Risk-benefit analysis of lumbar puncture to evaluate for nontraumatic subarachnoid hemorrhage in adult ED patients

Victoria L Migdal, W Kelly Wu, Drew Long, Candace D McNaughton, Michael J Ward, Wesley H Self
American Journal of Emergency Medicine 2015, 33 (11): 1597-601

OBJECTIVE: The objective of the study is to compare the risks and benefits of lumbar puncture (LP) to evaluate for subarachnoid hemorrhage (SAH) after a normal head computed tomographic (CT) scan.

METHODS: This was an observational study of adult emergency department patients at a single hospital who presented with headache and underwent LP after a normal head CT to evaluate for SAH. Lumbar puncture results classified as indicating a SAH included xanthochromia in cerebrospinal fluid (CSF) or red blood cells in the final tube of CSF with an aneurysm or arteriovenous malformation on cerebral angiography. An LP-related complication was defined as hospitalization or a return visit due to symptoms attributed to the LP. Proportions of the study patients who had SAH diagnosed by LP and who experienced an LP-related complication were compared.

RESULTS: The study included 302 patients, including 2 (0.66%) who were diagnosed with SAH based on LP (number needed to diagnose, 151); both of these patients had a known intracranial aneurysm. Eighteen (5.96%) patients experienced an LP-related complication (P < .01 compared with number with SAH diagnosed; number needed to harm, 17). Complications included 12 patients with low-pressure headaches, 4 with pain at the LP site, and 2 with contaminated CSF cultures.

CONCLUSION: The yield of LP for diagnosing SAH in adults with nontraumatic headache after a normal head CT was very low. The severity of LP-related complications was low, but complications were more common than SAH diagnoses. Lumbar puncture may not be advisable after a normal head CT to evaluate for SAH, particularly in patients with low-risk clinical features for SAH.

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