Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
World Neurosurg. 2021 Apr;148:e27-e34. doi: 10.1016/j.wneu.2020.11.152. Epub 2020 Dec 4.
While headache is a common neurologic symptom, subarachnoid hemorrhage (SAH) is a rare and potentially catastrophic cause of sudden-onset severe headache. The utility of the imaging modalities and interventional procedures are central to the investigation of the causes of headache; however, they are not without their limitations, risks, and complications.
A meta-analysis in accordance with the Preferred Reporting for Systematic Reviews and Meta-analysis guidelines was conducted searching PubMed, EMBASE, and Google Scholar. Patients investigated for suspected subarachnoid hemorrhage (SAH) with a negative computed tomography (CT) and positive lumbar puncture (LP) and final diagnosis of SAH were included. The sensitivity of LP in the context of a negative CT and vsubsequent imaging confirming the cause of SAH (computed tomography angiography, magnetic resonance angiography, digital subtraction angiography [DSA]) was quantified. The pooled data were analyzed using the DerSimonian-Laid random effects model.
Four studies with 2782 patients who presented with headache suspicious for SAH were included with an initial negative CT report and a subsequent LP to rule out SAH. All included studies had an observational prospective cohort design. A combined pooled proportion of 0.383 (0.077, 0.756); 0.086 (0.007, 0.238); and 0.22 (0.04, 0.49) for LP+, DSA+, and DSA/computed tomography angiography+ investigations were estimated with a 95% confidence interval.
The current clinical workflow of an LP after a negative CT head for a patient presenting with a sudden-onset severe headache is observed to have a high enough proportion to warrant its continued use despite the sensitivity of modern CT scanners of ≥97%.
头痛虽是常见的神经系统症状，但蛛网膜下腔出血（SAH）却是突发剧烈头痛的罕见且潜在灾难性病因。影像学方式和介入性操作的应用对于头痛病因的探查至关重要；然而，这些方法并非没有局限性、风险和并发症。
本研究遵循系统评价和荟萃分析的首选报告进行了荟萃分析，检索了 PubMed、EMBASE 和 Google Scholar。纳入了接受疑似蛛网膜下腔出血（SAH）检查的患者，其初始计算机断层扫描（CT）结果为阴性，腰椎穿刺（LP）结果为阳性，最终诊断为 SAH。本研究量化了 LP 在 CT 结果阴性且后续影像学检查（CT 血管造影、磁共振血管造影、数字减影血管造影 [DSA]）确定 SAH 病因时的敏感性。使用 DerSimonian-Laid 随机效应模型对汇总数据进行分析。
纳入了 4 项研究，共 2782 例以头痛为首发症状疑似 SAH 的患者，其初始 CT 报告为阴性，随后进行 LP 以排除 SAH。所有纳入的研究均采用观察性前瞻性队列设计。联合汇总的 LP+、DSA+和 DSA/CT 血管造影+检查的比例分别为 0.383（0.077，0.756）、0.086（0.007，0.238）和 0.22（0.04，0.49），95%置信区间为 0.086（0.007，0.238）和 0.22（0.04，0.49）。
目前对于以突发剧烈头痛就诊且 CT 头部扫描结果阴性的患者，临床流程中会进行 LP，虽然现代 CT 扫描仪的敏感性≥97%，但该检查的阳性比例足够高，仍有必要继续应用。
