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The following is an archived discussion of a featured article nomination. Please do not modify it. Subsequent comments should be made on the article's talk page or in Wikipedia talk:Featured article candidates. No further edits should be made to this page.

The article was promoted by User:SandyGeorgia 03:24, 10 July 2008 [1].

Subarachnoid hemorrhage

[edit]
Self-nominator(s): JFW | T@lk


This article on a relatively rare but devastating form of stroke has been receiving the attentions of WikiProject Medicine for the last few weeks. It achieved good article status and has subsequently been undergoing further improvements and reviews. It has been externally peer reviewed by a neurosurgeon, whose advice was followed in ensuring that the article reflected daily medical practice and covered the medical literature available. I believe it meets the featured article criteria, and would benefit from being accorded FA status. JFW | T@lk 23:36, 2 July 2008 (UTC)[reply]

  • Support Comments - ok, notes below - looks ok, complete yes and neutral, but prose needs soem work. I picked up the following - watch for repetition of words and lots of brackets. I will read again fter changes below, and note what others have to say. prose better now, others may find a few things more but i am pretty happy. Cheers, Casliber (talk · contribs) 01:48, 3 July 2008 (UTC)[reply]
    • ::The diagnosis is generally made with computed tomography (CT scanning) of the head - why not just 'The diagnosis is generally made with a CT scan of the head'?
      • Done 02:06, 3 July 2008 (UTC)
    • ::before arriving at a hospital - 'before reaching hospital' is smoother
      • Changed to before reaching a hospital delldot talk 02:06, 3 July 2008 (UTC)[reply]
        • Hmm, to me, I'd eliminate the article here, using 'hospital' as something like, well I am not sure but like a state I guess, and that's how I would use it in the UK or Australia. To me it flows better mentally. I will be interested to see what others think. Not a deal-breaker though. 02:39, 3 July 2008 (UTC)
    • ::). About a third (of all people with SAH) have no symptoms - could remove bracketed bit as it is obvious what we're talking about - try it
    • ::Combine first two paras as they are stubby in Signs and symptoms
    • ::(occurring in 3–13% of cases of SAH) - remove 'of SAH'
    • these are aimed at assessing the likelihood that the symptoms are due to SAH and identifying other potential causes. - somewhat cumbersome, but an alternative doesn't leap to mind.
      • How about these are aimed at determining whether the symptoms are due to SAH or to another cause? Slightly different meaning, but after all, that is the aim, ideally. delldot talk 02:10, 3 July 2008 (UTC)[reply]
    • ::The diagnosis (of subarachnoid hemorrhage) can however not be made on clinical grounds alone - can lose bracketed bit again
    • ::(The) management (of subarachnoid hemorrhage) consists of... can lose bracketed bits again
    • ::especially given that 15% have a further episode (rebleeding) soon after admission. --> as 15% may have further bleeding soon after admission.'
    • ::Hypertension, if present, should be left untreated. --> Hypertension should be left untreated if present. (no commas needed this way)
    • ::Delayed ischemia is characterized by new neurological symptoms; it can be confirmed by transcranial doppler or cerebral angiography. - bit clunky, maybe a comma and an 'and' make it flow better. 'Delayed ischemia is characterized by new neurological symptoms, and can be confirmed by transcranial doppler or cerebral angiography.'
    • ::Delayed ischemia is detected in about one third of all people admitted with subarachnoid hemorrhage, and half of those suffer permanent damage as a result. - passive and repetitive after preceding sentence, try 'About one third of all people admitted with subarachnoid hemorrhage will have delayed ischemia, and half of those suffer permanent damage as a result.'
    • ::Nimodipine, an oral calcium channel blocker, has been shown.. --> 'The oral calcium channel blocker Nimodipine has been shown...'
    • ::If the symptoms of delayed ischemia don't improve - 'do not' better here I think, or 'fail to improve'
    • ::Paras stubby in Other complications so combine all 3.
    • ::Ditto in Early morbidity and mortality - combine first two and rewrite first sentence of para 2 for flow Poorer outcome is associated with numerous other factors to 'other factors associated with poorer outcome include...'. And mention the 'many of which are not modifiable risk factors.' at the end or separately.
      • Reworded, combined, and did away with the modifiable thing, because it seemed patently obvious to me. Others working on the article are of course welcome to add it back in. delldot talk 02:58, 3 July 2008 (UTC)[reply]
    • ::seem to be at a higher risk --> 'increase risk'
    • ::Neurocognitive symptoms, such as fatigue, mood disturbances, and other related symptoms are common in people who have suffered a subarachnoid hemorrhage. --> 'Neurocognitive symptoms, such as fatigue, mood disturbances, and other related symptoms are common sequelae'
    • ::Cobine the 2 paras in Long-term outcomes
    • but the risk still increases with age. - --> although...
    • ::Genetics may play a role in a person's disposition to SAH, since risk (of SAH) is increased three- to fivefold in first-degree relatives of people who have suffered a subarachnoid hemorrhage - remove redundant
    • ::'The incidental detection of an aneurysm (e.g. when someone undergoes an MRI scan of the brain for a different reason) presents a conundrum, as all treatments for cerebral aneurysms are associated with potential complications.' needs rewriting - 'An aneurysm may be detected incidentally on brain imaging for an unrelated reason; this presents a conundrum, as all treatments for cerebral aneurysms are associated with potential complications.'
    • Wow, thanks so much Casliber! This was very helpful. delldot talk 03:06, 3 July 2008 (UTC)[reply]
  • Comments.
    • From "Signs and symptoms", paragraph 2: "Seizures make hemorrhage from an aneurysm more likely..." Does this mean that seizures cause hemorrhage from an aneurysm? I don't think so. Axl (talk) 16:44, 4 July 2008 (UTC)[reply]
    • From "Diagnosis", paragraph 1: "Lumbar puncture, in which cerebrospinal fluid (CSF) is removed with a needle from the lumbar sac, will show evidence of hemorrhage in 3% of people in whom CT was found normal..." I have never heard the term "lumbar sac" before. Is this a recognized anatomical description? Does the 3% refer to all-comers with thunderclap headache? Probably not. Axl (talk) 16:53, 4 July 2008 (UTC)[reply]
      • "Lumbar sac" Googles fine, and AFAIK it is a bona fide description of the CSF space around the distal cona medullaris where we take our LPs from. JFW | T@lk 23:31, 5 July 2008 (UTC)[reply]
      • Van Gijn bases this on PMID 7897421, a 175 patient case series. Oddly, the incidence of SAH in that cohort was quite high. JFW | T@lk 23:31, 5 July 2008 (UTC)[reply]
        • Indeed this is a remarkably high incidence: 117 confirmed on CT out of 175 with headache. This contrasts with the BMJ article: "Only about one in four people presenting with sudden severe headache will have had a subarachnoid haemorrhage.... Third generation computed tomography scanners miss about 2% of cases of subarachnoid haemorrhage within 12 hours and about 7% by 24 hours." Axl (talk) 06:47, 7 July 2008 (UTC)[reply]
      • Suarez goes as far as to state that the sensitivity is now 100%. LP would then only be needed if too much time elapsed between headache and CT (but they don't say that). JFW | T@lk 08:38, 7 July 2008 (UTC)[reply]
    • The timing of lumbar puncture is not mentioned. The default clinical practice is that LP should be delayed until at least 12 hours after the onset of headache. Timing of lumbar puncture Axl (talk) 17:07, 4 July 2008 (UTC)[reply]
      • Van Gijn mentions this. It depends on the method used. If all you do is look at the sample, any time is OK for LP. However, bilirubin is only generated after about 12 hours and therefore LP should be delayed if you're using spectrophotometry. Do we need to discuss these finer points in such detail? We have also agreed not to delve into "sentinel headaches" and whether LP is actually necessary. JFW | T@lk 23:18, 5 July 2008 (UTC)[reply]
        • I'm sure that you read the article that I linked to. It is not OK to just look at the sample. The sample must be sent for spectrophotometry. I have seen neurosurgeons insist on a repeat LP because it was done too soon. In my opinion, this is an important omission. It only requires a sentence on two in the article. I am happy to add it if this is helpful. Axl (talk) 06:53, 7 July 2008 (UTC)[reply]
      • A survey in the USA a few years back stated that 97% of labs were not using spectrophotometry. I will add something about timing LPs as easily sourced to Van Gijn and Cruikshank. JFW | T@lk 08:38, 7 July 2008 (UTC)[reply]
    • From "Classification": "In addition to the ubiquitously used Glasgow Coma Scale, three other specialized scores are in use. In all scores, a higher number is associated with a worse outcome." Although with GCS, I presume that a high score is associated with a better outcome? Axl (talk) 17:16, 4 July 2008 (UTC)[reply]
    • From "Treatment": "Management consists of general measures to stabilize the patient while using specific investigations and treatments to prevent rebleeding by obliterating the bleeding source, prevention of a phenomenon known as vasospasm, and prevention and treatment of complications." This long sentence should be split. Axl (talk) 17:23, 4 July 2008 (UTC)[reply]
    • From "Treatment", "General measures": "Analgesia (pain control) is generally restricted to non-sedating agents such as codeine...." Codeine is non-sedating? Axl (talk) 17:26, 4 July 2008 (UTC)[reply]
    • From "Treatment", "Prevention of rebleeding", paragraph 3: "On the whole, aneurysms of the middle cerebral artery and its related vessels are hard to reach with angiography and tend to be amenable to clipping, whilst those of the basilar artery and posterior cerebral artery are hard to reach surgically and are more accessible for endovascular management." Another long sentence. Also, the technical term "endovascular" doesn't have an appropriate link. I see that endovascular treatment of brain aneurysms redirects to Guglielmi Detachable Coil. Axl (talk) 17:37, 4 July 2008 (UTC)[reply]
      • I'll fix the long sentence. "Endovascular" would be a dicdef. It could be a disambiguation page for GDC (the term used by neurosurgeons), EVAR and perhaps those clever endovascular aortic valve replacements. JFW | T@lk 23:18, 5 July 2008 (UTC)[reply]
    • From "Treatment", "Vasospasm", paragraph 3: "Evidence for [triple-H] is inconclusive and no sufficiently large randomized controlled trials have been undertaken to demonstrate its benefits." The reference (Sen) indicates that no RCTs have been conducted. Axl (talk) 17:57, 4 July 2008 (UTC)[reply]
    • From "Epidemiology", paragraph 3: "Some protection of uncertain significance is conferred by ... diabetes mellitus." Curiously, the reference (Feigin) indicates a relative risk of 0.3 (95% confidence interval 0 to 2.2) for a cohort study, but an odds ratio of 0.7 (95% confidence interval 0.5 to 0.8) for case-control studies. Another reference (Rosengart) indicates an odds ratio of 1.46 (95% CI 1.18 to 1.80) in their univariate model. In my opinion, these conflicting findings do not support the tentative conclusion stated in the "Epidemiology" section. Axl (talk) 18:42, 4 July 2008 (UTC)[reply]
      • Feigin is talking about risk factors for developing SAH. Rosengart is referring to the prognosis after having developed SAH; it is no secret that diabetics are more at risk of hospitalisation-related complications. JFW | T@lk 23:18, 5 July 2008 (UTC)[reply]
Support. Many thanks to JFW and delldot for addressing my points and producing an excellent article. Axl (talk) 13:01, 7 July 2008 (UTC)[reply]
The above discussion is preserved as an archive. Please do not modify it. No further edits should be made to this page.
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