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Neuroimaging
Published in Ibrahim Natalwala, Ammar Natalwala, E Glucksman, MCQs in Neurology and Neurosurgery for Medical Students, 2022
Ibrahim Natalwala, Ammar Natalwala, E Glucksman
FALSE – SAHs are arterial bleeds that tend to follow the contours of the cerebral sulci. The patient classically complains of a ‘thunderclap’ headache. A CT scan is indicated acutely. Lumbar puncture can help confirm the diagnosis – look for xanthochromia.
Diagnostic testing and ominous causes of headache
Published in Stephen D. Silberstein, Richard B. Upton, Peter J. Goadsby, Headache in Clinical Practice, 2018
Stephen D. Silberstein, Richard B. Upton, Peter J. Goadsby
The best way to detect xanthochromia is by spectrophotometry, since it cannot be detected by the naked eye in about half of all cases.35 The probability of detecting xanthochromia by spectrophotometry at various times after SAH is: 12 hours, 100%; 1 week, 100%; 2 weeks, 100%; 3 weeks, > 70%; and after 4 weeks, > 40% (Table 4.6). Other causes of xanthochromia include: jaundice, usually with a total plasma bilirubin of 10–15 mg/dl; CSF protein > 150 mg/dl; dietary hypercarotenaemia; malignant melanomatosis; and oral intake of rifampin.36
Case 5: Sudden-Onset Headache
Published in Layne Kerry, Janice Rymer, 100 Diagnostic Dilemmas in Clinical Medicine, 2017
Analgesia and anti-emetics should be given initially. A probable diagnosis is that the patient has had a subarachnoid bleed. A lumbar puncture should be performed to identify xanthochromia in the cerebrospinal fluid (CSF). It takes at least 2 hours for the haemoglobin to degrade and be detected as xanthochromia in the CSF and the lumbar puncture should ideally be performed at least 12 hours after the onset of the headache to increase the sensitivity of the test. A positive result becomes increasingly unlikely after 10 days post-event and a magnetic resonance imaging (MRI) scan may need to be performed at this stage to identify the presence of old blood in the subarachnoid space.
Excluding subarachnoid haemorrhage within 24 hours: to LP or not to LP?
Published in British Journal of Neurosurgery, 2021
Carolyn Chee, Akmal Mohamad Roji, Nathan Lorde, Hrushikesh Divyateja, Graham Dow, Jagrit Shah, K. Chokkalingam
Of the 823 patients who had a normal initial head CT, 802 patients underwent LP for CSF xanthochromia. A total of 24 patients had CSF xanthochromia analysis suggestive of SAH. 17 patients proceeded to have further neuroimaging in the form of CT angiogram, magnetic resonance angiography, or cerebral angiography, and within this group only one patient was found to have cerebral aneurysms. Of the 802 patients who underwent LP, three were identified as having SAH or aneurysms on further neuroimaging and all three presented more than 24 hours after ictus. Another group of 87 patients had non-diagnostic xanthochromia results. Within this group, 55 patients were discharged from hospital based on clinical judgement and initial presenting symptoms, and all remained alive after 1 year of their initial presentation. The remaining 32 patients had further neuroimaging and 2 of these patients were found to have cerebral aneurysms and were treated. A group of 21 patients with normal initial head CT scans were discharged without undergoing LP, with 1 patient readmitted within 1 year of the initial presentation but died during admission. 7 patients were diagnosed with other conditions following a further clinical review. In total, 4 patients had a diagnosis of non-traumatic SAH following a normal head CT scan (Table 3).
Pituitary apoplexy mimicking meningoencephalitis: case report and scoping study
Published in Hospital Practice, 2020
Chun Chu, Gretchen A. Perilli, Casey Judge, Sen Sheng, Hussam A. Yacoub
CSF analysis revealed neutrophil-predominant pleocytosis in 100% of the cases (14/14) with a neutrophil percentage range of 73% to 98%. In 86% of the cases (12/14), CSF leukocyte count was less than 1000/ul. The presence of CSF erythrocyte was noticed in 92.9% of the cases (13/14) with a count ranging from 15 to 2030/ul. Xanthochromia was presents in the only case in which CSF erythrocytes were not present [20]. Elevated CSF protein was present in 100% of the cases (14/14) with a range of 69.8 to 239 mg/dl. The CSF glucose level varied between 12 mg/dl and 136 mg/dl, but it was greater than 40 mg/dl in 73% of the cases (8/11). All supporting data of this study are available within this article and/or its supplementary materials.
New method for the determination of the net bilirubin absorbance in cerebrospinal fluid that minimizes the interference of oxyhaemoglobin and biliverdin
Published in Scandinavian Journal of Clinical and Laboratory Investigation, 2020
Detecting the presence of xanthochromia in cerebrospinal fluid (CSF) is of capital importance in order to confirm the occurrence of subarachnoid haemorrhage (SAH). The latest generation of computed tomography scanners can detect with improved sensitivity the presence of any vascular damage in the brain, but they have not yet overcome the analysis of xanthochromia in CSF when the sample is obtained after 12 h from the beginning of headache ictus. In these conditions, the sensitivity of the CSF analysis by multiwavelength spectrophotometry is close to 100%, and it has this high sensitivity until the second week after the SAH [1,2].