Lb. Morgenstern et al., WORST HEADACHE AND SUBARACHNOID HEMORRHAGE - PROSPECTIVE, MODERN COMPUTED-TOMOGRAPHY AND SPINAL-FLUID ANALYSIS, Annals of emergency medicine, 32(3), 1998, pp. 297-304
Study objective: This study investigated the hypothesis that modern co
mputed tomographic (CT) imaging is sufficient to exclude subarachnoid
hemorrhage (SAH) in patients with severe headache. Methods: All 38,730
adult patients who presented to Hermann Hospital in Houston, Texas, d
uring a 16-month period were prospectively screened to detect those wi
th ''the worst headache of my life.'' Two neuroradiologists blinded to
the study hypothesis interpreted the CT scans. Patients with negative
scans underwent comprehensive cerebrospinal fluid (CSF) analysis incl
uding cell count in first and last tubes, visual and spectrophotometri
c detection of xanthochromia, and CSF D-dimer assay. Results: A chief
complaint of headache was elicited in 455 patients, and 107 of these h
ad ''worst headache'' and were enrolled in the study. CT-confirmed SAH
was found in 18 of the 107 (17%). Only 2 patients (2.5%, 95% confiden
ce interval,.3% to 8.8%) had SAH detected by CSF analysis among those
with negative CT imaging result. CSF spectrophotometric detection was
the most sensitive test for blood. Three patients with less than 6 red
blood cells in tube 1 had positive spectrophotometric results, but in
all 3, tube 4 was negative on spectrophotometric analysis, suggesting
a high false-positive rate. Conclusion: Modern CT imaging is sufficie
nt to exclude 97.5% of SAH in patients presenting to the ED with ''wor
st headache'' symptoms.