Elsevier

Mayo Clinic Proceedings

Volume 83, Issue 12, December 2008, Pages 1326-1331
Mayo Clinic Proceedings

ORIGINAL ARTICLE
Thunderclap Headache and Normal Computed Tomographic Results: Value of Cerebrospinal Fluid Analysis

https://doi.org/10.4065/83.12.1326Get rights and content

OBJECTIVE

To determine the sensitivity, specificity, and negative and positive predictive values of cerebrospinal fluid (CSF) xanthochromia for detection of ruptured cerebral aneurysms in patients with thunderclap headache (sudden and severe headache with maximal intensity at onset).

PATIENTS AND METHODS

We identified patients who presented to our emergency department with symptoms of thunderclap headache between January 1, 1998, and January 1, 2008. Those with normal results on computed tomography (CT) of the head were selected for inclusion in the study. All consenting adult patients had undergone a lumbar puncture procedure for CSF analysis. Xanthochromia was assessed by visual inspection. All patients with a normal CT result were further evaluated by conventional 4-vessel catheter angiography. If no aneurysms were detected in the initial study, the procedure was performed again within 7 to 14 days. All patients were followed up clinically for a mean period of approximately 29 months.

RESULTS

A total of 152 patients were identified (mean ± SD age, 44.7±15.8 years; 53 men). Cerebrospinal fluid xanthochromia was present in 18 patients (12%), 13 (72%) of whom were ultimately diagnosed as having aneurysmal subarachnoid hemorrhage. A single patient who tested negative for xanthochromia and had a normal CT result was subsequently found to have a ruptured middle cerebral artery aneurysm. The sensitivity, specificity, positive predictive value, and negative predictive value of CSF xanthochromia for detection of cerebral aneurysms were 93%, 95%, 72%, and 99%, respectively.

CONCLUSION

Although not perfect, visual inspection of CSF in patients with a history suggestive of subarachnoid hemorrhage remains a highly valuable and simple test to detect a recently ruptured aneurysm.

Section snippets

PATIENTS AND METHODS

A retrospective study of alert, neurologically intact, nontraumatic patients with TCH presenting to the ED of Saint Marys Hospital (Rochester, MN) between January 1, 1998, and January 1, 2008, was conducted. Alert was defined as a Glasgow Coma Scale score of 15. Nontraumatic was defined as the absence of falls or direct trauma to the head in the previous 14 days. Thunderclap headache was defined as a sudden and severe headache with maximum intensity at onset. All patients presented less than 2

RESULTS

Of the 4662 patients who presented with headache, 642 patients (14%) characterized their headache as “the worst of their life.” Only 152 patients (3%) described a sudden, severe headache, maximal at onset, despite a normal head CT result. Data analysis is limited to these 152 patients. A study flowchart is illustrated in Figure 1. The mean ± SD age of the patients was 44.7±15.8 years. The female-male ratio was 1.9:1. The mean elapsed time between the onset of headache and the CT study was 29.5

DISCUSSION

To our knowledge, our study of consecutive patients who presented to the ED with TCH and normal CT results shows for the first time that visual detection of CSF xanthochromia has a high PPV (72% in our population) for the presence of aneurysm on cerebral angiography. We also found that the red blood cell and total nucleated cell counts in the CSF were significantly higher in patients with angiographically documented aneurysms. Thus, these CSF parameters may be useful when trying to exclude the

CONCLUSION

Evidence of CSF xanthochromia on visual inspection in patients with TCH and negative CT results is associated with a high likelihood of finding an aneurysm on conventional angiography. Visual inspection and spectrophotometry for the evaluation of xanthochromia may provide complementary information to the ED physician triaging these patients. Physicians should be aware of each test's characteristics to ensure its proper use in the decision-making process. Elevated cell counts in the CSF may also

REFERENCES (17)

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