Determination of a Testing Threshold for Lumbar Puncture in the Diagnosis of Subarachnoid Hemorrhage after a Negative Head Computed Tomography: A Decision Analysis

Taylor, Richard A.; Gill, Harman S.; Marcolini, Evie G.; Meyers, H. Pendell; Faust, Jeremy Samuel; Newman, David H.

doi:10.1111/acem.13042

Cited by 10 publications

(7 citation statements)

References 62 publications

(118 reference statements)

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“…Accordingly, if the adjusted point estimates for odds of severe disability in this study (range = 0.43–1.68) were used in the authors' model, CT/LP would most likely have been deemed not cost‐effective compared to a CT‐only approach. Likewise in the study by Taylor et al., decreasing the odds of death following a delayed diagnosis of aSAH to 1.8‐fold (point estimates of 0.43–2.07 at 1 year in our analyses) raised the LP testing threshold to an aSAH probability of 15.6%, well beyond reported prevalences of aSAH among ED patients presenting with headaches …”

Section: Discussionsupporting

confidence: 77%

“…Considering other implications for clinical practice, these results can be used to better inform decision analyses, especially since the relative risk of mortality and unfavorable neurologic outcomes have been found to be among the most dominant factors driving the utility of post‐CT testing for aSAH . In the study by Ward et al., using an estimated threefold increased risk of severe disability following a delayed diagnosis of aSAH, the authors reported that performing a lumbar puncture (LP) following a nondiagnostic CT was a cost‐effective diagnostic approach.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis

Mark

Kene

Vinson

et al. 2017

Academic Emergency Medicine

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In a contemporary cohort of patients with aSAH, we observed no statistically significant increase in the adjusted odds of death or unfavorable neurologic outcomes among patients with clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis of aSAH. While these findings cannot exclude a smaller risk difference than previously reported, they can help refine decision analyses and testing threshold determinations for patients with possible aSAH.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis

Mark

Kene

Vinson

et al. 2017

Academic Emergency Medicine

View full text Add to dashboard Cite

show abstract

“…The post‐test threshold is up to the discretion of the individual clinician, in conjunction with informed decision making with the patient, and there is literature available to guide them such as a 2016 paper by Taylor et al . that specifically calculated a test‐threshold for LP after a negative CT.…”

Section: Discussionmentioning

confidence: 99%

Utility of lumbar puncture after a normal brain computed tomography scan in patients presenting to the emergency department with suspected subarachnoid haemorrhage: A new more rational approach?

Pouryahya

Haydon

Meyer

et al. 2020

Emerg Medicine Australasia

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Objective: The diagnostic approach for patients presenting to EDs with headaches suspicious for subarachnoid haemorrhage (SAH) remains challenging. Modern third-generation computed tomography (CT) has been shown to be extremely sensitive in identifying SAH and may eliminate the need for lumbar puncture (LP) which is an invasive, time-consuming procedure with limited accuracy and complications. The aim of this study is to assess the utility of LP in patients being evaluated for possible SAH in the ED after a negative non-contrast CT scan of the brain, as well as addressing the knowledge gap in regard to rational diagnostics among clinicians. Methods: We conducted a retrospective data analysis of patients being evaluated for possible SAH between June 2013 and June 2018 across three EDs in Victoria, Australia. A diagnosis of SAH was defined by SAH on CT or an abnormal cerebrospinal fluid result in conjunction with positive results on cerebral angiography. A follow-up period of 6 months was chosen. Results: A total of 4407 patients met inclusion criteria; 397 (9%) patients were diagnosed with SAH on CT. A total of 388 patients underwent LP and 778 were admitted to hospital for further investigations and management. A total of 2613 patients discharged from ED without LP remained well at 6 months from their initial presentation, but 230 cases were lost to follow up. One patient died from haemorrhagic stroke during his third hospitalisation. A single patient demonstrated a true positive LP after a normal CT brain. Conclusion: LP is not required in all patients with suspected SAH who have a negative CT scan. There are defining patient characteristics that can be used to risk stratify patients and may eliminate the need for LP.

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“…Wenn sich in der nativen CT-Aufnahme von Patienten mit Donnerschlagkopfschmerzen keine Auffälligkeiten zeigen, sollte zum Ausschluss einer Subarachnoidalblutung eine Lumbalpunktion erfolgen. Abweichend von dieser klassischen Lehrmeinung geht der aktuelle Trend jedoch zunehmend dahin, auf eine Lumbalpunktion zu verzichten, da es sich um ein invasives Verfahren mit einer geringen diagnostischen Ausbeute handelt, in dessen Folge sich sogar noch stärkere, postpunktionelle Kopfschmerzen entwickeln können [10,11]. Hinzu kommt, dass eine traumatische Lumbalpunktion die Spezifität weiter verringert.…”

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Akute Kopfschmerzen in der Notaufnahme

Guryildirim¹,

Kontzialis²,

Ozen³

et al. 2021

Neuroradiologie Scan

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Acute headache is a common symptom and is reported by approximately 2 % – 4 % of patients who present to the emergency department. Many abnormalities manifest with headache as the first symptom, and it is crucial to obtain a patient’s complete clinical history for correct diagnosis. Headache onset, duration, and severity; risk factors such as hypertension, immunosuppression, or malignancy; and the presence of focal neurologic deficits or systemic symptoms may aid the radiologist in deciding whether imaging is appropriate and which modality to choose. Imaging findings are more likely to be abnormal in patients with a “thunderclap” headache than in those with headaches of lesser severity. The causes of headache in the emergency setting are various. They may manifest at imaging as subarachnoid hemorrhage (ruptured aneurysm, reversible vasoconstriction syndrome, or pituitary apoplexy), parenchymal hemorrhage (hypertension, ruptured arteriovenous malformation, cerebral amyloid angiopathy, dural arteriovenous fistula, or sinus thrombosis), or parenchymal edema (posterior reversible encephalopathy syndrome, reversible cerebral vasoconstriction syndrome, sinus thrombosis, or encephalitis). Alterations in intracranial pressure that are related to idiopathic intracranial hypertension or spontaneous intracranial hypotension and prior lumbar puncture or epidural injection may manifest with specific imaging findings. With accumulating knowledge of disease pathophysiology, radiologists have started to play a more central role in making the correct diagnosis. This article reviews multiple causes of acute headache and their characteristic appearances at multimodality imaging and familiarizes the reader with current concepts in imaging.

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Determination of a Testing Threshold for Lumbar Puncture in the Diagnosis of Subarachnoid Hemorrhage after a Negative Head Computed Tomography: A Decision Analysis

Cited by 10 publications

References 62 publications

Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis

Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis

Utility of lumbar puncture after a normal brain computed tomography scan in patients presenting to the emergency department with suspected subarachnoid haemorrhage: A new more rational approach?

Akute Kopfschmerzen in der Notaufnahme

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