Wikipedia:Featured article candidates/Subarachnoid hemorrhage


 * 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.

Subarachnoid hemorrhage

 * 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)


 * Comments - sources look good, links checked out with the link checker tool. Ealdgyth - Talk 00:47, 3 July 2008 (UTC)


 * 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)
 * ::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)
 * 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)
 * Ah, ok, sounded weird to my American ears, but done.  delldot   talk  02:47, 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
 * Done delldot   talk  02:06, 3 July 2008 (UTC)
 * ::Combine first two paras as they are stubby in Signs and symptoms
 * Done delldot   talk  02:06, 3 July 2008 (UTC)
 * ::(occurring in 3–13% of cases of SAH) - remove 'of SAH'
 * Done delldot   talk  02:06, 3 July 2008 (UTC)
 * 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)
 * ::The diagnosis (of subarachnoid hemorrhage) can however not be made on clinical grounds alone - can lose bracketed bit again
 * Done delldot   talk  02:15, 3 July 2008 (UTC)
 * ::(The) management (of subarachnoid hemorrhage) consists of... can lose bracketed bits again
 * Done delldot   talk  02:15, 3 July 2008 (UTC)
 * ::especially given that 15% have a further episode (rebleeding) soon after admission. --> as 15% may have further bleeding soon after admission. '
 * Changed to especially since 15% may have further bleeding soon after admission, since I didn't want to imply that this would be the only reason. delldot   talk  02:15, 3 July 2008 (UTC)
 * ::Hypertension, if present, should be left untreated. --> Hypertension should be left untreated if present. (no commas needed this way)
 * Done delldot   talk  02:15, 3 July 2008 (UTC)
 * ::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.'
 * Done, but what would you think of Delayed ischemia, characterized by new neurological symptoms, can be confirmed by transcranial doppler or cerebral angiography?
 * That's fine too. Cheers, Casliber (talk · contribs) 02:39, 3 July 2008 (UTC)
 * I'll leave it your way and let the other folks working on this decide. delldot   talk  02:47, 3 July 2008 (UTC)
 * ::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.'
 * Good catch, done. delldot   talk  02:47, 3 July 2008 (UTC)
 * ::Nimodipine, an oral calcium channel blocker, has been shown.. --> 'The oral calcium channel blocker Nimodipine has been shown...'
 * Done delldot   talk  02:47, 3 July 2008 (UTC)
 * ::If the symptoms of delayed ischemia don't improve  - 'do not' better here I think, or 'fail to improve'
 * Changed to 'do not' delldot   talk  02:47, 3 July 2008 (UTC)
 * ::Paras stubby in Other complications so combine all 3.
 * Done delldot   talk  02:47, 3 July 2008 (UTC)
 * ::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)
 * ::seem to be at a higher risk  --> 'increase risk'
 * Changed to having two copies... seems to increase risk; I think that seems to is important--we aren't sure it does increase risk.  delldot   talk  02:58, 3 July 2008 (UTC)
 * ::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'
 * Done delldot   talk  03:06, 3 July 2008 (UTC)
 * ::Cobine the 2 paras in Long-term outcomes
 * Done delldot   talk  03:06, 3 July 2008 (UTC)
 * but the risk still increases with age.  - --> although...
 * Done delldot   talk  03:06, 3 July 2008 (UTC)
 * ::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
 * Done, and replaced the 'since' with a semicolon. delldot   talk  03:06, 3 July 2008 (UTC)
 * ::'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.'
 * Done delldot   talk  03:06, 3 July 2008 (UTC)
 * Wow, thanks so much Casliber! This was very helpful.  delldot   talk  03:06, 3 July 2008 (UTC)


 * Comments Brief ones, more to come later. Very comprehensive article, top-notch sources, and I especially like that you were able to arrange an external peer review—I'd like to see a lot more of those in science-related FACs. Fvasconcellos (t·c) 14:52, 3 July 2008 (UTC)
 * I don't suppose we could get an image of an aneurysm being coiled? :) An LP image would probably be a nice addition as well, but I'm not sure where to put it.
 * Doing.. I'll approach a neurosurgeon or neuroradiologist to try and get such an image. We've only one decent LP image on Commons and it's a child undergoing the procedure. Considering SAH is incredibly rare in children, it wouldn't be a good choice. — CycloneNimrod talk? contribs? 17:24, 3 July 2008 (UTC)
 * Thanks. Fvasconcellos (t·c) 20:40, 3 July 2008 (UTC)
 * For those of us with little or no experience interpreting scans, could captions be a tad more descriptive? (In Image:Subarachnoid hemorrhage CT.jpg, for instance—what are we looking at? Is that blood pooling in the posterior horns?)
 * I'm also doing a little copy editing. Looks good so far. Fvasconcellos (t·c) 14:52, 3 July 2008 (UTC)
 * We have no neurosurgical service in our hospital, so I could not prevail on them to borrow an image. I'll approach Mr Grundy. I will improve the image descriptions. JFW | T@lk  16:05, 3 July 2008 (UTC)
 * Thank you, thank you. I'm looking for something else to fault in the article; no luck so far ;) Fvasconcellos (t·c) 20:40, 3 July 2008 (UTC)
 * OK, one more thing: "Xanthochromia and spectrophotometry remain reliable tests several days after the onset of headache." May sound a bit pedantic, but xanthochromia isn't a test per se—you test for xanthochromia. Fvasconcellos (t·c) 16:22, 4 July 2008 (UTC)
 * Support. That's it from me; this one's ready for the big time :) Congratulations to JFW, Cyclone, delldot, and everyone else who worked on the article. Fvasconcellos (t·c) 16:22, 4 July 2008 (UTC)
 * Support This looks good to me. Gary King ( talk ) 19:41, 3 July 2008 (UTC)
 * Why is there a line running through Image:Subarachnoid hemorrhage CT.jpg? Is that some kind of bad watermarking? --Steven Fruitsmaak (Reply) 22:00, 3 July 2008 (UTC)
 * Could I clean this up in a graphics editor, or would that be too much of a change in the image?  delldot   talk  22:02, 3 July 2008 (UTC)
 * You could try but it would most likely look ugly, normally the original version shouldn't contain the line. I guess the image provider added it, better ask him. --Steven Fruitsmaak (Reply) 22:11, 3 July 2008 (UTC)
 * I don't think it adds much compared to the other CT already displayed at the top of the article. JFW | T@lk  22:26, 3 July 2008 (UTC)
 * The image from Dr. Gallo just came like that. Don't know why there is a line. It probably could be removed without making too much mess but as JFW said it doesn't really add much I suppose. Just thought the article looked a little bare at the time! — CycloneNimrod Talk? 22:46, 3 July 2008 (UTC)
 * Would it be useful to include Image:SAH.png? Some other useful free images can be found here. --Steven Fruitsmaak (Reply) 22:11, 3 July 2008 (UTC)
 * SAH.png seems to be a legend to go with a real CT image. I'm not sure if we can use images from the journal under the creative commons license. JFW | T@lk  22:26, 3 July 2008 (UTC)
 * Of course you can, that's the great thing about BioMedCentral. The entire article, including images, is licensed freely. Why your doubt? It's a great resource for images. --Steven Fruitsmaak (Reply) 22:31, 3 July 2008 (UTC)
 * If that is the case, then WP:BOLD. JFW | T@lk  08:36, 4 July 2008 (UTC)
 * Done, replaced the Gray's plate with coiling image. --Steven Fruitsmaak (Reply) 11:23, 4 July 2008 (UTC)
 * I don't think you should have removed Gray's plate. It is more helpful than the second CT brain. JFW | T@lk  23:18, 5 July 2008 (UTC)


 * 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)
 * I'll rephrase this again. JFW | T@lk  23:31, 5 July 2008 (UTC)
 * 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)
 * "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)
 * Okay. In that case it would benefit from a wikilink to a stub article. Axl (talk) 06:36, 7 July 2008 (UTC)
 * Van Gijn bases this on, 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)
 * 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)
 * 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)
 * 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)
 * 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)
 * 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)
 * 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)
 * 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)
 * Yikes, good catch. Reworded entire paragraph to avoid this implication.  delldot   talk  03:48, 5 July 2008 (UTC)
 * 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)
 * Done delldot   talk  03:48, 5 July 2008 (UTC)
 * 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)
 * Well, less sedating and not really in the GCS-dropping leage. I'll clarify. JFW | T@lk  23:18, 5 July 2008 (UTC)
 * 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)
 * 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)
 * 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)
 * I'll rephrase that to be true to its source. JFW | T@lk  23:18, 5 July 2008 (UTC)
 * 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)
 * 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)
 * Ah, yes, you're quite right. The sentence is fine as it stands. Axl (talk) 07:00, 7 July 2008 (UTC)


 * Support. Many thanks to JFW and delldot for addressing my points and producing an excellent article. Axl (talk) 13:01, 7 July 2008 (UTC)
 * The above discussion is preserved as an archive. Please do not modify it. No further edits should be made to this page.