Is a Negative Computed Tomography Scan of the Head and a Negative Lumbar Puncture Sufficient to Rule Out a Subarachnoid Hemorrhage?

✓The elucidation of predictive factors of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major area of both clinical and basic science research. It is becoming clear that many factors contribute to this phenomenon. The most consistent predictor of vasospasm has been the amount of SAH seen on the postictal computed tomography scan. Over the last 30 years, it has become clear that the greater the amount of blood within the basal cisterns, the greater the risk of vasospasm. To evaluate this risk, various grading schemes have been proposed, from simple to elaborate, the most widely known being the Fisher scale. Most recently, volumetric quantification and clearance models have provided the most detailed analysis. Intraventricular hemorrhage, although not supported as strongly as cisternal SAH, has also been shown to be a risk factor for vasospasm.

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The Relationship Between Delayed Infarcts and Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/neu.0b013e318285c3db ◽

2013 ◽

Vol 72 (5) ◽

pp. 702-708 ◽

Cited By ~ 54

Author(s):

Robert J. Brown ◽

Abhay Kumar ◽

Rajat Dhar ◽

Tomoko R. Sampson ◽

Michael N. Diringer

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Infarct Volume ◽

Delayed Cerebral Ischemia ◽

Computed Tomography Scan ◽

Angiographic Vasospasm ◽

Arterial Vasospasm ◽

The Relationship ◽

Tomography Scan

Abstract BACKGROUND: Delayed cerebral ischemia is common after aneurysmal subarachnoid hemorrhage (aSAH) and is a major contributor to poor outcome. Yet, although generally attributed to arterial vasospasm, neurological deterioration may also occur in the absence of vasospasm. OBJECTIVE: To determine the relationship between delayed infarction and angiographic vasospasm and compare the characteristics of infarcts related to vasospasm vs those unrelated. METHODS: A retrospective review of patients with aSAH admitted from July 2007 through June 2011. Patients were included if they were admitted within 48 hours of SAH, had a computed tomography scan both 24 to 48 hours following aneurysm treatment and ≥7 days after SAH, and had a catheter angiogram to evaluate for vasospasm. Delayed infarcts seen on late computed tomography but not postprocedurally were attributed to vasospasm if there was moderate or severe vasospasm in the corresponding vascular territory on angiography. Infarct volume was measured by perimeter tracing. RESULTS: Of 276 aSAH survivors, 134 had all imaging requisite for inclusion. Fifty-four (34%) had moderate or severe vasospasm, of whom 17 (31%) had delayed infarcts, compared with only 3 (4%) of 80 patients without vasospasm (P < .001). There were a total of 29 delayed infarcts in these 20 patients; 21 were in a territory with angiographic vasospasm, but 8 (28%) were not. Infarct volume did not differ between vasospasm-related (18 ± 25 mL) and vasospasm-unrelated (11 ± 12 mL) infarcts (P = .54), but infarcts in the absence of vasospasm were more likely watershed (50% vs 10%, P = .03). CONCLUSION: Delayed infarcts following aSAH can occur in territories without angiographic vasospasm and are more likely watershed in distribution.

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Is the Combination of Negative Computed Tomography Result and Negative Lumbar Puncture Result Sufficient to Rule Out Subarachnoid Hemorrhage?

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2007.10.025 ◽

2008 ◽

Vol 51 (6) ◽

pp. 707-713 ◽

Cited By ~ 54

Author(s):

Jeffrey J. Perry ◽

Alena Spacek ◽

Melissa Forbes ◽

George A. Wells ◽

Melodie Mortensen ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Lumbar Puncture ◽

Tomography Result ◽

Rule Out

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Fate of Clots in Patients With Subarachnoid Hemorrhage After Different Surgical Treatment Modality: A Comparison Between Surgical Clipping and Guglielmi Detachable Coil Embolization

Neurosurgery ◽

10.1227/neu.0b013e318208f1ba ◽

2011 ◽

Vol 68 (4) ◽

pp. 966-973 ◽

Cited By ~ 12

Author(s):

Satoshi Shirao ◽

Hiroshi Yoneda ◽

Hideyuki Ishihara ◽

Kei Harada ◽

Katsuhiko Ueda ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Coil Embolization ◽

Computed Tomography Scan ◽

Surgical Clipping ◽

Detachable Coil ◽

Symptomatic Vasospasm ◽

Guglielmi Detachable Coil ◽

Embolization Coil ◽

Tomography Scan

Abstract BACKGROUND: Subarachnoid clot is important in the development of delayed vasospasm after subarachnoid hemorrhage (SAH). OBJECTIVE: To compare the clearance of subarachnoid clot and the incidence of symptomatic vasospasm in surgical clipping and embolization with Guglielmi detachable coils for aneurysmal SAH. METHODS: The subjects were 115 patients with Fisher group 3 aneurysmal SAH on computed tomography scan at admission whose aneurysm was treated by surgical clipping (clip group; n = 86) or Guglielmi detachable coil embolization (coil group; n = 29) within 72 hours of ictus. Software-based volumetric quantification of the subarachnoid clot was performed, and the amount of hemoglobin in drained cerebrospinal fluid was measured. RESULTS: Clearance of the subarachnoid clot on the computed tomography scan was rapid in the clip group until the day after the operation but slow in the coil group (58.9% removed vs 27.8% removed; P = .008). However, postoperative clearance of the clot occurred more rapidly in the coil group. Reduction of the clot until days 3 through 5 did not differ significantly between the 2 groups (72.9% removed vs 75.2% removed). The amount of hemoglobin in the clip group was > 0.8 g/d until day 3 and then gradually decreased (n = 15), but hemoglobin in the coil group remained at > 0.8 g/d until day 5 (n = 17). The incidence of symptomatic vasospasm did not differ between the groups. CONCLUSION: Subarachnoid clot can be removed directly during surgical clipping, which is not possible with endovascular treatment. However, the percentage reduction of the clot on days 3 through 5 did not differ between the 2 groups.

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Comparison of Lumbar Puncture with Computed Tomography Scan as an Indicator of Intracerebral Hemorrhage in the Preterm Infant

PEDIATRICS ◽

10.1542/peds.66.3.432 ◽

1980 ◽

Vol 66 (3) ◽

pp. 432-437

Author(s):

Gerald Silverboard ◽

Anthony Lazzara ◽

Peter A. Ahmann ◽

James F. Schwartz

Keyword(s):

Computed Tomography ◽

Intracerebral Hemorrhage ◽

Ct Scan ◽

Preterm Infant ◽

Lumbar Puncture ◽

Intraventricular Hemorrhage ◽

Accurate Method ◽

Ct Scans ◽

Computed Tomography Scan ◽

Tomography Scan

Computed tomography (CT) scan is the most accurate method for diagnosing intracerebral hemorrhage in the high-risk preterm infant. The present study was undertaken to evaluate lumbar puncture (LP) as a reliable means of diagnosing such hemorrhages. Forty eight infants less than 35 weeks gestation, requiring intensive care, were evaluated by CT scan at 48 to 96 hours of life, and serial LPs were performed. The initial LP preceded the CT scan by one to four hours and repeat LPs were done three and five days later if the initial CT scan revealed intracerebral hemorrhage. The initial LP was successfully performed in 28 of 48 infants. Of these 48 infants, 15 had hemorrhage by CT scan. The initial LP was consistent with the diagnosis on scan in eight of these 15. In the other seven infants, initial LP was normal in three, traumatic in one, and unsuccessful in three. The second LP was consistent with hemorrhage in four of the latter seven. Thus, in only eight of 15 infants, in whom CT scans revealed intracerebral hemorrhage, was the initial LP useful in confirming the diagnosis. Furthermore, LPs showed bloody cerebrospinal fluid in 10 of 18 infants whose CT scans were normal. At the present time LP cannot be considered a reliable means of identifying infants with subependymal-intraventricular hemorrhage.

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