Diagnosing Subarachnoid Haemorrhage in Neuro Critical Care

Join the debate between Bill Knight and Fernanda Bellolio as they go head-to-head, discussing diagnosing subarachnoid haemorrhage in neuro critical care headache. Should you rely on CT and lumbar puncture or, CT followed by CT angiogram. Why should you care? Acute headache accounts for 4% of all visits to the emergency departments. These patients will often describe the “Worst headache of life” – a phrase which can ring the alarm bells in the clincian’s mind. 88% of these will be from benign causes including migraine, tension and cluster. However 10% will have a subarachnoid haemorrhage, of which the vast majority are caused by an aneurysm. These are frequently missed - up to 51% of the time in all settings and 6% of the time in the emergency department. It is in face one of the largest sources of US litigation claims and settlements. So – what is the best way to diagnosis subarachnoid haemorrhage? Bill asserts that the lumbar puncture (LP) following the CT is the way to go. He stresses that the “miss rate” needs to be 0% for subarachnoid haemorrhage. He argues that with the combination of CT and LP the sensitivity for subarachnoid haemorrhage is 100% Fernanda on the other hand is a big proponent of using the combination of CT followed by CT angiogram (CTA). She discusses the very low incidence of subarachnoid haemorrhade and takes this into account when calculating the pre- and post-test probability for her patients. She argues that if the pre-test probability is higher for a patient, then a CTA can be utilised. Bill Knight and Fernanda Bellolio present a compelling case for both sides when identifying the best way to diagnose subarachnoid haemorrhage in neuro critical care headache.

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