evaluation of the sudden and severe headache: diagnosis and management michael gerardi, md, faap,...
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Evaluation of the Sudden and Evaluation of the Sudden and Severe Headache:Severe Headache:
Diagnosis and ManagementDiagnosis and Management
Michael Gerardi, MD, FAAP, FACEPMichael Gerardi, MD, FAAP, FACEPVice-Chairman, Department of Emergency MedicineVice-Chairman, Department of Emergency Medicine
Morristown Memorial HospitalMorristown Memorial HospitalDirector, Pediatric Emergency MedicineDirector, Pediatric Emergency Medicine
Children’s Medical CenterChildren’s Medical CenterMorristown, New JerseyMorristown, New Jersey
Michael Gerardi, MD
The CaseThe Case
One hour prior to ED presentation, a One hour prior to ED presentation, a 42 year old man was jogging and 42 year old man was jogging and “hit” by the worst headache of his “hit” by the worst headache of his life. It was associated with some life. It was associated with some nausea and the feeling as if he was nausea and the feeling as if he was going to pass out. He rested for 30 going to pass out. He rested for 30 minutes but the headache persisted minutes but the headache persisted as a diffuse, throbbing pain as a diffuse, throbbing pain radiating to the base of his skull. radiating to the base of his skull.
Michael Gerardi, MD
EMS was called. The patient felt as if he could not EMS was called. The patient felt as if he could not
concentrate, there was no confusion, nor was concentrate, there was no confusion, nor was
there any other focal neurologic complaint.there any other focal neurologic complaint.
There was no past medical history, no medications, There was no past medical history, no medications,
no family history, and no significant use of no family history, and no significant use of
alcohol, tobacco or other drugs.alcohol, tobacco or other drugs.
The Case The Case (Continued)(Continued)
Michael Gerardi, MD
If a patient presented with the worst If a patient presented with the worst headache of his life, what is the work-headache of his life, what is the work-up that should be initiated?up that should be initiated?
a. Non-contrast CTa. Non-contrast CT
b. LP after neg. CTb. LP after neg. CT
c. LP without CTc. LP without CT
d. CT, LP, and angiographyd. CT, LP, and angiography
Michael Gerardi, MD
What is the differential of a “thunderclap What is the differential of a “thunderclap headache”?headache”?
What is the sensitivity of neuroimaging in What is the sensitivity of neuroimaging in subarachnoid hemorrhage (SAH)?subarachnoid hemorrhage (SAH)?
What constitutes a “positive” lumbar puncture in What constitutes a “positive” lumbar puncture in SAH and when should it be performed?SAH and when should it be performed?
Do patients with suspected SAH who have a Do patients with suspected SAH who have a negative CT and lumbar puncture require negative CT and lumbar puncture require additional imaging to “rule-out” expanded but additional imaging to “rule-out” expanded but unruptured aneurysm?unruptured aneurysm?
ObjectivesObjectives
Michael Gerardi, MD
• 1 of 10 top presenting complaints1 of 10 top presenting complaints
• 1 to 2% of visits to ED1 to 2% of visits to ED
• 18 million outpatient visits18 million outpatient visits
• 638 million days of work lost per year638 million days of work lost per year
• 78% of women and 64% of men had 78% of women and 64% of men had experienced at least one in the prior yearexperienced at least one in the prior year
• 36% of women and 19% men suffer from 36% of women and 19% men suffer from recurrent headachesrecurrent headaches
Michael Gerardi, MD
• Most have primary headache disordersMost have primary headache disorders
• migrainemigraine
• tensiontension
• Only a few have treatable secondary Only a few have treatable secondary causes that threaten life, limb, brain such causes that threaten life, limb, brain such as as subarachnoid hemorrhagesubarachnoid hemorrhage
• 1 - 4 % of headache visits1 - 4 % of headache visits
Michael Gerardi, MD
““Worst” HeadacheWorst” Headache
Normal exam: Normal exam: 12- 33% SAH12- 33% SAH Abnormal exam:Abnormal exam: 25% SAH25% SAH Initial hemorrhage may be fatalInitial hemorrhage may be fatal Early definitive surgery improves Early definitive surgery improves
outcomesoutcomes Patients with greatest likelihood of Patients with greatest likelihood of
benefiting from surgery are most likely to benefiting from surgery are most likely to receive incorrect diagnosisreceive incorrect diagnosis
Michael Gerardi, MD
Physicians Consistently Physicians Consistently Misdiagnose SAHMisdiagnose SAH
1. Failure to appreciate spectrum of clinical 1. Failure to appreciate spectrum of clinical presentationpresentation
2. Failure to understand limitations of CT2. Failure to understand limitations of CT
3. Failure to perform and correctly interpret 3. Failure to perform and correctly interpret the results of LPthe results of LP
Michael Gerardi, MD
ED Goals in Headache PatientsED Goals in Headache Patients
1. 1. Differentiate life-threatening from benignDifferentiate life-threatening from benign
2. Initiate prompt treatment2. Initiate prompt treatment
3. Provide prompt pain relief3. Provide prompt pain relief
4. Prevent drug seeking and refer4. Prevent drug seeking and refer
5. Minimize resource utilization in ED5. Minimize resource utilization in ED
6. Optimize patient use of ED6. Optimize patient use of ED
7. Increase pre-ED treatment and reduce ED 7. Increase pre-ED treatment and reduce ED useuse
Michael Gerardi, MD
Differential Diagnosis of HeadacheDifferential Diagnosis of HeadacheDifferential Diagnosis of HeadacheDifferential Diagnosis of Headache
OnsetOnset LocationLocation Associated symptomsAssociated symptoms Pain characteristicsPain characteristics DurationDuration Prior historyPrior history Diagnostic testsDiagnostic tests Physical examPhysical exam
Michael Gerardi, MD
Medical Conditions That Medical Conditions That Present With HeadachePresent With Headache
Medical Conditions That Medical Conditions That Present With HeadachePresent With Headache
PheochromocytomaPheochromocytoma HyperthyroidismHyperthyroidism SLESLE Giant Cell ArteritisGiant Cell Arteritis FibromyalgiaFibromyalgia
Michael Gerardi, MD
Types of Headaches in the EDTypes of Headaches in the ED
Final DiagnosisFinal Diagnosis PercentagePercentageInfection - not intracranialInfection - not intracranial 39.339.3Tension HATension HA 19.319.3MiscellaneousMiscellaneous 14.914.9Post-traumaticPost-traumatic 9.39.3Hypertension relatedHypertension related 4.84.8Vascular (Migraine)Vascular (Migraine) 4.54.5No diagnosisNo diagnosis 6.06.0SAHSAH 0.90.9MeningitisMeningitis 0.60.6
Michael Gerardi, MD
Ped HA Compared to Ped HA Compared to Literature: Serious ConditionsLiterature: Serious Conditions
Ped HA Compared to Ped HA Compared to Literature: Serious ConditionsLiterature: Serious Conditions
AuthorAuthor # # Age Tumor Bleed Meningitis Age Tumor Bleed Meningitis
BurtonBurton 288 288 2-18 2-18 0 0 00 0.3 0.3
FoddenFodden 106 106 0-90 0-90 4.7 4.7 8.58.5 0 0
LeichtLeicht 485485 15-89 2.7 15-89 2.7 1.0 1.0 0.8 0.8
DopeshiDopeshi 872 872 2-92 2-92 0.1 0.1 0.9 0.9 0.6 0.6
DickmanDickman 124 124 16-65 0 16-65 0 0 0 0 0
Michael Gerardi, MD
Causes of Headache That Causes of Headache That Require Specific TherapyRequire Specific Therapy
Subarachnoid hemorrhageSubarachnoid hemorrhage MeningitisMeningitis EncephalitisEncephalitis Cervicocranial-artery dissectionCervicocranial-artery dissection Temporal arteritisTemporal arteritis Acute angle-closure glaucomaAcute angle-closure glaucoma Hypertensive emergencyHypertensive emergency
Michael Gerardi, MD
Causes of Headache That Causes of Headache That Require Specific TherapyRequire Specific Therapy
Carbon Monoxide poisoningCarbon Monoxide poisoning Pseudotumor cerebriPseudotumor cerebri Cerebral venous and dural sinus thrombosisCerebral venous and dural sinus thrombosis Acute stroke (hemorrhagic or ischemic)Acute stroke (hemorrhagic or ischemic) Mass LesionMass Lesion
tumortumor abscessabscess intracranial hematomaintracranial hematoma
parameningeal infectionparameningeal infection
Michael Gerardi, MD
Headache Headache DangerDanger Signals SignalsHeadache Headache DangerDanger Signals Signals
Onset Onset after 40 yearsafter 40 years new or different headachenew or different headache subacute HA that worsenssubacute HA that worsens exertion, sex, coughing, strainingexertion, sex, coughing, straining
Worst ever experiencedWorst ever experienced
Michael Gerardi, MD
Headache Headache DangerDanger Signals: Associated Signals: Associated With Neurologic ChangeWith Neurologic Change
Headache Headache DangerDanger Signals: Associated Signals: Associated With Neurologic ChangeWith Neurologic Change
Memory impairmentMemory impairment AtaxiaAtaxia DrowsinessDrowsiness Sensory lossSensory loss Signs of meningeal irritationSigns of meningeal irritation
Michael Gerardi, MD
Headache Headache DangerDanger Signals: Signals: Associated With Neurologic ChangeAssociated With Neurologic Change
Headache Headache DangerDanger Signals: Signals: Associated With Neurologic ChangeAssociated With Neurologic Change
Progressive visual or neurologic Progressive visual or neurologic changechange
ConfusionConfusion WeaknessWeakness Loss of coordinationLoss of coordination Asymmetry of pupils, DTRsAsymmetry of pupils, DTRs
Michael Gerardi, MD
Headache Headache DangerDanger Signals: Signals: Abnormal Medical EvaluationAbnormal Medical EvaluationHeadache Headache DangerDanger Signals: Signals:
Abnormal Medical EvaluationAbnormal Medical Evaluation
FeverFever Chronic malaiseChronic malaise ArthralgiaArthralgia HTNHTN MyalgiaMyalgia Wt lossWt loss Tender, poorly pulsatile temporal Tender, poorly pulsatile temporal
arteriesarteries
Michael Gerardi, MD
Subarachnoid HemorrhageSubarachnoid HemorrhageSubarachnoid HemorrhageSubarachnoid Hemorrhage
10% of all acute CVAs10% of all acute CVAs 30,000 persons/year30,000 persons/year
10 -16/100,00010 -16/100,000 1% of all ED patients with acute cephalgia1% of all ED patients with acute cephalgia
Michael Gerardi, MD
Subarachnoid HemorrhageSubarachnoid Hemorrhage
Incidence of 16 /100,000Incidence of 16 /100,000 about 33,600 cases per yearabout 33,600 cases per year 54% secondary to ruptured 54% secondary to ruptured
aneurysmaneurysm Without treatment, 40% of aneurysm Without treatment, 40% of aneurysm
pts. have recurrent bleedingpts. have recurrent bleeding Aneurysm pt who survives initial Aneurysm pt who survives initial
rupture and is treated conservatively: rupture and is treated conservatively: 50% survival at one year50% survival at one year
Michael Gerardi, MD
Subarachnoid HemorrhageSubarachnoid HemorrhageSubarachnoid HemorrhageSubarachnoid Hemorrhage
Onset: Onset: AcuteAcute Location: Location: GlobalGlobal Ass Sx:Ass Sx: N,V, meningismus, focalN,V, meningismus, focal Pain: Pain: Worst everWorst ever Duration: Duration: BriefBrief Prior Hx: Prior Hx: NoNo Dx tests:Dx tests: CT 80-90%CT 80-90% Phys ex: Phys ex: Focal signs, LOC, meningismusFocal signs, LOC, meningismus
Michael Gerardi, MD
Subarachnoid HemorrhageSubarachnoid Hemorrhage
Warning leaks in 50%Warning leaks in 50% CT misses up to 10% small leaksCT misses up to 10% small leaks Suspect if:Suspect if:
> 35 years> 35 years no previous HAno previous HA no fading of HAno fading of HA came on with exertioncame on with exertion altered LOC or neuro deficitsaltered LOC or neuro deficits stiff neckstiff neck
Michael Gerardi, MD
Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Neurologic FindingsNeurologic Findings
Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Neurologic FindingsNeurologic Findings
Sudden HA without localizing findingsSudden HA without localizing findings Altered mentationAltered mentation
Confusion, lethargyConfusion, lethargy Bilateral extensor plantar reflexBilateral extensor plantar reflex Unusual to find focal deficitsUnusual to find focal deficits
Michael Gerardi, MD
Causes of Non-Traumatic Causes of Non-Traumatic Subarachnoid HemorrhageSubarachnoid HemorrhageCauses of Non-Traumatic Causes of Non-Traumatic
Subarachnoid HemorrhageSubarachnoid Hemorrhage
“ “Berry” aneurysmsBerry” aneurysms AVMAVM Cerebral angiomasCerebral angiomas Mycotic aneurysmMycotic aneurysm Extension from parenchymatous Extension from parenchymatous
hemorrhagehemorrhage Anticoagulation therapyAnticoagulation therapy
Michael Gerardi, MD
Causes of Non-Traumatic Causes of Non-Traumatic Subarachnoid HemorrhageSubarachnoid HemorrhageCauses of Non-Traumatic Causes of Non-Traumatic
Subarachnoid HemorrhageSubarachnoid Hemorrhage
Systemic bleeding diathesisSystemic bleeding diathesis Hemorrhagic encephalitisHemorrhagic encephalitis Hemorrhagic cerebral vasculitisHemorrhagic cerebral vasculitis Hemorrhage into CNS tumors or Hemorrhage into CNS tumors or
metastasesmetastases UnknownUnknown
Michael Gerardi, MD
Intracranial AneurysmsIntracranial AneurysmsIntracranial AneurysmsIntracranial Aneurysms
Women: men = 3 : 2Women: men = 3 : 2 4 million Americans4 million Americans
20% multiple aneurysms20% multiple aneurysms Increase in mid-20sIncrease in mid-20s Peak incidence of 12% by age 60Peak incidence of 12% by age 60 Risk of spontaneous rupture 1 to 3%/yrRisk of spontaneous rupture 1 to 3%/yr
Peak 40 to 60 yearsPeak 40 to 60 years
Michael Gerardi, MD
Arteriovenous MalformationsArteriovenous MalformationsArteriovenous MalformationsArteriovenous Malformations
10-15% of SAH10-15% of SAH Spontaneous hemorrhageSpontaneous hemorrhage
Any age but usually < 30Any age but usually < 30 Incidence 3% per yearIncidence 3% per year Incidence of major neurologic deficit Incidence of major neurologic deficit
or mortality: 50%or mortality: 50%
Michael Gerardi, MD
Conditions Associated with Conditions Associated with Cerebral Aneurysm DevelopmentCerebral Aneurysm Development
Conditions Associated with Conditions Associated with Cerebral Aneurysm DevelopmentCerebral Aneurysm Development
HTNHTN Polycystic kidney diseasePolycystic kidney disease Connective tissue disordersConnective tissue disorders Coarctation of aortaCoarctation of aorta Pregnancy induced HTNPregnancy induced HTN Family history of CVAsFamily history of CVAs Bacterial endocarditisBacterial endocarditis
Michael Gerardi, MD
Warning HeadacheWarning Headache
20 - 50% patients with SAH have HA days or 20 - 50% patients with SAH have HA days or weeks before index episodeweeks before index episode unusually severeunusually severe distinctdistinct
“ “Thunderclap” headacheThunderclap” headache Day and Raskin 1996Day and Raskin 1996 intense, acute, peak intensity at onsetintense, acute, peak intensity at onset develop in secondsdevelop in seconds maximal intensity in minutesmaximal intensity in minutes lasts hours to dayslasts hours to days
Michael Gerardi, MD
““Thunderclap” HeadacheThunderclap” Headache
25% associated with SAH25% associated with SAH ““Warning” headacheWarning” headache
followed by SAH in 5% to 60%followed by SAH in 5% to 60% Expansion or dissection of unruptured Expansion or dissection of unruptured
aneurysmaneurysm Cerebral venous thrombosisCerebral venous thrombosis Exertional / coital headacheExertional / coital headache
Michael Gerardi, MD
Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Morbidity and MortalityMorbidity and Mortality
Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Morbidity and MortalityMorbidity and Mortality
28,00028,000ruptured aneurysmsruptured aneurysms
10,00010,000 18,00018,000dead/disableddead/disabled available for Rxavailable for Rx
3,0003,000 7,0007,000 8,000 8,000 10,00010,000died rapidlydied rapidly misdiagnosed misdiagnosed dead ordead or
functionalfunctionalno warningno warning or missed or missed disabled disabled
survivorssurvivors
Michael Gerardi, MD
Misdiagnosis of Symptomatic Misdiagnosis of Symptomatic Cerebral Aneurysm: Mayer 1996Cerebral Aneurysm: Mayer 1996Misdiagnosis of Symptomatic Misdiagnosis of Symptomatic
Cerebral Aneurysm: Mayer 1996Cerebral Aneurysm: Mayer 1996
217 patients with symptomatic SAH217 patients with symptomatic SAH 54 / 217 misdiagnosed54 / 217 misdiagnosed 46 / 217 minimal findings46 / 217 minimal findings
viral meningitisviral meningitis 15%15% migrainemigraine 13%13% uncertain etiologyuncertain etiology 13%13%
Failure to consider SAHFailure to consider SAH
Michael Gerardi, MD
Missed Cerebral AneurysmsMissed Cerebral AneurysmsMayer 1996Mayer 1996
Missed Cerebral AneurysmsMissed Cerebral AneurysmsMayer 1996Mayer 1996
9 / 43 (21%) CTs initially read as neg.9 / 43 (21%) CTs initially read as neg. 6 of these 9 : (+) SAH6 of these 9 : (+) SAH
48% re-bleed or deteriorated (vs. 2%)48% re-bleed or deteriorated (vs. 2%) Good or excellent outcomesGood or excellent outcomes
91% initially correct91% initially correct 53% if misdiagnosed53% if misdiagnosed
Michael Gerardi, MD
SAH…But not “Classic”SAH…But not “Classic”
Roughly half have minor bleeding with atypical Roughly half have minor bleeding with atypical featuresfeatures
Nonstrenuous activities (34%)Nonstrenuous activities (34%) Sleep (12%)Sleep (12%) HA in any location (localized, generalized, mild)HA in any location (localized, generalized, mild) May be relieved by non-narcotic analgesicsMay be relieved by non-narcotic analgesics Diagnosed as migraine, tension-type, sinusitisDiagnosed as migraine, tension-type, sinusitis
Michael Gerardi, MD
SAH…But not “Classic”SAH…But not “Classic”
Prominent neck painProminent neck pain Cervical sprain, arthritisCervical sprain, arthritis
Confusion, agitation, restlessConfusion, agitation, restless psychiatric diagnosespsychiatric diagnoses
Syncope / traumaSyncope / trauma Traumatic SAHTraumatic SAH
Syncope / abnormal ECGSyncope / abnormal ECG “ “MI and then trauma”MI and then trauma” 91% SAH have cardiac dysrhythmias and 91% SAH have cardiac dysrhythmias and
ECGs mimicking ischemiaECGs mimicking ischemia
Michael Gerardi, MD
SAH: Most patients have...SAH: Most patients have...
Abrupt onset of severe, unique Abrupt onset of severe, unique headache, or neck painheadache, or neck pain
Abnormal findings on neurologic Abnormal findings on neurologic examinationexamination
Subtle meningismus or ocular Subtle meningismus or ocular findingsfindings
Michael Gerardi, MD
International Headache SocietyInternational Headache Society
A first episode of severe headache A first episode of severe headache cannotcannot be classified as migraine:be classified as migraine: more than 4 episodesmore than 4 episodes
nornor as tension-type headache: as tension-type headache: more than 9 episodesmore than 9 episodes
First or worst headache requires First or worst headache requires evaluationevaluation as do qualitatively different headachesas do qualitatively different headaches
Michael Gerardi, MD
Can a CT Scan Safely Can a CT Scan Safely “Rule Out” SAH?“Rule Out” SAH?
First diagnostic studyFirst diagnostic study Thin cuts ( 3 mm) through base of brainThin cuts ( 3 mm) through base of brain Blood on CT function of HgbBlood on CT function of Hgb
Hgb < 10: blood isodenseHgb < 10: blood isodense Sensitivity decreases over time from Sensitivity decreases over time from
onset of symptomsonset of symptoms
Michael Gerardi, MD
Acute HA of Recent OnsetAcute HA of Recent OnsetLeido A. Leido A. HeadacheHeadache 1994 1994
Acute HA of Recent OnsetAcute HA of Recent OnsetLeido A. Leido A. HeadacheHeadache 1994 1994
27 patients; 24 - 77 yo27 patients; 24 - 77 yo 1 hr to 13 days after HA onset1 hr to 13 days after HA onset no previous similar HAno previous similar HA no focal neurologic signsno focal neurologic signs all had CT; LP if CT negall had CT; LP if CT neg
Michael Gerardi, MD
Acute HA of Recent OnsetAcute HA of Recent OnsetLeido A. Leido A. HeadacheHeadache 1994 1994
Acute HA of Recent OnsetAcute HA of Recent OnsetLeido A. Leido A. HeadacheHeadache 1994 1994
9 of 27 (33%) : SAH9 of 27 (33%) : SAH 4 (+) CT4 (+) CT 5 normal CT, (+) LP5 normal CT, (+) LP
2 of 19 LPs: meningitis2 of 19 LPs: meningitis CT scanning should be done with CT scanning should be done with
first severe acute headachefirst severe acute headache
Michael Gerardi, MD
CT & Subarachnoid Hemorrhage:CT & Subarachnoid Hemorrhage:Sames et al: 1996Sames et al: 1996
Sensitivity of NGCT:Sensitivity of NGCT:
Group 1 (symptoms < 24 hrs)Group 1 (symptoms < 24 hrs) 93.1%93.1%
Group 2 (symptoms > 24 hrs)Group 2 (symptoms > 24 hrs) 83.8%83.8%
““A normal NGCT does not reliably exclude A normal NGCT does not reliably exclude the need for LP”the need for LP”
Michael Gerardi, MD
SAH: CT SensitivitySAH: CT SensitivitySames: Sames: Acad Emerg Med Acad Emerg Med Jan 1996Jan 1996SAH: CT SensitivitySAH: CT SensitivitySames: Sames: Acad Emerg Med Acad Emerg Med Jan 1996Jan 1996
181 patients; aged 13-86 with SAH181 patients; aged 13-86 with SAH Sensitivity Sensitivity 91.2% 91.2%
pain < 24 hrspain < 24 hrs 93.1% 93.1% pain > 24 hrspain > 24 hrs 83.8% 83.8%
LP 100% sensitive if neg CTLP 100% sensitive if neg CT ““A normal NGCT does not reliably A normal NGCT does not reliably
exclude the need for LP”exclude the need for LP”
Michael Gerardi, MD
SAH Diagnosis: LP NeededSAH Diagnosis: LP NeededSidman: Sidman: Acad Emerg Med Acad Emerg Med Sep 1996Sep 1996SAH Diagnosis: LP NeededSAH Diagnosis: LP NeededSidman: Sidman: Acad Emerg Med Acad Emerg Med Sep 1996Sep 1996
140 patients; aged 10-88140 patients; aged 10-88 Sensitivity of CTSensitivity of CT
< 12 hrs< 12 hrs 80/8080/80 100%100% > 12 hrs> 12 hrs 49/6049/60 81.7%81.7%
Overall, 11/140 had (-) CT and (+) LPOverall, 11/140 had (-) CT and (+) LP overall sensitivityoverall sensitivity 92.1%92.1%
Michael Gerardi, MD
Morgenstern LB, et al:Morgenstern LB, et al: Worst headache and Worst headache and SAH: Prospective, modern CT and spinal SAH: Prospective, modern CT and spinal fluid analysis.fluid analysis. Ann Emerg MedAnn Emerg Med Sept 1998 Sept 1998..
38,730 patients over 16 months, 38,730 patients over 16 months, prospectively screened for “worst HA”prospectively screened for “worst HA”
Blinded neuroradiologistsBlinded neuroradiologists Neg CTNeg CT LPLP
cell count x 2cell count x 2visual and spectrophotometric visual and spectrophotometric
detection of xanthochromiadetection of xanthochromiaCSF D-dimer assayCSF D-dimer assay
Michael Gerardi, MD
Morgenstern, et al: Morgenstern, et al: Ann Emerg MedAnn Emerg Med 19981998
455 headaches & 107 “worst headache”455 headaches & 107 “worst headache” CT:CT: 18 of 107 (17%): (+) SAH 18 of 107 (17%): (+) SAH (-) CT/ (+) SAH:(-) CT/ (+) SAH: Only 2 (2.5%) Only 2 (2.5%)
(95% CI, 0.3%to 8.8%)(95% CI, 0.3%to 8.8%) Modern CT is sufficient to exclude 98% of Modern CT is sufficient to exclude 98% of
SAH in patients SAH in patients
Michael Gerardi, MD
Morgenstern, et al: Morgenstern, et al: Ann Emerg MedAnn Emerg Med 1998 (1998 (107107 “Worst HA’s) “Worst HA’s)
VariablesVariables CT-/LP- CT+ CT-/LP+ CT-/LP- CT+ CT-/LP+PhotophobiaPhotophobia 4545 2828 50 50Stiff neckStiff neck 2626 3737 100 100NauseaNausea 6565 3636 100 100LethargyLethargy 1717 4040 5050Time < 24 hTime < 24 h 5858 7575 5050MigraineMigraine 2020 1111 0 0HeadacheHeadache 4848 2727 0 0
Michael Gerardi, MD
CT is Normal: Do LP?CT is Normal: Do LP?
Yes!Yes!
Michael Gerardi, MD
What about LP First?What about LP First?
Duffy et al; 1982: 55 patients who underwent Duffy et al; 1982: 55 patients who underwent LP as initial w/uLP as initial w/u Condition deteriorated immediately in 7 Condition deteriorated immediately in 7
patientspatients Hillman et al; 1986: 4 alert patients with SAH Hillman et al; 1986: 4 alert patients with SAH
who deteriorated after lumbar puncturewho deteriorated after lumbar puncture Both studies:Both studies:
clots on CT or a dilated pupilclots on CT or a dilated pupil
Michael Gerardi, MD
LP First?LP First?Schull: Schull: Acad Emerg MedAcad Emerg Med 1999 1999
CT sensitivity: 86%CT sensitivity: 86% LP after 12 hours: 100%LP after 12 hours: 100% Mathematical modeling for 100 Mathematical modeling for 100
patientspatients 9 more LPs9 more LPs 81 fewer CT scans81 fewer CT scans
Michael Gerardi, MD
Traumatic TapsTraumatic Taps
20% of LPs20% of LPs 0.5% and 6% has incidental intracranial 0.5% and 6% has incidental intracranial
aneurysmaneurysm Impression or “3-tube” method not reliable in Impression or “3-tube” method not reliable in
detecting traumatic tapdetecting traumatic tap Erythrocytes disseminate rapidlyErythrocytes disseminate rapidly Released Hgb Released Hgb oxyhemoglobin oxyhemoglobin
xanthochromiaxanthochromia bilirubinbilirubin
Michael Gerardi, MD
XanthochromiaXanthochromia
Bilirubin, enzyme-dependent process, Bilirubin, enzyme-dependent process, is diagnostically more reliable but:is diagnostically more reliable but: takes up to 12 hourstakes up to 12 hours
Timing is importantTiming is important CSF should be centrifuged and CSF should be centrifuged and
examined promptly so RBCs don’t examined promptly so RBCs don’t undergo lysis in vitro, causing undergo lysis in vitro, causing xanthochromia from oxyhemoglobinxanthochromia from oxyhemoglobin
Michael Gerardi, MD
Xanthochromia vs. ErythrocytesXanthochromia vs. Erythrocytes
XanthochromiaXanthochromia primary criterion for SAH if neg CTprimary criterion for SAH if neg CT advocates: spectrophotometryadvocates: spectrophotometry
ErythrocytesErythrocytes considered more accurate by someconsidered more accurate by some used visual inspection which can used visual inspection which can
miss discoloration in up to 50%miss discoloration in up to 50%
Michael Gerardi, MD
Timing the TapTiming the Tap
With spectrophotometry, and waiting 12 With spectrophotometry, and waiting 12 hours after onset of headache: very hours after onset of headache: very accurateaccurate traumatic tap done earlier does not lead traumatic tap done earlier does not lead
to xanthochromia and confusionto xanthochromia and confusion Waiting: Waiting:
prolongation of ED stayprolongation of ED stay risk “ultra-early” rebleedingrisk “ultra-early” rebleeding
Michael Gerardi, MD
Normal CT & Persistently Normal CT & Persistently Bloody CSF ???Bloody CSF ???
Not prudent to delay LPNot prudent to delay LP Without xanthochromia and clinical Without xanthochromia and clinical
suspicion is high?suspicion is high? Vascular imagingVascular imaging
Xanthochromia present and clinical Xanthochromia present and clinical suspicion is high?suspicion is high? Vascular imagingVascular imaging
Michael Gerardi, MD
Thunderclap Headache: Thunderclap Headache: NL CT & NL LP - Vascular Imaging?NL CT & NL LP - Vascular Imaging?
Unruptured cerebral aneurysmUnruptured cerebral aneurysm Day and Raskin: 1 patient - clippedDay and Raskin: 1 patient - clipped Raps et al: 7 patientsRaps et al: 7 patients Witham: 1 patient - very thin Witham: 1 patient - very thin
aneurysm dome; clippedaneurysm dome; clipped
Michael Gerardi, MD
Thunderclap Headache: Thunderclap Headache: NL CT & NL LP Vascular Imaging?NL CT & NL LP Vascular Imaging?
Wijdicks et al; Lancet, 1988Wijdicks et al; Lancet, 1988 Retrospective evaluation 71 patientsRetrospective evaluation 71 patients no SAH in 3.3 years f/uno SAH in 3.3 years f/u Half dx’d with migraine or tension HAHalf dx’d with migraine or tension HA
Markus 1991; Linn 1994; Harling 1989Markus 1991; Linn 1994; Harling 1989 117 patients117 patients no SAH, no sudden deathsno SAH, no sudden deaths
Michael Gerardi, MD
SAH High Risk FactorsSAH High Risk Factors
Clinical HistoryClinical History Onset of HAOnset of HA: abrupt, maximal at onset, : abrupt, maximal at onset,
“thunderclap” headache“thunderclap” headache Severity of headacheSeverity of headache: usually the “worst of : usually the “worst of
life” or very severelife” or very severe QualityQuality: First of this intensity; unique or : First of this intensity; unique or
differentdifferent Associated signs / sx’sAssociated signs / sx’s: LOC, diplopia, : LOC, diplopia,
seizure, focal neurologic signsseizure, focal neurologic signs
Michael Gerardi, MD
SAH High Risk Factors: SAH High Risk Factors: EpidemiologicEpidemiologic
Cigarette smokingCigarette smoking HypertensionHypertension Alcohol consumption (binge?)Alcohol consumption (binge?) Personal or family historyPersonal or family history Polycystic kidney diseasePolycystic kidney disease Heritable connective tissue diseasesHeritable connective tissue diseases Sickle Cell AnemiaSickle Cell Anemia
Pregnancy and childbirthPregnancy and childbirth Valsalva maneuverValsalva maneuver CoitusCoitus Cocaine abuseCocaine abuse AmphetaminesAmphetamines
Michael Gerardi, MD
Predisposing Factors for Predisposing Factors for Aneurysmal RuptureAneurysmal Rupture
Predisposing Factors for Predisposing Factors for Aneurysmal RuptureAneurysmal Rupture
Pregnancy and childbirthPregnancy and childbirth Poorly controlled HTNPoorly controlled HTN Valsalva maneuverValsalva maneuver CoitusCoitus Heavy ETOH consumptionHeavy ETOH consumption Cocaine abuseCocaine abuse AmphetaminesAmphetamines
Michael Gerardi, MD
HA: Cough, Exertional, & SexHA: Cough, Exertional, & SexPascual: Pascual: NeurologyNeurology 1996 1996
HA: Cough, Exertional, & SexHA: Cough, Exertional, & SexPascual: Pascual: NeurologyNeurology 1996 1996
72 patients72 patients Intracranial lesions on neuroimagingIntracranial lesions on neuroimaging
cough-inducedcough-induced 17 / 3017 / 30 42% 42% exertionalexertional 12 / 2812 / 28 43% 43% sexsex 1 / 141 / 14 7% 7%
Michael Gerardi, MD
HA: Cough, Exertional, & SexHA: Cough, Exertional, & SexPascual: Pascual: NeurologyNeurology 1996 1996
HA: Cough, Exertional, & SexHA: Cough, Exertional, & SexPascual: Pascual: NeurologyNeurology 1996 1996
Cough-induced: underlying lesion was always Cough-induced: underlying lesion was always Chiari type I malformationChiari type I malformation
Indomethacin- effective in benign but not with Indomethacin- effective in benign but not with underlying lesionsunderlying lesions
SAHSAH 10 / 12 : 10 / 12 : exercise - inducedexercise - induced 1/ 14 : 1/ 14 : sexual activitysexual activity
Michael Gerardi, MD
HA: Cough, Exertional, & SexHA: Cough, Exertional, & SexPascual: Pascual: NeurologyNeurology 1996 1996
HA: Cough, Exertional, & SexHA: Cough, Exertional, & SexPascual: Pascual: NeurologyNeurology 1996 1996
ALL patients with SAH:ALL patients with SAH: single HAsingle HA prolongedprolonged severe generally accompanied bysevere generally accompanied by
nauseanausea vomitingvomiting photophobiaphotophobia
Michael Gerardi, MD
Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Morbidity and MortalityMorbidity and Mortality
Subarachnoid Hemorrhage: Subarachnoid Hemorrhage: Morbidity and MortalityMorbidity and Mortality
28,00028,000ruptured aneurysmsruptured aneurysms
10,00010,000 18,00018,000dead/disableddead/disabled available for Rxavailable for Rx
3,0003,000 7,0007,000 8,000 8,000 10,00010,000died rapidlydied rapidly misdiagnosed misdiagnosed dead ordead or
functionalfunctionalno warningno warning or missed or missed disabled disabled
survivorssurvivors