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