Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

doi:10.1136/bmj.h568

Multicenter Study

. 2015 Feb 18:350:h568.

doi: 10.1136/bmj.h568.

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

Affiliations

¹ Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9 jperry@ohri.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9.
³ University of Ottawa, Department of Emergency Medicine, Ottawa, ON, Canada.
⁴ Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
⁵ Hopital de l'Enfant-Jesus, Department of Emergency Medicine, Faculty of Medicine, Quebec City, QC, Canada G1J 1Z4.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁷ Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
⁸ Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
⁹ Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Division of Emergency Medicine, University of Western Ontario, London, ON, Canada.
¹¹ Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.
¹² Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada.
¹³ Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

PMID: 25694274
PMCID: PMC4353280
DOI: 10.1136/bmj.h568

Multicenter Study

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

Jeffrey J Perry et al. BMJ. 2015.

. 2015 Feb 18:350:h568.

doi: 10.1136/bmj.h568.

Authors

Affiliations

¹ Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9 jperry@ohri.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9.
³ University of Ottawa, Department of Emergency Medicine, Ottawa, ON, Canada.
⁴ Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada.
⁵ Hopital de l'Enfant-Jesus, Department of Emergency Medicine, Faculty of Medicine, Quebec City, QC, Canada G1J 1Z4.
⁶ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁷ Department of Emergency Medicine, McMaster University, Hamilton, ON, Canada.
⁸ Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
⁹ Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Division of Emergency Medicine, University of Western Ontario, London, ON, Canada.
¹¹ Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.
¹² Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada.
¹³ Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

PMID: 25694274
PMCID: PMC4353280
DOI: 10.1136/bmj.h568

Abstract

Objectives: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture.

Design: A substudy of a prospective multicenter cohort study.

Setting: 12 Canadian academic emergency departments, from November 2000 to December 2009.

Participants: Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage.

Main outcome measure: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death.

Results: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%).

Conclusion: No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.

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Conflict of interest statement

Competing Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work ; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

None — **Fig 1** Identification and flow of patients with acute non-traumatic headache

See this image and copyright information in PMC

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References

1. De Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007;78:1365-72. - PMC - PubMed
1. Thomas LE, Czuczman AD, Boulanger AB, Peak DA, Miller ES, Brown DF, et al. Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging. J Neurosurg 2014;121:24-31. - PubMed
1. Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29-36. - PubMed
1. Byyny RL, Mower WR, Shum N, Gabayan GZ, Fang S, Baraff LJ. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med 2008;51:697-703. - PubMed
1. Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008;52:407-36. - PubMed

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[1] De Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007;78:1365-72. - PMC - PubMed

[2] De Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007;78:1365-72. - PMC - PubMed

[3] Thomas LE, Czuczman AD, Boulanger AB, Peak DA, Miller ES, Brown DF, et al. Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging. J Neurosurg 2014;121:24-31. - PubMed

[4] Thomas LE, Czuczman AD, Boulanger AB, Peak DA, Miller ES, Brown DF, et al. Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging. J Neurosurg 2014;121:24-31. - PubMed

[5] Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29-36. - PubMed

[6] Edlow JA, Caplan LR. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29-36. - PubMed

[7] Byyny RL, Mower WR, Shum N, Gabayan GZ, Fang S, Baraff LJ. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med 2008;51:697-703. - PubMed

[8] Byyny RL, Mower WR, Shum N, Gabayan GZ, Fang S, Baraff LJ. Sensitivity of noncontrast cranial computed tomography for the emergency department diagnosis of subarachnoid hemorrhage. Ann Emerg Med 2008;51:697-703. - PubMed

[9] Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008;52:407-36. - PubMed

[10] Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008;52:407-36. - PubMed

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Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

Affiliations

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Similar articles

Cited by

References

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MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical

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Abstract

Conflict of interest statement

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