Defending a traditional practice in the modern era: The use of lumbar puncture in the investigation of subarachnoid haemorrhage

Martin, Sean; Teo, Mario; Young, Adam M. H.; Godber, Ian M; Mandalia, Sachin; George, Elena S.; McGregor, Calum

doi:10.3109/02688697.2015.1084998

Cited by 12 publications

(4 citation statements)

References 18 publications

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“…Lumbar puncture is a skill used to diagnose a variety of diseases, including life-threatening conditions such as central nervous system infections 1 and subarachnoid hemorrhage. 2 Residents are expected to learn the procedure, 3 however, despite clinical training new graduates and residents remain uncertain about how to perform lumbar puncture and their skills do not comply with stakeholders' expectations 4,5 . Residents' disproportionate concerns about the risk of iatrogenic harms may lead to reluctance to perform the procedure.…”

Section: Introductionmentioning

confidence: 99%

Assessment of Residents Readiness to Perform Lumbar Puncture: A Validation Study

et al. 2017

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Section: Introductionmentioning

confidence: 99%

Assessment of Residents Readiness to Perform Lumbar Puncture: A Validation Study

et al. 2017

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“…Although guidelines are not ‘railroads’ for clinicians to follow, 17 omission of LP in suspected SAH diagnosis has been widely criticised, 8 10 11 18 and attributed to a lack of awareness and education. 10 14 However, the role of LP has been called into question due to reported low specificity, low clinical impact, low diagnostic yield and improved sensitivity of modern CT. 3 4 19–23 Doctors are also known to vary in their tolerance of risk and uncertainty which may influence management decisions.…”

Section: Introductionmentioning

confidence: 99%

Subarachnoid haemorrhage guidelines and clinical practice: a cross-sectional study of emergency department consultants' and neurospecialists' views and risk tolerances

et al. 2016

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ObjectivesTo establish if emergency medicine and neuroscience specialist consultants have different risk tolerances for investigation of suspected spontaneous subarachnoid haemorrhage (SAH), and to establish if their risk–benefit appraisals concur with current guidelines.Setting4 major neuroscience centres in London.Participants58 consultants in emergency medicine and neuroscience specialities (neurology, neurosurgery and neuroradiology) participated in an anonymous survey.Primary and secondary outcome measuresThe primary outcome measure was the highest stated acceptable risk of missing SAH in the neurologically intact patient presenting with sudden onset headache. Secondary outcome measures included agreement with guideline recommendations, risk/benefit appraisal and required performance of diagnostic tests, including lumbar puncture.ResultsEmergency department clinicians accepted almost 3 times the risk of a missed SAH diagnosis compared with the neuroscience specialists (2.8% vs 1.1%; p=0.02), were more likely to accept a higher risk of missed diagnosis for the benefit of a non-invasive test (p=0.04) and were more likely to disagree with current published guidelines stipulating the need for LP in all CT-negative cases (p=0.001).ConclusionsDivergence from recognised procedures for SAH investigation is often criticised and attributed to a lack of knowledge of guidelines. This study indicates that divergence from guidelines may be explained by alternative risk–benefit appraisals made by doctors with their patients. Guideline recommendations may gain wider acceptance if they accommodate the requirements of the doctors and patients using them. Further study of clinical risk tolerance may help explain patterns of diagnostic test use and other variations in healthcare delivery.

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“…With such a large number of patients presenting to the ED with a chief complaint of headache [79][80][81][82][83][84], the description of headache can help differentiating those with a benign cause from those with an emergent etiology such as SAH. The diagnosis of SAH should be considered in any patient with a severe and sudden onset or rapidly escalating headache (Figure 5).…”

Section: Initial Imagingmentioning

confidence: 99%

Endovascular Treatment of Brain Aneurysms

Altschul¹,

Vats²,

Unda³

2020

New Insight Into Cerebrovascular Diseases - An Updated Comprehensive Review

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Topic: Chapter discussing the indications for treatment of brain aneurysms, endovascular techniques, tips and tricks. 1. Pathophysiology of aneurysms: Discuss the formation of aneurysms, current thinking of aneurysm development 2. Prevalence/Incidence of aneurysms: Discussion of current state of aneurysm prevalence and how it differs in different populations 3. Unruptured Aneurysms: Diagnosis, Management and Treatment: Imaging paradigms of brain aneurysms, current thoughts on how to follow aneurysms which are being observed, different treatment options for unruptured aneurysms, including clipping, coiling, stent assisted coiling, flow diverter stent, flow disruptors, including the medical management of stent placement 4. Ruptured Aneurysms: Diagnosis, Management and Treatment: Imaging paradigms of ruptured aneurysms, management options for co-morbidities associated with aneurysm rupture, treatment options including coiling, clipping, flow diverter stents, flow disruptors 5. Complication Avoidance: Tips and tricks to avoid complications in the treatment of brain aneurysms.

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Defending a traditional practice in the modern era: The use of lumbar puncture in the investigation of subarachnoid haemorrhage

Abstract: LP has a high diagnostic yield, eliminating the need for neurosurgical opinion or investigation in almost 90% of cases. The test is both cost and time efficient and subjects only a small number of patients to the radiation and contrast risks of angiography.

Cited by 12 publications

References 18 publications

Assessment of Residents Readiness to Perform Lumbar Puncture: A Validation Study

Assessment of Residents Readiness to Perform Lumbar Puncture: A Validation Study

Subarachnoid haemorrhage guidelines and clinical practice: a cross-sectional study of emergency department consultants' and neurospecialists' views and risk tolerances

Endovascular Treatment of Brain Aneurysms

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