Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

McCormack, Robert F.; Hutson, Alan D.

doi:10.1111/j.1553-2712.2010.00694.x

Cited by 130 publications

(86 citation statements)

References 39 publications

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“…Thus, if a patient presents several days after ictus, a negative non-contrast CT is commonly supplemented with a lumbar puncture to evaluate for xanthochromia. Alternatively, CT angiography (CTA) has also been used to increase the detection rate of ruptured cerebral aneurysms in instances where there is a high index of clinical suspicion and a negative noncontrast CT. McCormack et al [15] reported that a negative non-contrast CT followed by a negative CT angiogram carries a post-test probability of 99.43 % of being negative for aneurysmal subarachnoid hemorrhage. The investigators argued that a lumbar puncture in this setting would carry a less than 1 % probability of detecting subarachnoid hemorrhage and that patients should be informed of the low probability when lumbar puncture is offered.…”

Section: Computed Tomography and Ct Angiographymentioning

confidence: 99%

Imaging of cerebral aneurysms: a clinical perspective

et al. 2016

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Neuroimaging is a critical element in evaluating and treating patients with cerebral aneurysms. Each neuroimaging technique has unique strengths, weaknesses, and current developments. In this review, we discuss the utility of two primary noninvasive radiological techniques-computed tomography angiography (CTA) and magnetic resonance angiography (MRA)-as well as of digital subtraction angiography (DSA) for evaluation of cerebral aneurysms. These techniques allow comprehensive evaluation of aneurysm size, location, rupture status, and other imaging characteristics that guide clinicians to make appropriate and timely treatment recommendations.

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Section: Computed Tomography and Ct Angiographymentioning

confidence: 99%

Imaging of cerebral aneurysms: a clinical perspective

et al. 2016

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“…SAH from other causes tends to have a better prognosis and repeat angiography is generally unwarranted (18). A recent analysis of the utility of CTA in the workup of possible SAH determined that, if the pretest probability of SAH is # 15% (acute-onset headache, nonfocal neurologic examination), then a negative NCCT and negative CTA would correlate to a <1% chance of SAH due to AVM or aneurysm (29). These authors stated that in patients with a higher pretest probability (e.g., those with classic presentation, abnormal neurologic examination, or risk factors), a strategy incorporating NCCT, CTA, and LP may be appropriate.…”

Section: Ct/ctamentioning

confidence: 99%

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Meurer

Walsh

Vilke

et al. 2016

The Journal of Emergency Medicine

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, Abstract-Background: Subarachnoid hemorrhage (SAH) is frequently caused by the rupture of an intracranial aneurysmal vessel or arteriovenous malformation, leading to a cascade of events that can result in severe disability or death. When evaluating for this diagnosis, emergency physicians have classically performed a noncontrast computed tomography (NCCT) scan, followed by a lumbar puncture (LP). Recently, however, as CT technology has advanced, many studies have questioned the necessity of the LP in the SAH diagnostic algorithm and have instead advocated for noninvasive techniques, such as NCCT alone or NCCT with CT angiogram (CTA). Objective: The primary goal of this literature search was to determine the appropriate emergency department (ED) management of patients with suspected SAH. Methods: A MEDLINE literature search from October 2008 to June 2015 was performed using the keywords computed tomography AND subarachnoid hemorrhage AND lumbar puncture, while limiting the search to human studies written in the English language. General review articles and single case reports were omitted. Each of the selected articles then underwent a structured review. Results: Ninety-one articles were identified, with 31 papers being considered appropriate for analysis. These studies then underwent a rigorous review from which recommendations were developed. Conclusions: The literature search supports that NCCT followed by CTA is a reasonable approach in the evaluation of ED patients with possible SAH. Ó 2016 Elsevier Inc.

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“…22 A single prospective study of patients with clinical presentations suggestive of SAH has been performed directly comparing CT/CTA with CT/ LP in 106 patients. 6 Based on strict criteria, 2 patients had positive results of LP, and in both cases aneurysms were revealed by CTA and confirmed by DSA.…”

Section: Discussionmentioning

confidence: 99%

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

Thomas

Czuczman

Boulanger

et al. 2014

JNS

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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.

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Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

Cited by 130 publications

References 39 publications

Imaging of cerebral aneurysms: a clinical perspective

Imaging of cerebral aneurysms: a clinical perspective

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

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

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