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{{Subarachnoid hemorrhage}}
{{Subarachnoid hemorrhage}}


{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; {{SaraM}}
{{CMG}}; {{AE}} {{SAH}} {{CZ}}; {{SaraM}}
==Overview==
==Overview==
A [[lumbar puncture]] will identify another 3% of the cases by demonstrating ''[[xanthochromic|xanthochromia]]'' or [[bilirubin]] in the CSF. Despite of the normal [[CT|head CT]], [[Lumbar puncture|lumbar puncture (LP)]] seems necessary when there is a strong suspicion of subarachnoid hemorrhage. [[Lumbar puncture|Lumbar puncture (LP)]] is the most sensitive techniques to detect the blood in CSF especially 12 hours after onset of symptoms.<ref name="pmid2556195">{{cite journal| author=Miles JS, Wolf CR| title=Principles of DNA cloning. | journal=BMJ | year= 1989 | volume= 299 | issue= 6706 | pages= 1019-22 | pmid=2556195 | doi= | pmc=1837892 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2556195  }} </ref><ref name="pmid2191083">{{cite journal| author=Vermeulen M, van Gijn J| title=The diagnosis of subarachnoid haemorrhage. | journal=J Neurol Neurosurg Psychiatry | year= 1990 | volume= 53 | issue= 5 | pages= 365-72 | pmid=2191083 | doi= | pmc=488050 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2191083  }} </ref>
A [[lumbar puncture]] will identify another 3% of the cases by demonstrating ''[[xanthochromic|xanthochromia]]'' or [[bilirubin]] in the CSF. Despite of the normal [[CT|head CT]], [[Lumbar puncture|lumbar puncture (LP)]] seems necessary when there is a strong suspicion of subarachnoid hemorrhage. [[Lumbar puncture|Lumbar puncture (LP)]] is the most sensitive techniques to detect the blood in CSF especially 12 hours after onset of symptoms.<ref name="pmid2556195">{{cite journal| author=Miles JS, Wolf CR| title=Principles of DNA cloning. | journal=BMJ | year= 1989 | volume= 299 | issue= 6706 | pages= 1019-22 | pmid=2556195 | doi= | pmc=1837892 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2556195  }} </ref><ref name="pmid2191083">{{cite journal| author=Vermeulen M, van Gijn J| title=The diagnosis of subarachnoid haemorrhage. | journal=J Neurol Neurosurg Psychiatry | year= 1990 | volume= 53 | issue= 5 | pages= 365-72 | pmid=2191083 | doi= | pmc=488050 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2191083  }} </ref>


==Laboratory findings==
==Laboratory findings==
*The laboratory findings of sub-arachnoid hemorrhage is given below:<ref name="pmid2556195" /><ref name="pmid15814927">{{cite journal| author=Heasley DC, Mohamed MA, Yousem DM| title=Clearing of red blood cells in lumbar puncture does not rule out ruptured aneurysm in patients with suspected subarachnoid hemorrhage but negative head CT findings. | journal=AJNR Am J Neuroradiol | year= 2005 | volume= 26 | issue= 4 | pages= 820-4 | pmid=15814927 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15814927  }} </ref><ref name="pmid14503985">{{cite journal| author=UK National External Quality Assessment Scheme for Immunochemistry Working Group| title=National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage. | journal=Ann Clin Biochem | year= 2003 | volume= 40 | issue= Pt 5 | pages= 481-8 | pmid=14503985 | doi=10.1258/000456303322326399 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14503985  }} </ref><ref name="pmid2769274">{{cite journal| author=Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J| title=Xanthochromia after subarachnoid haemorrhage needs no revisitation. | journal=J Neurol Neurosurg Psychiatry | year= 1989 | volume= 52 | issue= 7 | pages= 826-8 | pmid=2769274 | doi= | pmc=1031927 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2769274  }} </ref><ref name="pmid17478736">{{cite journal| author=Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D et al.| title=Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. | journal=Stroke | year= 2007 | volume= 38 | issue= 6 | pages= 2001-23 | pmid=17478736 | doi=10.1161/STROKEAHA.107.183689 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17478736  }} </ref><ref name="pmid9737490">{{cite journal| author=Morgenstern LB, Luna-Gonzales H, Huber JC, Wong SS, Uthman MO, Gurian JH et al.| title=Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. | journal=Ann Emerg Med | year= 1998 | volume= 32 | issue= 3 Pt 1 | pages= 297-304 | pmid=9737490 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9737490  }} </ref><ref name="pmid2191083" />
===Lumbar puncture (LP)===
===Lumbar puncture (LP)===
Despite of the normal [[CT|head CT]], [[Lumbar puncture|lumbar puncture (LP)]] seems necessary when there is a strong suspicion of subarachnoid hemorrhage. [[Lumbar puncture|Lumbar puncture (LP)]] is the most sensitive techniques to detect the blood in CSF especially 12 hours after onset of symptoms.<ref name="pmid2556195">{{cite journal| author=Miles JS, Wolf CR| title=Principles of DNA cloning. | journal=BMJ | year= 1989 | volume= 299 | issue= 6706 | pages= 1019-22 | pmid=2556195 | doi= | pmc=1837892 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2556195  }} </ref><ref name="pmid2191083">{{cite journal| author=Vermeulen M, van Gijn J| title=The diagnosis of subarachnoid haemorrhage. | journal=J Neurol Neurosurg Psychiatry | year= 1990 | volume= 53 | issue= 5 | pages= 365-72 | pmid=2191083 | doi= | pmc=488050 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2191083  }} </ref>


The classic findings of subarachnoid hemorrhage may include:<ref name="pmid15814927">{{cite journal| author=Heasley DC, Mohamed MA, Yousem DM| title=Clearing of red blood cells in lumbar puncture does not rule out ruptured aneurysm in patients with suspected subarachnoid hemorrhage but negative head CT findings. | journal=AJNR Am J Neuroradiol | year= 2005 | volume= 26 | issue= 4 | pages= 820-4 | pmid=15814927 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15814927  }} </ref><ref name="pmid14503985">{{cite journal| author=UK National External Quality Assessment Scheme for Immunochemistry Working Group| title=National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage. | journal=Ann Clin Biochem | year= 2003 | volume= 40 | issue= Pt 5 | pages= 481-8 | pmid=14503985 | doi=10.1258/000456303322326399 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14503985  }} </ref><ref name="pmid2769274">{{cite journal| author=Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J| title=Xanthochromia after subarachnoid haemorrhage needs no revisitation. | journal=J Neurol Neurosurg Psychiatry | year= 1989 | volume= 52 | issue= 7 | pages= 826-8 | pmid=2769274 | doi= | pmc=1031927 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2769274  }} </ref><ref name="pmid17478736">{{cite journal| author=Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D et al.| title=Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. | journal=Stroke | year= 2007 | volume= 38 | issue= 6 | pages= 2001-23 | pmid=17478736 | doi=10.1161/STROKEAHA.107.183689 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17478736  }} </ref><ref name="pmid9737490">{{cite journal| author=Morgenstern LB, Luna-Gonzales H, Huber JC, Wong SS, Uthman MO, Gurian JH et al.| title=Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. | journal=Ann Emerg Med | year= 1998 | volume= 32 | issue= 3 Pt 1 | pages= 297-304 | pmid=9737490 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9737490  }} </ref>
*Despite of the normal [[CT|head CT]], [[Lumbar puncture|lumbar puncture (LP)]] seems necessary when there is a strong suspicion of subarachnoid hemorrhage.  
*Elevated opening pressure  
*[[Lumbar puncture|Lumbar puncture (LP)]] is the most sensitive test (blood in csf in >12hours).
*Elevated [[red blood cell|red blood cell (RBC)]]  
*Elevated opening pressure.
**[[RBCs|RBC count]] does not diminish from CSF tube one to tube four and it helps to differentiate bleeding in SAH from traumatic [[Spinal tap|spinal tap.]] However, decrease in the number of [[RBCs]] in later tubes can also happen in subarachnoid hemorrhage
*Elevated [[red blood cell|red blood cell (RBC)]].
**CSF samples taken within 24 hours of the ictus usually show a WBC-to-RBC ratio of 1:1000 that is consistent with the normal conditions. After 24 hours, secondary to chemical [[meningitis]] the CSF samples may demonstrate a [[Polymorphonuclear leukocytes|polymorphonuclear]] and [[Mononuclear cell|mononuclear polycytosis.]]
**CSF samples taken within 24 hours.
*[[Xanthochromic|Xanthochromia]] (represents [[Hemoglobin]] degradation products)  
*[[Xanthochromic|Xanthochromia]] (represents [[Hemoglobin]] degradation products)  
**Indicates that blood has been in the CSF for at least two hour and can last for two weeks or more
**Indicates that blood has been in the CSF for at least two hour and can last for two weeks or more
*[[Spectrophotometry]]  
*[[Spectrophotometry]]  
**It detects blood breakdown products ([[oxyhemoglobin]] to [[methemoglobin]] to [[bilirubin]]
**It detects blood breakdown products ([[oxyhemoglobin]] to [[methemoglobin]] to [[bilirubin]])
**More sensitivity compare to [[Xanthochromic|xanthochromia]] but not widely used  
**More sensitivity compare to [[Xanthochromic|xanthochromia]] but not widely used
 
===Other lab findings===
===Other lab findings===
Beside positive [[Lumbar puncture|lumbar puncture (LP)]], other laboratory findings for subarachnoid may include the following:
Beside positive [[Lumbar puncture|lumbar puncture (LP)]], other laboratory findings for subarachnoid may include the following:


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[[Category:Neurosurgery]]
[[Category:Neurosurgery]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]

Latest revision as of 05:30, 14 November 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Ahsan Hussain, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Sara Mehrsefat, M.D. [4]

Overview

A lumbar puncture will identify another 3% of the cases by demonstrating xanthochromia or bilirubin in the CSF. Despite of the normal head CT, lumbar puncture (LP) seems necessary when there is a strong suspicion of subarachnoid hemorrhage. Lumbar puncture (LP) is the most sensitive techniques to detect the blood in CSF especially 12 hours after onset of symptoms.[1][2]

Laboratory findings

Lumbar puncture (LP)

Other lab findings

Beside positive lumbar puncture (LP), other laboratory findings for subarachnoid may include the following:

Blood test Test result Rationale
Complete blood count and platelet
Basic metabolic panel (BMP)
  • Increased or decreased serum NA2+, K+, Ca2+
  • To establish a baseline for detection of future complication
PT/APTT/INR[8][9][10]
  • Increased PT/APTT/INR
BUN/Creatinine[11]
  • Increased BUN and creatinine
  • To establish a baseline for detection of future complication
Toxicology screen/Serum alcohol level
  • Increased levels of serum
  • Identify illicit drug use or excessive alcohol
  • Identify exogenous toxins that can cause subarachnoid hemorrhage
Lipid profile
  • Decreased levels of lipids
  • Associated with higher incidence of subarachnoid hemorrhage
Blood typing
  • Blood typing and screening -
  • To prepare for possible intraoperative transfusions
Cardiac enzymes
  • Increased serum levels of Trop I, Trop T, CK-MB
  • May suggest ongoing myocardial ischemia
  • Useful only as a predictor for the occurrence of pulmonary and cardiac complications.
Pregnancy test
  • Serum and urine B-HCG
  • Rule out pregnancy in all female patients with hemorrhagic stroke

References

  1. ↑ 1.0 1.1 Miles JS, Wolf CR (1989). "Principles of DNA cloning". BMJ. 299 (6706): 1019–22. PMC 1837892. PMID 2556195.
  2. ↑ 2.0 2.1 Vermeulen M, van Gijn J (1990). "The diagnosis of subarachnoid haemorrhage". J Neurol Neurosurg Psychiatry. 53 (5): 365–72. PMC 488050. PMID 2191083.
  3. ↑ Heasley DC, Mohamed MA, Yousem DM (2005). "Clearing of red blood cells in lumbar puncture does not rule out ruptured aneurysm in patients with suspected subarachnoid hemorrhage but negative head CT findings". AJNR Am J Neuroradiol. 26 (4): 820–4. PMID 15814927.
  4. ↑ UK National External Quality Assessment Scheme for Immunochemistry Working Group (2003). "National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage". Ann Clin Biochem. 40 (Pt 5): 481–8. doi:10.1258/000456303322326399. PMID 14503985.
  5. ↑ Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, van Gijn J (1989). "Xanthochromia after subarachnoid haemorrhage needs no revisitation". J Neurol Neurosurg Psychiatry. 52 (7): 826–8. PMC 1031927. PMID 2769274.
  6. ↑ Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D; et al. (2007). "Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group". Stroke. 38 (6): 2001–23. doi:10.1161/STROKEAHA.107.183689. PMID 17478736.
  7. ↑ Morgenstern LB, Luna-Gonzales H, Huber JC, Wong SS, Uthman MO, Gurian JH; et al. (1998). "Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis". Ann Emerg Med. 32 (3 Pt 1): 297–304. PMID 9737490.
  8. ↑ Cucchiara B, Messe S, Sansing L, Kasner S, Lyden P, CHANT Investigators (2008). "Hematoma growth in oral anticoagulant related intracerebral hemorrhage". Stroke. 39 (11): 2993–6. doi:10.1161/STROKEAHA.108.520668. PMID 18703803.
  9. ↑ Broderick JP, Diringer MN, Hill MD, Brun NC, Mayer SA, Steiner T; et al. (2007). "Determinants of intracerebral hemorrhage growth: an exploratory analysis". Stroke. 38 (3): 1072–5. doi:10.1161/01.STR.0000258078.35316.30. PMID 17290026.
  10. ↑ Flaherty ML, Tao H, Haverbusch M, Sekar P, Kleindorfer D, Kissela B; et al. (2008). "Warfarin use leads to larger intracerebral hematomas". Neurology. 71 (14): 1084–9. doi:10.1212/01.wnl.0000326895.58992.27. PMC 2668872. PMID 18824672.
  11. ↑ Miller CM, Vespa PM, McArthur DL, Hirt D, Etchepare M (2007). "Frameless stereotactic aspiration and thrombolysis of deep intracerebral hemorrhage is associated with reduced levels of extracellular cerebral glutamate and unchanged lactate pyruvate ratios". Neurocrit Care. 6 (1): 22–9. doi:10.1385/NCC:6:1:22. PMID 17356187.

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