BMJ 2013;347:f7578 doi: 10.1136/bmj.f7578 (Published 23 December 2013)

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Letters

LETTERS SUBARACHNOID HAEMORRHAGE

Importance of lumbar puncture in diagnosing subarachnoid haemorrhage 1

Chris E Uff neurosurgeon , Catriona Harrison specialist registrar in emergency medicine

2

King’s College Hospital, London SE5 9RS, UK; 2Royal Free Hospital, London, UK

1

The recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report into the management of patients with aneurysmal subarachnoid haemorrhage in the UK was published on 22 November and subsequently reported in the BMJ.1 2 One of its main conclusions was that failure to recognise the signs and symptoms of subarachnoid haemorrhage causes diagnostic delay and results in poorer outcomes.

Although a GP who sees several patients with headache each day might understandably miss a diagnosis of subarachnoid haemorrhage (as occurred in 32/75 patients), an NHS hospital that can perform computed tomography of the head but not the necessary subsequent investigation is less acceptable. Axial computed tomography of the head remains the initial investigation of choice for subarachnoid haemorrhage, but patients with a good history and a normal computed tomogram should be investigated with lumbar puncture.3 4 The NCEPOD report found that 52/204 hospitals (25.5%) could not perform a lumbar puncture at all hours of the day and 11/204 hospitals

(5.4%) were unable to perform one at all. Given that lumbar puncture is the gold standard for diagnosis of aneurysmal subarachnoid haemorrhage,3 it is surprising that this basic skill is unavailable in hospitals that can perform computed tomography. Competing interests: None declared. 1

2 3 4

National Confidential Enquiry into Patient Outcome and Death. Managing the flow? A review of the care received by patients who were diagnosed with an aneurysmal subarachnoid haemorrhage. 2013. www.hqip.org.uk/assets/NCAPOP-Library/CORPLibrary/NCEPODManaging-the-FlowSAH-full-report.pdf. Mayor S. Earlier diagnosis is needed to reduce deaths and disability from aneurysmal subarachnoid haemorrhage. BMJ 2013;347:f6925. (22 November.) Edlow J, Caplan L. Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 2000;342:29-36. Perry J, Stiell I, Sivilotti M, Bullard M, Lee JS, Eisenhauer M, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ 2010;341:c5204.

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Importance of lumbar puncture in diagnosing subarachnoid haemorrhage.

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