Lesson of the week: Lumbar puncture still has an important role in diagnosing subarachnoid haemorrhage

Wasserberg, Jonathan; Barlow, Philip

doi:10.1136/bmj.315.7122.1598

Cited by 17 publications

(21 citation statements)

References 9 publications

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“…This has led to the recommendation by some authors that the lumbar puncture should not be performed until at least 12 h from the time of the onset of symptoms, in order to minimise the chances of a false negative xanthochromia result. 7,13 Fifty-seven percent of the CSF samples identified as traumatic taps in the present study demonstrated xanthochromia on spectrophotometry. This false-positive rate is excessive and demonstrates a failure of the test as a tool to discriminate between contaminated CSF and true SAH.…”

Section: Discussionmentioning

confidence: 96%

CSF spectrophotometry in the diagnosis and exclusion of spontaneous subarachnoid haemorrhage

Wood¹,

Dimeski

Nowitzke³

2005

Journal of Clinical Neuroscience

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Section: Discussionmentioning

confidence: 96%

CSF spectrophotometry in the diagnosis and exclusion of spontaneous subarachnoid haemorrhage

Wood¹,

Dimeski

Nowitzke³

2005

Journal of Clinical Neuroscience

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“…This practice is predicated on the belief that CT misses up to 10% of SAHs, and presumably a disproportionately greater number among alert, neurologically intact patients. 8 However, there is no consensus regarding what constitutes a positive LP. Because the red blood cell count can be falsely elevated by a traumatic tap, the presence of xanthochromia attributable to hemoglobin oxidation products several hours after the headache onset is considered the sine qua non of SAH.…”

mentioning

confidence: 99%

Should Spectrophotometry Be Used to Identify Xanthochromia in the Cerebrospinal Fluid of Alert Patients Suspected of Having Subarachnoid Hemorrhage?

Perry

Sivilotti²,

Stiell³

et al. 2006

Stroke

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Background and Purpose-The absence of xanthochromia in the cerebrospinal fluid (CSF) is often used to exclude subarachnoid hemorrhage (SAH). Authorities advocate spectrophotometry to measure xanthochromia, but most North American hospitals use visual inspection. We studied the diagnostic accuracy of spectrophotometry for SAH, and its potential impact on current practice. Methods-This was a prospective cohort study comparing the diagnostic accuracy of tests. The study was set in 3 university-affiliated tertiary care emergency departments. We enrolled consecutive neurologically intact adults with nontraumatic headache undergoing lumbar puncture (LP) to rule out SAH. CSF was centrifuged, frozen and analyzed later in batch. SAH was defined by (1) subarachnoid blood on CT, (2) Ͼ5ϫ10 6 red blood cells/L in the final CSF tube and positive angiography, or (3) visible xanthochromia in CSF and positive angiography. All subjects lacking a normal CT and LP were telephoned at 30 days. Results-We enrolled 220 patients (mean age 42Ϯ16 years; CT rate 87.7%; angiography rate 5.9%). Two SAHs were identified: 1 with red blood cells without xanthochromia in the CSF and 1 with visibly xanthochromic CSF. The specificity of xanthochromia was 97% (95% CI: 92% to 99%) for visual inspection, but as low as 29% (95% CI: 23% to 35%) for 2 of the spectrophotometric definitions. Introducing spectrophotometry could lead to angiography in as many as 11% to 71% of patients undergoing LP. Conclusions-Spectrophotometric definitions of xanthochromia have only moderate to low specificity for SAH. Using spectrophotometry could increase angiography rates, thereby identifying more incidental aneurysms, increasing patient anxiety and exposing patients to unnecessary surgical or investigational complications without benefit. (Stroke. 2006; 37:2467-2472.)

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“…Data from the literature and from this study suggest that computed tomography is diagnostic in 97% of cases. 4 The demonstrated delay in obtaining scans is therefore unacceptable.…”

Section: Discussionmentioning

confidence: 99%

Brain attack!--How good is the early management of subarachnoid haemorrhage in accident and emergency departments?

Thomson

Ryan²,

Lyndon³

2000

Emergency Medicine Journal

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Objectives-The aim of this study was to assess the characteristics and audit the management of patients for whom a diagnosis of subarachnoid haemorrhage was made and who were admitted to a neurosurgical centre from an accident and emergency (A&E) departent. The objective was to use the results to make recommendations for improving care in this group of patients. Methods-Four neurosurgical centres in the South Thames Region provided lists of patients admitted with a diagnosis of subarachnoid haemorrhage during 1997. The medical records and computed tomography of 162 patient episodes from 20 A&E departments were reviewed. The speed of presentation, the provisional diagnosis and the referral patterns were examined. Patient records were audited to investigate what proportion were treated according to established guidelines while in the A&E departments. Results-63.7% of patients presented to A&E within six hours of ictus and 81.1% within three days. Some 49.2% of patients were seen by a doctor within 30 minutes and 74.7% within one hour. Computed tomography was performed on 18.8% within two hours and only 66.3% within six hours of arrival at the A&E department. Eighteen per cent were treated with nimodipine, 26% with intravenous fluids and 32% were given analgesia before leaving the department. Delays occurred in obtaining computed tomography. Conclusions-The management of patients who present to A&E departments with subarachnoid haemorrhage is suboptimal. Improved awareness of the disorder, management by senior A&E staV and clear care pathways could help with management. (J Accid Emerg Med 2000;17:176-179)

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Lesson of the week: Lumbar puncture still has an important role in diagnosing subarachnoid haemorrhage

Cited by 17 publications

References 9 publications

CSF spectrophotometry in the diagnosis and exclusion of spontaneous subarachnoid haemorrhage

CSF spectrophotometry in the diagnosis and exclusion of spontaneous subarachnoid haemorrhage

Should Spectrophotometry Be Used to Identify Xanthochromia in the Cerebrospinal Fluid of Alert Patients Suspected of Having Subarachnoid Hemorrhage?

Brain attack!--How good is the early management of subarachnoid haemorrhage in accident and emergency departments?

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