British Medical Journal 2015

1. BMJ. 2015 Nov 9;351:h5762. doi: 10.1136/bmj.h5762.

Diagnostic yield and accuracy of CT angiography, MR angiography, and digital
subtraction angiography for detection of macrovascular causes of intracerebral
haemorrhage: prospective, multicentre cohort study.

van Asch CJ(1), Velthuis BK(2), Rinkel GJ(3), Algra A(4), de Kort GA(2), Witkamp
TD(2), de Ridder JC(3), van Nieuwenhuizen KM(3), de Leeuw FE(5), Schonewille
WJ(6), de Kort PL(7), Dippel DW(8), Raaymakers TW(9), Hofmeijer J(10), Wermer
MJ(11), Kerkhoff H(12), Jellema K(13), Bronner IM(14), Remmers MJ(15), Bienfait
HP(16), Witjes RJ(17), Greving JP(18), Klijn CJ(19); DIAGRAM Investigators.

Author information: 
(1)Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus,
University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands
c.j.j.vanasch@gmail.com. (2)Department of Radiology, University Medical Center
Utrecht, Utrecht, Netherlands. (3)Department of Neurology and Neurosurgery, Brain
Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA
Utrecht, Netherlands. (4)Department of Neurology and Neurosurgery, Brain Center
Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, 
Netherlands Julius Center for Health Sciences and Primary Care, University
Medical Center Utrecht, Utrecht, Netherlands. (5)Department of Neurology, Donders
Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, 
Nijmegen, Netherlands. (6)Department of Neurology, St Antonius Hospital,
Nieuwegein, Netherlands. (7)Department of Neurology, St Elisabeth Hospital,
Tilburg, Netherlands. (8)Department of Neurology, Erasmus MC, University Medical
Center Rotterdam, Rotterdam, Netherlands. (9)Department of Neurology, Meander
Medical Center, Amersfoort, Netherlands. (10)Department of Neurology, Rijnstate
Hospital, Arnhem, Netherlands. (11)Department of Neurology, Leiden University
Medical Center, Leiden, Netherlands. (12)Department of Neurology, Albert
Schweitzer Hospital, Dordrecht, Netherlands. (13)Department of Neurology, MCH
Westeinde, The Hague, Netherlands. (14)Department of Neurology, Flevo Hospital,
Almere, Netherlands. (15)Department of Neurology, Amphia Hospital, Breda,
Netherlands. (16)Department of Neurology, Gelre Hospital, Apeldoorn, Netherlands.
(17)Department of Neurology, Tergooi Hospitals, Blaricum, Netherlands. (18)Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht, Netherlands. (19)Department of Neurology and Neurosurgery, Brain Center
Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, 
Netherlands Department of Neurology, Donders Institute for Brain, Cognition and
Behaviour, Radboud University Medical Center, Nijmegen, Netherlands.

STUDY QUESTION: What are the diagnostic yield and accuracy of early computed
tomography (CT) angiography followed by magnetic resonance imaging/angiography
(MRI/MRA) and digital subtraction angiography (DSA) in patients with
non-traumatic intracerebral haemorrhage?
METHODS: This prospective diagnostic study enrolled 298 adults (18-70 years)
treated in 22 hospitals in the Netherlands over six years. CT angiography was
performed within seven days of haemorrhage. If the result was negative, MRI/MRA
was performed four to eight weeks later. DSA was performed when the CT
angiography or MRI/MRA results were inconclusive or negative. The main outcome
was a macrovascular cause, including arteriovenous malformation, aneurysm, dural
arteriovenous fistula, and cavernoma. Three blinded neuroradiologists
independently evaluated the images for macrovascular causes of haemorrhage. The
reference standard was the best available evidence from all findings during one
year's follow-up.
STUDY ANSWER AND LIMITATIONS: A macrovascular cause was identified in 69 patients
(23%). 291 patients (98%) underwent CT angiography; 214 with a negative result
underwent additional MRI/MRA and 97 with a negative result for both CT
angiography and MRI/MRA underwent DSA. Early CT angiography detected 51
macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT
angiography with MRI/MRA identified two additional macrovascular causes (18%, 14%
to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This
last extensive strategy failed to detect a cavernoma, which was identified on MRI
during follow-up (reference strategy). The positive predictive value of CT
angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and
of additional DSA was 100% (75% to 100%). None of the patients experienced
complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA
experienced permanent sequelae. Not all patients with negative CT angiography and
MRI/MRA results underwent DSA. Although the previous probability of finding a
macrovascular cause was lower in patients who did not undergo DSA, some small
arteriovenous malformations or dural arteriovenous fistulas may have been missed.
WHAT THIS STUDY ADDS: CT angiography is an appropriate initial investigation to
detect macrovascular causes of non-traumatic intracerebral haemorrhage, but
accuracy is modest. Additional MRI/MRA may find cavernomas or alternative
diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT
angiography or MRI/MRA.
FUNDING, COMPETING INTERESTS, DATA SHARING: Dutch Heart Foundation and The
Netherlands Organisation for Health Research and Development, ZonMw. The authors
have no competing interests. Direct requests for additional data to the
corresponding author.

© van Asch et al 2015.

PMCID: PMC4637845
PMID: 26553142  [PubMed - in process]


2. BMJ. 2015 May 14;350:h2219. doi: 10.1136/bmj.h2219.

Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by
meticillin resistant Staphylococcus aureus: randomised controlled trial.

Paul M(1), Bishara J(2), Yahav D(3), Goldberg E(4), Neuberger A(5), Ghanem-Zoubi
N(6), Dickstein Y(7), Nseir W(8), Dan M(9), Leibovici L(3).

Author information: 
(1)Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital,
Petah-Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv,
Israel paulm@post.tau.ac.il. (2)Unit of Infectious Diseases, Rabin Medical
Center, Beilinson Hospital, Petah-Tikva, Israel Sackler Faculty of Medicine,
Tel-Aviv University, Ramat-Aviv, Israel. (3)Sackler Faculty of Medicine, Tel-Aviv
University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine E, Rabin
Medical Center, Beilinson Hospital, Petah-Tikva. (4)Sackler Faculty of Medicine, 
Tel-Aviv University, Ramat-Aviv, Israel Unit of Infectious Diseases, Medicine F, 
Rabin Medical Center, Beilinson Hospital, Petah-Tikva. (5)Division of Infectious
Diseases, Medicine B, Rambam Health Care Campus, Haifa, Israel Technion-Israel
Institute of Technology and the Ruth & Bruce Rappaport Faculty of Medicine,
Haifa. (6)Division of Infectious Diseases, Rambam Health Care Campus, Haifa.
(7)Technion-Israel Institute of Technology and the Ruth & Bruce Rappaport Faculty
of Medicine, Haifa Division of Infectious Diseases, Medicine A, Rambam Health
Care Campus, Haifa. (8)Internal Medicine Department, Holy Family Hospital,
Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan Univesity, Safed, Israel. 
(9)Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
Infectious Diseases Unit, E Wolfson Hospital, Holon, Israel.

Comment in
    Evid Based Med. 2015 Aug;20(4):140.

OBJECTIVE: To show non-inferiority of trimethoprim-sulfamethoxazole compared with
vancomycin for the treatment of severe infections due to meticillin resistant
Staphylococcus aureus (MRSA).
DESIGN: Parallel, open label, randomised controlled trial.
SETTING: Four acute care hospitals in Israel.
PARTICIPANTS: Adults with severe infections caused by MRSA susceptible to
trimethoprim-sulfamethoxazole and vancomycin. Patients with left sided
endocarditis, meningitis, chronic haemodialysis, and prolonged neutropenia were
excluded.
INTERVENTIONS: Trimethoprim-sulfamethoxazole 320 mg/1600 mg twice daily versus
vancomycin 1 g twice daily for a minimum of seven days and then by indication.
MAIN OUTCOME MEASURES: The primary efficacy outcome was treatment failure
assessed at day 7, consisting of death, persistence of haemodynamic instability
or fever, stable or worsening Sequential Organ Failure Assessment score, and
persistence of bacteraemia. The primary safety outcome was all cause mortality at
day 30. Non-inferiority was defined by a difference of less than 15% for
treatment failure.
RESULTS: 252 patients were included in the trial, of whom 91 (36%) had
bacteraemia. No significant difference in treatment failure was seen for
trimethoprim-sulfamethoxazole (51/135, 38%) versus vancomycin (32/117, 27%)-risk
ratio 1.38 (95% confidence interval 0.96 to 1.99). However,
trimethoprim-sulfamethoxazole did not meet the non-inferiority criterion-absolute
difference 10.4% (95% confidence interval -1.2% to 21.5%). For patients with
bacteraemia, the risk ratio was 1.40 (0.91 to 2.16). In a multivariable logistic
regression analysis, trimethoprim-sulfamethoxazole was significantly associated
with treatment failure (adjusted odds ratio 2.00, 1.09 to 3.65). The 30 day
mortality rate was 32/252 (13%), with no significant difference between arms.
Among patients with bacteraemia, 14/41 (34%) treated with
trimethoprim-sulfamethoxazole and 9/50 (18%) with vancomycin died (risk ratio
1.90, 0.92 to 3.93).
CONCLUSIONS: High dose trimethoprim-sulfamethoxazole did not achieve
non-inferiority to vancomycin in the treatment of severe MRSA infections. The
difference was particularly marked for patients with bacteraemia. Trial
registration Clinical trials NCT00427076.

© Paul et al 2015.

PMCID: PMC4431679
PMID: 25977146  [PubMed - indexed for MEDLINE]


3. BMJ. 2015 Mar 4;350:h910. doi: 10.1136/bmj.h910.

The diagnostic accuracy of the natriuretic peptides in heart failure: systematic
review and diagnostic meta-analysis in the acute care setting.

Roberts E(1), Ludman AJ(2), Dworzynski K(3), Al-Mohammad A(4), Cowie MR(5),
McMurray JJ(6), Mant J(7); NICE Guideline Development Group for Acute Heart
Failure.

Author information: 
(1)Maudsley Hospital, South London and the Maudsley Mental Health Trust, London, 
UK. (2)Royal Devon & Exeter NHS Foundation Trust, Wonford, Exeter EX2 5DW, UK
a.ludman@nhs.net. (3)National Clinical Guideline Centre, Royal College of
Physicians, London, UK. (4)South Yorkshire Cardiothoracic Centre, Sheffield
Teaching Hospitals NHS Foundation Trust, Sheffield, UK. (5)National Heart and
Lung Institute, Imperial College London (Royal Brompton Hospital), London, UK.
(6)British Heart Foundation (BHF) Cardiovascular Research Centre, University of
Glasgow, Glasgow, UK. (7)Primary Care Unit, Department of Public Health & Primary
Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, UK.

OBJECTIVES: To determine and compare the diagnostic accuracy of serum natriuretic
peptide levels (B type natriuretic peptide, N terminal probrain natriuretic
peptide (NTproBNP), and mid-regional proatrial natriuretic peptide (MRproANP)) in
people presenting with acute heart failure to acute care settings using
thresholds recommended in the 2012 European Society of Cardiology guidelines for
heart failure.
DESIGN: Systematic review and diagnostic meta-analysis.
DATA SOURCES: Medline, Embase, Cochrane central register of controlled trials,
Cochrane database of systematic reviews, database of abstracts of reviews of
effects, NHS economic evaluation database, and Health Technology Assessment up to
28 January 2014, using combinations of subject headings and terms relating to
heart failure and natriuretic peptides.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Eligible studies evaluated one or
more natriuretic peptides (B type natriuretic peptide, NTproBNP, or MRproANP) in
the diagnosis of acute heart failure against an acceptable reference standard in
consecutive or randomly selected adults in an acute care setting. Studies were
excluded if they did not present sufficient data to extract or calculate true
positives, false positives, false negatives, and true negatives, or report age
independent natriuretic peptide thresholds. Studies not available in English were
also excluded.
RESULTS: 37 unique study cohorts described in 42 study reports were included,
with a total of 48 test evaluations reporting 15 263 test results. At the lower
recommended thresholds of 100 ng/L for B type natriuretic peptide and 300 ng/L
for NTproBNP, the natriuretic peptides have sensitivities of 0.95 (95% confidence
interval 0.93 to 0.96) and 0.99 (0.97 to 1.00) and negative predictive values of
0.94 (0.90 to 0.96) and 0.98 (0.89 to 1.0), respectively, for a diagnosis of
acute heart failure. At the lower recommended threshold of 120 pmol/L, MRproANP
has a sensitivity ranging from 0.95 (range 0.90-0.98) to 0.97 (0.95-0.98) and a
negative predictive value ranging from 0.90 (0.80-0.96) to 0.97 (0.96-0.98). At
higher thresholds the sensitivity declined progressively and specificity remained
variable across the range of values. There was no statistically significant
difference in diagnostic accuracy between plasma B type natriuretic peptide and
NTproBNP.
CONCLUSIONS: At the rule-out thresholds recommended in the 2012 European Society
of Cardiology guidelines for heart failure, plasma B type natriuretic peptide,
NTproBNP, and MRproANP have excellent ability to exclude acute heart failure.
Specificity is variable, and so imaging to confirm a diagnosis of heart failure
is required. There is no statistical difference between the diagnostic accuracy
of plasma B type natriuretic peptide and NTproBNP. Introduction of natriuretic
peptide measurement in the investigation of patients with suspected acute heart
failure has the potential to allow rapid and accurate exclusion of the diagnosis.

© Roberts et al 2015.

PMCID: PMC4353288
PMID: 25740799  [PubMed - indexed for MEDLINE]


4. BMJ. 2015 Mar 31;350:h1225. doi: 10.1136/bmj.h1225.

Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic
review and meta-analysis of randomised placebo controlled trials.

Machado GC(1), Maher CG(2), Ferreira PH(3), Pinheiro MB(3), Lin CW(2), Day RO(4),
McLachlan AJ(5), Ferreira ML(6).

Author information: 
(1)The George Institute for Global Health, Sydney Medical School, University of
Sydney, Sydney, NSW 2000, Australia gmachado@georgeinstitute.org.au. (2)The
George Institute for Global Health, Sydney Medical School, University of Sydney, 
Sydney, NSW 2000, Australia. (3)Faculty of Health Sciences, University of Sydney,
Sydney, NSW 2141, Australia. (4)Department of Clinical Pharmacology, St Vincent's
Hospital and University of New South Wales, Sydney, NSW 2010, Australia School of
Medical Sciences, Department of Medicine, University of New South Wales, Sydney, 
NSW 2033, Australia. (5)Faculty of Pharmacy, University of Sydney, Sydney, NSW
2050, Australia Centre for Education and Research on Ageing, Concord Hospital,
Sydney, NSW 2139, Australia. (6)The George Institute for Global Health, Sydney
Medical School, University of Sydney, Sydney, NSW 2000, Australia Institute of
Bone and Joint Research, The Kolling Institute, Sydney Medical School, University
of Sydney, Sydney, NSW 2065, Australia.

Comment in
    Ugeskr Laeger. 2015 May 11;177(20):995.
    Ann Intern Med. 2015 Jul 21;163(2):JC10.
    BMJ. 2015;350:h2221.
    BMJ. 2015;350:h2223.
    BMJ. 2015;350:h1352.
    BMJ. 2015;350:h2220.
    Praxis (Bern 1994). 2015 Jul 1;104(14):757.

OBJECTIVE: To investigate the efficacy and safety of paracetamol (acetaminophen) 
in the management of spinal pain and osteoarthritis of the hip or knee.
DESIGN: Systematic review and meta-analysis.
DATA SOURCES: Medline, Embase, AMED, CINAHL, Web of Science, LILACS,
International Pharmaceutical Abstracts, and Cochrane Central Register of
Controlled Trials from inception to December 2014.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials
comparing the efficacy and safety of paracetamol with placebo for spinal pain
(neck or low back pain) and osteoarthritis of the hip or knee.
DATA EXTRACTION: Two independent reviewers extracted data on pain, disability,
and quality of life. Secondary outcomes were adverse effects, patient adherence, 
and use of rescue medication. Pain and disability scores were converted to a
scale of 0 (no pain or disability) to 100 (worst possible pain or disability). We
calculated weighted mean differences or risk ratios and 95% confidence intervals
using a random effects model. The Cochrane Collaboration's tool was used for
assessing risk of bias, and the GRADE approach was used to evaluate the quality
of evidence and summarise conclusions.
RESULTS: 12 reports (13 randomised trials) were included. There was "high
quality" evidence that paracetamol is ineffective for reducing pain intensity
(weighted mean difference -0.5, 95% confidence interval -2.9 to 1.9) and
disability (0.4, -1.7 to 2.5) or improving quality of life (0.4, -0.9 to 1.7) in
the short term in people with low back pain. For hip or knee osteoarthritis there
was "high quality" evidence that paracetamol provides a significant, although not
clinically important, effect on pain (-3.7, -5.5 to -1.9) and disability (-2.9,
-4.9 to -0.9) in the short term. The number of patients reporting any adverse
event (risk ratio 1.0, 95% confidence interval 0.9 to 1.1), any serious adverse
event (1.2, 0.7 to 2.1), or withdrawn from the study because of adverse events
(1.2, 0.9 to 1.5) was similar in the paracetamol and placebo groups. Patient
adherence to treatment (1.0, 0.9 to 1.1) and use of rescue medication (0.7, 0.4
to 1.3) was also similar between groups. "High quality" evidence showed that
patients taking paracetamol are nearly four times more likely to have abnormal
results on liver function tests (3.8, 1.9 to 7.4), but the clinical importance of
this effect is uncertain.
CONCLUSIONS: Paracetamol is ineffective in the treatment of low back pain and
provides minimal short term benefit for people with osteoarthritis. These results
support the reconsideration of recommendations to use paracetamol for patients
with low back pain and osteoarthritis of the hip or knee in clinical practice
guidelines.
SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42013006367.

© Machado et al 2015.

PMCID: PMC4381278
PMID: 25828856  [PubMed - indexed for MEDLINE]


5. BMJ. 2015 Mar 24;350:h1354. doi: 10.1136/bmj.h1354.

Restrictive versus liberal transfusion strategy for red blood cell transfusion:
systematic review of randomised trials with meta-analysis and trial sequential
analysis.

Holst LB(1), Petersen MW(2), Haase N(2), Perner A(2), Wetterslev J(3).

Author information: 
(1)Department of Intensive Care 4131, Copenhagen University Hospital,
Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
lars.broksoe.holst@regionh.dk. (2)Department of Intensive Care 4131, Copenhagen
University Hospital, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. 
(3)Copenhagen Trial Unit, Centre for Clinical Intervention Research 7812,
Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.

Comment in
    BMJ. 2015;350:h1463.

OBJECTIVE: To compare the benefit and harm of restrictive versus liberal
transfusion strategies to guide red blood cell transfusions.
DESIGN: Systematic review with meta-analyses and trial sequential analyses of
randomised clinical trials.
DATA SOURCES: Cochrane central register of controlled trials, SilverPlatter
Medline (1950 to date), SilverPlatter Embase (1980 to date), and Science Citation
Index Expanded (1900 to present). Reference lists of identified trials and other
systematic reviews were assessed, and authors and experts in transfusion were
contacted to identify additional trials.
TRIAL SELECTION: Published and unpublished randomised clinical trials that
evaluated a restrictive compared with a liberal transfusion strategy in adults or
children, irrespective of language, blinding procedure, publication status, or
sample size.
DATA EXTRACTION: Two authors independently screened titles and abstracts of
trials identified, and relevant trials were evaluated in full text for
eligibility. Two reviewers then independently extracted data on methods,
interventions, outcomes, and risk of bias from included trials. random effects
models were used to estimate risk ratios and mean differences with 95% confidence
intervals.
RESULTS: 31 trials totalling 9813 randomised patients were included. The
proportion of patients receiving red blood cells (relative risk 0.54, 95%
confidence interval 0.47 to 0.63, 8923 patients, 24 trials) and the number of red
blood cell units transfused (mean difference -1.43, 95% confidence interval -2.01
to -0.86) were lower with the restrictive compared with liberal transfusion
strategies. Restrictive compared with liberal transfusion strategies were not
associated with risk of death (0.86, 0.74 to 1.01, 5707 patients, nine lower risk
of bias trials), overall morbidity (0.98, 0.85 to 1.12, 4517 patients, six lower
risk of bias trials), or fatal or non-fatal myocardial infarction (1.28, 0.66 to
2.49, 4730 patients, seven lower risk of bias trials). Results were not affected
by the inclusion of trials with unclear or high risk of bias. Using trial
sequential analyses on mortality and myocardial infarction, the required
information size was not reached, but a 15% relative risk reduction or increase
in overall morbidity with restrictive transfusion strategies could be excluded.
CONCLUSIONS: Compared with liberal strategies, restrictive transfusion strategies
were associated with a reduction in the number of red blood cell units transfused
and number of patients being transfused, but mortality, overall morbidity, and
myocardial infarction seemed to be unaltered. Restrictive transfusion strategies
are safe in most clinical settings. Liberal transfusion strategies have not been
shown to convey any benefit to patients.
TRIAL REGISTRATION: PROSPERO CRD42013004272.

© Holst et al 2015.

PMCID: PMC4372223
PMID: 25805204  [PubMed - indexed for MEDLINE]


6. BMJ. 2015 Feb 18;350:h568. doi: 10.1136/bmj.h568.

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage:
prospective cohort study.

Perry JJ(1), Alyahya B(2), Sivilotti ML(3), Bullard MJ(4), Émond M(5), Sutherland
J(6), Worster A(7), Hohl C(8), Lee JS(9), Eisenhauer MA(10), Pauls M(11), Lesiuk
H(12), Wells GA(13), Stiell IG(2).

Author information: 
(1)Department of Emergency Medicine, University of Ottawa, Ottawa Hospital
Research Institute, Ottawa Hospital 1053 Carling Avenue Room F647, Ottawa, ON,
Canada, K1Y 4E9 jperry@ohri.ca. (2)Department of Emergency Medicine, University
of Ottawa, Ottawa Hospital Research Institute, Ottawa Hospital 1053 Carling
Avenue Room F647, Ottawa, ON, Canada, K1Y 4E9. (3)University of Ottawa,
Department of Emergency Medicine, Ottawa, ON, Canada. (4)Department of Emergency
Medicine, University of Alberta, Edmonton, AB, Canada. (5)Hopital de
l'Enfant-Jesus, Department of Emergency Medicine, Faculty of Medicine, Quebec
City, QC, Canada G1J 1Z4. (6)Clinical Epidemiology Program, Ottawa Hospital
Research Institute, Ottawa, ON, Canada. (7)Department of Emergency Medicine,
McMaster University, Hamilton, ON, Canada. (8)Department of Emergency Medicine,
University of British Columbia, Vancouver, BC, Canada. (9)Division of Emergency
Medicine, University of Toronto, Toronto, ON, Canada. (10)Division of Emergency
Medicine, University of Western Ontario, London, ON, Canada. (11)Department of
Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada. (12)Division of
Neurosurgery, University of Ottawa, Ottawa, ON, Canada. (13)Department of
Epidemiology and Community Medicine, University of Ottawa, Ottawa Hospital
Research Institute, Ottawa, ON, Canada.

OBJECTIVES: To describe the findings in cerebrospinal fluid from patients with
acute headache that could distinguish subarachnoid hemorrhage from the effects of
a traumatic lumbar puncture.
DESIGN: A substudy of a prospective multicenter cohort study.
SETTING: 12 Canadian academic emergency departments, from November 2000 to
December 2009.
PARTICIPANTS: Alert patients aged over 15 with an acute non-traumatic headache
who underwent lumbar puncture to rule out subarachnoid hemorrhage.
MAIN OUTCOME MEASURE: Aneurysmal subarachnoid hemorrhage requiring intervention
or resulting in death.
RESULTS: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on
cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube
of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15
(0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results
of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells
in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid
hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%)
and specificity of 91.2% (88.6% to 93.3%).
CONCLUSION: No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably
excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with
acute headache who meet this cut off will need no further investigations and
aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.

© Perry et al 2015.

PMCID: PMC4353280
PMID: 25694274  [PubMed - indexed for MEDLINE]

Diagnostic

 

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