Department of Emergency Medicine, University of Maryland Upper Chesapeake Medical Center, Bel Air, Maryland;
J Neurosurg. 2014 Jul;121(1):24-31. doi: 10.3171/2014.3.JNS132239. Epub 2014 Apr 18.
OBJECT.: When patients present to the emergency department (ED) with acute headache concerning for subarachnoid hemorrhage (SAH) and a lumbar puncture (LP) shows blood in the CSF, it is difficult to distinguish the results of a traumatic LP from those of SAH. CT angiography (CTA) is often performed, but the long-term outcome for patients with a positive LP and normal neurovascular imaging remains uncertain. The primary objective of this study was to determine whether patients who presented to the ED with acute headache and had red blood cells (RBCs) in their CSF on LP but negative cerebrovascular imaging suffered subsequent SAH.
A case series study of consecutive adult ED patients who incurred charges for LP between 2001 and 2009 was performed from 2010 through 2011. Inclusion criteria were: headache, > 5 RBCs/mm(3) in CSF, noncontrast head CT with no evidence of hemorrhage, and cerebrovascular CTA or MRA without aneurysm or vascular lesion within 2 weeks of the ED visit. Patients with less than 6 months of available follow-up were excluded. The primary outcomes were 1) subsequent nontraumatic SAH and 2) new vascular lesion. Secondary outcomes were complications related to SAH, or LP or angiography.
Of 4641 ED patients billed for an LP, 181 patients (mean age 42 years) were included in this study. Over a median follow-up of 53 months, 0 (0%) of 181 patients (95% CI 0%-2.0%) had a subsequent SAH or new vascular lesion identified. Although not the primary outcome, there was 1 patient who was ultimately diagnosed with vasculitis. Eighteen (9.9%) of 181 patients (95% CI 6.0%-15.3%) had an LP-related complication and 0 (0%) of 181 patients (95% CI 0%-2.0%) had an angiography-related complication.
Patients who present to the ED with acute headache concerning for SAH and have a finding of bloody CSF on LP but negative findings on cerebrovascular imaging are at low risk for subsequent SAH and thus are likely to be safe for discharge. Replacement of the CT/LP with a CT/CTA diagnostic algorithm merits further investigation.
当患者因蛛网膜下腔出血（SAH）而出现急性头痛并到急诊科就诊，且腰椎穿刺（LP）显示脑脊液中带血时，很难区分 LP 结果是创伤性的还是 SAH 的结果。通常会进行 CT 血管造影（CTA）检查，但对于 LP 阳性且神经血管成像正常的患者的长期预后仍不确定。本研究的主要目的是确定因急性头痛到急诊科就诊的患者，LP 显示脑脊液中存在红细胞（RBC）但脑血管成像未见异常，随后是否会发生 SAH。
对 2010 年至 2011 年期间进行的 2001 年至 2009 年连续成年 ED 患者 LP 费用进行病例系列研究。纳入标准为：头痛，CSF 中>5 RBC/mm(3)，非对比头部 CT 无出血证据，ED 就诊后 2 周内 CTA 或 MRA 未见动脉瘤或血管病变。排除随访时间少于 6 个月的患者。主要结局为 1）随后发生非创伤性 SAH 和 2）新血管病变。次要结局为与 SAH、LP 或血管造影相关的并发症。
在 4641 名接受 LP 计费的 ED 患者中，有 181 名患者（平均年龄 42 岁）纳入本研究。在中位数为 53 个月的随访中，181 名患者（95%CI0%-2.0%）中无 1 例（0 例）发生随后的 SAH 或新血管病变。虽然不是主要结局，但有 1 例患者最终被诊断为血管炎。181 名患者中 18 名（9.9%）（95%CI6.0%-15.3%）发生 LP 相关并发症，181 名患者中无 1 名（0%）（95%CI0%-2.0%）发生血管造影相关并发症。
因急性头痛而怀疑 SAH 并出现 LP 血性脑脊液但脑血管成像未见异常的患者发生随后的 SAH 风险较低，因此很可能适合出院。用 CT/CTA 诊断算法替代 CT/LP 值得进一步研究。
