SAH is a common and devastating condition
SAH affects up to 30,000 persons annually in the United States (US)
Mortality rates are as high as 45% with significant morbidity among survivors
These recommendations summarize the best available evidence for treatment of patients with aneurysmal SAH 
SAH incidence varies greatly between countries, from 2 cases/ 100,000 in China to 22.5/100,000 in Finland
Many cases of SAH are misdiagnosed
Thus, the annual incidence of aneurysmal SAH in the US may exceed 30,000
Incidence increases with age, occurring most commonly between 40 and 60 years of age (mean age > 50 years)
SAH is ~1.6 times higher in women than men
Risk factors for SAH include hypertension, smoking, female gender and heavy alcohol use
Cocaine-related SAH occurs in younger patients
Familial intracranial aneurysm (FIA) syndrome occurs when two first- through third-degree relatives have intracranial aneurysms

Natural History and Outcome of an Aneurysmal SAH
30-day mortality rate after SAH ranges from 33-50%
Severity of initial hemorrhage, age, sex, time to treatment, and medical comorbidities impact SAH outcome
Aneurysm size, location in the posterior circulation, and morphology may also impact outcome
Endovascular services at a given institution, the volume of SAH patients treated, and the facility where the patient is first evaluated may also impact outcome

Acute Evaluation - Diagnosis
“The worst headache of my life” is described by ~80% of patients
“Sentinel” headache is described by ~20%
Nausea/vomiting, stiff neck, loss of consciousness, or focal neurological deficits may occur
Misdiagnosis of SAH occurred in as many as 64% of cases prior to 1985
Recent data suggest an SAH misdiagnosis rate of approximately 12%
Importance of recognition of a warning or sentinel leak cannot be overemphasized
A high index of suspicion is warranted in the ED
The diagnostic sensitivity of CT scanning is not 100%, thus diagnostic lumbar puncture should be performed if the initial CT scan is negative 

Acute Evaluation – Preventing Re-bleeding
Up to 14% of SAH patients may experience re-bleeding within 2 hours of the initial hemorrhage
Re-bleeding was more common in those with a systolic blood pressure      >160mm Hg
Anti-fibrinolytic therapy may reduce re-bleeding but has not been shown to improve outcomes
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