Thunderclap Headache and Normal Computed Tomographic Results: Value of Cerebrospinal Fluid Analysis

Dupont, Stefan A.; Wijdicks, Eelco F. M.; Manno, Edward M.; Rabinstein, Alejandro A.

doi:10.4065/83.12.1326

Cited by 52 publications

(26 citation statements)

References 15 publications

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“…142 Sampling of CSF, usually by lumbar puncture, is another method of detecting SAH for the relatively uncommon situation in which neuroimaging is normal or equivocal but clinical suspicion is high. Visual inspection of CSF for xanthochromia, yellowish discoloration that occurs with SAH caused by breakdown of heme from red blood cells in the CSF, was associated with a sensitivity, specificity, positive predictive value, and negative predictive value of 93%, 95%, 72%, and 99%, respectively, for detecting SAH in 1 study, 143 while another study found sensitivity to be only 47.3%. 144 In a prospective study of patients who presented with acute headache to 2 tertiary care centers, the combination of negative CT and negative lumbar puncture was sufficient to rule out SAH with a sensitivity of 100%.…”

Section: Subarachnoid Hemorrhagementioning

confidence: 99%

An Updated Definition of Stroke for the 21st Century

Sacco¹,

Kasner²,

Broderick³

et al. 2013

Stroke

2,614

1,029

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Despite the global impact and advances in understanding the pathophysiology of cerebrovascular diseases, the term “stroke” is not consistently defined in clinical practice, in clinical research, or in assessments of the public health. The classic definition is mainly clinical and does not account for advances in science and technology. The Stroke Council of the American Heart Association/American Stroke Association convened a writing group to develop an expert consensus document for an updated definition of stroke for the 21st century. Central nervous system infarction is defined as brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. Central nervous system infarction occurs over a clinical spectrum: Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction by definition causes no known symptoms. Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage. The updated definition of stroke incorporates clinical and tissue criteria and can be incorporated into practice, research, and assessments of the public health.

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Section: Subarachnoid Hemorrhagementioning

confidence: 99%

An Updated Definition of Stroke for the 21st Century

Sacco¹,

Kasner²,

Broderick³

et al. 2013

Stroke

2,614

1,029

View full text Add to dashboard Cite

show abstract

“…If the appropriate history and symptoms are present, the classic teaching is to perform a noncontrast computed tomography (NCCT) scan of the head, followed by a lumbar puncture (LP) if the NCCT does not show clear evidence of SAH (8)(9)(10). If the LP shows no signs of xanthrochromia (visual or spectrophotometric) or elevated red blood cells, then one can safely exclude SAH as a diagnosis, with very few exceptions (11)(12)(13).…”

Section: Introductionmentioning

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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“…Of note, this study defined a positive LP as the presence of bilirubin by spectrophotometry (ie, xanthochromia), which is known to be sensitive but lacks specificity. 33,34 In an ED population of patients with isolated thunderclap headache who present early enough to undergo CT within 6 hours of symptom onset, the incidence of SAH is reported ≈13% (higher than in patients with thunderclap headache who present later).…”

mentioning

confidence: 99%

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage

Dubosh

Bellolio

Rabinstein

et al. 2016

Stroke

Self Cite

122

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H eadache accounts for ≈2% of all emergency department (ED) visits. 1 A subset of these patients present with abrupt onset of a severe headache reaching peak intensity within 60 s referred to as a thunderclap headache. 2 The most serious cause of thunderclap headache is aneurysmal subarachnoid hemorrhage (SAH), which accounts for 4% to 12% of ED patients with a thunderclap headache. [3][4][5][6] Current clinical practice calls for a noncontrast computed tomography (CT) of the brain followed by a lumbar puncture (LP) if the CT scan is negative to exclude SAH. [7][8][9][10] This is because the sensitivity of CT scans for detecting subarachnoid blood ranges from 90% to 100% when performed within the first 24 hours after symptom onset. The sensitivity decreases as time from onset to CT elapses because the blood is progressively diluted by the normal flow of cerebrospinal fluid. 6,[11][12][13][14][15][16] Recent data suggest that in neurologically intact patients, the sensitivity of modern CT scanners for SAH approaches 100% when performed within 6 hours of headache onset and interpreted by qualified radiologists. 11,13,[17][18][19][20] These data suggest that in this early-presenting population, an LP is not necessary to rule out SAH and an initial negative CT can be considered a rule-out test. An LP is associated with patient anxiety and discomfort and can be complicated by postprocedure headache (15%-20% of patients). 21 Traumatic taps, which occur in 10% to 15% of patients, may lead to unnecessary vascular imaging and other downstream consequences. 3,[20][21][22] We conducted a systematic review and meta-analysis to determine the diagnostic accuracy of early CT only in the diagnosis of spontaneous SAH. Our objective was to determine the sensitivity, specificity, and positive and negative Background and Purpose-Emerging evidence demonstrating the high sensitivity of early brain computed tomography (CT) brings into question the necessity of always performing lumbar puncture after a negative CT in the diagnosis of spontaneous subarachnoid hemorrhage (SAH). Our objective was to determine the sensitivity of brain CT using modern scanners (16-slice technology or greater) when performed within 6 hours of headache onset to exclude SAH in neurologically intact patients. Methods-After conducting a comprehensive literature search using Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus, we conducted a meta-analysis. We included original research studies of adults presenting with a history concerning for spontaneous SAH and who had noncontrast brain CT scan using a modern generation multidetector CT scanner within 6 hours of symptom onset. Our study adheres to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Results-A total of 882 titles were reviewed and 5 articles met inclusion criteria, including an estimated 8907 patients.Thirteen had a missed SAH (incidence 1.46 per 1000) on brain CTs within 6 hours. Overall sensitivity of the CT was 0.987 (95% confidence intervals, 0.971-0.994) and s...

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Thunderclap Headache and Normal Computed Tomographic Results: Value of Cerebrospinal Fluid Analysis

Cited by 52 publications

References 15 publications

An Updated Definition of Stroke for the 21st Century

An Updated Definition of Stroke for the 21st Century

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage

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