Differential diagnostic yield of lumbar puncture in investigation of suspected subarachnoid haemorrhage: a retrospective study

Brunell, Anna; Ridefelt, Peter; Zelano, Johan

doi:10.1007/s00415-013-6846-x

Cited by 22 publications

(16 citation statements)

References 17 publications

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“…Six studies examined diagnostic accuracy of xanthrochromia on CSF analysis, but investigators used variable methods to assess xanthochromia ranging from visible inspection to multiple different spectrophotometric assays (Table , Figure ) . For visible xanthochromia the pooled meta‐analysis results were as follows: sensitivity was 85% (95% CI = 66% to 96%, I 2 = 0%), specificity as 97% (95% CI = 96% to 98%, I 2 = 13%), LR+ was 24.67 (95% CI = 12.13 to 50.14, I 2 = 64%), and LR− was 0.22 (95% CI = 0.09 to 0.54, I 2 = 13%).…”

Section: Resultsmentioning

confidence: 99%

“…Brunell et al noted that LP provided an alternative diagnosis in 3% of suspected SAH cases, but only altered subsequent management in 0.44% of individuals who had an LP. This equates to 227 LPs (1/0.0044) to identify one central nervous system infection requiring antibiotics in suspected SAH patients.…”

Section: Discussionmentioning

confidence: 99%

“…Yet many patients fear having an LP because an LP is painful and invasive and can lead to a post‐LP headache in 6%–30% of patients depending on the gauge of the LP needle . Additional clinician‐level barriers to LP testing include the time needed to perform and low diagnostic yield . In addition, LP may be contraindicated if a patient has a bleeding disorder or increased intracranial pressure or simply does not consent to the procedure .…”

Section: Potential Etiologies Of Spontaneous Sahmentioning

confidence: 99%

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Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

Carpenter

Hussain

Ward

et al. 2016

Academic Emergency Medicine

108

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Background Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The diagnosis of SAH is especially challenging in alert, neurologically intact patients, as missed or delayed diagnosis can be catastrophic. Objectives To perform a diagnostic accuracy systematic review and meta-analysis of history, physical examination, cerebrospinal fluid (CSF) tests, computed tomography (CT), and clinical decision rules for spontaneous SAH. A secondary objective was to delineate probability of disease thresholds for imaging and lumbar puncture (LP). Methods PUBMED, EMBASE, SCOPUS, and research meeting abstracts were searched up to June 2015 for studies of emergency department (ED) patients with acute headache clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and, when appropriate, meta-analysis was conducted using random effects models. Outcomes were sensitivity, specificity, positive (LR+) and negative (LR−) likelihood ratios. To identify test- and treatment-thresholds, we employed the Pauker-Kassirer method with Bernstein test-indication curves using the summary estimates of diagnostic accuracy. Results A total of 5,022 publications were identified, of which 122 underwent full text-review; 22 studies were included (average SAH prevalence 7.5%). Diagnostic studies differed in assessment of history and physical exam findings, CT technology, analytical techniques used to identify xanthochromia, and criterion standards for SAH. Study quality by QUADAS-2 was variable; however, most had a relatively low-risk of biases. A history of neck pain (LR+ 4.1 [95% CI 2.2-7.6]) and neck stiffness on physical exam (LR+ 6.6 [4.0-11.0]) were the individual findings most strongly associated with SAH. Combinations of findings may rule out SAH, yet promising clinical decision rules await external validation. Non-contrast cranial CT within 6 hours of headache onset accurately ruled-in (LR+ 230 [6-8700]) and ruled-out SAH (LR− 0.01 [0-0.04]); CT beyond 6 hours had a LR− of 0.07 [0.01-0.61]. CSF analyses had lower diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia. At a threshold RBC count of 1,000 × 106/L, the LR+ was 5.7 [1.4-23] and LR− 0.21 [0.03-1.7]. Using the pooled estimates of diagnostic accuracy and testing risks and benefits, we estimate LP only benefits CT negative patients when the pre-LP probability of SAH is on the order of 5%, which corresponds to a pre-CT probability greater than 20%. Conclusions Less than one in ten headache patients concerning for SAH are ultimately diagnosed with SAH in recent studies. While certain symptoms and signs increase or decrease the likelihood of SAH, no single characteristic is sufficient to rule-in or rule-out SAH. Within 6 hours of symptom onset, non-contrast cranial CT is highly accurate, while a negative CT beyond 6 hours substantially reduces the likelihood of SAH. LP appears to benefit relatively few patients within a narrow pre-test probability range. With improvements in CT technology and an e...

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Potential Etiologies Of Spontaneous Sahmentioning

confidence: 99%

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Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

Carpenter

Hussain

Ward

et al. 2016

Academic Emergency Medicine

108

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“…Given the low rates of patients receiving lumbar puncture and catheter angiography in our study, the possibility of missed SAH may not be excluded. Nevertheless, based on the high sensitivity of the modern CT to detect SAH and CTA/MRA to detect aneurysm and the fact that no patients developed SAH during at least 6 months of follow-up, the contribution of missed SAH to the low SAH percentage in our study may be minor [17,28,29]. …”

Section: Discussionmentioning

confidence: 99%

A common cause of sudden and thunderclap headaches: reversible cerebral vasoconstriction syndrome

2014

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BackgroundThunderclap headache (TCH) is a sudden headache (SH) with accepted criteria of severe intensity and onset to peak within one minute. It is a well-known presentation for subarachnoid hemorrhage (SAH) but most patients with TCH or SH run a benign course without identifiable causes. Reversible cerebral vasoconstriction syndrome (RCVS), a recently recognized syndrome characterized by recurrent TCH attacks, has been proposed to account for most of these patients.MethodsWe recruited consecutive patients presenting with SH at our headache clinic. Computed tomography and/or magnetic resonance imaging with angiography were performed to exclude structural causes and to identify vasoconstriction. Catheter angiography and lumbar puncture were performed with patients consent. Reversibility of vasoconstriction was confirmed by follow-up study.ResultsFrom July 2010 to June 2013, 31 patients with SH were recruited. Twenty-four (72.7%) of these SH patients exhibited headache fulfilling the TCH criteria. The diagnosis of RCVS was confirmed in 14 (45.2%) of patients with SH and 11 (45.8%) of patients with TCH. Other diagnoses were as follows: primary headaches (SH: 41.9%, TCH: 45.8%) and other secondary causes (SH: 12.9%, TCH: 8.3%). Compared with non-RCVS patients, patients with RCVS were older (50.8 ± 9.3 years vs. 40.8 ± 10.0 years, P = 0.006) and less likely to experience short headache duration of < 1 hour (23.1% vs. 78.6%, P = 0.007). Patients with RCVS were more likely to cite bathing (42.9% vs. 0%, P = 0.004) and less likely to cite exertion (0% vs. 29.4%, P = 0.048) as headache triggers.ConclusionsReversible cerebral vasoconstriction syndrome is a common cause of SH and TCH. Considering the potential mortality and morbidity of RCVS, systemic examination of cerebral vessels should be performed in these patients.

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“…Brunell and colleagues found that a LP could reveal an alternative diagnosis in 3% of the patients, eg, meningitis. 19 Post-dural-puncture headache occurs in many, and patients with pre-morbid headaches are particularly at risk. 20 Rare serious complications include cerebral venous sinus thrombosis, CNS infections, and brain herniation.…”

Section: Post Contrast T1-weighted Mri (Picture In the Middle) Shows mentioning

confidence: 99%

What is Currently the Best Investigational Approach to the Patient With Sudden‐Onset Severe Headache?

Sjulstad

Alstadhaug

2019

Headache

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A 48-year-old man with no previous medical history suddenly experienced severe intense retro-bulbar pain of pulsating character on the right side, and was seen in the emergency department 7 hours later. He was then alert and oriented, but in excruciating pain. There was no neck stiffness and no fever. The blood pressure was 141/80 mm Hg, and the pulse regular with a frequency of 48. Neurological examination was normal. Query by Dr. Sjulstad: When does actually sudden-onset severe headache represent a potential life-threatening condition?Response by Dr. Alstadhaug: There is no definite answer to that question. Atypical presentation of subarachnoid hemorrhage (SAH) with mild, or slowly progressive headache over minutes, and even absence of headache may occur in up to 3.8% of patients as reported in a recent Japanese study, 1 but previously up to 10% has been reported. 2 In a case series with 42 patients who had bled from an aneurysm, the headache came instantly in 50%, after 2-60 seconds in 24%, and within 1-5 minutes in 19%. 3 In 10%-40% of patients with diagnosed bleeding from an aneurysm, there has been an episode with hyperacute headache prior to the one that led to the diagnosis. 4 Such a warning leak has typically been reported to occur a couple of weeks earlier, but the risk of re-bleeding after SAH is highest within the first 24 hours. Non-ruptured aneurysms may also cause headache (dissection in the aneurysm wall, acute expansion or thrombosis), but more often they cause focal symptoms/signs due to mass effect Headache

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Differential diagnostic yield of lumbar puncture in investigation of suspected subarachnoid haemorrhage: a retrospective study

Cited by 22 publications

References 17 publications

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

A common cause of sudden and thunderclap headaches: reversible cerebral vasoconstriction syndrome

What is Currently the Best Investigational Approach to the Patient With Sudden‐Onset Severe Headache?

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