Severe, abrupt onset headache raises concern for aneurysmal subarachnoid hemorrhage (SAH). The current standard work-up is brain CT scan followed by LP if the CT is non-diagnostic in patients with a normal neurological exam. Some have suggested that angiography is also indicated in this common clinical situation. Is evaluation with brain CT and LP for thunderclap headache to rule out SAH sufficient and is angiography needed?
We systematically searched for studies that followed neurologically-intact patients with thunderclap headache and normal CT and LP for at least 1 year. The primary outcome was SAH. We estimated the proportion of patients who developed SAH and the one-sided upper 95% confidence bound.
Seven studies including 813 patients were identified. None of the patients developed SAH during follow-up (pooled proportion=0, upper 95% confidence bound=0.004).
Although our methods have important limitations, we believe that this analysis will give clinicians better tools to decide whether or not to pursue further work-up with angiography in patients with thunderclap headache and normal neurological exam, CT, and LP.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Journal of the Neurological Sciences
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Thunderclap headache: symptom of unruptured cerebral aneurysm.Lancet. 1986; 2: 1247-1248
- Aneurysmal subarachnoid leak with normal CT and CSF spectrophotometry.Neurology. 2005; 64: 923
- Unruptured cerebral aneurysm producing a thunderclap headache.Am J Emerg Med. 2000; 18: 88-90
- The clinical spectrum of unruptured intracranial aneurysms.Arch Neurol. 1993; 50: 265-268
- Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid haemorrhage.Lancet. 1988; 2: 68-70
- A prospective follow up of thunderclap headache mimicking subarachnoid haemorrhage.J Neurol Neurosurg Psychiatry. 1991; 54: 1117-1118
- Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage.Lancet. 1994; 344: 590-593
- Sudden onset headache: a prospective study of features, incidence and causes.Cephalalgia. 2002; 22: 354-360
- Thunderclap headache: is it migraine?.Cephalalgia. 1989; 9: 87-90
- The “warning leak” in spontaneous subarachnoid haemorrhage.Med J Aust. 1983; 1: 514-516
- 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
- Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage.Acad Emerg Med. 2006; 13: 486-492
- Thunderclap headache with normal CT and lumbar puncture: further investigations are unnecessary: against.Stroke. 2008; 39: 1394-1395
- Thunderclap headache with normal CT and lumbar puncture: further investigations are unnecessary: for.Stroke. 2008; 39: 1392-1393
- Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000; 283: 2008-2012
- If nothing goes wrong, is everything all right? Interpreting zero numerators.JAMA. 1983; 249: 1743-1745
- Systematic reviews of evaluations of diagnostic and screening tests.in: Egger M. Davey Smith G. Altman D.G. Systematic reviews in health care: meta-analysis in context. 2nd ed. BMJ Books, London2001
- An assessment of clinically useful measures of the consequences of treatment.N Engl J Med. 1988; 318: 1728-1733
- Intracranial aneurysms.N Engl J Med. 1997; 336: 28-40
Accepted: September 16, 2008
Received: July 4, 2008
© 2008 Elsevier B.V. Published by Elsevier Inc. All rights reserved.