Acute Headache of Recent Onset and Subarachnoid Hemorrhage: A Prospective Study

Abstract

Twenty-seven patients with acute severe headache of recent onset were prospectively recruited in the Emergency Room. Mean duration of headache was 61 hours. CT scan disclosed subarachnoid bleeding in 4 patients and spinal tap revealed subarachnoid hemorrhage (SAH) in 5 patients with normal CT scan. In most SAH cases pain was bilateral, very intense and involving the occipital region. Four of these patients had doubtful or no nuchal rigidity and in one, pain improved while in the Emergency Room. In every case with an intense acute severe headache of recent onset CT scan and (if normal) a lumbar puncture are warranted to help rule out a SAH.

Lumbar Puncture First: An Alternative Model for the Investigation of Lone Acute Sudden Headache

“…Studies suggest that 8 -12% of patients meeting the LASH criteria have SAH. 2,3 Within this prevalence range, for every 100 patients investigated, the LP-first model would be expected to result in 79 to 83 fewer CT scans and only seven to 11 additional LPs, as compared with the traditional model of CT followed by LP for negative scans. The lower a physician's threshold for initiating investigations for suspected SAH (i.e., the lower the prevalence of SAH among investigated patients), the greater the relative benefit of this model.…”

“…The prevalence of SAH among LASH patients was assumed to be 10% for the initial analysis. 2,3,8 The sensitivity of the CT scanner was initially assumed to be 90% for SAH in patients meeting LASH criteria, 9 -15 while the CT specificity was assumed to be 99% throughout. No published article could be found regarding the rate of indeterminate LPs, and the 10% rate represented our best estimate.…”

“…1 Subarachnoid hemorrhage (SAH) is the cause of approximately 1% of all headaches seen in the ED, 1 and up to a third of acute sudden headaches. 2,3 Subarachnoid hemorrhage occurs in young people, with a median age of 50 years, and has a 50% mortality at six months.…”

“…While most LASH patients have benign headaches, they should none-theless be investigated given that prospective series have shown an 8 -12% rate of SAH. 2,3,8 Computed tomography scanning alone cannot be relied on to rule out SAH, since its sensitivity at 24 hours varies from 81% to 100%, and decreases rapidly thereafter, 9 -15 even with newergeneration CT scanners. 12,15,16 Also, CT sensitivity varies with the neurologic status of the patient; CT is only 86% sensitive in alert patients with SAH, as compared with 99.4% sensitivity in stuporous or comatose patients with SAH.…”

Thunderclap Headache in HIV Positive Patients: Aetiology, Clinical Findings and Long Term Follow-up of a Series of 5 Cases

“…7,10 There are other varieties of causes depending on authors and include; intracerebral haemorrhage, brain tumours, cerebral venous thrombosis, meningitis, acute glaucoma and sinusitis. [11][12][13] The incidence of thunderclap headache worldwide is not known because of this multitude of aetiologies. 8,10 In Cameroon, the prevalence of HIV infection in adults is 5, 3%.…”