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Differentiation Between Traumatic Tap and Aneurysmal BMJ: First Published As 10.1136/Bmj.H568 on 18 February 2015 RESEARCH OPEN ACCESS Differentiation between traumatic tap and aneurysmal BMJ: first published as 10.1136/bmj.h568 on 18 February 2015. Downloaded from subarachnoid hemorrhage: prospective cohort study Jeffrey J Perry,1 Bader Alyahya,1 Marco L A Sivilotti,2 Michael J Bullard,3 Marcel Émond,4 Jane Sutherland,5 Andrew Worster,6 Corinne Hohl,7 Jacques S Lee,8 Mary A Eisenhauer,9 Merril Pauls,10 Howard Lesiuk,11 George A Wells,12 Ian G Stiell1 For numbered affiliations see ABSTRACT end of article. OBJECTIVES 100 000 person years.1 2 When a patient presents to the Correspondence to: J J Perry, To describe the findings in cerebrospinal fluid from emergency department with sudden severe headache, Clinical Epidemiology Unit, patients with acute headache that could distinguish traditional teaching is to perform computed tomography F647, Ottawa Hospital, 1053, Carling Avenue, Ottawa, ON, subarachnoid hemorrhage from the effects of a of the brain and, if the results are negative for subarach- Canada K1Y 4E9 jperry@ ohri.ca traumatic lumbar puncture. noid hemorrhage, carry out a lumbar puncture to ana- 3–6 Additional material is published DESIGN lyze the cerebrospinal fluid to exclude that diagnosis. online only. To view please visit The sensitivity of modern thin sliced computed tomogra- the journal online (http:// A substudy of a prospective multicenter cohort study. phy for subarachnoid hemorrhage is 100% (95% confi- dx.doi.org/10.1136/BMJ.h568) SETTING dence interval 97% to 100%) when it is performed within Cite this as: BMJ 2015;350:h568 12 Canadian academic emergency departments, from six hours of onset of the headache. If it is carried out after doi: 10.1136/bmj.h568 November 2000 to December 2009. six hours, however, its sensitivity decreases to 85.7% Accepted: 03 January 2015 PARTICIPANTS (78.3% to 90.6%).7 Therefore, if the scan is performed Alert patients aged over 15 with an acute non-traumatic more than six hours after headache onset and is negative headache who underwent lumbar puncture to rule out for subarachnoid hemorrhage, the physician will typi- subarachnoid hemorrhage. cally perform lumbar puncture to rule it out. MAIN OUTCOME MEASURE Unfortunately, it can be difficult to differentiate Aneurysmal subarachnoid hemorrhage requiring whether the blood in the cerebrospinal fluid results intervention or resulting in death. from trauma related to the lumbar puncture itself or RESULTS from a subarachnoid hemorrhage. A so called “trau- Of the 1739 patients enrolled, 641 (36.9%) had matic tap” is estimated to occur in 10–30% of lumbar abnormal results on cerebrospinal fluid analysis punctures, rendering the procedure non-diagnostic and http://www.bmj.com/ with > 1 × 106/L red blood cells in the final tube of often resulting in additional testing and diagnostic cerebrospinal fluid and/or xanthochromia in one or uncertainty.8 Several studies have attempted to find more tubes. There were 15 (0.9%) patients with methods to differentiate traumatic tap from subarach- aneurysmal subarachnoid hemorrhage based on noid hemorrhage, but they have either been too small abnormal results of a lumbar puncture. The presence or had inconclusive results.9–11 Xanthochromia is con- of fewer than 2000 × 106/L red blood cells in addition sidered to be pathognomonic for subarachnoid hemor- to no xanthochromia excluded the diagnosis of rhage, but it is believed to take several hours to develop on 2 October 2021 by guest. Protected copyright. aneurysmal subarachnoid hemorrhage, with a after headache onset. While xanthochromia can indi- sensitivity of 100% (95% confidence interval 74.7% to cate subarachnoid blood, this blood might be caused by 100%) and specificity of 91.2% (88.6% to 93.3%). a perimesencephalic bleed or other non-aneurysmal CONCLUSION bleed, which generally require only observation and No xanthochromia and red blood cell count < 2000 × 106/L have a good prognosis.12–14 reasonably excludes the diagnosis of aneurysmal We assessed the cerebrospinal fluid in prospectively subarachnoid hemorrhage. Most patients with acute enrolled patients with acute non-traumatic headache to headache who meet this cut off will need no further determine if characteristics of cerebrospinal fluid can investigations and aneurysmal subarachnoid hemorrhage distinguish between traumatic tap and clinically relevant can be excluded as a cause of their headache. subarachnoid hemorrhage.15 We aimed to determine the optimal cut point for erythrocyte count in cerebrospinal Introduction fluid for clinically important subarachnoid hemorrhage Subarachnoid hemorrhage is a life threatening neurosur- and whether a combination of red blood cell count cut gical emergency. The estimated incidence is nine per point and visual xanthochromia can reliably differenti- ate between traumatic tap and clinically relevant sub- arachnoid hemorrhage irrespective of the interval WH AT IS ALREADY KNOWN ON THIS TOPIC between the onset of headache and the lumbar puncture. It is often difficult to differentiate blood in cerebrospinal fluid from subarachnoid hemorrhage or as a result of traumatic tap Methods WH AT THIS STUDY ADDS Study design and setting This was a planned substudy from a prospective multi- A red blood cell count of less than 2000 106/L and no xanthochromia reasonably × center cohort study, designed to derive and validate the rules out an aneurysmal subarachnoid hemorrhage Ottawa SAH (subarachnoid hemorrhage) rule (n = 4141). the bmj | BMJ 2015;350:h568 | doi: 10.1136/bmj.h568 1 RESEARCH It was conducted between November 2000 and December the brain or xanthochromia on examination of cerebro- 2009. Patients were enrolled from 12 Canadian academic spinal fluid or red blood cells in the final tube of cere- BMJ: first published as 10.1136/bmj.h568 on 18 February 2015. Downloaded from emergency departments. Study sites had a mean of 52 000 brospinal fluid and they had an aneurysm shown with visits annually and a mean of 445 inpatient beds. cerebral angiography (digital subtraction, magnetic resonance, or computed tomography) requiring any Study population neurovascular intervention or resulting in death. We We enrolled alert patients aged over 15 who presented did not include non-aneurysmal subarachnoid hemor- to the emergency department with acute non-traumatic rhages in our outcome definition. headache and underwent lumbar puncture to rule out Experienced radiologists or neuroradiologists, who subarachnoid hemorrhage. “Alert patients” were were unaware of our study, assessed computed tomo- defined as having a score on the Glasgow coma scale of grams as per normal practice. We utilized their final 15 (that is, alert and oriented), “Non-traumatic” was report to determine the presence of subarachnoid blood defined as no fall or direct head trauma in the seven on the scan. The assessment of cerebrospinal fluid was days before presentation. “Acute headache” was done at the site hospital laboratories following their defined as one that reached maximum intensity within local protocols. Five of the six sites utilized visual xan- an hour of onset. Patients were excluded if they pre- thochromia, with one site using spectrophotometry to sented more than 14 days after the onset of headache; determine xanthochromia. had recurrent headaches (three or more headaches of similar character and intensity as the presenting head- Proxy outcome measure ache over a period of more than six months); were As this was an observational study, we could not alter transferred from another hospital with a confirmed sub- current practice. Therefore patients discharged without arachnoid hemorrhage; and had focal neurological having both computed tomography imaging and a nor- deficits, papilledema, or a history of subarachnoid mal result on lumbar puncture were assessed with our hemorrhage, aneurysm, ventricular shunt, or brain proxy outcome assessment tool. This assessment tool neoplasm. Computed tomography was performed at the included a structured telephone interview one month discretion of the treating physician. Lumbar puncture and six months after assessment in the emergency was also performed at the discretion of the treating phy- department as well as a review of medical records to sician, who was aware of the clinical decision rule study identify any patients who experienced a subsequent but was advised not to alter usual care because of the subarachnoid hemorrhage. The telephone call assessed study. While many physicians order a lumbar puncture repeat physician visits, change in diagnosis, and subse- after normal results on computed tomography, some quent testing with computed tomography, lumbar http://www.bmj.com/ physicians follow the strategy of lumbar puncture puncture, angiography, or magnetic resonance imag- first.16 The decision of whether a lumbar puncture was ing. We internally validated our follow-up tool to iden- warranted and when it was performed was at the discre- tify subarachnoid hemorrhage during our previous tion of the treating physician. phase I derivation study.17 18 When available, patients without telephone follow-up or subsequent hospital Data collection encounters at the enrolling sites were further checked Treating physicians recorded clinical histories and against the provincial coroner’s office to identify any on 2 October 2021 by guest. Protected copyright. examination findings, and research registered nurses deaths compatible with subarachnoid hemorrhage. collected additional reliably recorded data (such as Any patients found to have a subsequent aneurysmal demographics
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