Subarachnoid hemorrhage laboratory findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

A lumbar puncture (removal of cerebrospinal fluid/CSF with a needle from the lumbar sac under local anesthetic) will identify another 3% of the cases by demonstrating xanthochromia (yellow appearance of centrifugated fluid) or bilirubin (a breakdown product of hemoglobin) in the CSF.

Laboratory findings

Lumbar puncture (LP)

Lumbar puncture (LP) is mandatory if there is a strong suspicion of SAH despite a normal head CT [20,27]. Clinical prediction rules are NOT sufficiently sensitive to exclude SAH without a lumbar puncture [34]. (See 'Head CT scan' above.)^[1]^[2]

The classic findings of subarachnoid hemorrhage may include:^[3]^[4]^[5]^[6]^[7]

Elevated opening pressure
Elevated red blood cell (RBC)
- RBC count does not diminish from CSF tube one to tube four and it helps to differentiate bleeding in SAH from traumatic spinal tap. However, decrease in the number of RBCs in later tubes can also happen in subarachnoid hemorrhage
Xanthochromia (Hemoglobin degradation products)
- Indicates that blood has been in the CSF for at least two hour and can last for two weeks or more
Spectrophotometry
- It detects blood breakdown products (progress from oxyhemoglobin to [methemoglobin] to bilirubin. It has more sensitivity compare to xanthochromia but not widely used

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	Leukocytosis Polycythemia Thrombocytopenia	Monitor for infection Assess hematocrit and platelet count to identify hemorrhagic risk and complications
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	Identify a coagulopathy
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

↑ Miles JS, Wolf CR (1989). "Principles of DNA cloning". BMJ. 299 (6706): 1019–22. PMC 1837892. PMID 2556195.
↑ Vermeulen M, van Gijn J (1990). "The diagnosis of subarachnoid haemorrhage". J Neurol Neurosurg Psychiatry. 53 (5): 365–72. PMC 488050. PMID 2191083.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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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[pmid2556195-1] Miles JS, Wolf CR (1989). "Principles of DNA cloning". BMJ. 299 (6706): 1019–22. PMC 1837892. PMID 2556195.

[pmid2191083-2] Vermeulen M, van Gijn J (1990). "The diagnosis of subarachnoid haemorrhage". J Neurol Neurosurg Psychiatry. 53 (5): 365–72. PMC 488050. PMID 2191083.

[pmid15814927-3] 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.

[pmid14503985-4] 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.

[pmid2769274-5] 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.

[pmid17478736-6] 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.

[pmid9737490-7] 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.

[pmid18703803-8] 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.

[pmid17290026-9] 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.

[pmid18824672-10] 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.

[pmid17356187-11] 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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