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. 2018 Mar 28;91(1):3-11.
eCollection 2018 Mar.

The Utility of Lumbar Puncture After a Negative Head CT in the Emergency Department Evaluation of Subarachnoid Hemorrhage

Harman Singh Gill  1 , Evie Grace Marcolini  2 , Douglas Barber  3 , Charles R Wira  1
Affiliations

The Utility of Lumbar Puncture After a Negative Head CT in the Emergency Department Evaluation of Subarachnoid Hemorrhage

Harman Singh Gill et al. Yale J Biol Med. .

Abstract

Background: American College of Emergency Physicians (ACEP) [1] recommends that patients presenting with acute non-traumatic headache concerning for subarachnoid hemorrhage (SAH) undergo lumbar puncture (LP) when non-contrast head computed tomography (CT) is negative. The diagnostic yield of this approach is unknown. Objective: Evaluate the diagnostic yield, lengths of stay and complication rates of LPs in patients undergoing Emergency Department (ED) evaluation for aneurysmal SAH. Methods: Multi-center, retrospective, hypothesis-blinded, explicit chart review of patients undergoing ED-based lumbar puncture between 2007 and 2012. Charts of neurologically intact patients presenting with headache that had a negative head CT and underwent LP primarily to rule out SAH were reviewed. Trained data abstractors blinded to study hypothesis used standardized data forms with predefined terms for chart abstraction. We re-abstracted and assessed inter-rater agreement for 20 percent of charts with a 100 percent inter-rater agreement. Data were descriptive, using 95 percent confidence intervals. Results: 1,282 LPs were performed, and 342 patients met inclusion criteria but only 1 percent were deemed positive for SAH in the chart. No aneurysm or vascular malformation was identified in those with positive LPs for SAH. Complications were in 4 percent and xanthochromia was found in 13 percent. Total length of stay was 7.8 hours (0.95 CI; 7.5 - 8.2). No patient discharged from the ED after a negative workup for SAH was re-admitted for SAH or underwent a neurosurgical procedure during a three-month follow-up period. Conclusions: LP in our cohort of neurologically intact CT-negative ED headache patients did not identify any cases of aneurysmal SAH but was associated with serious complications, a significant false positive rate, and extended ED length of stay.

Keywords: Emergency Department evaluation; Head CT; Headache; Lumbar puncture; Subarachnoid hemorrhage; utility and yield of lumbar puncture.

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Figures

Figure 1
Figure 1
Inclusion and exclusion criteria for enrollment of study patients.
Figure 2
Figure 2
Yearly breakdown of the number of neurosurgical interventions undertaken amongst those patients who had a negative head CT but a LP considered by the emergency medicine provider to be positive for SAH.
Figure 3
Figure 3
Average times for head CT, CSF collection, CSF collection to disposition and overall length of stay to describe overall efficiency associated with the CT-LP workflow.
Figure 4
Figure 4
Yearly complication rate for all LPs performed.
Figure 5
Figure 5
The yearly occurrence of all LPs that reported xanthochromia compared with those LPs that were considered positive for SAH and had xanthochromia.
See this image and copyright information in PMC

References

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