Yield of Catheter Angiography After Computed Tomography Negative, Lumbar Puncture Positive Subarachnoid Hemorrhage

Abstract

Background and Purpose Patients suspected of having aneurysmal subarachnoid hemorrhage (SAH) are initially evaluated with noncontrast head computed tomography (CT). If the CT is negative, but clinical concern for SAH is high, a lumbar puncture (LP) with cerebrospinal fluid (CSF) analysis is typically performed. The purpose of this study was to evaluate the accuracy of CSF xanthochromia and erythrocytosis for aneurysmal SAH. Methods Medical records of all patients who underwent catheter angiography at Barnes Jewish Hospital between July 2002 and April 2012 for clinical suspicion of a ruptured brain aneurysm after a negative CT scan and an LP suspicious for SAH were reviewed. The CSF analysis results, angiographic findings and outcomes of each case were recorded. Results Fifty nine patients were identified. Two angiographic lesions were identified in patients with xanthochromia was 8.3% (2/24), both of which were confirmed to have ruptured. The diagnostic yield in patients with non-clearing erythrocytosis and no xanthrochromia was 6.3% (1/16), though this lesion was not considered the source of SAH. Conclusion Catheter angiography should be performed in patients with CT negative but suspicious LP, particularly in the presence of xanthrochromia. The benefit of angiography in patients with erythrocytosis only is unclear and deserves future study.

Appreciation of CT-negative, lumbar puncture-positive subarachnoid haemorrhage: risk factors for presence of aneurysms and diagnostic yield of imaging

“…Notably, 43% of patients in this series were found to harbour a vascular lesion, highlighting the need for an adequate diagnostic workup. This is in line with the recently published study by Chalouhi et al 10 in which 46% harboured a vascular lesion, but higher than the study performed by Wallace et al 11 (6.3%). The incidence rate of CT-negative, LP-positive SAH in our cohort was 6.5% (94/1448 patients).…”

“…Factors such as visual erythrocytosis or xanthochromia were considered inconclusive 11. Spectrophotometry is more specific for SAH because it can differentiate between in vivo blood degradation products and in vitro lysis of erythrocytes following a traumatic tap.…”

“…In two recent papers, the incidence of an underlying ruptured aneurysm ranged from 6.3% to 45.7%, as diagnosed by cerebral catheter digital subtraction angiography (DSA) 10 11. Clinical risk factors for the presence of a vascular lesion are unknown for this patient category, although Horstman et al 12 recently published a small series in which the chance of finding an aneurysm increased with the interval between ictus and LP.…”

Cerebral Angiography for Evaluation of Patients with CT Angiogram-Negative Subarachnoid Hemorrhage: An 11-Year Experience

“…However, prior studies have found aneurysms as a cause of xanthochromia in approximately 8% of patients. 34 Similarly, prior studies have found a high yield of DSA in patients with isolated IVH, though the sensitivity of CTA in the setting of isolated IVH has been poorly described. 35 Therefore, at least 1 DSA is prudent in these patients.…”

Validation of cerebrospinal fluid findings in aneurysmal subarachnoid hemorrhage

“…As a result, when abnormal numbers of RBCs are present in the CSF of a patient with possible "CT-negative" SAH (subarachnoid hemorrhage), angiography is often recommended to exclude a vascular etiology of hemorrhage [6][7][8]. Unfortunately false-positive LPs because of elevated RBC counts are common, most often attributed to traumatic technique ("traumatic taps," with reported rates up to 30%) [9][10][11].…”