Subarachnoid haemorrhage

To LP or not to LP? A service evaluation investigating the prevalence of subarachnoid haemorrhage in patients undergoing a lumbar puncture in the acute medical setting

Original Articles, Volume 24, Issue 2, Pages 61 – 108 (2025)

Subarachnoid haemorrhage (SAH) is a potentially life-threatening cause of acute severe headache. This service evaluation aimed to investigate the prevalence of SAH in patients referred to acute medicine with acute severe headache who underwent a lumbar puncture (LP) at a tertiary teaching hospital, over a four-year period. Of the 677 samples analysed for CSF bilirubin, 619 were negative (91.5%), 48 indeterminate (7%), and 10 classified as positive (1.5%). Only one patient (0.1%) was diagnosed with an aneurysmal SAH and underwent intervention. Therefore, the diagnostic yield of an LP to exclude SAH in this setting is extremely low. This service evaluation challenges the dogma that LP is necessary in all patients with acute severe headache.

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An Acute Severe Headache

Picture Quiz - Answers, Volume 15, Issue 2, Pages 49 - 108 (2016)

Discussion

Severe headaches are a frequent presentation to the Emergency Department, accounting for around 1% of presentations. Of these, 13-16% will have a sinister underlying pathology but accurate diagnosis of headaches on the medical take remain difficult for non-specialists. A retrospective study from the UK found that, of those presenting to Emergency Department with sudden onset severe headaches, only 60% were given a specific headache diagnosis, with one third of these given their diagnoses despite an inadequate history.

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Presentations to An Acute Medical Unit Due to Headache: A Review of 306 Consecutive Cases

Research Audit and Clinical Practice, Volume 11, Issue 3, Pages 129 - 185 (2012)

Abstract

The United Kingdom National Health Service has recently prioritised the need for ambulatory care pathways for acute headache. The present study sought to better characterise patients referred to an Acute Medical Unit so as to inform pathway development. In 2011, York Hospital received 306 referrals due to acute headache, representing 3% of acute medical admissions. Investigations included CT scan (38%), lumbar puncture (38%), and MRI (18%); there were no specialised investigations in 26%, and 18% of patients were discharged on the day of presentation. Subarachnoid haemorrhage occurred in only 4 patients (1%), meningitis in 10 (3%), and intracranial tumour in 5 (2%). The findings indicate that a significant proportion of patients with acute headache could be managed by ambulatory care.

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Magnesium and the Acute Physician

Clinical Reviews, Volume 11, Issue 1, Pages 1 - 56 (2012)

Abstract

Magnesium deficiency, and to a lesser extent magnesium excess, is commonly encountered in patients admitted to the Acute Medical Unit. It is important that acute physicians are able to identify those at risk of these states and initiate appropriate investigation and treatment. This article aims to provide the reader with a sound understanding of magnesium physiology and its effect at a cellular level. The causes, symptoms and treatment of magnesium disorders are discussed along with a review of evidence regarding the therapeutic use of magnesium.

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Cerebrospinal Fluid analysis in Suspected Subarachnoid Haemorrhage

Clinical Reviews, Volume 5, Issue 1, Pages 1 - 40 (2006)

Abstract

Aneurysmal subarachnoid haemorrhage (SAH) is an acute life-threatening neurological disorder. A delay in diagnosis can lead to substantial and avoidable morbidity and mortality. It is important to identify patients with SAH promptly, to enable specialist referral to neurosurgical centres. This review aims to provide an up-to-date practical guide concerning the interpretation of spinal fluid results in patients with suspected SAH.

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Sudden Headaches

Clinical Reviews, Volume 3, Issue 1, Pages 1 - 44 (2004)

Abstract

Sudden severe headache is a cardinal feature of subarachnoid haemorrhage (SAH) and other potentially life threatening neurological conditions. Early diagnosis and management improves the outcome of SAH. In general practice, benign thunderclap headache vastly outnumbers SAH as a cause of sudden headache. Thunderclap headache is a diagnosis of exclusion and all patients admitted with a first presentation of a severe headache lasting more than one hour should be investigated with a CT and lumbar puncture. It must be borne in mind that these investigations may miss diagnoses such as venous sinus thrombosis and Magnetic Resonance Angiography (MRA) should be performed if clinical suspicion remains high.

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