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ArchiveĀ 1

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The mortality figures given on this page seem way out of date however i don't have time at the moment to reference accurate ones.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%

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. JFWĀ |Ā T@lk 19:08, 13 March 2007 (UTC)

There's a slightly older review (Brain 2001) that is presently free (PMIDĀ 11157554) and could be used for verification purposes. JFWĀ |Ā T@lk 08:21, 19 June 2008 (UTC)

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. PMIDĀ 16647856.

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

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. ā€”The preceding unsigned comment was added by Linda Keigher (talk ā€¢ 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. JFWĀ |Ā T@lk 09:37, 30 July 2007 (UTC)

Hypopituitarism

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

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."
  • 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. JFWĀ |Ā 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.
  • 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

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

Hypertension

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

Triple H

The "triple H" treatment for the prevention of vasospasm cannot be left undiscussed. The classic reference is PMIDĀ 7133349. JFWĀ |Ā 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. JFWĀ |Ā 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)

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" ("unauffƤllig") 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. JFWĀ |Ā 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. JFWĀ |Ā T@lk 13:04, 18 March 2008 (UTC)

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. JFWĀ |Ā T@lk 22:17, 15 March 2008 (UTC)
Persuasion, huh? Ā ;-) 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. JFWĀ |Ā T@lk 13:03, 18 March 2008 (UTC)

Stuff to consider

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

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

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

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? JFWĀ |Ā T@lk 23:25, 2 April 2008 (UTC)

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". JFWĀ |Ā T@lk 11:38, 21 May 2008 (UTC)
You speed demon you! Awesome work.Ā :-) delldot talk 12:20, 21 May 2008 (UTC)
Speed demon! Lucifer on amphetamines! JFWĀ |Ā T@lk 10:11, 22 May 2008 (UTC)

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. JFWĀ |Ā 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. JFWĀ |Ā 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)

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. JFWĀ |Ā 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. JFWĀ |Ā 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.Ā :-) 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. JFWĀ |Ā T@lk 06:27, 25 May 2008 (UTC)

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. JFWĀ |Ā T@lk 10:30, 22 May 2008 (UTC)

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. JFWĀ |Ā T@lk 10:56, 22 May 2008 (UTC)

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

Hydrocephalus

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

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? Ā 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). Ā Not done Not widely discussed.
  • Causes - as above, do we know why cocaine and sickle cell disease etc can cause SAH? Ā Done We don't.
  • Classification - Delldot - could you turn these lists into pretty tables?
  • 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. JFWĀ |Ā T@lk 08:45, 23 May 2008 (UTC)
  • 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. Ā 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 Ā Done
    2. can we tidy up the section on "clipping vs coiling" Ā Done
    3. we need discussion of hyponatraemia and hydrocephalus with references references Ā Done
    4. we need a solid study on outcomes with regards to mobility Ā Done
    5. we should mention the outcomes wrt headache, fatigue and neuropsychological deficts (probably in "prognosis" though) Ā Done
  • Prognosis - as above.
    1. PMIDĀ 17569871 is a meta-analysis of four trials and seems to be ideal. Ā Done
    2. ISAT has some data on seizures, and there's PMIDĀ 18325027. Ā Not done Not sure of the relevance.
  • We need a history section - PMIDĀ 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. PMIDĀ 11175986 is a historical review but I have no acccess.
    So's PMIDĀ 6387987 but ditto. I can't get 11175986 either. delldot on a public computer talk 08:56, 23 May 2008 (UTC)
    I have ordered PMIDĀ 11175986 (may turn out to cost me some money...). Otherwise this section is pretty much {{done}} and acceptable. Ā 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. JFWĀ |Ā 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. JFWĀ |Ā 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. MastCellĀ Talk 19:11, 22 May 2008 (UTC)
I need to print out the papers and read them over a good glass of wine. JFWĀ |Ā T@lk 21:48, 22 May 2008 (UTC)

Cerebrovascular inflammation following subarachnoid hemorrhage

Quickly searching PubMed found this: PMIDĀ 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. JFWĀ |Ā T@lk 16:33, 25 May 2008 (UTC)

Preparing for GAC

Thanks to CyclonenimĀ (talkĀ Ā· contribs), StevenfruitsmaakĀ (talkĀ Ā· contribs) and WouterstompĀ (talkĀ Ā· 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. JFWĀ |Ā T@lk 18:02, 25 May 2008 (UTC)

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. JFWĀ |Ā 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. JFWĀ |Ā 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! JFWĀ |Ā 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... (in 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. JFWĀ |Ā T@lk 07:49, 26 May 2008 (UTC)

GAC

Thanks to the three wise men. Off to GAC with you![1] JFWĀ |Ā 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! JFWĀ |Ā T@lk 21:47, 25 May 2008 (UTC)

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. JFWĀ |Ā T@lk 07:55, 26 May 2008 (UTC)

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?
  • In this case, the patient became sedated, and it became impossible to monitor the GCS properly. As a result, the rebleed was identified late. JFWĀ |Ā 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 (?)'...
Ā 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.

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

External peer review

A stroke physician I know (who once edited as DokaneĀ (talkĀ Ā· 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. JFWĀ |Ā T@lk 18:43, 26 May 2008 (UTC)

PMIDĀ 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: PMIDĀ 16487432 Other options are PMIDĀ 7299468 (which speaks about SIADH) and PMIDĀ 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. JFWĀ |Ā 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! JFWĀ |Ā 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. JFWĀ |Ā T@lk 10:41, 30 May 2008 (UTC)

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
    Ā 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?
    Ā 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?
    Ā 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. JFWĀ |Ā T@lk 09:29, 27 May 2008 (UTC)

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. JFWĀ |Ā 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)

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) ā€” 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. JFWĀ |Ā T@lk 14:30, 3 June 2008 (UTC)

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? JFWĀ |Ā 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). JFWĀ |Ā 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)

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. JFWĀ |Ā 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. JFWĀ |Ā 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. JFWĀ |Ā 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. JFWĀ |Ā 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. JFWĀ |Ā 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 ā€” PMIDĀ 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! JFWĀ |Ā T@lk 11:59, 8 June 2008 (UTC)

Mayberg et al

PMIDĀ 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. JFWĀ |Ā 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. JFWĀ |Ā 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. JFWĀ |Ā T@lk 11:59, 8 June 2008 (UTC)

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 ā€” 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)

Pronunciation

Do we have a source for the pronunciation? Right now it doesn't really look accurate to meā€”"suh-buh-ruk-nood hay-maw-rhee-ghee"? /ĖŒsŹŒbəĖˆrƦknɔÉŖd ĖˆhɛmrÉŖdŹ’/ would be more like it. FvasconcellosĀ (tĀ·c) 23:39, 15 June 2008 (UTC)

You're probably right. The original IPA was from Cyclonenim, so let's see where he got his pronunciation from... JFWĀ |Ā T@lk 05:59, 16 June 2008 (UTC)
Wow, well that was a big mistakeĀ :\ Thanks for the correction. I did get it from Wikipedia's article on IPA though. Clearly some misunderstanding on my part! I'll replace it with your version. Regards, CycloneNimrod talk?contribs? 13:56, 16 June 2008 (UTC)
I thought I was going crazy there for a second. Didn't know you'd added itā€”I hope you don't think I'm following you around! :D FvasconcellosĀ (tĀ·c) 14:39, 16 June 2008 (UTC)
Haha, not at all! Have I encountered you before on WP by any chance? Regards, CycloneNimrod talk?contribs? 14:58, 16 June 2008 (UTC)

Meninges image?

What do folks thing about adding a diagram of the meninges, so we can show where the subarachnoid space is? If folks want one, I can try to either track one down or make one in inkscape. But looking at the article I can't see where a good place would be to stick it. delldot talk 23:47, 17 June 2008 (UTC)

Not a bad idea. JFWĀ |Ā T@lk 07:20, 18 June 2008 (UTC)
Sure, why not. Perhaps in the causes section? Regards, CycloneNimrod talk?contribs? 07:31, 18 June 2008 (UTC)
I don't see anything I like on commons, maybe I'll adapt this one to svg and simplify it a little. Causes seems a little far down for such introductory content though, ideally it would be right below the lead (and it would still be nice to have an aneurysm image in causes). Maybe we could switch the causes and diagnosis sections (which would be more in line with MEDMOS and also mean diagnosis would come right before the explanation of the different grading systems, maybe more intuitive). If I've suggested that before, ignore me. delldot talk 14:55, 18 June 2008 (UTC)
That's a better idea, I suppose! Regards, CycloneNimrod talk?contribs? 18:00, 18 June 2008 (UTC)

External peer review 2

I believe CycloneNim has already tried to get an external expert to review this article, but it seems Dr Jallo is a bit busy. Does anyone else know a neurosurgeon? I personally feel that a medical article can't really be an FA candidate until it has received external scrunity for factual correctness. JFWĀ |Ā T@lk 07:58, 18 June 2008 (UTC)

It's a shame that Dr. Jallo hasn't managed to report back. I'll email round a few local neurosurgeons when I get the chance. I'm currently trying to get some work experience shadowing a neurologist or neurosurgeon so if I get that then i'll try and get them to take a quick look! Regards, CycloneNimrod talk?contribs? 17:58, 18 June 2008 (UTC)

Oh! Cold-calling your local neurosurgeon! Just make sure they don't do a punitive craniotomy. JFWĀ |Ā T@lk 18:21, 18 June 2008 (UTC)

Perhaps a little more polite than cold-callingĀ :) I don't think they'll mind me asking all that much but I wouldn't be surprised if they said they were too busy! Regards, CycloneNimrod talk?contribs? 18:46, 18 June 2008 (UTC)
And thinking properly about it, I could swear there was a neurosurgeon at my church. Must verify that. Regards, CycloneNimrod talk?contribs? 18:47, 18 June 2008 (UTC)

Note to self

Thunderclap headache is a symptom in only about a third of all SAH patients

Looking back, I find this hard to believe. I must go back to the VanGijn paper and verify this. If I can't trace it we should probably remove it. JFWĀ |Ā T@lk 18:28, 18 June 2008 (UTC)

It's from PMIDĀ 9810961, and it was indeed incorrect. I'll fix it. JFWĀ |Ā T@lk 07:25, 19 June 2008 (UTC)

The warning leak

One of the undecided debates in SAH land is the concept of "warning leaks" or "sentinel headaches". It posits that many people with SAH describe previous headaches, and that these may constitute episodes of minor haemorrhage preceding "the big one". This is hard to fault, because those headaches are almost by definition never investigated.

The debate as to whether sentinel headaches exist, or whether they are conceptually helpful, seems to be continuing. Suarez et al in their NEJM review seem to uphold their relevance, but the Utrecht group that has more or less written the book on SAH epidemiology has published several papers doubting their relevance (PMIDĀ 7914965 - Lancet, PMIDĀ 10675215 - JNNP). Other relevant papers suggest that sentinel headaches are of clinical relevance, e.g. in predicting risk of rebleed (PMIDĀ 17008633).

Given that this is a major topic that has been the subject of conflict in reviews, it might be worth including with the usual WP:NPOV provisos. Any opinions from the panel? JFWĀ |Ā T@lk 07:41, 19 June 2008 (UTC)

I think it's our role when writing an article to fully investigate and inform of both sides (WP:NPOV), regardless of controversy. In that sense, it's probably worth mentioning. Regards, CycloneNimrod talk?contribs? 16:35, 19 June 2008 (UTC)

I agree in principle, but there are numerous controversies that we cannot cite. I think we agreed earlier on not to delve into the debate about whether to do lumbar punctures or not. This might be another one of those. JFWĀ |Ā T@lk 17:38, 19 June 2008 (UTC)

True, but is there any harm in mentioning both sides of the debate or simply stating that there is a controversy? Regards, CycloneNimrod talk?contribs? 18:34, 19 June 2008 (UTC)

Well, you see, Van Gijn doesn't mention the concept, while Suarez takes it for granted. There is not actually a debate with protagonists and antagonists - it is just that various lines of evidence are contradictory. In practical terms, I'm not really sure what the article would need to say. Because a headache is a headache, and a headache suggesting any form of bleed warrants a CT scan. JFWĀ |Ā T@lk 19:21, 19 June 2008 (UTC)

ISAT continued

doi:10.3171/JNS/2008/108/3/0437 - further follow-up study from ISAT indicates that people under 40 might be better of with neurosurgery, because the difference between clipping and coiling vanishes in people with long life expectancy and therefore higher stochastic risk of rebleeding over those years. But I'm sure this will end up needing inclusion in absence of a review to support its applicability. JFWĀ |Ā T@lk 18:11, 19 June 2008 (UTC)

Preparing for FAC

From WP:WIAFA:

A featured article exemplifies our very best work and features professional standards of writing and presentation. In addition to meeting the requirements for all Wikipedia articles, it has the following attributes.
  1. It is well-written, comprehensive, factually accurate, neutral, stable
  2. It follows style guidelines, including the provision of a lead, appropriate structure, consistent citations
  3. Images
  4. Length

After all the work of the last few weeks I have little doubt that the content meets criterion 1, there are no major MOS issues, it has a good amount of images and tabulated information, and its depth and length are reasonable. I was hoping other major contributors to this article have their own look at WIAFA and decide whether they are happy that the present article is suitable for FAC. JFWĀ |Ā T@lk 17:48, 19 June 2008 (UTC)

I'm all for going over to FAC really, I don't think there are many gaping holes in the article and as you've said it's of a decent length and depth. Images are fine too, any improvements that need to be made will most likely be minor, pointed out by FAC and can be made with relative ease. Regards, CycloneNimrod talk?contribs? 18:34, 19 June 2008 (UTC)

Febrile course

minor point. in the context of the paper cited, 'temperature >38 c. on day 8' fits. in the context of this article 8 days seems oddly too specific. i wonder if something like 'persistent febrile course' wouldn't be better.gotta remember we're not writing for neurosurgeons and neurologists. just a thought.also, more specifics on cognitive deficits? in my own, obviously anecdotal exposure to this disorder, these have included short term memory impairment and personality changes. i really don't know if those are charactertistic or not. Toyokuni3 (talk) 20:29, 19 June 2008 (UTC)

No, the study specifically measured temperature on day 8. If the patient was febrile on that day, it was associated with a poorer outcome. That's why I chose "presence of".
Cognitive deficit is a very broad range of abnormalities, and theoretically all are possible. The JNNP paper addresses numerous areas. JFWĀ |Ā T@lk 22:22, 19 June 2008 (UTC)

Thoughts for improvement

A few thoughts to deal with or ignore before going to FAC:

  • I did a few copy edits, the edit summary was going to be "Feel free to rv me if you don't like them", but my enter key is right next to the apostrophe, and it sometimes gets a little overeager :P
  • Sections not mentioned in lead: prognosis, history. Classifications too, but I don't know if that should be mentioned. The lead seems a little short to me.
  • Ā Done It is hard to cover the numerous factors from "prognosis" in summary style. I have expanded the intro to include some historical information. JFWĀ |Ā T@lk 22:22, 19 June 2008 (UTC)
  • The image from Jallo: I don't see anything abnormal on it. Is it just my laypersonness? Maybe we should stick an arrow on there pointing to the bleed. The image could probably also stand to be cropped a little, and we can black out the white lines from the thing they were laying on (this part I can do, but I wouldn't know where to put the arrow. Should I crop it and someone else can add an arrow to the cropped version?)
  • Ā Doing... There is blood sedimenting in the occipital horn of both lateral ventricles. Agree the image could do with some touching up. JFWĀ |Ā T@lk 22:22, 19 June 2008 (UTC)
  • Actually, there is perimesencephalic blood as well. Would have helped if Dr Jallo had given us the formal reportĀ :-). JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • I still think we should have a citation after every sentence with a statistic, e.g. "1 in 14 have seizures", for the reasons listed above.
  • 22 uses of "patient", I guarantee someone will object at FAC.
  • "In a patient with thunderclap headache, none of the signs mentioned are helpful in confirming or ruling out hemorrhage, although seizures are more common if the bleeding is the result of a ruptured aneurysm as opposed to other causes." I don't get what the first part of the sentence has to do with the second part. Also, this sentence doesn't make a good topic sentence for the rest of the paragraph, which is about eye symptoms (maybe combine with the sentences about intraocular bleeding?). What do the eye symptoms have to do with the other symptoms not being good for determining SAH? Maybe the sentence I quoted should go at the end of the paragraph that lists the symptoms it's referring to. "none of the signs mentioned" is kind of vague, maybe it should list which ones (especially since more may be/have been added since this was written).
  • Ā Doing... JFWĀ |Ā T@lk 22:22, 19 June 2008 (UTC)
  • Ā Done The point in that paragraph was to list any clues from history and examination that might assist in confirming the diagnosis. None are perfect, but seizures predict aneurysmal haemorrhage and third nerve palsy predicts PCA involvement. I have removed the point about history & examination not being specific enough, because we make a similar point in "Diagnosis". JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • "SAH is regarded as a severe complication of head injury, especially if it is associated with deterioration in the level of consciousness." Why? Presumably because it's extremely deadly? Or does it take a lot of force to cause? Head trauma geek that I am, I'd love to see more about trauma, but how important is trauma in SAH? I mean, what percentage of SAH's are from trauma?
  • In that case, should we be giving trauma SAH a more thorough treatment? There's currently no mention of trauma in causes, I'd think it should get its own paragraph. delldot talk 13:12, 22 June 2008 (UTC)

Hitting save now, more to follow in a bit. delldot talk 21:20, 19 June 2008 (UTC)

More:

  • "Most traumatic SAHs occur near a skull fracture or intracerebral contusion." Short, one-sentence paragraphs are discouraged. Is this really all there is to say about trauma as a cause of SAH?
  • Ā Done I have merged the sections. The problem with tSAH is probably that while it is statistically the most common form of SAH it does not occur on its own and is therefore hard to disentangle diagnostically and therapeutically. We are not presently citing a CT classification system for head injury (Marshall LF, Marshall SB, Klauber MR, et al. A new classification of head injury based on computerised tomography. J Neurosurg 1991;75(suppl):S14ā€“20) which apparently has a dedicated tSAH subscore. I could not find a good recent free review to enhance the TBI-SAH content, so please guide me on this one. JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • "about one in ten people who seek medical care with [thunderclap headache] are later diagnosed with a subarachnoid hemorrhage", then later, "Only 10ā€“25% of patients admitted to the emergency department with a thunderclap headache are suffering from an SAH"-- a contradiction? At the very least, we don't need this twice.
  • Ā Done I think 25% is a gross overestimate. Don't know where Longmore et al get those figures from. The highest estimate I have seen (in the JAMA Rational Clinical Examination paper) is 14%. JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • "The CSF sample is examined for xanthochromia ā€” the yellow appearance of centrifugated fluid, or using spectrophotometry (measuring the absorption of particular wavelengths of light) for bilirubin, a breakdown product of hemoglobin in the CSF." unclear
    Ā Done Regards, CycloneNimrod talk?contribs? 07:47, 20 June 2008 (UTC)
  • May want to reorganize the differential diagnosis stuff in the Diagnosis section to group it all together (Intracerebral hemorrhage, migraine...).
  • Ā Done Have moved the differential diagnosis down and merged with diagnostic delay. All of these are peripheral to the diagnostic process ideally followed to confirm SAH. JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • "obliterate the source of bleeding" is obliterate used in the medical jargon? Seems like a funny word to use.
  • Ideally, it'd be great to get survival rates for the Fisher and World Federation of Neurosurgeons classification tables as well.
  • Ā Not done I'm not sure if those exist. I have certainly not seen any papers to that effect. Contrary to Hunt & Hess, they were not formulated on the basis of a clinical cohort. JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • "The only situation where a randomized controlled trial has been conducted" awkward. Maybe "The only randomized controlled trial that has been conducted..."
  • "death or dependency" maybe define dependency.
  • ">120 cm/second" should this be written out?
  • "is detected in about one third of all people admitted with subarachnoid hemorrhage, and causes permanent damage in half those people." clearly the "those people" is referring to the third, not the "all people admitted...", but it seems like the article's saying the opposite this way.
  • Also no mention of complications and long-term outcomes in the lead, I think those are important enough to mention (e.g. long-term complications like personality change, headaches).
  • Ā Done As I mentioned earlier, exact data on headaches are hard to find, but I've listed neurological and cognitive impairment in survivors. JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • In symptoms "1 in 14 have seizures", in Other complications "Seizures occur in about a third of all cases", so it looks like we need to define the time frames here.
  • "many health professionals believe that some patients might benefit" Can we be any more specific here? I bet we'll get criticized for weasel wording at FAC.
  • In the lead, "Half of all SAH cases are fatal", in Prognosis "The mortality rate for SAH is between 40 and 50%". How about "up to half" in the lead?
  • "those carrying two particular copies the gene encoding apolipoprotein E" 'particular copies'?
  • "about 25% higher in women above 55" ...than in younger women, presumably?
  • Ā Done No, it's compared to men. Until the age of about 55 the incidence is comparable, but the lines separate there. JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)
  • "close relatives have a 3ā€“5 fold increase chance of SAH." close relatives of people who have had SAH? Does "chance of SAH" sound awkward?
  • "Prevention of subarachnoid hemorrhage depends on the detection of cerebral aneurysms, and safety and expected benefit from treatment for aneurysms detected in this way." Unclear
  • The history section uses both Dr. and Dr
  • "The first surgical intervention was performed by Mr Norman Dott, who was a pupil of Dr Harvey Cushing then working in Edinburgh... American neurosurgeon Dr Walter Dandy, working in Baltimore, was the first to introduce clips." In what years did these achievements take place?
  • I feel like some folks at FAC may say the article still reads too much like it's written for medical professionals and that the prose needs to be dumbed down. For example, "If symptomatic vasospasm is resistant to medical treatment..."; "They are managed symptomatically"
  • I think the article could use a better copyedit than I'm able to give it. Anyone know a member of the LoCE who owes them a favor?

That's it from me, looks very close! I would definitely get a copy editor to give it a go-over; a lot of attention is paid to prose at FAC. delldot talk 22:40, 19 June 2008 (UTC)

Thanks for all your help, Delldot. I will see what can be done about getting a LoCE member on board. JFWĀ |Ā T@lk 11:07, 22 June 2008 (UTC)

Comments from the field

I approached Mr Paul Grundy, consultant neurosurgeon at Wessex Neurological Centre (at Southampton General Hospital). He was kind enough to review the article from his perspective, and has given me permission to list his response here. JFWĀ |Ā T@lk 22:27, 19 June 2008 (UTC)

  • oculomotor abnormalities occur usually with expansion of a posterior communicating aneurysm (SAH not necessarily present - often isn't). the pupil will be involved and therefore the pupil response will not be normal
Ā Done I was once told that PCA aneurysms spare the pupil. In any case, I have removed the qualification about the pupil and focused on the ptosis and "down & out" appearance. JFWĀ |Ā T@lk 11:02, 20 June 2008 (UTC)
  • overall trauma is the commonest cause - it is very often seen in pts even with mild TBI after a significant injury and usually has no sequelae apart from headache - which you get anyway after tbi. so i would not state that it is a severe complication of head injury
Ā Done I have rephrased this. JFWĀ |Ā T@lk 11:02, 20 June 2008 (UTC)
  • the csf in LP will also show high red cell count (in all bottles if you do that sort of thing)
Ā Done That was a plain omission. I have added this now and sourced it to Suarez' review. JFWĀ |Ā T@lk 11:02, 20 June 2008 (UTC)
  • cerebral angiography is the gold standard investigation not CTA. if you diagnose SAH then you can not exclude anuerysm on CTA - you will need formal angio. we use CTA as a screening tool to plan management in early stages. risks of formal angio are very low (less than 1%)
Ā Done I have made the paragraph a bit more vague, as I could imagine that some cases proceed to formal angiography without CTA. Van Gijn maintains that in a perimesencephalic haemorrhage, good quality CTA is sufficient to exclude aneurysms. JFWĀ |Ā T@lk 11:02, 20 June 2008 (UTC)
  • perimesencephalic SAH - should say blood is limited to sub-archnoid spaces around midbrain
Ā Done I believe this qualification is made in the "causes" section. I will rephrase it slightly. JFWĀ |Ā T@lk 11:02, 20 June 2008 (UTC)
  • you can also get SAH fom AVMs, dural AV fistulae and tumours too
Ā Done I have specifically listed AVMs. Tumors were mentioned. JFWĀ |Ā T@lk 11:02, 20 June 2008 (UTC)
  • coiling vs clipping - you can't say they is little scientific evidence! ISAT is one of the very few and best RCTs in surgery, demonstrating a benefit from coiling! i appreciate the problems with it but it is still good evidence and has totally changed the way we mange these pts i would re-word this section
Ā Doing... What was intended was that RCTs are only available in one group of patients, and the rest are guided by experience and technical limitations. I will fix this later. JFWĀ |Ā T@lk 11:02, 20 June 2008 (UTC)
Ā Done Rephrased as suggested. JFWĀ |Ā T@lk 07:25, 22 June 2008 (UTC)
  • vasospasm is a clinical diagnosis on the whole with the development of a 'delayed ischaemic neurological deficit' usually occus day 4-14. we would rarley perform angio for these cases in UK, some do in US. TCDs are of very questionable benefit but are often used. what matters is the pts condition and whether you can reverse it with treatment (HHH therapy)
Ā Done I thought we should be reflecting US practice as well (as documented by Suarez et al), but I have placed more emphasis on the clinical presentation. JFWĀ |Ā T@lk 07:25, 22 June 2008 (UTC)
  • you could probably say that nimodipine is used for all cases upto 21 days on basis of the study - it should be started before 96 hours so is ususally given immediately. pts only receive normal saline iv and not dextrose solutions becasue of the tendenecy to get SIADH or cerebral salt wasting (and therefore hyponatraemia)
Ā Done I thought we shouldn't go in detail as to the choice of fluids, but I have qualified the time when nimodipine has been shown to be of benefit. JFWĀ |Ā T@lk 07:25, 22 June 2008 (UTC)
  • most hydrocephalus is transient and responds to CSF diversion through EVD or lumbar drain - some cases need shunt
Ā Done I have added the other modalities. JFWĀ |Ā T@lk 07:25, 22 June 2008 (UTC)
  • we don't advise prophylactic AEDs
Ā Not done Some of the references seem to indicate that this is still being done in places. Do you think it is excessive? JFWĀ |Ā T@lk 07:25, 22 June 2008 (UTC)
  • the estimated prevalence of aneurysms in population is 1% - so not that uncommon - most probably don't rupture - see ISUIA
I will cite that number. JFWĀ |Ā T@lk 07:25, 22 June 2008 (UTC)

hope that is of some help - PG

I has been indeed. I will address each concern as soon as possible. JFWĀ |Ā T@lk 22:27, 19 June 2008 (UTC)

Image improvements?

Since there is quite a bit of focus on lumbar puncture in the article, perhaps we should try and find a suitable image for placement within it that shows LP. I tried searching Commons but little luck for a good image. Regards, CycloneNimrod talk?contribs? 14:10, 22 June 2008 (UTC)

Sorry for slashing your quote, Cyclonenim. The paper in question basically confirms, with Hunt & Hess, that being comatose from SAH carries an absolutely miserable prognosis. Otherwise, this is a case series from a single institute and many of their practices deviate significantly from current clinical practice. JFWĀ |Ā T@lk 19:46, 22 June 2008 (UTC)

tSAH

At Delldot's suggestion I have added some content on traumatic SAH. A 2006 review seems to suggest that it might be a direct contributor to morbidity and mortality, or it could be a bystander phenomenon. Unfortunately I have no access to the fulltext article but it was one of the few reviews that covered tSAH separately. Anyone with access is free to expand the content in "causes". JFWĀ |Ā T@lk 16:11, 22 June 2008 (UTC)

I had always understood tSAH to be very serious, but I wasn't necessarily right. I can try to grab some time this week to add some on tSAH, not sure how much time I'll have, but it'll be my first Wikipedia priority. delldot talk 17:57, 22 June 2008 (UTC)

The review I added seems to suggest that it very hard to know the chicken & egg here. I haven't worked in neurosurgery long enough (three weeks exactly...) to get an appreciation of the signifance of tSAH. JFWĀ |Ā T@lk 19:17, 22 June 2008 (UTC)

Is a review from the late '90s too outdated? delldot talk 21:18, 22 June 2008 (UTC)

Uhh, Armin et al is from 2006. I suppose the IMPACT trial will eventually yield the answer. JFWĀ |Ā T@lk 22:08, 22 June 2008 (UTC)

Yeah, I was asking about the late '90s to find out if I should bother to read another one I found. delldot talk 13:11, 23 June 2008 (UTC)

Causes

I don't know if it would be possible, but I'd love to see a breakdown by causes (i.e. what percentage of SAH's are aneurysmal, what percentage are from AVMs, and so on). If that info's ever been collected somewhere, I could make a pie chart for the causes section (or would such a chart belong in epidemiology instead?). delldot talk 13:09, 23 June 2008 (UTC)

I really don't know, but I'll ask Mr Grundy. JFWĀ |Ā T@lk 17:44, 23 June 2008 (UTC)

wording

"tSAH] usually happens in the setting of other traumatic brain injury" -- does it happen in any other context? Or should we eliminate the 'usually'? delldot talk 13:37, 23 June 2008 (UTC)

Oh, I misread this, the sentence is saying it happens with other types of TBI like contusion, right? delldot talk 14:03, 23 June 2008 (UTC)

Perhaps this needs rephrasing. JFWĀ |Ā T@lk 17:44, 23 June 2008 (UTC)

Recent additions

I've just added and cited the following:

  • Neck stiffness occurs roughly six hours since onset of SAH.
  • Distressed patients can be treated with benzodiazepines.
  • Leave hypertension untreated.
  • Bladder catheter should be placed to monitor fluid balance.
  • Pituitary apoplexy is another, albeit rarer, cause of SAH.
  • Replaced "several bottles are collected" with "At least three tubes are collected" as this is more correct with practice (apparently).

From the Oxford Textbook of Medicine, Fourth Edition, Volume 3. They had an excellent section by van Gijn which I read whilst I was at my central library.

I found a comment by van Gijn that said that antifibrinolytic drugs decrease rate of rebleeding but not the overall outcome. I was unsure of whether this is relevent enough to add to the section on prevention of rebleeding? ā€” CycloneNimrod talk?contribs? 16:34, 2 July 2008 (UTC)

Suarez mentions same on antifibrinolytics (tranexamic acid, aminocaproic acid). The main source here is doi:10.1161/01.STR.0000089030.04120.0E which finds decreased rebleeding offset by more delayed ischemia. JFWĀ |Ā T@lk 17:36, 2 July 2008 (UTC)
Worth adding then? ā€” CycloneNimrod talk?contribs? 18:46, 2 July 2008 (UTC)
On the basis of that review, I would imagine that it is an outdated practice that should be confined to the rubbish bins of medicine. Not entirely convinced we should even mention it. JFWĀ |Ā T@lk 22:54, 2 July 2008 (UTC)

Featured article candidacy

I think this article meets the featured article criteria, and am nominating it for featured article candidacy. My warmest commendations to all editors who have been working on this, including CycloneNim, Stevenfruitsmaak, Wouterstomp, and of course our indefatigable reviewer Delldot! JFWĀ |Ā T@lk 23:32, 2 July 2008 (UTC)

A heartfelt 'Yay!' is all I can say, really. Let's get this doneĀ :) Great work folks. ā€” CycloneNimrod talk?contribs? 11:43, 3 July 2008 (UTC)

Things we are not presently covering

Just to summarise the things we are presently not covering but have been discussed at some point:

  1. Whether an LP is actually needed if the CT is clear. (All reviews still suggest LP after negative CT.)
  2. Whether there is such a thing as a "sentinel headache" and what it means. (Seems to boil down to semantics - if an SAH is suspected, even a warning leak, diagnostic workup is desirable.)
  3. Use of plasmin inhibitors. (Proven to be useless in studies.)
  4. Timing of LP. (Should be >12 hours after onset of headache, but only if spectrophotometry is used rather than serial bottles.)

It is of course entirely possible to expand the article further, and cover these things. But most are actually pretty marginal discussions that would make the article fairly bloated. Opinions of course welcome. JFWĀ |Ā T@lk 22:09, 6 July 2008 (UTC)

The article is well within recommended WP:SIZE, with roughly 3900 words (24Ā kB) of readable prose; most FAs are quite longer if I recall correctly. I personally feel FAs should be as comprehensive as possible while catering to a general audience, and while the above are probably not major facts or details (what would constitute a minor detail, by the way? I should ask SandyĀ :), they can certainly make the cut without pushing the page over the low end of what constitutes a "long article". FvasconcellosĀ (tĀ·c) 00:20, 7 July 2008 (UTC)

I have no problems expanding into these topics, because the sources are plentiful, but I need to know which ones should be included. I think 1. is an extreme minority view as all reviews insist LP is necessary. I think 2. is an ongoing debate of little relevance to the reader. We could discuss 3. as Suarez lists it (if my memory serves). And 4. is easily traced. JFWĀ |Ā T@lk 06:30, 7 July 2008 (UTC)

Seems a good summary of what could vs. should be included to me. As for 2., I won't pretend to be familiar with the concept, but a quick search/skim suggests there is already some high-quality literature available. Perhaps a brief sentenceā€”but, again, this is already a Featured Article in my book; if you do feel something is best left out, that's coolĀ ;) FvasconcellosĀ (tĀ·c) 12:45, 7 July 2008 (UTC)
  1. Overwhelming evidence: yes. No further clarification needed. Axl (talk) 14:03, 7 July 2008 (UTC)
  2. Worth a mention, perhaps one sentence. Axl (talk) 14:03, 7 July 2008 (UTC)
  3. Not really adding to the article. Axl (talk) 14:03, 7 July 2008 (UTC)
  4. Essential. Thanks for adding this to the article already. Axl (talk) 14:03, 7 July 2008 (UTC)

Good. I consider myself tasked with adding the thorny issue of sentinel headaches... Always nice for a night shift. JFWĀ |Ā T@lk 14:58, 7 July 2008 (UTC)

Ā Done - now what do we do with the dissenting studies that attribute the whole phenomenon to recall bias? JFWĀ |Ā T@lk 19:35, 7 July 2008 (UTC)
Where would Joe Biden be without his warning bleed? NY Times 1988 JFWĀ |Ā T@lk 20:45, 10 September 2008 (UTC)

We made it!

Congratulations and thanks to all those who contributed to making this one of Wikipedia's best articles! ā€” CycloneNimrodĀ  Talk? 19:49, 10 July 2008 (UTC)

Spoken version added

I have added a spoken version of this article; see the link above. Hassocks5489 (tickets please!) 22:14, 9 August 2008 (UTC)

Well done, especially the medical jargon! JFWĀ |Ā T@lk 08:07, 10 August 2008 (UTC)

Terminology

This page has excellent information but it could be improved even more by adding the information that a SAH is a type of stroke. I think it would be useful to emphasize this, given that a lot of people who have had SAH seem to be unaware that they have had a hemorrhagic stroke. They may be aware that SAH can cause hemorrhagic stroke, but seem unaware that all SAH is also known as hemorrhagic stroke. Canadian Prof (talk) 21:15, 6 September 2008 (UTC)Canadian Prof

Hi Prof, there's a mention in the second paragraph of the lead: Subarachnoid hemorrhage is considered a form of stroke and causes 1ā€“7% of all strokes. Do you think this is enough, or should it be emphasized more? If the latter, can you suggest a sentence that would provide the needed emphasis? Peace, delldot talk 01:24, 7 September 2008 (UTC)

Hi, I think that you could just remove the word "considered" so that the sentence reads "Subarachnoid hemorrhage is a form of stroke and causes 1ā€“7% of all strokes." OR better yet, emphasize the point by saying "Although people who have had SAH are not always told this, they have actually had a hemorrhagic stroke. SAH causes 1ā€“7% of all strokes."[3] What do you think? Canadian Prof (talk) 17:39, 13 September 2008 (UTC)Canadian Prof

I prefer your former version. We are aiming for an encyclopedic entry rather than a patient's information leaflet. [Of course the article should also inform patients too.] Axl Ā¤ [Talk] 19:41, 13 September 2008 (UTC)
I used the word "considered" because there are substantial differences between the clinical symptoms of SAH and the more common forms of stroke (e.g. focal signs may be absent, loss of consciousness is more likely to be a feature etc etc). If asked, I suspect many doctors would not spontaneously classify SAH as a stroke syndrome.
With regards to your point about distinguishing between SAH and (ischaemic) stroke, I agree that this risk exists. However, to suggest "people who have had SAH are not always told this" is original research. There are many diseases that are insufficiently explained to patients: I'm always shocked how many COPD patients think they have asthma, and how many people with heart failure have never actually heard the term. That is a communications problem not intrinsic to this particular article. JFWĀ |Ā T@lk 20:54, 13 September 2008 (UTC)

Misleading intro

See also http://en.wikipedia.org/w/index.php?title=Wikipedia%3AMain_Page%2FErrors&diff=245224625&oldid=245216350. As I have not followed the creation of this article, I'll leave it to the regulars to correct it, but speaking as a medicine professional I must say that the description of treatment options in the intro is quite misleading. Kosebamse (talk) 14:14, 14 October 2008 (UTC)

I'm confused as to your main objection. If you'd like to state it here I'll gladly correct it assuming it's backed up in the sources we've used. ā€”Cyclonenim (talk Ā· contribs Ā· email) 16:15, 14 October 2008 (UTC)
My objection is that "SAH is managed with close observation and prompt neurosurgical investigations, medications and other treatment methods" speaks diffusely of "other treatment methods". There are two options which offer a definitive, curative treatment, namely, surgery and interventional radiology. These should be mentioned in that very sentence, not later in the introduction. Currently, that sentence is like talking about how to handle a fire by saying: "a fire is handled by observation, evacuation of residents, administrative measures and other methods", and mentioning methods of putting out a fire somewhere later. Kosebamse (talk) 17:41, 14 October 2008 (UTC)
I agree radiology should be mentioned in that sentence, and I will add it as such. As for surgery, this is covered by the term 'neurosurgical investivations.' ā€”Cyclonenim (talk Ā· contribs Ā· email) 18:39, 14 October 2008 (UTC)
I have to disagree there, as "investigation" means more or less the same as "diagnostic procedures", and therapy, a quite different category of measures, is an essential part of the management of SAH. As discussed further down in the article, both interventional radiology and surgery are valid options of therapy.. Kosebamse (talk) 19:19, 14 October 2008 (UTC)
I'll replace investigations with therapies, then. ā€”Cyclonenim (talk Ā· contribs Ā· email) 19:26, 14 October 2008 (UTC)

It's going to crash!

There is an aviation novel, where a small airplane's pilot suffers SH and falls unconscious and then a chase pilots talks the blonde girl passanger to Earth. It's "Talk Down" by Brian Lecomber. Yes, I know trivia section are discouraged for Wikipedia articles. 82.131.210.162 (talk) 15:24, 14 October 2008 (UTC)

Slightly odd sentence

"Subarachnoid hemorrhage is considered a form of stroke and causes 1ā€“7% of all strokes"

Can a stroke cause a stroke? SteveRwanda (talk) 20:26, 14 October 2008 (UTC)

Nicely pointed out. This is more suited as "Subarachnoid hemorrhage is considered a form of stroke, and makes up 1-7% of all strokes". I'll make the change. ā€”Cyclonenim (talk Ā· contribs Ā· email) 20:53, 14 October 2008 (UTC)
I have just modified it having seeing the first comment, but not the second. I think that we have all got the same sort of idea about it. Snowman (talk) 20:55, 14 October 2008 (UTC)
Great. I've moved it to the third paragraph in lead. It's not a particularly suitable opening statementĀ :) Thanks for doing the edit, though. ā€”Cyclonenim (talk Ā· contribs Ā· email) 21:01, 14 October 2008 (UTC)

Bramwell reference

I've never used WikiBlame, but I'm puzzled why the Bramwell 1886;32:101 reference was replaced with 1887;31:101. Does anyone know what happened here? In any case, I have never been satisfied with the limited verifiability of this reference, so I have approached the editors of the Scottish Medical Journal (which followed on from Edinburgh Medical Journal in 1956) to see if they can corroborate one version or the other. JFWĀ |Ā T@lk 23:48, 15 October 2008 (UTC)

Based on the new user's contributions, I have assumed that it was vandalism and reverted it. WhatamIdoing (talk) 02:50, 16 October 2008 (UTC)
I saw that, I'm pretty sure I reverted it when I saw it. Perhaps not... ā€”Cyclonenim (talk Ā· contribs Ā· email) 08:21, 16 October 2008 (UTC)

Thanks guys. I'm patiently awaiting a reply from Scotland, though, because I've never been able to verify the reference completely (beyond stealing it from Todd et al). Would be nice if they emailed me a reprint for my collection... JFWĀ |Ā T@lk 22:16, 16 October 2008 (UTC)

From Neurosurgical Classics, p. 437 by Wilkins: 1886, volume 32, p. 101. Axl Ā¤ [Talk] 11:38, 17 October 2008 (UTC)

Cheers mate, that's sorted then. JFWĀ |Ā T@lk 11:53, 17 October 2008 (UTC)

Screening in relatives

doi:10.1093/brain/awn187 uses a huge Swedish database to establish risk in first-degree relatives. A single first-degree relative with aneurysmal SAH confers a 2.15 relative risk (still very low in absolute terms, given 9/100,000 incidence). With two or more first-degree relatives (doesn't really matter what the nature of the relationship is), the risk increases to 51, and absolute lifetime risk becomes worrying enough. This quantitative data supports the commonly used policy of screening as we are stating. Given that it's a primary research study it may not need citing, but the data now exists. JFWĀ |Ā T@lk 14:12, 2 November 2008 (UTC)

I haven't read it yet but it'll be interesting to see what:
"Risks and benefits of screening for intracranial aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage". The New England journal of medicine. 341 (18): 1344ā€“50. 1999. PMIDĀ 10536126. Retrieved 2008-11-02. {{cite journal}}: Unknown parameter |month= ignored (help)
Says about screening. ā€”Cyclonenim (talk Ā· contribs Ā· email) 17:17, 2 November 2008 (UTC)

The MARS study is cited in White & Wardlaw's article (ref 46 currently). The drawback is that MRA is not the gold standard, as it can occasionally miss aneurysms. The above Swedish study doesn't seem to care much for aneurysm size but more for bleeding. In any case, it affirms the current recommendations. JFWĀ |Ā T@lk 20:04, 2 November 2008 (UTC)

Illegal Drug Overdose

Noticed that cocaine and I just added Methamphetamine is listed but is that usually with chronic abusers? (I'm still working on it.) Raquel Baranow (talk) 16:04, 18 March 2009 (UTC)

It is not mentioned in the sources on which the article is based. I have temporarily removed the addition until a source is made available. JFWĀ |Ā T@lk 20:58, 18 March 2009 (UTC)
U'll see all sorts of sources if U Google the two words, "Subarachnoid hemorrhage" & "Methamphetamine" I'd add a reference if I knew how . . . I tried to add a reference once or twice elsewhere but it never worked. Raquel Baranow (talk) 07:07, 19 March 2009 (UTC)

More ISAT

http://www.mrc.ac.uk/Newspublications/News/MRC005799 - apparently ISAT is yielding yet more data, including improved mortality figures in those who were coiled. Needs watching. Anyone seen the publication? JFWĀ |Ā T@lk 23:55, 13 April 2009 (UTC)

doi:10.1016/S1474-4422(09)70080-8 JFWĀ |Ā T@lk 23:58, 13 April 2009 (UTC)

PMIDĀ 19390078

Hyperglycemia on admission associated with poorer outcome. FvasconcellosĀ (tĀ·c) 15:14, 13 June 2009 (UTC)

Nimodipine

so can't nimodipine cause more bleeding as it opposed body's haemostasis to control bleeding by vasospasm? --203.81.166.2 (talk) 07:33, 14 July 2009 (UTC)

I think you've got things wrong. Nimodipine has no effect on coagulation. Rather, it relaxes the blood vessels and therefore counteracts vasospasm. JFWĀ |Ā T@lk 18:16, 14 July 2009 (UTC)

To JFW: coagulation is only one aspect of hemostasis.

To 203.81.166.2: vessels do indeed vasoconstrict in response to bleeding. Together with platelet aggregation and coagulation, the bleeding is controlled. However this vasoconstriction can lead lead to ischemia of the brain tissue. Nimodipine helps to prevent this ischemia. In the event of a re-bleed, there is a theoretical risk of increasing bleeding due to nimodipine. However I couldn't find any evidence to support this in clinical practice. Axl Ā¤ [Talk] 07:55, 15 July 2009 (UTC)

Of course, I hadn't thought of vasospasm as an intrinsic form of haemostasis. Thanks for setting me straight. JFWĀ |Ā T@lk 10:39, 15 July 2009 (UTC)

Pract Neurol - background reading

The article doi:10.1136/jnnp.2009.182444 (in Practical Neurology) gives a useful overview about the care for an SAH patient. It is mostly expertise-based medicine, and given the nature of the journal it might not be a very good WP:MEDRS, but useful as background reading. JFWĀ |Ā T@lk 16:07, 19 July 2009 (UTC)

CT and SAH

This study was just commented on in the medical post. No LP needed if presenting within 6 hrs and CT normal. http://www.medicalpost.com/therapeutics/neurology/article.jsp?content=20090804_095306_9428 Should we add or should we wait for the full paper / or a review / guideline?--Doc James (talk Ā· contribs Ā· email) 00:54, 5 August 2009 (UTC)

That website (medicalpost) is asking me to register. I'm not registering. Do you have a pubmed citation for the study, or even just the name of the study and the authors? Axl Ā¤ [Talk] 06:56, 5 August 2009 (UTC)
Here is a section of the article From the annual meeting of the Canadian Association of Emergency Physicians CT alone can safely exclude subarachnoid hemorrhage within six hours of headache onset CALGARY | Modern CT scanners are good enough to rule out a subarachnoid hemorrhage on their own, without the added use of lumbar punctureā€”at least in patients who present to the emergency department within six hours of headache onset. Unable to find a published copy yet. Might be a few weeks before it comes out. Will keep an eye out for it. This will be big news. It reverses previous recommendations that LP is needed routinely post negative CT. If we include a mention of this study it should be done weakly however. I am sure there will be a great deal of work to confirm this.--Doc James (talk Ā· contribs Ā· email) 07:41, 5 August 2009 (UTC)
How about A single study has found that modern CT scanners may be able to rule out a sub arachnoid hemorrhage if completed within six hours of onset of symptoms.[1] Further evidence will be required to confirm these results. I am sure we will be able to find something in the next few days to confirm the latter part.--Doc James (talk Ā· contribs Ā· email) 07:44, 5 August 2009 (UTC)
Is "medicalpost" a reliable source? I'm not convinced. I would prefer to wait and see a formal article in the peer-reviewed medical literature. Axl Ā¤ [Talk] 17:07, 5 August 2009 (UTC)
It is going to take a while before every single body is going to change its recommendations. At the moment the American ACEP and the Scottish SIGN guidelines firmly demand LP if SAH suspected. Until these guidelines are revised, we can only say "some bodies now advise that LP is not needed etc". JFWĀ |Ā T@lk 06:08, 7 August 2009 (UTC)
I was thinking we should keep it more vague than even that. We should just say a single study says we may not need it but confirmation is required. Will keep an eye out for the actual study.--Doc James (talk Ā· contribs Ā· email) 06:28, 7 August 2009 (UTC)
James, can you give us a reliable source for the study? Axl Ā¤ [Talk] 07:20, 7 August 2009 (UTC)
Will do when it is published. Unable to find it at this point.Doc James (talk Ā· contribs Ā· email) 07:59, 7 August 2009 (UTC)
Okay, thanks. Axl Ā¤ [Talk] 16:09, 7 August 2009 (UTC)

"4 EARLY CT without LP reliably excludes subarachnoid hemorrhage in neurologically intact ED patients with acute headache Perry JJ, Stiell IG, Sivilotti MLA, Bullard M, Symington C, Lee J, Ɖmond M, Pauls M, Eisenhauer M, Mackey D, Sutherland J, Lesiuk H, Wells G; University of Ottawa, Ottawa, ON Introduction: It is widely recommended that acute headache patients undergo lumbar puncture (LP) to rule out subarachnoid hemorrhage (SAH) even after normal computed tomography (CT). Our objective was to determine the sensitivity of modern CT scans for SAH overall and when done < 6 hours from headache onset in ED patients with normal neurological exam. Methods: This prospective cohort study was conducted at 12 university EDs. Patients ā‰„ 15 years, with normal neurological exam, GCS 15, and a complaint of a nontraumatic, acute (< 1 h from onset to peak) headache investigated with a CT were enrolled over 8 years. Physicians completed data forms prior to work-up. The outcome criterion, SAH, was defined by any of: 1) SAH on CT, 2) xanthochromia in the cerebrospinal fluid (CSF), or 3) red blood cells in the final tube of CSF with positive cerebral angiography. Patients without both a normal CT and LP had 6-month structured telephone follow-up. Analysis included sensitivity with corresponding 95% confidence intervals. A preplanned subgroup analysis was performed for patients with CT scan < 6 hours from onset of headache. Results: There were 3123 enrolled patients including 234 with SAH. 80.3% of eligible patients were enrolled. Mean age was 45.1 years (SD 17.2) with 60.2% female. Overall sensitivity of CT for SAH was 93.1% (95% CI 89-96%). Of the 960 patients with CT performed < 6 hours from headache onset, 124 had SAH. The sensitivity of CT for SAH in this group was 100% (95% CI 97-100%). Of 401 LPs performed in this subgroup with a negative CT, 0 demonstrated xanthochromia and 128 had red blood cells > 5 Ɨ 106/L and 305 patients underwent angiography (all negative for aneurysm, except 1 where aneurysm seen on CT without SAH). Conclusion: This large prospective study of neurologically intact patients found that CT alone is highly sensitive for SAH when performed < 6 hours from headache onset. When done within 6 hours of headache onset, CT alone is sufficient to exclude SAH, rendering LP unnecessary. Keywords: headache, subarachnoid hemorrhage, neuroimaging"" May 2009 Vol 11, No 3 in CJEM It however is not a formal publication by the looks of it. Just an abstract at this point.Doc James (talk Ā· contribs Ā· email) 03:03, 14 August 2009 (UTC)

Nice big case series and methodologically fairly sound but not yet published in a WP:MEDRS and will not displace advice from professional guidelines currently. JFWĀ |Ā T@lk 23:27, 15 August 2009 (UTC)

References

  1. ^ http://www.medicalpost.com/therapeutics/neurology/article.jsp?content=20090804_095306_9428

3H still sucks

doi:10.1186/cc8886 review of 3H and its components. It doesn't work. There is some anecdotal evidence for hypertension but nil for haemodilution and nil for hypervolaemia. JFWĀ |Ā T@lk 21:20, 1 March 2010 (UTC)

SAH CT and LP

These are two interesting paper. One is not a review but wondering if we should comment on them?

What are you suggesting? JFWĀ |Ā T@lk 17:17, 4 June 2010 (UTC)

Another study on CT and LP

I think the time is coming when LP will not be necessary in certain cases. But still not sufficient for inclusion in anything but a tentative form.

  • [2] Cortnum S, SĆørensen P, JĆørgensen J (2010). "Determining the sensitivity of computed tomography scanning in early detection of subarachnoid hemorrhage". Neurosurgery. 66 (5): 900ā€“2, discussion 903. doi:10.1227/01. NEU.0000367722.66098.21. PMIDĀ 20404693. {{cite journal}}: Check |doi= value (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Doc James (talk Ā· contribs Ā· email) 01:27, 7 August 2010 (UTC)

More references

Excuse me for butting in, interestingly, I had a SaH AVM at 20, and underwent neurosurgery for it. I found two books that may be useful for this SAH wiki entry:

Bryce Weir's SaH Causes and Cures (1998):

http://books.google.co.uk/books?id=aEx6FjLduiIC&printsec=frontcover&dq=yanagihara+et+al+sah&source=gbs_similarbooks_s&cad=1#v=onepage&q&f=false

And a volume by Yanagihara, et al. (1998):

http://books.google.co.uk/books?id=MgP3pu2yBmAC&printsec=frontcover&dq=yanagihara+et+al+sah&source=gbs_similarbooks_s&cad=1#v=onepage&q&f=false

Hope that's useful, cheers.

twitter.com/jontycampbell 21:13, 20 July 2010 (UTC) ā€”Preceding unsigned comment added by Radiojonty (talk ā€¢ contribs)

Do these sources give any information that is not already covered in the article? JFWĀ |Ā T@lk 06:03, 21 July 2010 (UTC)

I don't know, I'm no neurosurgeon, but I didn't spot those volumes as refs in the citations list, so I thought maybe not - still, hope these two are useful.

twitter.com/jontycampbell 00:03, 19 January 2011 (UTC) ā€” Preceding unsigned comment added by Radiojonty (talk ā€¢ contribs)

Not all sources that exist need to be cited. If a source is absolutely the most widely acknowledged standard work about a condition, it may be mentioned in "further reading". In this case, I don't think that applies. JFWĀ |Ā T@lk 01:21, 19 January 2011 (UTC)

Case of ECG changes

I have added an ECG and a 2009 review article. Do people think it looks better with the little circles or should I upload an copy without them? Doc James (talk Ā· contribs Ā· email) 07:48, 7 August 2010 (UTC)

CT image

The previous CT image was a little grainy so I have replaced it with a slightly better quality. It has a bit of reflect in it. I could get a direct copy I guess rather than an image taken from the screen.Doc James (talk Ā· contribs Ā· email) 07:57, 7 August 2010 (UTC)

An interesting paper

Perry JJ, Stiell IG, Sivilotti ML; etĀ al. (2010). "High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study". BMJ. 341: c5204. PMCĀ 2966872. PMIDĀ 21030443. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) Doc James (talk Ā· contribs Ā· email) 18:50, 4 December 2010 (UTC)

The commentary (by Gabriel Rinkel of the Utrecht group) was less than glowing. JFWĀ |Ā T@lk 22:48, 4 December 2010 (UTC)
Yes not ready for prime time yet. Doc James (talk Ā· contribs Ā· email) 02:38, 5 December 2010 (UTC)

Triggers

This study in Stroke (link) got into the popular press in the UK. It uses a case-control approach to study triggers for aneurysmal rupture. It is not a MEDRS, just something to follow through. JFWĀ |Ā T@lk 12:44, 6 May 2011 (UTC)

CSF RBCs

Almost no one is brave enough to come out with a number of RBCs that nearly rules out SAH. Here is an interesting paper which says less than 500 rules out the diagnosis.Gorchynski, J (2007 Feb). "Interpretation of traumatic lumbar punctures in the setting of possible subarachnoid hemorrhage: who can be safely discharged?". The California journal of emergency medicine / California Chapter of the American Academy of Emergency Medicine. 8 (1): 3ā€“7. PMIDĀ 20440386. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

It of course is tentative but should we include it in some way? I guess we could create a sub article to discuss these fine details in further detail. Doc James (talk Ā· contribs Ā· email) 10:53, 3 June 2011 (UTC)

Hmm, not a MEDRS and not consistent with current guidance to rely on spectrophotometry. JFWĀ |Ā T@lk 11:45, 3 June 2011 (UTC)
Few people have those spectrophotometers. And xanthochromia does not develop until some time after the start of the pain. Thus a combination is used. Doc James (talk Ā· contribs Ā· email) 11:50, 3 June 2011 (UTC)

Symonds

doi:10.1093/qjmed/os-118.69.93 (yes, the DOI has been reported to Crossref) is Symonds' 31-page account of SAH, including the diagnosis. On closer reading it provides some fertile material from the 19th century that certainly displaces Bramwell as having described SAH in modern times. Both clinical and pathological reports are cited. I may need to make alternations to make sure that this content is adequate. JFWĀ |Ā T@lk 01:14, 26 June 2011 (UTC)

Describes Terson phenomenon also! JFWĀ |Ā T@lk 01:15, 26 June 2011 (UTC)

A prospective study

This text even though support by a primary research study does not over step the studies conclusions.


Within six hours of the onset of symptoms a single study has reported that CT is 100% sensitive.Perry, JJ (2011 Jul 18). "Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study". BMJ (Clinical research ed.). 343: d4277. PMIDĀ 21768192. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)


Doc James (talk Ā· contribs Ā· email) 22:30, 1 August 2011 (UTC)

Another review

doi:10.1055/s-0030-1268862 (Semin Neurol 2010) is a recent review that might be incorporated if it includes anything new. JFWĀ |Ā T@lk 10:13, 13 September 2011 (UTC)

Salts

The Dublin people have put out a review of salt and water disorders in neurosurgery. doi:10.1210/jc.2011-3201. It's a strange one, because it combines a literature review with the single-centre experience. My view is that the article is in essence a review. It might thus be suitable for citation here. JFWĀ |Ā T@lk 12:52, 3 July 2012 (UTC)

I only have access to the abstract. To me, it looks like a primary source. Axl Ā¤ [Talk] 22:30, 3 July 2012 (UTC)
I agree that the abstract gives the impression of a primary study. A quick perusal of the fulltext gives a different picture. Confusing, and very strange that JCEM have published it in this format. JFWĀ |Ā T@lk 22:14, 4 July 2012 (UTC)

Cholesterol

Newer reference of a meta-analysis for cholesterol statement, which reaffirms supposed inverse association but stops short of confirmation due to a lack of well-designed studies. Any thoughts to my recent changes? --ā€”Cyclonenim |Ā ChatĀ  12:20, 23 January 2014 (UTC)

This paper supports the finding. However the conclusion conflicts with this paper. Axl Ā¤ [Talk] 17:43, 23 January 2014 (UTC)
In the conflicting paper, Table 3 asserts that serum concentrations of above 6.23 mmol/L are associated with increased risk of SAH, especially in men. --ā€”Cyclonenim |Ā ChatĀ  14:34, 24 January 2014 (UTC)
Yes. (Over 5.59 in men.) Axl Ā¤ [Talk] 16:16, 24 January 2014 (UTC)
Oops, sorry. Thought you were saying it conflicts with the reference I put in. I gotchaĀ :) --ā€”Cyclonenim |Ā ChatĀ  19:11, 24 January 2014 (UTC)
Er, yes, it does conflict with the reference that you put in (Wang). Axl Ā¤ [Talk] 19:42, 24 January 2014 (UTC)
I am happy with the addition of this review, as it is a good quality secondary source. Incidentally, I hope you don't mind that I removed PMIDĀ 24134085 (Cohen-Gadol & Bohnstedt) as it adds little over Feigin's review. JFWĀ |Ā T@lk 20:08, 23 January 2014 (UTC)
Not at allĀ :) Good to be back... --ā€”Cyclonenim |Ā ChatĀ  14:34, 24 January 2014 (UTC)

Fresh sources

doi::10.1016/S0140-6736(14)60975-2 - ISAT 10-year follow-up. Can't really be added yet, await a secondary source.

doi:10.1016/S1474-4422(14)70015-8 - unruptured aneurysms, Lancet Neurol can definitely be added (April 2014).

I also need to find a secondary source that talk about the Perry BMJ study about sensitivity of CT within 6h approaching 100%. JFWĀ |Ā T@lk 09:03, 31 October 2014 (UTC)

Phillip Hughes death

I have removed from the lead, here, an unsourced mention of the death of Australian cricketer Phillip Hughes from " ... vertebral artery dissection leading to subarachnoid haemorrhage." [3]. According to the ABC News (Australia) source it is only the second known case of " 'VAD' leading to 'SAH' " caused by a cricket ball. It's likely others will re-add it, as Hughes death has already been added to his WP page, Sean Abbott's (the bowler), Bouncer (cricket), cricket ball, and maybe others.

This page has had a very noticeable ā‰ˆ8x jump in page views from 26 -27 November. So I ask, do other editors think Phillip Hughes death from SAH is notable enough for a mention here? --220 of Borg 04:12, 28 November 2014 (UTC)

Sounds like a dissection. Doc James (talk Ā· contribs Ā· email) 04:58, 28 November 2014 (UTC)
Vertebral artery dissection in the V4 part can definitely lead to SAH because this part extends intracranially and the vessel is thin-walled. Blood will accumulate in the subarachnoid space. VAD is usually caused by trauma, and it matters little that it was a cricket ball (as opposed to a chiropractor etc) caused the trauma.
The VAD article already has a mention, based on a reasonable quality secondary source. I worry more about the fact that we are doing a disservice to the famous people who died from SAH but are not currently listed. JFWĀ |Ā T@lk 11:33, 28 November 2014 (UTC)
Yes, @Jfdwolff: If a 'famous' wp:Notable person had a SAH perhaps they should be briefly mentioned on the page. In my edit summary here I suggested a mention of Hughes in a 'Notable cases' or similar section. Problem there is, everyone then seems to think that their friend/brother/cousin/neighbour etc. who had SAH/VAD is notable!
ā€¢ So Hughes death has now been mentioned on the 4 pages I noted above in my original posting, on vertebral artery dissection as you said (ā„– 5), and we now have a new page List of fatal accidents in cricket with Hughes mentioned (ā„– 6!). --220 of Borg 09:51, 29 November 2014 (UTC)
220 of Borg There is always a worry about WP:NOTNEWS for these sections. I am not convinced that Philip Hughes will be remembered for this cause of death, or that this illness will make a lasting change in the popular perception of either VAD or SAH, but there you go. I will support a mention if someone can find other famous people who have experienced subarachnoid haemorrhage. JFWĀ |Ā T@lk 21:20, 29 November 2014 (UTC)

"The other similar incident"

Here is another (or the other?) example of SAH from a cricket ball. 23 February 1946, and also in Australia! "death was due to an extensive sub-anachroid haemorrhage caused by a rupture of a small branch of the lateral venous sinus." Source:"CRICKET FATALITY". The West Australian (Perth, WA: 1879 - 1954). Perth, W.A.: National Library of Australia. 6 April 1946. p.Ā 6. Retrieved 29 November 2014. I borrowed this source from Talk:Phillip Hughes#The other similar incident, courtesy of Moondyne--220 of Borg 10:49, 29 November 2014 (UTC)

That is something quite different from what Philip Hughes died from. JFWĀ |Ā T@lk 21:20, 29 November 2014 (UTC)
Thanks @Jfdwolff: Yes I noted "rupture .... lateral venous sinus" rather than 'VAD". I presumed from my sparse medical knowledge it was a 'ruptured' vein rather than a 'dissected' artery'. Is Transverse sinuses or Dural venous sinuses the relevant WP page? Is there some simple way of explaining the difference? (You can answer on my talk if this is getting too tangential for this talkpage). Regards, 220 of Borg 22:48, 29 November 2014 (UTC)
Hi 220 of Borg, dural venous sinuses is a collective name so if the exact venous sinus is known then the link should ideally be to the most appropriate page. On the other hand, a descriptive explanation may need to be required because most readers won't be able to tell what the cerebral/dural venous sinuses are. They are unrelated to the sinuses where people get sinusitis. JFWĀ |Ā T@lk 22:51, 29 November 2014 (UTC)

Poor grade SAH - critical care management

doi:10.1186/s13054-016-1193-9 JFWĀ |Ā T@lk 09:59, 4 February 2016 (UTC)

Also: doi:10.1007/s12028-011-9605-9 (consensus statement on SAH on critical care in general). JFWĀ |Ā T@lk 08:57, 30 June 2016 (UTC)

ESO guidelines

doi:10.1159/000346087 JFWĀ |Ā T@lk 09:02, 30 June 2016 (UTC)

Lancet seminar

doi:10.1016/S0140-6736(16)30668-7 - not yet in print. JFWĀ |Ā T@lk 09:08, 2 December 2016 (UTC)

It is in print now.
doi:10.1056/NEJMcp1605827 is in this week's NEJM. JFWĀ |Ā T@lk 12:37, 20 July 2017 (UTC)

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