Plötzliche und stärkste Kopfschmerzen: Wie sicher ist der kombinierte Einsatz von Computertomografie und Lumbalpunktion zum Ausschluss einer Subarachnoidalblutung?

Zusammenfassung

Die Subarachnoidalblutung gehört zu den neurologischen Notfällen mit intensivmedizinischer Behandlungsbedürftigkeit. Die Diagnose ist in den überwiegenden Fällen aufgrund der charakteristischen klinischen Symptome und dem Nachweis von Blut in der zerebralen Computertomografie oder im Liquor problemlos zu stellen. Bei einigen Patienten verbleibt jedoch aufgrund der eindeutigen Symptome trotz unauffälliger Befunde in der Routinediagnostik eine Restunsicherheit. Wir beschreiben die Krankheitsverläufe dreier Patienten, bei denen die Diagnose einer Subarachnoidalblutung vermutet wurde, obwohl Computertomografie und Lumbalpunktion einen unauffälligen Befund ergeben hatten. In diesen Fällen konnten Vasospasmen mittels transkranieller Doppler-Sonografie und/oder ein zerebrales Aneurysma mittels konventioneller Angiografie nachgewiesen werden. Wir weisen auf die Besonderheiten dieser seltenen Präsentation einer schwerwiegenden akuten neurologischen Erkrankung hin, diskutieren differenzialdiagnostische Überlegungen und die Vor- und Nachteile der einzelnen diagnostischen Schritte.

Abstract

Subarachnoid haemorrhage constitutes a neurological emergency. In most cases the diagnosis is easy to establish by cerebral computed tomography or cerebrospinal fluid tap. However, in rare cases verification of the diagnosis is more difficult and a residual uncertainty remains. We describe three patients supposed to have a subarachnoid haemorrhage without pathological findings in both cerebral computed tomography and cerebrospinal fluid. In these cases vasospasm or cerebral aneurysm were detected by means of transcranial Doppler sonography and/or conventional angiography. We comment on the special features of this rare presentation of a severe acute neurological emergency, and we discuss diagnostic work-up and differential diagnoses.

Schlüsselwörter

Subarachnoidalblutung - Liquor - neurologische Intensivmedizin

Keywords

subarachnoid haemorrhage - cerebrospinal fluid - neurological critical care

Literatur

• 1 Hunt W E, Hess R M. Surgical risk as related to time of intervention in the repair of intracranial aneurysms.  J Neurosurg. 1968;  28 14-20
• 2 Edlow J A, Caplan L R. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage.  N Engl J Med. 2000;  342 29-36
• 3 Mayer P L, Awad I A, Todor R et al. Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions.  Stroke. 1996;  27 1558-1563
• 4 Scotti G, Ethier R, Melancon D et al. Computed tomography in the evaluation of intracranial aneurysms and subarachnoid hemorrhage.  Radiology. 1977;  123 85-90
• 5 Gijn van J, Dongen K J. The time course of aneurysmal haemorrhage on computed tomograms.  Neuroradiology. 1982;  23 153-156
• 6 Morgenstern L B, Luna-Gonzales van H, Huber Jr J C et al. Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis.  Ann Emerg Med. 1998;  32 297-304
• 7 Vermeulen M, Gijn van J. The diagnosis of subarachnoid haemorrhage.  J Neurol Neurosurg Psychiatry. 1990;  53 365-372
• 8 Leblanc R. The minor leak preceding subarachnoid hemorrhage.  J Neurosurg. 1987;  66 35-39
• 9 Eggers C, Liu W, Brinker G et al. Do negative CCT and CSF findings exclude a subarachnoid haemorrhage? A retrospective analysis of 220 patients with subarachnoid haemorrhage.  Eur J Neurol. 2010;  Jul 19 [Epub ahead of print]
• 10 Lindegaard K F, Nornes H, Bakke S J et al. Cerebral vasospasm after subarachnoid haemorrhage investigated by means of transcranial Doppler ultrasound.  Acta Neurochir Suppl. 1988;  42 81-84
• 11 Day J W, Raskin N H. Thunderclap headache: symptom of unruptured cerebral aneurysm.  Lancet. 1986;  2 1247-1248
• 12 Perry J J, Spacek A, Forbes M et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage?.  Ann Emerg Med. 2008;  51 707-713
• 13 Wijdicks E F, Kerkhoff H, Gijn van J. Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid haemorrhage.  Lancet. 1988;  2 68-70
• 14 Dodick D W, Brown Jr R D, Britton J W et al. Nonaneurysmal thunderclap headache with diffuse, multifocal, segmental, and reversible vasospasm.  Cephalalgia. 1999;  19 118-123
• 15 Markus H S. A prospective follow up of thunderclap headache mimicking subarachnoid haemorrhage.  J Neurol Neurosurg Psychiatry. 1991;  54 1117-1118
• 16 Sturm J W, Macdonell R A. Recurrent thunderclap headache associated with reversible intracerebral vasospasm causing stroke.  Cephalalgia. 2000;  20 132-135
• 17 Gerretsen P, Kern R Z. Reversible cerebral vasoconstriction syndrome: a thunderclap headache-associated condition.  Curr Neurol Neurosci Rep. 2009;  9 108-114
• 18 Hantson P, Forget P. Reversible cerebral vasospasm, multilobular intracerebral hemorrhages, and nonaneurysmal subarachnoid hemorrhage: review of possible interrelationships.  Curr Pain Headache Rep. 2010;  14 228-232
• 19 Edlow J A, Malek A M, Ogilvy C S. Aneurysmal subarachnoid hemorrhage: update for emergency physicians.  J Emerg Med. 2008;  34 237-251
• 20 Edlow J A, Panagos P D, Godwin S A et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.  Ann Emerg Med. 2008;  52 407-436
• 21 Buruma O J, Janson H L, Den Bergh F A et al. Blood-stained cerebrospinal fluid: traumatic puncture or haemorrhage?.  J Neurol Neurosurg Psychiatry. 1981;  44 144-147
• 22 Gijn van J, Kerr R S, Rinkel G J. Subarachnoid haemorrhage.  Lancet. 2007;  369 306-318
• 23 Wiesmann M, Mayer T E, Yousry I et al. Detection of hyperacute subarachnoid hemorrhage of the brain by using magnetic resonance imaging.  J Neurosurg. 2002;  96 684-689
• 24 Mohamed M, Heasly D C, Yagmurlu B et al. Fluid-attenuated inversion recovery MR imaging and subarachnoid hemorrhage: not a panacea.  AJNR Am J Neuroradiol. 2004;  25 545-550
• 25 Sloan M A, Haley Jr E C, Kassell N F et al. Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage.  Neurology. 1989;  39 1514-1518
• 26 Suarez J I, Qureshi A I, Yahia A B et al. Symptomatic vasospasm diagnosis after subarachnoid hemorrhage: evaluation of transcranial Doppler ultrasound and cerebral angiography as related to compromised vascular distribution.  Crit Care Med. 2002;  30 1348-1355
• 27 Chaudhary S R, Ko N, Dillon W P et al. Prospective evaluation of multidetector-row CT angiography for the diagnosis of vasospasm following subarachnoid hemorrhage: a comparison with digital subtraction angiography.  Cerebrovasc Dis. 2008;  25 144-150