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Diagnosis of subarachnoid haemorrhage

1997; Elsevier BV; Volume: 350; Issue: 9072 Linguagem: Inglês

10.1016/s0140-6736(05)62381-1

1474-547X

J J Craig, VH Patterson, R.S. Cooke, LG Rocke, C S McKinstry,

Neurosurgical Procedures and Complications

We agree with Jan van Gijn's May 24 commentary1van Gijn J Slip-ups in diagnosis of subarachnoid haemorrhage.Lancet. 1997; 349: 1492Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar that patients with severe headache of sudden onset should be assessed in hospital and that a rational strategy is needed to ensure that the diagnosis of subarachnoid haemorrhage is not delayed or missed. In the UK such a strategy must involve accident and emergency departments to which up to 60% of patients with headache refer themselves.2Fodden DI Peatfield RC Milsom PL Beware the patient with a headache in the accident and emergency department.Arch Emerg Med. 1989; 6: 7-12Crossref PubMed Scopus (34) Google Scholar In addition, because of the limited number of beds in neurosurgical and neurological units in the UK, most patients with suspected subarachnoid haemorrhage are admitted to general medical wards, specialist services only being sought for subsequently confirmed cases of subarachnoid haemorrhage. Although recent studies highlight the frequency of missed or delayed diagnosis of subarachnoid haemorrhage,3Mayer PL Awad IA Todor R et al.Misdiagnosis of symptomatic cerebral aneurysm-prevalence and correlation with outcome at four institutions.Stroke. 1996; 27: 1558-1563Crossref PubMed Scopus (118) Google Scholar, 4Neil-Dwyer G Lang D ‘Brain attack’– aneurysmal subarachnoid haemorrhage: death due to delayed diagnosis.J R Coll Physicians. 1997; 31: 49-52PubMed Google Scholar they potentially underestimate the problem by missing those patients who die before they reach hospital after a further event or who have not haemorrhaged within the follow-up period. Future studies must examine the entire process of management prospectively from symptom onset to determine the real scale of the incorrect or delayed diagnosis of subarachnoid haemorrhage. We have conducted an audit in a large teaching hospital of consecutive patients who underwent a computed tomography (CT) brain scan to exclude a subarachnoid haemorrhage. We wanted to know if the accepted guideline of a lumbar puncture with spectrophotometric analysis of the cerebrospinal fluid was being adhered to in the context of a negative CT scan. 45 cases of subarachnoid haemorrhage were identified in the study period. The CT scan was abnormal in 16, revealing a subarachnoid haemorrhage in nine patients. Of the 29 patients with a normal CT scan, lumbar puncture was done in only eight cases, and revealed xanthochromia in one. 21 patients who were therefore felt to warrant a CT scan to exclude subarachnoid haemorrhage did not have a lumbar puncture. Although the results for patients who had lumbar puncture cannot be extrapolated to those who did not, one can only conclude that not implementing accepted guidelines leads to a substantial number of missed diagnoses and, therefore, excess morbidity and mortality. Linn and colleagues5Linn FHH Wijdicks EFM van der Graf Y et al.Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage.Lancet. 1994; 344: 590-593Summary PubMed Scopus (232) Google Scholar showed that family doctors who are aware of the difficulties involved in the diagnosis of subarachnoid haemorrhage can screen effectively for the disorder.5Linn FHH Wijdicks EFM van der Graf Y et al.Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage.Lancet. 1994; 344: 590-593Summary PubMed Scopus (232) Google Scholar All hospital doctors who deal with this patient group should do the same and implement accepted guidelines of care which will ultimately improve outcome.