Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging

Abstract

Object When patients present to the emergency department (ED) with acute headache concerning for subarachnoid hemorrhage (SAH) and a lumbar puncture (LP) shows blood in the CSF, it is difficult to distinguish the results of a traumatic LP from those of SAH. CT angiography (CTA) is often performed, but the long-term outcome for patients with a positive LP and normal neurovascular imaging remains uncertain. The primary objective of this study was to determine whether patients who presented to the ED with acute headache and had red blood cells (RBCs) in their CSF on LP but negative cerebrovascular imaging suffered subsequent SAH. Methods A case series study of consecutive adult ED patients who incurred charges for LP between 2001 and 2009 was performed from 2010 through 2011. Inclusion criteria were: headache, > 5 RBCs/mm3 in CSF, noncontrast head CT with no evidence of hemorrhage, and cerebrovascular CTA or MRA without aneurysm or vascular lesion within 2 weeks of the ED visit. Patients with less than 6 months of available follow-up were excluded. The primary outcomes were 1) subsequent nontraumatic SAH and 2) new vascular lesion. Secondary outcomes were complications related to SAH, or LP or angiography. Results Of 4641 ED patients billed for an LP, 181 patients (mean age 42 years) were included in this study. Over a median follow-up of 53 months, 0 (0%) of 181 patients (95% CI 0%–2.0%) had a subsequent SAH or new vascular lesion identified. Although not the primary outcome, there was 1 patient who was ultimately diagnosed with vasculitis. Eighteen (9.9%) of 181 patients (95% CI 6.0%–15.3%) had an LP-related complication and 0 (0%) of 181 patients (95% CI 0%–2.0%) had an angiography-related complication. Conclusions Patients who present to the ED with acute headache concerning for SAH and have a finding of bloody CSF on LP but negative findings on cerebrovascular imaging are at low risk for subsequent SAH and thus are likely to be safe for discharge. Replacement of the CT/LP with a CT/CTA diagnostic algorithm merits further investigation.

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

“…For values of 100-10 000×10 6 /L, it is unclear how sensitive a cut point of 2000×10 6 /L would be for aneurysmal subarachnoid hemorrhage in their series. 2 32 …”

“…The estimated incidence is nine per 100 000 person years. 1 2 When a patient presents to the emergency department with sudden severe headache, traditional teaching is to perform computed tomography of the brain and, if the results are negative for subarachnoid hemorrhage, carry out a lumbar puncture to analyze the cerebrospinal fluid to exclude that diagnosis. 3 4 5 6 The sensitivity of modern thin sliced computed tomography for subarachnoid hemorrhage is 100% (95% confidence interval 97% to 100%) when it is performed within six hours of onset of the headache.…”

An Observational Study of 2,248 Patients Presenting With Headache, Suggestive of Subarachnoid Hemorrhage, Who Received Lumbar Punctures Following Normal Computed Tomography of the Head

“…We found vascular pathology in nine (9.7%) of the 92 patients with positive CSF for blood (eight aneurysms and one carotid cavernous fistula), and conversely no cause for SAH was found in more than 90% of positive LPs. Patients with positive LP and normal subsequent imaging have an excellent prognosis . Causes of spontaneous SAH in these cases include perimesencephalic hemorrhage, brain or spinal arteriovenous malformation , cerebral arterial dissection, vasculitis, stroke, venous sinus thrombosis, sickle cell disease, pituitary apoplexy, and substance abuse.…”

Evaluation of Vascular Endothelial Growth Factor A and Selected Parameters of Coagulation and Fibrinolysis in a Group of Patients with Subarachnoid Haemorrhage

“…During Drevs' and Scheufler's experiment it was proved that the complex morphological and biochemical changes within the microvasculature of the brain after SAH are related to, among others, the expression of molecules such as VEGF-A, tumor necrosis factor (TNF), and fibroblast growth factor [30]. At the same time the correlation between performed surgery in patients with SAH and the increase in the concentration of VEGF-A was observed.…”