CT negative subarachnoid hemorrhage in emergency department
Languages of publication
Background Subarachnoid hemorrhage (SAH) is rare but potentially life-threatening cause of acute headache. First diagnostic test performed in the Emergency Department (ED) for acute “thunderclap” headache is computed tomography of the head (CT) without contrast enhancement. Negative non-contrast head CT may be erroneously interpreted as an exclusion of SAH and lead to ED discharge. The consequences of overlooking SAH are of special interest to the Emergency Physician. The aim of this study was to assess prevalence and clinical picture of CT-negative cases of SAH admitted to the ED. Material and methods Retrospective analysis of charts of patients admitted to the ED and diagnosed with SAH during 18 consecutive months. Results Our data gives information about clinical picture of patients with CT-negative SAH and their further clinical course. Out of 126 patients diagnosed with SAH, 5 (4.0%) were diagnosed with SAH despite negative non-contrast head CT scan. All cases were diagnosed by means of lumbar puncture and analysis of cerebrospinal fluid. In all patients with CT-negative SAH computed tomographic angiography (CTA) was performed and no vascular abnormalities were found. In one case digital subtraction angiography was performed due to equivocal CTA picture and it demonstrated small unruptured aneurysm of the medial cerebral artery. All patients with CT-negative SAH were admitted to a neurological ward and later discharged from the hospital without neurological deficit. There were no episodes of clinical deterioration and none of the patients required an urgent neurosurgical intervention. Conclusions Although lumbar puncture remains a gold standard in exclusion of SAH, head CT scan without contrast enhancement appears to be a satisfying diagnostic tool in ED.
- Perry JJ, Stiell IG, Sivilotti MLA, Bullard MJ, Hohl CM, Sutherland J, et al. Clinical Decision Rules to Rule Out Subarachnoid Hemorrhage for Acute Headache. JAMA [Internet]. 2013;310(12):1248–55. Available from: https://doi.org/10.1001/jama.2013.278018.
- Kowalski RG. Initial Misdiagnosis and Outcome After Subarachnoid Hemorrhage. JAMA [Internet]. 2004;291(7):866–9. Available from: https://doi.org/10.1001/jama.291.7.866.
- Perry JJ, Stiell IG, Sivilotti MLA, Bullard MJ, Emond M, Symington C, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ [Internet]. 2011;343(jul18 1):d4277–d4277. Available from: https://doi.org/10.1136/bmj.d4277.
- 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 [Internet]. 2008;52(4):407–36. Available from: https://doi.org/10.1016/j.annemergmed.2008.07.001.
- Gill HS, Marcolini EG, Barber D, Wira CR. The Utility of Lumbar Puncture After a Negative Head CT in the Emergency Department Evaluation of Subarachnoid Hemorrhage. Yale J Biol Med [Internet]. 2018;91(1):3–11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29599652.
- Doherty CM, Forbes RB. Diagnostic Lumbar Puncture. Ulster Med J [Internet]. 2014;83(2):93–102. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4113153.
- Perry JJ, Sivilotti MLA, Sutherland J, Hohl CM, Émond M, Calder LA, et al. Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. Can Med Assoc J [Internet]. 2017;189(45):E1379–85. Available from: https://doi.org/10.1503/cmaj.170072.
- Lansley J, Selai C, Krishnan AS, Lobotesis K, Jäger HR. Subarachnoid haemorrhage guidelines and clinical practice: a cross-sectional study of emergency department consultants’ and neurospecialists’ views and risk tolerances. BMJ Open [Internet]. 2016;6(9):e012357. Available from: http://dx.doi.org/10.1136/bmjopen-2016-012357.
- Mark DG, Hung Y-Y, Offerman SR, Rauchwerger AS, Reed ME, Chettipally U, et al. Nontraumatic Subarachnoid Hemorrhage in the Setting of Negative Cranial Computed Tomography Results: External Validation of a Clinical and Imaging Prediction Rule. Ann Emerg Med [Internet]. 2013;62(1):1-10.e1. Available from: https://doi.org/10.1016/j.annemergmed.2012.09.003.
- 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 [Internet]. 2008;51(6):697–703. Available from: https://doi.org/10.1016/j.annemergmed.2007.10.007.
- Mark DG, Sonne DC, Jun P, Schwartz DT, Kene M V., Vinson DR, et al. False-negative Interpretations of Cranial Computed Tomography in Aneurysmal Subarachnoid Hemorrhage. O’Neil BJ, editor. Acad Emerg Med [Internet]. 2016;23(5):591–8. Available from: http://doi.wiley.com/10.1111/acem.12941.
- Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage. Stroke [Internet]. 2016;47(3):750–5. Available from: https://doi.org/10.1161/STROKEAHA.115.011386.
- Williams TS, Seupaul RA. Can Noncontrast Head Computed Tomography Within 6 Hours of Symptom Onset Exclude Aneurysmal Subarachnoid Hemorrhage? Ann Emerg Med [Internet]. 2016;68(3):352–3. Available from: https://doi.org/10.1016/j.annemergmed.2016.04.034.
- Carpenter CR, Hussain AM, Ward MJ, Zipfel GJ, Fowler S, Pines JM, et al. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Zehtabchi S, editor. Acad Emerg Med [Internet]. 2016;23(9):963–1003. Available from: http://doi.wiley.com/10.1111/acem.12984.
- Chong MY, Martin SC, Phang I, St George EJ, Suttner N, Teo MK. The Prevalence of Cerebrovascular Abnormalities Detected in Various Diagnostic Subgroups of Spontaneous Subarachnoid Hemorrhage in the Modern Era. World Neurosurg [Internet]. 2018;111:e355–61. Available from: https://doi.org/10.1016/j.wneu.2017.12.077.
- Mark DG, Kene M V., Vinson DR, Ballard DW. Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis. Stephen Huff J, editor. Acad Emerg Med [Internet]. 2017;24(12):1451–63. Available from: http://doi.wiley.com/10.1111/acem.13252.
- Yarmohammadian M, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency departments: A review of strategies to decrease future challenges. J Res Med Sci [Internet]. 2017;22(1):23. Available from: https://doi.org/10.4103/1735-1995.200277.
- Yoon P, Steiner I, Reinhardt G. Analysis of factors influencing length of stay in the emergency department. CJEM [Internet]. 2003;5(03):155–61. Available from: https://doi.org/10.1017/S1481803500006539.
- Sprivulis PC, Da Silva J-A, Jacobs IG, Frazer ARL, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust [Internet]. 2006;184(5):208–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16515429.
- Edlow BL, Samuels O. Emergency Neurological Life Support: Subarachnoid Hemorrhage. Neurocrit Care [Internet]. 2017;27(S1):116–23. Available from: https://doi.org/10.1007/s12028-017-0458-8.
- McCormack RF, Hutson A. Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute-onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan? Acad Emerg Med [Internet]. 2010;17(4):444–51. Available from: http://doi.wiley.com/10.1111/j.1553-2712.2010.00694.x.
- Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared Decision Making: A Model for Clinical Practice. J Gen Intern Med [Internet]. 2012;27(10):1361–7. Available from: https://doi.org/10.1007/s11606-012-2077-6.
- Long B, Koyfman A. Controversies in the Diagnosis of Subarachnoid Hemorrhage. J Emerg Med [Internet]. 2016;50(6):839–47. Available from: https://doi.org/10.1016/j.jemermed.2015.10.020.
- Steffens S, Tucker P, Evans DD. Acute Headache in the Emergency Department. Adv Emerg Nurs J [Internet]. 2018;40(2):78–86. Available from: http://journals.lww.com/01261775-201804000-00002.
- Grasso G, Alafaci C, Macdonald Rl. Management of aneurysmal subarachnoid hemorrhage: State of the art and future perspectives. Surg Neurol Int [Internet]. 2017;8(1):11. Available from: https://doi.org/10.4103/2152-7806.198738.
Publication order reference