Sayer David, Bloom Ben, Fernando Katalin, Jones Stuart, Benton Sally, Dev Shumontha, Deverapalli Sathish, Harris Tim
Department of Neurosurgery, Queen's Hospital, Barking, Havering and Redbridge NHS Trust, Romford, Essex.
Department of Emergency Medicine, Bart's Health NHS Trust, London, UK.
Acad Emerg Med. 2015 Nov;22(11):1267-73. doi: 10.1111/acem.12811. Epub 2015 Oct 19.
The objective was to determine the incidence of subarachnoid hemorrhage (SAH) diagnosed by lumbar puncture (LP) when the head computed tomography (CT) was reported as demonstrating no subarachnoid blood.
Data were obtained on patients who received LP to diagnose or exclude SAH attending six hospitals over 5 years. Subsequent investigations and outcomes were reviewed in all patients with LPs that did not exclude SAH.
A total of 2,248 patients were included. A total of 1,898 LPs were suitable for biochemical analysis, of which 92 (4.8%) were positive for blood, suggesting SAH; 1,507 (79.4%) were negative; and 299 (15.6%) were inconclusive. Of the 92 patients with positive cerebrospinal fluid analysis, eight patients (0.4%) had aneurysms on further imaging, and one had a carotid cavernous fistula.
In patients presenting to the emergency department with acute severe headache, LP to diagnose or exclude SAH after negative head CT has a very low diagnostic yield, due to low prevalence of the disease and uninterpretable or inconclusive samples. A clinical decision rule may improve diagnostic yield by selecting patients requiring further evaluation with LP following nondiagnostic or normal noncontrast CT brain imaging.
本研究旨在确定在头颅计算机断层扫描（CT）报告显示无蛛网膜下腔出血时，通过腰椎穿刺（LP）诊断的蛛网膜下腔出血（SAH）的发生率。
收集了5年间在6家医院接受LP以诊断或排除SAH的患者的数据。对所有未排除SAH的LP患者的后续检查和结果进行了回顾。
共纳入2248例患者。共有1898次LP适合进行生化分析，其中92次（4.8%）血液检测呈阳性，提示SAH；1507次（79.4%）为阴性；299次（15.6%）结果不确定。在92例脑脊液分析阳性的患者中，8例（0.4%）在进一步影像学检查中发现动脉瘤，1例患有颈内动脉海绵窦瘘。
对于因急性重度头痛就诊于急诊科的患者，在头颅CT阴性后进行LP诊断或排除SAH的诊断率非常低，原因是该疾病的患病率低以及样本难以解释或结果不确定。临床决策规则可能通过选择在非诊断性或正常非增强CT脑成像后需要进一步进行LP评估的患者来提高诊断率。
