Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage

The lumbar puncture (LP) is a relatively simple diagnostic test. However, significant diagnostic ambiguity can arise when trauma from the needle causes bleeding into the subarachnoid space, especially when trying to make the diagnosis of subarachnoid hemorrhage (SAH). The purpose of this article is to assist emergency physicians in distinguishing traumatic LPs from SAH. To correctly interpret the findings of a traumatic tap, a few concepts must be understood. Timing of the LP in relation to the onset of the SAH affects the results of the cerebrospinal fluid (CFS) analysis; the typical findings will change with time. With a few caveats, xanthochromia, the yellow discoloration of the CSF resulting from hemoglobin catabolism, is often critical in making a diagnosis of SAH. A few of the most essential methods for distinguishing traumatic LP from true SAH include: the "three tube test," opening pressure, and inspection for visual xanthochromia.     

腰椎穿刺置管稳压引流脑脊液治疗蛛网膜下腔出血的临床研究

目的 探讨蛛网膜下腔出血（SAH）的有效治疗方法。方法 对69例SAH患者进行治疗；治疗组（39例）腰椎穿刺置管稳压引流脑脊液，对照组（30例）间断腰椎穿刺放脑脊液。结果 治疗组头痛减轻程度、痊愈率明显优于对照组，脑血管痉挛、脑积水发生率明显低于对照组，而未增加再出血、脑疝发生率及病死率。结论 腰椎穿刺置管稳压引流脑脊液是一种安全、有效的治疗SAH的方法。     

连续腰椎穿刺引流在动脉瘤性蛛网膜下腔出血栓塞术后的作用

目的探讨连续腰椎穿刺引流对动脉瘤性蛛网膜下腔出血（a SAH）患者血管栓塞治疗后的作用。方法 42例a SAH患者接受颅内动脉栓塞治疗后,根据是否采取连续腰椎穿刺分为观察组20人和对照组22人。观察2组患者迟发性缺血性神经功能缺陷（DIDN）、头痛缓解和Rankin评分差异。结果观察组患者头痛缓解天数短于对照组（P〈0.05）;治疗期内,观察组患者DIDN发生率低于对照组（P〈00.05）,14 d时Rankin评分低于对照组（P〈0.05）。结论 a SAH患者栓塞治疗后行早期连续腰椎穿刺引流,能降低DIND发生风险,促进神经和认知功能早期恢复。     

Gross xanthochromia on lumbar puncture may not represent an acute subarachnoid hemorrhage

Headache is a common presenting complaint in the emergency department (ED) that sometimes requires a diagnostic workup including a lumbar puncture (LP). An LP is often used to evaluate patients in the ED for an acute neurologic process. Xanthochromia seen on cerebrospinal fluid from an LP is often considered to be highly suggestive of a subarachnoid hemorrhage. We describe 2 cases where gross xanthochromia was noted during LP but the patients did not have an acute subarachnoid hemorrhage.     

EPs do not accept the strategy of "lumbar puncture first" in subarachnoid hemorrhage

It has been proposed that the workup of suspected subarachnoid hemorrhage should begin with lumbar puncture (LP) rather than computed tomography (CT) scan. We investigated whether EPs would in fact advocate this strategy in an index hypothetical case and in variations of the index case. An eight-question survey was distributed to EM physicians attending national continuing medical education meetings. Questions included whether the responders would advocate "LP first" in the following scenarios: (1) the index case in which the patient's symptoms had been present for more than 12 hours, other diagnoses were very unlikely, the patient was fully insured, and CT scan was available immediately; (2) a case in which the patient is not insured; (3) a case in which the respondent is the patient; and (4) a case in which there is a delay in obtaining a CT scan. Two hundred forty-one of 275 surveys were completed for a response rate of 88%. Given the index scenario, only 22.8% of the respondents would advise patients to have an LP first versus 17.9% if they themselves were the patient (P=.11). Compared with the index scenario, 34.0% of respondents would advise LP first if their patient did not have insurance (P<.0001); a majority, 57.1%, would advise LP first if the CT were delayed (P<.0001). The "LP first" strategy for workup of subarachnoid hemorrhage was rejected by most EM physicians except when the CT scan would entail delay. Compared with the index case, an added number of physicians would advocate this strategy if the patient was uninsured. The ethical implication of advocating a strategy because of financial concerns and that most physicians would not favor for themselves or their patients merits attention.     

自发性蛛网膜下腔出血MSCTA检查的临床价值

目的 探讨多层螺旋CT血管造影(MSCTA)对自发性蛛网膜下腔出血病因诊断的临床价值。方法 经CT平扫诊断为自发性蛛网膜下腔出血39例，进行MSCTA检查及三维图像后处理，并均与DSA检查对照，适合介人治疗的病例，进行介人栓塞治疗。结果 全部39例自发性蛛网膜下腔出血的病例共检查出动脉瘤23例，脑动静脉畸形1例，脑动脉硬化1例，未见异常14例。其中颈内动脉动脉瘤5例，前交通动脉动脉瘤7例，大脑中动脉动脉瘤5例，大脑前动脉动脉瘤1例，基底动脉动脉瘤1例，椎动脉动脉瘤1例，多发动脉瘤1例，23例患者中共检出24个动脉瘤，有1例为2个动脉瘤。脑血管病变的阳性率为64．3％。结论 MSCTA检查是自发性蛛网膜下腔出血病因检查的一种简单、快速、无创及有效的方法。     

Severe intracranial and intraspinal subarachnoid hemorrhage after lumbar puncture: a rare case report

The lumbar puncture is considered as a safe routine procedure in widespread clinical use for nearly a century. To the best of our knowledge, intracranial and intraspinal subarachnoid hemorrhage has never been reported as a complication after a lumbar puncture. We presented a case of a 76-year-old woman who fell in a deep coma after a lumbar puncture with diffuse subarachnoid hemorrhage and acute obstructive hydrocephalus on computed tomographic scans. Magnetic resonance imaging studies of the whole spine showed the hematoma spread along the spinal cord upward to the intracranial subarachnoid space. Remarkably, an extravasation of contrast medium presented at the level of L1 through L2, which was subsequently evaluated using the spinal angiography. There was an ongoing bleeding at the terminus of L1 lumbar segmental artery that lay within the spinal cord. Then a transarterial embolization followed and the hemorrhage stopped immediately. This case reminds us that although lumbar puncture is safe and simple, severe potential complication, such as intracranial and intraspinal subarachnoid hematoma, could occur.     

腰椎穿刺在动脉瘤性蛛网膜下腔出血诊断中的价值

目的 探讨腰椎穿刺在动脉瘤性蛛网膜下腔出血(SAH)诊断中的价值.方法 回顾分析13例经头CT为阴性诊断而腰椎穿刺诊断为SAH,数字减影血管造影(DSA)确诊颅内动脉瘤的患者的临床资料.结果 腰椎穿刺诊断SAH阳性率为100%.结论 腰椎穿刺诊断动脉瘤性SAH具有重要意义.     

Sensitivity of newer-generation computed tomography scanners for subarachnoid hemorrhage: a Bayesian analysis

Background

Subarachnoid hemorrhage (SAH) is a life-threatening condition considered in patients presenting to the emergency department (ED) with acute and severe-onset headache. Currently, the practice pattern for suspected SAH is to perform a non-contrasted computed tomography (CT) scan of the head, followed by lumbar puncture (LP) if the CT is negative. Newer-generation 16-slice CT scanners have been shown in one study to be very sensitive for SAH.

Objective

We sought to validate these findings at our institution by retrospectively analyzing the sensitivity of our 16-slice or better CT scanner and performing a bayesian analysis with the results.

Methods

We utilized ED electronic medical records and the Department of Neurosurgery research database to search for patients admitted from the ED with a diagnosis of SAH from January 1, 2005 to December 31, 2008. We found a total of 134 patients admitted with SAH during this time frame.

Results

Average age was 53.8 years; 62% were female. Presenting complaint was headache in 57%, paresthesia or weakness in 7%, unresponsive in 10%, confusion or altered mental status in 5%, and “other” in 10%. Sensitivity of 16-slice or better CT scanner in our study was 131/134, or 97.8% (95% confidence interval 93.1–99.4%). No patient with a negative CT had a lesion requiring intervention.

Conclusion

Our study confirms the high sensitivity of 16-slice or better CT scanners for SAH. This calls into question the need for LP after negative head CT when 16-slice CT or better is used.     

The efficacy of routine head computed tomography (CT scan) prior to lumbar puncture in the emergency department

The efficacy of using unenhanced head computed tomography (CT scans) as a routine screening procedure prior to lumbar puncture in the emergency department is studied retrospectively by comparing opening pressure during lumbar puncture to CT scan diagnosis in 42 patients. No correlation was found between CT scan findings and opening pressure.     

三维CT血管重建成像在急性蛛网膜下腔出血的应用分析

目的：探讨三维CT血管重建成像在急性蛛网膜下腔出血的应用及局限性分析。方法：对147例CT表现为急性蛛网膜下腔出血患者进行CTA检查,由神经和放射两名医生对结果分析,对CTA阴性以及诊断有争议患者进行DSA检查。结果：在147例急性蛛网膜下腔出血患者中,109例患者3D-CTA结合出血CT图像确诊动脉瘤,瘤体直径2-12mm,均在手术或者介入治疗中证实;其余病例中,7例CT图像有明显的责任灶的蛛网膜下腔出血,3D-CTA阴性,通过DSA发现并经手术证实为动脉瘤,23例普通CT表现为中脑周围出血以及均匀弥漫蛛网膜下腔出血病例CTA提示阴性患者DSA检查也为阴性;3例CTA可疑动脉瘤均被DSA证实为动脉起始的壶腹,CTA在诊断颅内动脉瘤的敏感性和特异性分别为94％和100％。结论：对急性蛛网膜下腔出血患者使用CTA筛查是相对快捷、低风险检查方式,但结果的分析需结合CT图像出血形式以及放射和神经外科医生共同阅片可以完成CTA的诊断效能。     

腰穿脑脊液置换对蛛网膜下腔出血患者神经系统功能恢复的影响

Background: Death and disability of subarachnoid hemorrhage(SAH) are caused by lesions of cerebral hernia, spasm of cerebral blood vessels, injuries the blood brain barrier, or communicating hydrocephalus.Cerebrospinal fluid displacement through lumbar puncture can clear the bloody cerebrospinal fluid and reduce the blood pollution of the cerebrospinal fluid, shorten xanthochromia time, reduce the intracranial pressure early and meninges stimulation. Intrathecal injection of dexamethasone can reduce defense reaction of the meninges, tissue adhesion and organization at the same time.     

Effect of cerebrospinal fluid displacement through lumbar puncture on function recover of nerve system in subarachnoid hemorrhage patients

Death and disability of subarachnoid hemorrhage (SAH) are caused by lesions of cerebral hernia,spasm of cerebral blood vessels,injuries the blood-brain barrier,or communicating hydrocephalus.Cerebrospinal fluid displacement through lumbar puncture can clear the bloody cerebrospinal fluid and reduce the blood pollution of the cerebrospinal fluid,shorten xanthochromia time,reduce the intracranial pressure early and meninges stimulation.Intrathecal injection of dexamethasone can reduce defense reaction of the meninges,tissue adhesion and organization at the same time.     

螺旋CT脑血管成像在自发性蛛网膜下腔出血病因诊断中的应用

目的 探讨螺旋CT脑血管成像(spiral computed tomograplic angiography，SCTA)、三维重建(three-dimensional，3D)在不明原因的自发性蛛网膜下腔出血(spontameous subarachnoid hemorrhage，SAH)的病因诊断中的临床应用价值。方法 对39例原因不明的自发性SAH患者行螺旋CT扫描获得原始图像，增强扫描，用表面阴影成像和最大强度投影技术进行三维重建，血管成像。结果 动脉瘤20例，脑动静脉畸形11例，脑血管畸形3例，烟雾病2例，肿瘤卒中l例，未见异常2例。无并发症发生。结论 3D-SCTA能清晰显示颅内动脉瘤和脑动静脉畸形的部位、形状、大小及与周围结构的关系，可用于临床诊断。     

The role of hyperbaric oxygen in the management of subarachnoid hemorrhage

Objective To determine the role of hyperoxic and hyperbaric therapy following experimental subarachnoid hemorrhage (SAH).Design Prospective, randomized, controlled animal study.Subjects Thirty male Wistar rats.Interventions Thirty rats were assessed for an initial neurologic status as double-blinded by two different neurosurgeons using a neurologic severity score (NSS) and then underwent an initial angiographic examination. Two days later, 0.3 ml of homologous blood was injected into the cisterna magna to produce a SAH-induced cerebral vasospasm. The NSS and angiographic examination were then repeated. The rats having no spasm or a spasm under 50% (n=8) and 50% or over 50% (n=22) were grouped separately, as groups 1 and 2, respectively. The rats having 50% or more spasm were further divided randomly into group 2A and 2B. The rats in groups 1 and 2A (n=11) underwent a 60-min course of 100% oxygen at the atmospheric pressure 1 atmosphere absolute (ata), and group 2B (n=11) received 100% oxygen at 3 ata for 1 h. Neurologic assessment was repeated on the next day and 7 days later.Measurements and main results The animals having no spasm or less than 50% spasm had a better NSS and outcome when compared with the animals having 50% or more spasm. But the animals with 50% or more spasm which underwent hyperbaric therapy were shown to have a better outcome compared to the animals having hyperoxic therapy.Conclusion Exposure to hyperbaric oxygen therapy seemed to accelerate the recovery of neurologic deficits secondary to experimental SAH.     

腰椎穿刺脑脊液置换疗法治疗蛛网膜下腔出血60例疗效观察

目的：探讨腰椎穿刺脑脊液置换疗法治疗蛛网膜下腔出血（ＳＡＨ）的临床疗效。方法：采用腰椎穿刺脑脊液置换疗法治疗继发性ＳＡＨ３１例（治疗组）和原发性ＳＡＨ２９例（对照组）,间隔２～３日置换１次,可置换２～５次。结果：治疗组总有效率（９０．３％）与对照组总有效率（９３．１％）比较无显著性差异（χ２＝０．１５,Ｐ＞０．０５）。结论：腰椎穿刺脑脊液置换疗法能降低原发性ＳＡＨ和继发性ＳＡＨ的颅内压,改善脑脊液循环,清除脑血管内活性物质,防止脑血管痉挛,减少蛛网膜粘连,降低病死率,且未见脑疝及其他不良反应