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The Diagnosis of Subarachnoid Haemorrhage

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The Diagnosis of Subarachnoid Haemorrhage Journal ofNeurology, Neurosurgery, and Psychiatry 1990;53:365-372 365 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.5.365 on 1 May 1990. Downloaded from OCCASIONAL REVIEW The diagnosis of subarachnoid haemorrhage M Vermeulen, J van Gijn Lumbar puncture (LP) has for a long time been of 55 patients with SAH who had LP, before the mainstay of diagnosis in patients who CT scanning and within 12 hours of the bleed. presented with symptoms or signs of subarach- Intracranial haematomas with brain shift was noid haemorrhage (SAH). At present, com- proven by operation or subsequent CT scan- puted tomography (CT) has replaced LP for ning in six of the seven patients, and it was this indication. In this review we shall outline suspected in the remaining patient who stop- the reasons for this change in diagnostic ped breathing at the end of the procedure.5 approach. In the first place, there are draw- Rebleeding may have occurred in some ofthese backs in starting with an LP. One of these is patients. that patients with SAH may harbour an We therefore agree with Hillman that it is intracerebral haematoma, even if they are fully advisable to perform a CT scan first in all conscious, and that withdrawal of cerebro- patients who present within 72 hours of a spinal fluid (CSF) may occasionally precipitate suspected SAH, even if this requires referral to brain shift and herniation. Another disadvan- another centre.4 tage of LP is the difficulty in distinguishing It could be argued that by first performing between a traumatic tap and true subarachnoid CT the diagnosis may be delayed and that this haemorrhage. Secondly, the use of CT within may be dangerous if the patient has bacterial the first two or three days offers a wealth of meningitis. However, the likelihood of menin- information about the origin and extent of the gitis is extremely small in patients with an haemorrhage, and about the presence of early adequate history of headache or unconscious- complications requiring urgent treatment. An ness coming on within seconds and only rarely early brain scan also serves as a baseline against is the distinction more difficult, for instance, in which future changes can be measured. The patients who have been found in a- confused information about the location of the haemor- state, with marked neck stiffness and moderate rhage is especially valuable in patients with fever. SAH and a negative angiogram. This is a Ideally, patients with suspected SAH should heterogeneous group of patients which will be not be admitted to a hospital without CT http://jnnp.bmj.com/ discussed separately. The review continues scanning facilities (and patients with confirmed with guidelines about the interpretation of the SAH not to hospitals without a neurosurgical CSF in patients with a negative CT scan, which unit). is the only remaining indication for LP in the diagnosis of SAH. The final paragraph points out the many pitfalls in the diagnosis of Traumatic tap or intracranial bleeding? rebleeding by analysis of CSF samples, which Neck stiffness following SAH takes three to 12 makes serial CT scanning by far the preferred hours to develop-it is an unreliable test to on September 27, 2021 by guest. Protected copyright. method. perform on domiciliary calls. Patients arriving in casualty with a history of "thunderclap headache" a few hours earlier and with equi- The dangers of lumbar puncture vocal neck stiffness may either have a true SAH The possibility of a haematoma being present or a more usual type of headache with an in patients who present with the clinical unusual onset.' If an LP is performed and features of SAH should be considered. In a blood-stained CSF is found it is difficult to series of 100 consecutive patients who were distinguish between a traumatic tap and intra- suspected of aneurysmal rupture, fifteen had a cranial bleeding. It is a widely held belief that non-aneurysmal haematoma and eight of these this distinction can be made by collecting the were located in the cerebellum.' It is obvious CSF in three test tubes and by counting the red that an LP could have done harm in these cells in the consecutive tubes. A decrease in red patients. In addition, a third of patients with a cells would indicate a traumatic tap. Indeed, a Department of Neurology, University ruptured aneurysm harbour an intracerebral decrease in red cells occurs more often in Hospital Dijkzigt, haematoma,`'' and even in patients without traumatic punctures than in intracranial bleed- Rotterdam neurological signs other than neck stifEfess 10 ing, but it also occurs in patients with a M Vermeulen per cent may have a haematoma of at least previous bleed.9 Conversely, a constant num- University 30 mm.4 ber of cells can be seen with traumatic taps. In Department of Neurology, Utrecht, Deterioration after LP is not only a theor- the individual case therefore no firm diagnosis The Netherlands etical possibility as shown by Duffy, who can be made with this "three tube method". J van Gijn described severe clinical deterioration in seven The opinion of the doctor who carried out 366 Vermeulen, van Giin the LP also appears unreliable. In a study by as possible. On the day of SAH, intracranial J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.5.365 on 1 May 1990. Downloaded from Buruma et al doctors were often unable to blood is detected in about 95% of patients. decide for themselves whether the blood- This proportion declines to 90% after one day, stained CSF had resulted from the procedure 80% after five days, and 50% after one week.316 or not.9 The form ofthe red cells changes in the In the first place, if intracranial blood is CSF, and this so-called crenation of red cells detected, the site of the haemorrhage often has been advocated as a means of differentiat- indicates the likely source. In case of an ing a traumatic tap from a true haemorrhage. intracerebral haematoma, it is often possible to However, crenation of red cells occurs very distinguish primary intraparenchymal bleed- soon after red cells have entered the CSF and ing from SAH extending into the brain tissue may therefore be seen in many traumatic taps.'0 (fig 1).1' It is not always easy to determine Cytology of the CSF is also of limited value. whether a haematoma associated with The presence of erythrophages indicates aneurysm rupture is in fact intraparenchymal intracranial haemorrhage if an LP was not or whether it has only distended the subarach- carried out earlier, but it takes some time before noid space, usually the frontal interhemis- siderophages are demonstrable. Moreover, pheric or sylvian fissure.'8 However, this dis- negative cytology does not exclude a haemor- tinction is of limited importance for practical rhage.9 management, and follow up scans will usually The most reliable method for distinguishing resolve the issue. In case the extravasated blood a traumatic tap from a genuine bleed is to spin is confined to the basal cisterns, a ruptured down the CSF and to examine the supernatant aneurysm can be diagnosed ifthe subarachnoid fluid for the presence of xanthochromia. clots are most dense at one of the classical Examination ofthe supernatant should be dohe aneurysm sites (fig 2): the frontal interhemis- with spectrophotometry and not with the pheric fissure (aneurysm of the anterior com- naked eye, since direct vision is a rather in- municating artery), the chiasmatic cistern on sensitive method. In a series of32 CSF samples one side (aneurysm of the internal carotid in which spectrophotometry had detected xan- artery, usually at the origin of the posterior thochromia, this was visible with the naked eye communicating artery), or the most lateral part in only half the samples." The pigments that of the sylvian fissure (aneurysm of the middle are responsible for the yellow colour ofthe CSF cerebral artery).' '9 after a haemorrhage result from lysis of red Bleeding from aneurysms at more unusual cells. The average survival of red cells in the sites may be more difficult to recognise; CSF is much shorter than in the circulation. aneurysmal bleeding from a posterior inferior This rapid haemolysis has not been fully ex- cerebellar artery, for instance, may be easily plained. Recently, it has been suggested that missed by CT.202' Predicting the site of a red cells in the subarachnoid space lose their ruptured aneurysm from the CT scan is more identity as autologous cells and this results in than an intellectual game. This information is immune mediated haemolysis.'2 helpful in planning angiography, in particular In the classic study by Barrows et al the the order and the extent of selective catheter- development of xanthochromia was studied by isation, and it is vital ifmore than one aneurysm means of spectrophotometry.'3 This technique is found.' 21-23 Even the uncommon event oftwo http://jnnp.bmj.com/ measures the light intensity in different regions aneurysms rupturing at the same time can be of the visible spectrum (400-700 nm), after correctly documented by CT.24 Visualisation of transmission of light through the coloured the aneurysm itself, after injection of contrast, CSF. Three different pigments can be distin- used to be the exception with CT, indicating guished by their characteristic absorption that the aneurysm is very large, with or without bands in the spectrum: oxyhaemoglobin, calcification.' High-resolution CT scanning, methaemoglobin, and bilirubin. The wave- with 1-5 mm slices, is more sensitive but not length where absorption occurs permits quali- infallible.25 Magnetic resonance imaging on September 27, 2021 by guest. Protected copyright.
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