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.

Subarachnoidalblutung - Liquor - neurologische Intensivmedizin

subarachnoid haemorrhage - cerebrospinal fluid - neurological critical care

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