DOCSLIB.ORG

Ruptured Aneurysmal Subarachnoid Hemorrhage in The

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Ruptured Aneurysmal Subarachnoid Hemorrhage in The View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Clinical Biochemistry 48 (2015) 634–639 Contents lists available at ScienceDirect Clinical Biochemistry journal homepage: www.elsevier.com/locate/clinbiochem Ruptured aneurysmal subarachnoid hemorrhage in the emergency department: Clinical outcome of patients having a lumbar puncture for red blood cell count, visual and spectrophotometric xanthochromia after a negative computed tomography Anne Gangloff a,c,1, Linda Nadeau b,c, Jeffrey J. Perry d,e, Pierre Baril c,MarcelÉmonda,b,c,⁎,1 a Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Quebec, Canada b Université Laval, Quebec, Canada c CHU de Québec, Emergency departement d Ottawa Hospital Research Institute, Ottawa, Canada e University of Ottawa Department of Emergency Medicine, Ottawa, Canada article info abstract Article history: Objectives: Over the last decade, computed tomography scanners have gained resolution and have become Received 25 November 2014 the standard of care in the investigation of neurologically intact patients suffering from acute headache. The Received in revised form 17 March 2015 added value of the combined assessment of red blood cells count, visual and spectrophotometric xanthochromia, Accepted 18 March 2015 to detect ruptured aneurysmal subarachnoid hemorrhage (ASAH) following a negative head computed tomography Available online 26 March 2015 (NHCT) was studied. Methods: The population consisted of all patients who had cerebrospinal fluid tested for spectrophotometric Keywords: xanthochromia between 2003 and 2009 identified through the clinical-laboratory database and who met all the Aneurysmal subarachnoid haemorrhage N Cerebrospinal fluid inclusion criteria: 14 years old, had an initial Glasgow Coma Score of 15, a non-traumatic acute headache with a Spectrophotometric xanthochromia suspected subarachnoid hemorrhage recorded in the initial ED differential diagnosis and an initial negative head Visual xanthochromia CT scan. Negative head computed tomography Results: A total of 706 patients were included. LP identified 5 ASAH (prevalence: 0.7%). In these patients, LP parameters were as follows: high red blood cell count (from 1310 to 63,000 × 106/L), positive visual xanthochromia in 4 out of 5 ASAH, and positive spectrophotometric xanthochromia in 5 out of 5 ASAH. All ASAH patients were neurologically intact after intervention. No deaths or missed ASAH were reported. Angiographies were performed on 127 patients (19.5%) of which 47 (34.1%) had positive xanthochromia (visual or spectrophotometric). Conclusions: Considering the low prevalence of ASAH following an NHCT, intense resources were utilized to identify all 5 ASAH. Lumbar puncture analyses combining red blood cell count, visual and spectrophotometric xanthochromia identified all ASAH, allowing intervention and a positive clinical outcome. Our data support 1) that LP identifies the presence of a ruptured ASAH after an NHCT and 2)` that a guide to define a subpopulation of patients who would benefit from a lumbar puncture after an NHCT would be desirable. © 2015 The Authors. The Canadian Society of Clinical Chemists. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction 66.7% [2]. Neurologically intact patients in good clinical condition with symptomatic cerebral aneurysms are commonly misdiagnosed and are Subarachnoid hemorrhage accounts for only 4.4% of stroke mortality more likely to deteriorate clinically than correctly diagnosed patients: but occurs at a young age, producing a relatively large burden of prema- thus this subpopulation of patients have a worse overall outcome [3]. ture mortality, comparable to ischemic stroke [1]. It is associated with Mayer et al. described that among patients initially presenting as a high mortality and high morbidity. Case fatality ranges from 8.3% to Hunt and Hess clinical grade 1 or 2, an overall good or excellent out- come was achieved in 91% of those with a correct initial diagnosis. Good or excellent outcomes dropped to 53% of patients initially misdiagnosed [3]. In the 1990s, only about 3% of patients with acute ⁎ Corresponding author. E-mail address: [email protected] (M. Émond). headache and normal head third-generation computed tomography 1 These authors contributed equally to this work. (CT) had a subarachnoid hemorrhage [4]. Since missing the diagnosis http://dx.doi.org/10.1016/j.clinbiochem.2015.03.011 0009-9120/© 2015 The Authors. The Canadian Society of Clinical Chemists. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). A. Gangloff et al. / Clinical Biochemistry 48 (2015) 634–639 635 can have life threatening consequences, the small risk of missing a SAH radiologist. The investigation after the initial NHCT was left to the at- has to be weighed against the fact that a curative treatment exists. tending physician. Charts were reviewed with a standardized data col- Aneurysmal subarachnoid hemorrhage (ASAH) is a dreadful condi- lection sheet by 2 trained observers. Socio-demographic, clinical tion to rule out in the emergency department (ED). It is usually features, radiology reports, surgical/radiology interventions and labora- suspected from the clinical presentation, including thunderclap head- tory data were recorded. Inter-observer agreements were assessed and ache, a sudden and severe headache, which is a cardinal symptom of reported. All patients had a lumbar puncture performed by an emergency subarachnoid hemorrhage [5]. Head CT scan is a well-established first physician or resident after head imaging. The retrospective design of the line test to detect subarachnoid hemorrhage in the ED. A recent Canadi- study identified consecutive patients. CT scanners were from Siemens an study demonstrated that third generation head CT scans detected all (Sensation 4 from 2003 to 2008, Sensation 16 from 2008 to the end of subarachnoid hemorrhage, when performed within 6 h of the onset of the study). symptoms [6]. However, as the time between the onset of the symp- Outcome of patients discharged from the ED and “Safety-net”:as toms and the CT scan increases, the sensitivity for subarachnoid hemor- most missed aneurysm rebleed shortly after their initial medical assess- rhage detection decreased to 85% for patients scanned after 6 h [6]. ment [21], our study had a safety-net for possible missed subarachnoid Therefore, patients suffering from acute headache with a negative CT hemorrhage: the Hôpital de l’Enfant-Jésus is the only neurosurgical refer- are usually further investigated [5,7]. The conservative practice is to ral center covering more than half of the province of Quebec (roughly 2 use lumbar puncture to verify red blood cell count and the presence of million residents), a false-negative patient discharged from the emer- xanthochromia in order to identify patients who would benefit gency department would eventually be picked up on a follow-up visit the most from an angiography investigation [5]. This practice has been or readmission to the emergency department/hospital or in event of challenged [8,9] and remains the subject of much debate. any sudden death through coroner investigation. The presence of Visual xanthochromia is the yellow discoloration of CSF detected medical encounter that occurred after the initial visit to the emergency by visual inspection of the supernatant of a centrifuged cerebrospinal department was recorded and patients were considered “alive” and free fluid [10]. Optimal assessment of visual xanthochromia requires a of ASAH. The Comité d'éthique du CHU de Québec approved this study standardized procedure including trained personnel, appropriate light- (project #2012-1387). ening [11], assessment of CSF color against a white background and compared with a similar tube filled with water. Spectrophotometric Laboratory assessment of cerebrospinal fluid xanthochromia xanthochromia is the measurement of hemoglobin breakdown prod- ucts, especially bilirubin which is only formed in vivo, allowing to distin- Visual and spectrophotometric xanthochromia were performed on guish between a traumatic lumbar puncture tap and a subarachnoid fresh, centrifuged, light protected cerebrospinal fluid kept at room tem- hemorrhage [10,12]. Spectrophotometric xanthochromia is a heteroge- perature and analyzed immediately after arrival to the laboratory on a neous term referring to all methods that use a spectrophotometer to 24/7 basis. Visual analysis was performed by observing the supernatant measure hemoglobin breakdown products such as bilirubin. Among of a cerebrospinal fluid sample centrifuged at room temperature for the different spectrophotometric methods, the United Kingdom Nation- 10 min and 900 g: CSF was described as xanthochromic if the color al External Quality Assessment Service (UKNEQAS) 2008 approach [13] was yellow. Visual assessment was made by the technologist on duty. and the iterative method [13] are commonly used. The UKNEQAS 2008 The technologists were not systematically instructed to compare the approach consists of drawing a tangent to the scan and calculating the CSF with a similar tube filled with water and against a white back- net bilirubin absorbance at 476 nm and the net oxyhemoglobin absor- ground. Spectrophotometric analysis of cerebrospinal
Load more

Recommended publications
  • 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.
    [Show full text]
  • Cerebrospinal Fluid in Critical Illness
    Cerebrospinal Fluid in Critical Illness B. VENKATESH, P. SCOTT, M. ZIEGENFUSS Intensive Care Facility, Division of Anaesthesiology and Intensive Care, Royal Brisbane Hospital, Brisbane, QUEENSLAND ABSTRACT Objective: To detail the physiology, pathophysiology and recent advances in diagnostic analysis of cerebrospinal fluid (CSF) in critical illness, and briefly review the pharmacokinetics and pharmaco- dynamics of drugs in the CSF when administered by the intravenous and intrathecal route. Data Sources: A review of articles published in peer reviewed journals from 1966 to 1999 and identified through a MEDLINE search on the cerebrospinal fluid. Summary of review: The examination of the CSF has become an integral part of the assessment of the critically ill neurological or neurosurgical patient. Its greatest value lies in the evaluation of meningitis. Recent publications describe the availability of new laboratory tests on the CSF in addition to the conventional cell count, protein sugar and microbiology studies. Whilst these additional tests have improved our understanding of the pathophysiology of the critically ill neurological/neurosurgical patient, they have a limited role in providing diagnostic or prognostic information. The literature pertaining to the use of these tests is reviewed together with a description of the alterations in CSF in critical illness. The pharmacokinetics and pharmacodynamics of drugs in the CSF, when administered by the intravenous and the intrathecal route, are also reviewed. Conclusions: The diagnostic utility of CSF investigation in critical illness is currently limited to the diagnosis of an infectious process. Studies that have demonstrated some usefulness of CSF analysis in predicting outcome in critical illness have not been able to show their superiority to conventional clinical examination.
    [Show full text]
  • Thunderclap Headache and Subarachnoid Hemorrhage
    Thunderclap Headache and Subarachnoid Hemorrhage W David Freeman, MD No conflicts of interest or disclosures Subarachnoid Hemorrhage Neurocrit Care. 2017 Sep;27(Suppl 1):116- 123. doi: 10.1007/s12028-017-0458-8. Objectives •Recognize the symptoms (thunderclap headache) and Subarachnoid signs of SAH Hemorrhage •Initiate workup for suspected SAH •Initial management of SAH patient Case • 39 year old woman presents with severe headache, uncertain time of onset, associated with nausea • PMH: long history of migraine headaches • Meds: • Reports taking ibuprofen prior to ED, with moderate improvement of headache • Taking warfarin for a pelvic DVT - year prior during pregnancy • Exam: sleepy, yet follows commands, left eye droop and dilated pupil, moving all extremities • BP 160/95 mmHg, RR 24/min, HR 98/min • Breathing shallow and rapid, airway protection uncertain Initial Checklist in Emergency Dept. ☐ Brain Imaging ☐ Labs: PT/PTT, CBC, electrolytes, BUN, Cr, troponin, toxicology screen ☐ 12 lead ECG ☐ Blood pressure goal established ☐ Consult neurosurgery ☐ Address hydrocephalus SAH Algorithm Neurocrit Care. 2017 Sep;27(Suppl 1):116- 123. doi: 10.1007/s12028-017-0458-8. SAH Symptoms and Signs CLASSIC NOT-SO-CLASSIC Abrupt onset of severe headache (HA), HA is not reported as abrupt (patient may i.e. thunderclap not remember event well) “Worst or first” headache of one’s life HA responds well to non-narcotic that is instantaneously maximal at onset analgesics (“thunderclap” after lightening strike) May have nausea, vomiting and neck pain HA
    [Show full text]
  • Effect of Methemoglobin Formation on the MR Appearance of Subarachnoid Hemorrhage1
    William G. Bradley, Jr., M.D., Ph.D. Effect of Methemoglobin Formation Paul G. Schmidt, Ph.D. on the MR Appearance of Subarachnoid Hemorrhage1 Subarachnoid hemorrhage has a much T HE EARLIEST reports of magnetic resonance (MR) images of in- higher intensity in magnetic resonance tracranial hemorrhage (1, 2) suggested a relatively intense ap- (MR) images with the passage of time. peanance of the hemorrhage relative to the surrounding brain. This Acute subarachnoid hemorrhage is diff i- was attributed to the short Ti relaxation time of the presumably cult to see; within 1 week its appearance paramagnetic, iron-containing hemoglobin. Figure 1 illustrates this has become intensified on Ti-weighted appearance in a patient imaged 1 week after rupture of an aneurysm images. Different concentrations of blood in an anterior communicating artery, with resulting intraparenchy- and lysed red blood cells in cerebrospinal mal hematoma and subarachnoid hemorrhage. The short Ti charac- fluid (CSF) were examined spectroscopi- ten of the injured area is enhanced relative to surrounding brain on cally but did not significantly alter Ti a Ti-weighted spin-echo image. and T2 relaxation of CSF acutely. Ultra- As experience was gained, subsequent reports (3, 4) indicated violet visible spectroscopy of bloody CSF that acute intracranial hemorrhage could be much more difficult to stored hypoxically for 3 days showed the detect on MR images. This was attributed by Sipponen et al. (3) to a presence of methemoglobin. The iron in lack of Ti shortening during the acute phase; however, they at- methemoglobin is paramagnetic; in com- tempted no explanation of this phenomenon.
    [Show full text]
  • D40. Cerebrospinal Fluid.Pdf
    CEREBROSPINAL FLUID D40 (1) Cerebrospinal Fluid (CSF) Last updated: June 3, 2019 PHYSIOLOGY ............................................................................................................................................ 1 CSF PRODUCTION .................................................................................................................................. 1 CSF REABSORPTION ............................................................................................................................... 1 PARAMETERS ........................................................................................................................................... 2 NORMAL ................................................................................................................................................ 2 OPENING PRESSURE ................................................................................................................................ 3 COLOR ................................................................................................................................................... 3 BLOODY CSF ......................................................................................................................................... 3 VISCOSITY & TURBIDITY ....................................................................................................................... 4 CELLS ...................................................................................................................................................
    [Show full text]
  • Cerebrospinal Fluid and Hydrocephalus: Physiology, Diagnosis, and Treatment Andreas K
    cancercontroljournal.org Vol. 24, No. 1, January 2017 H. LEE MOFFITT CANCER CENTER & RESEARCH INSTITUTE, AN NCI COMPREHENSIVE CANCER CENTER Cerebrospinal Fluid and Hydrocephalus: Physiology, Diagnosis, and Treatment Andreas K. Filis, MD, Kamran Aghayev, MD, and Frank D. Vrionis, MD, PhD Clinical Presentation, Diagnosis, and Radiological Findings of Neoplastic Meningitis Georgios Rigakos, MD, Chrysoula I. Liakou, MD, Naillid Felipe, et al Neoplastic Meningitis Due to Lung, Breast, and Melanoma Metastases Emilie Le Rhun, MD, Sophie Taillibert, MD, and Marc C. Chamberlain, MD Diagnosis and Management of Leukemic and Lymphomatous Meningitis Hemant Murthy, MD, Claudio Anasetti, MD, and Ernesto Ayala, MD Experimental Treatments for Leptomeningeal Metastases From Solid Malignancies Solmaz Sahebjam, MD, Peter A. Forsyth, MD, Keiran S. Smalley, PhD, et al Surgical Treatment for Leptomeningeal Disease Andrey A. Volkov, DO, Andreas K. Filis, MD, and Frank D. Vrionis, MD, PhD Cancer Control is included in Index Medicus/MEDLINE Editorial Board Members Editor: Conor C. Lynch, PhD Production Team: Assistant Member Lodovico Balducci, MD Veronica Nemeth Tumor Biology Senior Member Editorial Coordinator Program Leader, Senior Adult Oncology Program Kristen J. Otto, MD Sherri Damlo Moffitt Cancer Center Associate Member Managing Medical Editor Head and Neck and Endocrine Oncology Diane McEnaney Deputy Editor: Graphic Design Consultant Julio M. Pow-Sang, MD Michael A. Poch, MD Senior Member Assistant Member Associate Editor of Chair, Department of Genitourinary Oncology Genitourinary Oncology Educational Projects Director of Moffitt Robotics Program Jeffery S. Russell, MD, PhD John M. York, PharmD Moffitt Cancer Center Assistant Member Akita Biomedical Consulting Endocrine Tumor Oncology 1111 Bailey Drive Editor Emeritus: Elizabeth M.
    [Show full text]
  • Thunderclap Headache
    Thunderclap headache A.A.Okhovat,MD Assistant Professor of Neurology Tehran University of Medical Sciences Sina Hospital definition: ▷A headache that is very severe and has abrupt onset, reaching maximum intensity in less than 1 minute. ▷not defined solely by its high-intensity pain, but also by the rapidity with which it reaches maximum intensity. ▷Its explosive and unexpected nature. Epidemiology: ▷incidence ~43 per 100,000 adults per year. Differential Diagnosis: ▷Most Common Causes of Thunderclap Headache: -Reversible cerebral vasoconstriction syndrome -Subarachnoid hemorrhage ▷Less Common Causes of Thunderclap Headache: -Cerebral infection -Cerebral venous sinus thrombosis -Cervical artery dissection -Complicated sinusitis -Hypertensive crisis -Intracerebral hemorrhage -Ischemic stroke -Spontaneous intracranial hypotension -Subdural hematoma ▷Uncommon Causes of Thunderclap Headache: -Aqueductal stenosis -Brain tumor -Giant cell arteritis -Pituitary apoplexy -Pheochromocytoma -Retroclival hematoma -Third ventricle colloid cyst ▷Possible Causes of Thunderclap Headache: -Primary or idiopathic thunderclap headache -Unruptured intracranial aneurysm CLINICAL PRESENTATION ▷differentiated from other severe headaches, such as migraine or cluster, by the rapidity with which they reach their maximum intensity. ▷cannot be differentiated from other headache types based solely upon the intensity of the headache. Key points in PHx ▷altered level of consciousness ▷visual symptoms ▷papilledema ▷meningismus ▷Fever ▷tinnitus, auditory muffling ▷Horner
    [Show full text]
  • Pdf/ 14 Tolias CM, Choksey MS
    J R Coll Physicians Edinb 2013; 43:207–14 Paper http://dx.doi.org/10.4997/JRCPE.2013.304 © 2013 Royal College of Physicians of Edinburgh A pilot survey of decisions by acute medicine staff CLINICAL after thunderclap headache 1B Dobb, 2J Cooper 1Specialty Registrar, Acute Medicine; 2Consultant, Emergency Medicine, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK ABSTRACT Correspondence to B Dobb Introduction and aims: Traditionally, neurologically pristine patients with a Acute Medicine thunderclap headache are investigated with a non-contrast computed tomography Aberdeen Royal Infirmary, (CT) brain scan, which if negative is followed by a lumbar puncture (LP) to exclude Foresterhill, Aberdeen important secondary causes, particularly subarachnoid haemorrhage (SAH). AB25 2ZN, UK However, misdiagnosis of such patients is still a cause of significant human and financial cost and a regular reason for medical litigation. This study explores the tel. +44 (0)785 435 0744 e-mail [email protected] approach of emergency medicine and acute medicine clinicians to the investigation of a patient with thunderclap headache. Methods: Clinicians were invited to complete an online survey based on a clinical vignette of a 45-year-old man presenting with a thunderclap headache who had a pristine neurological examination. Results: A total of 160 clinicians responded. The majority (89%) elected to perform a non-contrast CT brain as their first investigation, though five clinicians discharged the patient without investigation. If the CT was negative, only 84% would then proceed to LP, but 20% would undertake this investigation before 12 hours from headache onset. Conclusions: Most clinicians investigate neurologically intact patients with thunderclap headache following a CT/LP strategy, but deviations from recommended practice are common.
    [Show full text]
  • Cerebrospinal Fluid (CSF) Analysis and Interpretation in Neurocritical Care for Acute Neurological Conditions Ajay Prasad Hrishi1, Manikandan Sethuraman2
    NEUROCRITICAL CARE Cerebrospinal Fluid (CSF) Analysis and Interpretation in Neurocritical Care for Acute Neurological Conditions Ajay Prasad Hrishi1, Manikandan Sethuraman2 ABSTRACT Cerebrospinal fluid (CSF) is a clear fluid circulating in the intracranial and spinal compartments. Under normal conditions, the composition of CSF remains constant. However, in various neurological disease especially in acute conditions, the composition, quantity and its pressure can be altered. By measuring the levels of various CSF components using relevant techniques, diagnosis, severity and prognostication of neurological conditions like infections, subarachnoid hemorrhage, demyelinating conditions, tumor like conditions, etc. can be done. In this review, alterations in CSF components and its relevance to the emergency care physician to help in the management of patients are enumerated. Keywords: Acute neurological condition, Cerebrospinal fluid analysis, Demyelination: trauma, Meningitis, SAH Indian Journal of Critical Care Medicine (2019): 10.5005/jp-journals-10071-23187 INTRODUCTION 1,2Department of Anaesthesiology, Sree Chitra Tirunal Institute for Cerebrospinal fluid is a clear fluid which is formed as a ultra Medical Sciences and Technology, Thiruvananthapuram, Kerala, India filtrate of plasma. CSF is present in both the intracranial and spinal Corresponding Author: Manikandan Sethuraman, Department of compartments. It is continuously being secreted by the choroid Anaesthesiology, Sree Chitra Tirunal Institute for Medical Sciences plexus at a constant rate inside the ventricles of the brain and and Technology, Thiruvananthapuram, Kerala, India, Phone: circulates in the subarachnoid space of the brain and spinal cord +919446334711, e-mail: [email protected] through CSF pathways. The total volume of CSF in the adult is How to cite this article: Hrishi AP, Sethuraman M.
    [Show full text]
  • 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.
    [Show full text]
  • Nonconvulsive Seizures After Subarachnoid Hemorrhage: Multimodal Detection and Outcomes
    ORIGINAL ARTICLE Nonconvulsive Seizures after Subarachnoid Hemorrhage: Multimodal Detection and Outcomes Jan Claassen, MD, PhD,1,2,3 Adler Perotte, MD,4 David Albers, PhD,4 Samantha Kleinberg, PhD,4 J. Michael Schmidt, PhD,1 Bin Tu, MD,2 Neeraj Badjatia, MD,1,3 Hector Lantigua, MD,1 Lawrence J. Hirsch, MD,2 Stephan A. Mayer, MD,1,3 E. Sander Connolly, MD,3 and George Hripcsak, MD4 Objective: Seizures have been implicated as a cause of secondary brain injury, but the systemic and cerebral physio- logic effects of seizures after acute brain injury are poorly understood. Methods: We analyzed intracortical electroencephalographic (EEG) and multimodality physiological recordings in 48 comatose subarachnoid hemorrhage patients to better characterize the physiological response to seizures after acute brain injury. Results: Intracortical seizures were seen in 38% of patients, and 8% had surface seizures. Intracortical seizures were accompanied by elevated heart rate (p 5 0.001), blood pressure (p < 0.001), and respiratory rate (p < 0.001). There were trends for rising cerebral perfusion pressure (p 5 0.03) and intracranial pressure (p 5 0.06) seen after seizure onset. Intracortical seizure–associated increases in global brain metabolism, partial brain tissue oxygenation, and regional cerebral blood flow (rCBF) did not reach significance, but a trend for a pronounced delayed rCBF rise was seen for surface seizures (p 5 0.08). Functional outcome was very poor for patients with severe background attenua- tion without seizures and best for those without severe attenuation or seizures (77% vs 0% dead or severely disabled, respectively). Outcome was intermediate for those with seizures independent of the background EEG and worse for those with intracortical only seizures when compared to those with intracortical and scalp seizures (50% and 25% death or severe disability, respectively).
    [Show full text]
  • Spontaneous Spinal Cerebrospinal Fluid Leaks: a Review
    Neurosurg Focus 9 (1):Article 8, 2000, Click here to return to Table of Contents Spontaneous spinal cerebrospinal fluid leaks: a review WOUTER I. SCHIEVINK, M.D. Cedars-Sinai Neurosurgical Institute, Los Angeles, and Department of Neurosurgery, University of California, Irvine, California Spontaneous intracranial hypotension has become a well-recognized clinical entity, but it remains an uncommonly, and probably underdiagnosed, cause of headache; its estimated prevalence is only one in 50,000 individuals. The clin- ical spectrum of spontaneous intracranial hypotension is quite variable and includes headache, neck stiffness, cranial nerve dysfunction, radicular arm pain, and symptoms of diencephalic or hindbrain herniation. Leakage of the spinal cerebrospinal fluid (CSF) is the most common cause of spontaneous intracranial hypotension. A combination of an underlying weakness of the spinal meninges and a more or less trivial traumatic event is often found to cause this event in these patients. Typical magnetic resonance imaging findings include diffuse pachymeningeal enhancement, sub- dural fluid collections, and downward displacement of the brain, sometimes mimicking a Chiari I malformation. Opening pressure is often, but not always, low, and examination of CSF may reveal pleocytosis, an elevated protein count, and xanthochromia. The use of myelography computerized tomography scanning is the most reliable method for the accurate localization of the CSF leak. Most CSF leaks are found at the cervicothoracic junction or in the tho- racic spine. The initial treatment of choice is a lumbar epidural blood patch, regardless of the location of the CSF leak. If the epidural blood patch fails, the blood patch procedure can be repeated at the lumbar level, or a blood patch can be directed at the exact site of the leak.
    [Show full text]