 2014 Sep-Oct; 46: 289-292
        • Suwatcharangkoon S.
        • Meyers E.
        • Falo C.
        • Schmidt J.M.
        • Agarwal S.
        • Claassen J.
        • et al.
        Loss of consciousness at onset of subarachnoid hemorrhage as an important marker of early brain injury.
        JAMA Neurol. 2016 Jan; 73: 28-35
        • Latchaw R.E.
        • Silva P.
        • Falcone S.F.
        The role of CT following aneurysmal rupture.
        Neuroimaging Clin N Am. 1997 Nov; 7: 693-708
        • Mitchell P.
        • Wilkinson I.D.
        • Hoggard N.
        • Paley M.N.
        • Jellinek D.A.
        • Powell T.
        • et al.
        Detection of subarachnoid haemorrhage with magnetic resonance imaging.
        J Neurol Neurosurg Psychiatry. 2001 Feb; 70: 205-211
        • Farzad A.
        • Radin B.
        • Oh J.S.
        • Teague H.M.
        • Euerle B.D.
        • Nable J.V.
        • et al.
        Emergency diagnosis of subarachnoid hemorrhage: an evidence-based debate.
        J Emerg Med. 2013 May; 44: 1045-1053
        • Malhotra A.
        • Wu X.
        • Kalra V.B.
        • Schindler J.
        • Forman H.P.
        Cost-effectiveness analysis of follow-up strategies for thunderclap headache patients with negative noncontrast CT.
        Acad Emerg Med. 2016 Mar; 23: 243-250
        • Mortimer A.M.
        • Bradley M.D.
        • Stoodley N.G.
        • Renowden S.A.
        Thunderclap headache: diagnostic considerations and neuroimaging features.
        Clin Radiol. 2013 Mar; 68: e101-e113