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Response to Letter Regarding Article,
“­Time-­Dependent Test Characteristics of
Head CT in Patients Suspected of
Nontraumatic Subarachnoid Hemorrhage”
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transmural section provoking SAH. Without the proof of a positive
cerebrospinal fluid examination in this patient, the authors can in our
view not conclude that a lumbar puncture would have been helpful in
this patient. Third, the patient was described to have neck stiffness.
Because a patient with neck stiffness has not a normal neurological
examination, the treating physician should not be reluctant to question the interpretation of head CT by the radiologist. We urge further
examinations in patients with neck stiffness to diagnose the cause.
In our view, lumbar puncture should have been performed anyway
in this patient.
We cannot disagree more with the suggestion that a CT angiography might help in reducing mortality and ­long-­term disability
in patients with acute headache and a negative CT. This approach
will also result in the detection of asymptomatic and often very
small aneurysms that may need f­ollow-­up over time instead of
being treated. The detection of asymptomatic aneurysms has a
considerable impact on quality of life.2 In patients with acute
headache, it is pivotal to first rule in or out a SAH. Further examinations to find an aneurysm or other cause of the SAH should be
performed only in patients with a proven SAH.
Response:
We thank Dr Yeo and coworkers for their interest in our study,
in which we concluded that in patients presenting with acute
headache and a normal head CT ≤6 hours after ictus, there is no
added value of cerebrospinal fluid analysis.1
Dr Yeo and coworkers warn that our results need to be interpreted with caution. We cannot agree more, and that is why we
emphasized (as Yeo et al do) that our results only can be extrapolated to ­high-­volume tertiary care centers where head CT scans
are interpreted by experienced neuroradiologists.1 However, Yeo
et al end with the recommendation that in patients with acute
headache but a negative early CT scan, a lumbar puncture should
still be performed and perhaps even combined with a CT angiography. They illustrate their recommendation with a patient
with severe frontal headache of sudden onset, nausea, vomiting,
photophobia, and neck stiffness. An initial noncontrast CT scan
performed at 2 hours after symptom onset was unremarkable.
Fourteen hours later, this patient had a generalized tonic–clonic
seizure. A subsequent head CT showed subarachnoid hemorrhage
(SAH) extending to the ventricles.
We would like to make 3 comments on this patient and the conclusion the authors draw. First, unfortunately the authors do not show
the initial scan. It is well known that in patients with SAH, head CT
can show only subtle signs of bleeding. A w
­ ell-­known pitfall in the
interpretation of head CT in patients with SAH is isolated blood in
the interhemispheric fissure or interpeduncular cistern. Therefore,
we stress in our article that our recommendation only applies if the
CT scan is interpreted by an experienced neuroradiologist working
in a center with a high volume of patients with SAH. Second, the
authors make the assumption that if a lumbar puncture had been performed, it had shown signs of SAH. This assumption might very well
be erroneous. The patient might have been one of the rare patients
who have an intracranial intramural dissection causing acute headache but without hemorrhage and a few hours later extension into a
Disclosures
None.
Daan Backes, MD
Gabriel J. E. Rinkel, MD
Mervyn D. I. Vergouwen, MD, PhD
UMC Utrecht Stroke Center
Department of Neurology and Neurosurgery
Rudolf Magnus Institute of Neuroscience
University Medical Center Utrecht
Utrecht, the Netherlands
1.Backes D, Rinkel GJ, Kemperman H, Linn FH, Vergouwen MD.
­Time-­dependent test characteristics of head computed tomography in
patients suspected of nontraumatic subarachnoid hemorrhage. Stroke.
2012;43:2115–2119.
2. Wermer MJ, van der Schaaf IC, Van Nunen P, Bossuyt PM, Anderson CS,
Rinkel GJ. Psychosocial impact of screening for intracranial aneurysms in
relatives with familial subarachnoid hemorrhage. Stroke. 2005;36:836–840.
(Stroke. 2012;43:e164.)
© 2012 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.112.672899
e164
Response to Letter Regarding Article, ''Time-Dependent Test Characteristics of Head CT
in Patients Suspected of Nontraumatic Subarachnoid Hemorrhage''
Daan Backes, Gabriel J. E. Rinkel and Mervyn D. I. Vergouwen
Downloaded from http://stroke.ahajournals.org/ by guest on June 17, 2017
Stroke. 2012;43:e164; originally published online September 13, 2012;
doi: 10.1161/STROKEAHA.112.672899
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2012 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628
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