Computed tomography is not sufficient to exclude early subarachnoid hemorrhage [Classics Series]

This study summary is an excerpt from the book 2 Minute Medicine’s The Classics in Medicine: Summaries of Historical Trials

1. In a retrospective review of 119 patients with sudden onset headache, computed tomography (CT) scans within 12 hours of symptom onset failed to identify all patients with established subarachnoid hemorrhage (SAH).

2. Lumbar puncture 12 hours after onset of symptoms is a definitive diagnosis for all patients with SAH.

Originally Posted: March 1995

Study rundown: The most common cause of subarachnoid hemorrhage is due to cystic aneurysm rupture and is associated with high mortality and significant neurological morbidity. Although non-contrast CT offers high sensitivity in detecting SAH within 24 hours, due to the significant morbidity associated with missed diagnosis, definitive diagnosis by lumbar puncture is generally recommended when CT scan is negative. The purpose of this retrospective trial was to determine whether non-contrast CT scan earlier in presentation (within 12 hours) could improve the accuracy of SAH detection and eliminate the need for lumbar puncture. Of the 175 retrospectively reviewed patients with severe headache, 119 consecutive patients with a confirmed type of SAH lumbar puncture received a CT scan within 12 hours of presentation. At the conclusion of the trial, there was evidence of subarachnoid blood on CT in 117 cases. Two cases of normal SAH were reported with no evidence of blood or other abnormalities on frequent interpretation. Both cases underwent angiography which showed vascular haemorrhages in the PICA and the posterior connected artery, respectively. The results of this study demonstrated that computed tomography cannot definitively exclude SAH in patients presenting within 12 hours after symptom onset. Therefore, further diagnostic testing of bile by lumbar puncture is recommended in patients with normal head CT. This trial was one of the first studies to demonstrate the diagnostic accuracy of CT scans for detecting SAH in patients presenting early after symptom onset. Although a recent study by Cortnum et al. The results of the study by Van Der Wee et al. They are still used to inform recent guidelines from the American Stroke Association that continue to recommend the use of lumbar punctures in patients suspected of having SAH with regular CT head examination.

Click to read the study in the Journal of Neurology, Neurosurgery and Psychiatry

in depth [retrospective cohort]: This retrospective study reviewed the outcomes of 175 patients who presented to two hospitals in the Netherlands with severe headache between 1989 and 1993. Patients were excluded if they had any focal neurological deficit or if CT scans were performed 12 hours after symptom onset. CT scans were evaluated by a neuroradiologist and two neurologists. The primary outcome was the accuracy of the CT scan in detecting the presence of SAH. At the conclusion of the trial, 117 (67%) patients showed evidence of SAH on CT. However, a lumbar puncture identified two patients (2%) with SAH confirmation that the CT scan was normal. The two patients without CT evidence of SAH were found to have PICA aneurysms and PCa aneurysms, respectively. Among the 117 patients with CT evidence of SAH, the etiology distribution consisted of aneurysms from the anterior cerebral artery (n = 29), carotid artery (n = 26), middle cerebral artery (n = 17), and posterior circulation ( n = 29). n = 5).

Van der Wee N, Rinkel GJ, Hasan D, van Gijn J. Detection of subarachnoid hemorrhage in early computed tomography.Is a lumbar puncture still needed after a negative examination? J Neurol Neurosurg Psychiatry. 1995 March; 58 (3): 357-9.

Additional review:

Cortnum S, Sørensen P, Jørgensen J. Determination of computed tomography sensitivity in early detection of subarachnoid hemorrhage. Neurosurgery. 2010 May; 66 (5): 900–2.

Connolly S, Rabinstein AA, Karhuapuma Jr, Derden CB, Dion J, Higashida RT, et al. Guidelines for the management of subarachnoid aneurysm hemorrhage A guide for healthcare professionals from the American Heart Association/American Stroke Association Stroke. 2012 Jun 1; 43 (6): 1711–37.

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