Risk-benefit analysis of lumbar puncture to evaluate for nontraumatic subarachnoid hemorrhage in adult ED patients

Victoria L. Migdal, W. Kelly Wu, Drew Long, Candace D. McNaughton, Michael J. Ward, Wesley H. Self

Research output: Contribution to journalArticle

Abstract

Objective The objective of the study is to compare the risks and benefits of lumbar puncture (LP) to evaluate for subarachnoid hemorrhage (SAH) after a normal head computed tomographic (CT) scan. Methods This was an observational study of adult emergency department patients at a single hospital who presented with headache and underwent LP after a normal head CT to evaluate for SAH. Lumbar puncture results classified as indicating a SAH included xanthochromia in cerebrospinal fluid (CSF) or red blood cells in the final tube of CSF with an aneurysm or arteriovenous malformation on cerebral angiography. An LP-related complication was defined as hospitalization or a return visit due to symptoms attributed to the LP. Proportions of the study patients who had SAH diagnosed by LP and who experienced an LP-related complication were compared. Results The study included 302 patients, including 2 (0.66%) who were diagnosed with SAH based on LP (number needed to diagnose, 151); both of these patients had a known intracranial aneurysm. Eighteen (5.96%) patients experienced an LP-related complication (P <.01 compared with number with SAH diagnosed; number needed to harm, 17). Complications included 12 patients with low-pressure headaches, 4 with pain at the LP site, and 2 with contaminated CSF cultures. Conclusion The yield of LP for diagnosing SAH in adults with nontraumatic headache after a normal head CT was very low. The severity of LP-related complications was low, but complications were more common than SAH diagnoses. Lumbar puncture may not be advisable after a normal head CT to evaluate for SAH, particularly in patients with low-risk clinical features for SAH.

Original languageEnglish (US)
Pages (from-to)1597-1601
Number of pages5
JournalAmerican Journal of Emergency Medicine
Volume33
Issue number11
DOIs
StatePublished - Nov 2015
Externally publishedYes

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Spinal Puncture
Subarachnoid Hemorrhage
Head
Headache
Cerebrospinal Fluid
Cerebral Angiography
Arteriovenous Malformations
Intracranial Aneurysm
Observational Studies
Aneurysm
Hospital Emergency Service
Hospitalization

ASJC Scopus subject areas

  • Emergency Medicine

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Risk-benefit analysis of lumbar puncture to evaluate for nontraumatic subarachnoid hemorrhage in adult ED patients. / Migdal, Victoria L.; Wu, W. Kelly; Long, Drew; McNaughton, Candace D.; Ward, Michael J.; Self, Wesley H.

In: American Journal of Emergency Medicine, Vol. 33, No. 11, 11.2015, p. 1597-1601.

Research output: Contribution to journalArticle

Migdal, Victoria L. ; Wu, W. Kelly ; Long, Drew ; McNaughton, Candace D. ; Ward, Michael J. ; Self, Wesley H. / Risk-benefit analysis of lumbar puncture to evaluate for nontraumatic subarachnoid hemorrhage in adult ED patients. In: American Journal of Emergency Medicine. 2015 ; Vol. 33, No. 11. pp. 1597-1601.
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abstract = "Objective The objective of the study is to compare the risks and benefits of lumbar puncture (LP) to evaluate for subarachnoid hemorrhage (SAH) after a normal head computed tomographic (CT) scan. Methods This was an observational study of adult emergency department patients at a single hospital who presented with headache and underwent LP after a normal head CT to evaluate for SAH. Lumbar puncture results classified as indicating a SAH included xanthochromia in cerebrospinal fluid (CSF) or red blood cells in the final tube of CSF with an aneurysm or arteriovenous malformation on cerebral angiography. An LP-related complication was defined as hospitalization or a return visit due to symptoms attributed to the LP. Proportions of the study patients who had SAH diagnosed by LP and who experienced an LP-related complication were compared. Results The study included 302 patients, including 2 (0.66{\%}) who were diagnosed with SAH based on LP (number needed to diagnose, 151); both of these patients had a known intracranial aneurysm. Eighteen (5.96{\%}) patients experienced an LP-related complication (P <.01 compared with number with SAH diagnosed; number needed to harm, 17). Complications included 12 patients with low-pressure headaches, 4 with pain at the LP site, and 2 with contaminated CSF cultures. Conclusion The yield of LP for diagnosing SAH in adults with nontraumatic headache after a normal head CT was very low. The severity of LP-related complications was low, but complications were more common than SAH diagnoses. Lumbar puncture may not be advisable after a normal head CT to evaluate for SAH, particularly in patients with low-risk clinical features for SAH.",
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N2 - Objective The objective of the study is to compare the risks and benefits of lumbar puncture (LP) to evaluate for subarachnoid hemorrhage (SAH) after a normal head computed tomographic (CT) scan. Methods This was an observational study of adult emergency department patients at a single hospital who presented with headache and underwent LP after a normal head CT to evaluate for SAH. Lumbar puncture results classified as indicating a SAH included xanthochromia in cerebrospinal fluid (CSF) or red blood cells in the final tube of CSF with an aneurysm or arteriovenous malformation on cerebral angiography. An LP-related complication was defined as hospitalization or a return visit due to symptoms attributed to the LP. Proportions of the study patients who had SAH diagnosed by LP and who experienced an LP-related complication were compared. Results The study included 302 patients, including 2 (0.66%) who were diagnosed with SAH based on LP (number needed to diagnose, 151); both of these patients had a known intracranial aneurysm. Eighteen (5.96%) patients experienced an LP-related complication (P <.01 compared with number with SAH diagnosed; number needed to harm, 17). Complications included 12 patients with low-pressure headaches, 4 with pain at the LP site, and 2 with contaminated CSF cultures. Conclusion The yield of LP for diagnosing SAH in adults with nontraumatic headache after a normal head CT was very low. The severity of LP-related complications was low, but complications were more common than SAH diagnoses. Lumbar puncture may not be advisable after a normal head CT to evaluate for SAH, particularly in patients with low-risk clinical features for SAH.

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