A Review of the Clinical Significance of Lumbar Puncture in the Diagnostic Approach of Aneurysmal Subarachnoid Hemorrhage (SAH): A Case Report of CT-Negative and Lumbar Puncture–Positive SAH


Headaches are a common presentation in the emergency department (ED). Even though not all are potentially serious, some such as subarachnoid hemorrhage (SAH) can be more dangerous than others. SAH is a medical emergency with an almost 50% mortality rate. It is crucial not to miss the diagnosis of SAH, as a missed or delayed diagnosis can be severely detrimental. It classically presents as thunderclap headache, a severe, sudden-onset headache. There are various approaches in diagnosing or excluding SAH, which is classically done by performing a computed tomography (CT) scan followed by a lumbar puncture (LP). But with the improved sensitivity of more modern diagnostic tools, more physicians are in support of changing this classical teaching. The aim of this case report is to review the advantages and disadvantages of LP in diagnosing SAH, along with other diagnostic tools commonly used.


Keywords: subarachnoid hemorrhage, lumbar puncture, cerebrospinal fluid, aneurysmal subarachnoid hemorrhage, brain ct scan, brain ct angiography, brain mr angiography

  1. Etminan N, Chang HS, Hackenberg K, De Rooij NK, Vergouwen MDI, Rinkel GJE, et al. Worldwide incidence of aneurysmal subarachnoid hemorrhage according to region, time period, blood pressure, and smoking prevalence in the population: A systematic review and meta-analysis. JAMA Neurol . 2019 May 1;76[5]:588.

  2. Landtblom AM, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: A prospective study of features, incidence and causes. Cephalalgia . 2002 Jun;22[5]:354–60.

  3. Nieuwkamp DJ, Setz LE, Algra A, Linn FH, De Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. The Lancet Neurology . 2009 Jul;8[7]:635–42.

  4. Carstairs SD, Tanen DA, Duncan TD, Nordling OB, Wanebo JE, Paluska TR, et al. Computed tomographic angiography for the evaluation of aneurysmal subarachnoid hemorrhage. Academic Emergency Medicine . 2006 May;13[5]:486–92.

  5. Rehman S, Phan HT, Reeves MJ, Thrift AG, Cadilhac DA, Sturm J, et al. Case-fatality and functional outcome after subarachnoid hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT). Journal of Stroke and Cerebrovascular Diseases . 2022 Jan;31[1]:106201.

  6. Perry JJ, Stiell IG, Sivilotti MLA, Bullard MJ, Emond M, Symington C, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ . 2011 Jul 18;343[jul18 1]:d4277–d4277.

  7. Backes D, Rinkel GJE, Kemperman H, Linn FHH, Vergouwen MDI. Time-dependent test characteristics of head computed tomography in patients suspected of nontraumatic subarachnoid hemorrhage. Stroke . 2012 Aug;43[8]:2115–9.

  8. Gottlieb M, Morgenstern J. Lumbar puncture should not be routinely performed for subarachnoid hemorrhage after a negative head CT. Annals of Emergency Medicine . 2021 Jun;77[6]:643–5.

  9. Carpenter CR, Hussain AM, Ward MJ, Zipfel GJ, Fowler S, Pines JM, et al. Spontaneous subarachnoid hemorrhage: A systematic review and meta-analysis describing the diagnostic accuracy of history, physical examination, imaging, and lumbar puncture with an exploration of test thresholds. In: Zehtabchi S, editor. Acad Emerg Med . 2016 Sep;23[9]:963–1003.

  10. Marcolini E, Hine J. Approach to the diagnosis and management of subarachnoid hemorrhage. WestJEM . 2019 Feb 28;20[2]:203–11.

  11. McCormack RF, Hutson A. Can computed tomography angiography of the brain replace lumbar puncture in the evaluation of acute-onset headache after a negative noncontrast cranial computed tomography scan? Academic Emergency Medicine . 2010 Apr;17[4]:444–51.

  12. Hoh BL, Ko NU, Amin-Hanjani S, Hsiang-Yi Chou S, Cruz-Flores S, Dangayach NS, et al. 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke [Internet]. 2023 Jul [cited 2023 Sep 17];54[7]. Available from: https://www.ahajournals.org/doi/10.1161/STR.0000000000000436

  13. Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke . 2007 Apr;38[4]:1216–21.

  14. Edlow JA, Fisher J. Diagnosis of subarachnoid hemorrhage: Time to change the guidelines? Stroke . 2012 Aug;43[8]:2031-2.

  15. Perry JJ, Stiell IG, Sivilotti MLA, Bullard MJ, Hohl CM, Sutherland J, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA . 2013 Sep 25;310[12]:1248.

  16. Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA. Sensitivity of early brain computed tomography to exclude aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Stroke . 2016 Mar;47[3]:750–5.

  17. Cortnum S, Sørensen P, Jørgensen J. Determining the sensitivity of computed tomography scanning in early detection of subarachnoid hemorrhage. Neurosurgery . 2010 May;66[5]:900–2; discussion 903.

  18. Long B, Koyfman A. Controversies in the diagnosis of subarachnoid hemorrhage. The Journal of Emergency Medicine . 2016 Jun;50[6]:839–47.

  19. Claveau D, Dankoff J. Is lumbar puncture still needed in suspected subarachnoid hemorrhage after a negative head computed tomographic scan? CJEM . 2014 May;16[03]:226–8.

  20. Perry JJ, Eagles D, Clement CM, Brehaut J, Kelly AM, Mason S, et al. An international study of emergency physicians’ practice for acute headache management and the need for a clinical decision rule. CJEM . 2009 Nov;11[06]:516–22.

  21. Hop JW, Rinkel GJE, Algra A, Van Gijn J. Case-fatality rates and functional outcome after subarachnoid hemorrhage: A systematic review. Stroke . 1997 Mar;28[3]:660–4.

  22. English SW. Long-term outcome and economic burden of aneurysmal subarachnoid hemorrhage: Are we only seeing the tip of the iceberg? Neurocrit Care . 2020 Aug;33[1]:37–8.

  23. Gill HS, Marcolini EG, Barber D, Wira CR. The utility of lumbar puncture after a negative head CT in the emergency department evaluation of subarachnoid hemorrhage. Yale J Biol Med . 2018 Mar;91[1]:3–11.

  24. Kameda-Smith M, Aref M, Jung Y, Ghayur H, Farrokhyar F. Determining the Diagnostic utility of lumbar punctures in computed tomography negative suspected subarachnoid hemorrhage: A systematic review and meta-analysis. World Neurosurgery . 2021 Apr;148:e27–34.

  25. Perry JJ, Spacek A, Forbes M, Wells GA, Mortensen M, Symington C, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Annals of Emergency Medicine . 2008 Jun;51[6]:707–13.

  26. Perry JJ, Alyahya B, Sivilotti MLA, Bullard MJ, Emond M, Sutherland J, et al. Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study. BMJ . 2015 Feb 18;350[feb18 8]:h568–h568.

  27. Bakr A, Silva D, Cramb R, Flint G, Foroughi M. Outcomes of CSF spectrophotometry in cases of suspected subarachnoid haemorrhage with negative CT: two years retrospective review in a Birmingham hospital. British Journal of Neurosurgery . 2017 Mar 4;31[2]:223–6.

  28. Subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management. London: NICE; 2022. (NICE guideline).

  29. UK National External Quality Assessment Scheme for Immunochemistry Working Group. National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid haemorrhage. Ann Clin Biochem . 2003 Sep 1;40[5]:481–8.

  30. Godwin SA, Cherkas DS, Panagos PD, Shih RD, Byyny R, Wolf SJ, et al. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Annals of Emergency Medicine . 2019 Oct;74[4]:e41–74.

  31. Long B, Koyfman A, Runyon MS. Subarachnoid hemorrhage. Emergency Medicine Clinics of North America . 2017 Nov;35[4]:803–24.

  32. Youssef NA, Gordon AJ, Moon TH, Patel BD, Shah SJ, Casey EM, et al. Emergency Department patient knowledge, opinions, and risk tolerance regarding computed tomography scan radiation. The Journal of Emergency Medicine . 2014 Feb;46[2]:208–14.

  33. Westerlaan HE, Van Dijk JMC, Jansen-van Der Weide MC, De Groot JC, Groen RJM, Mooij JJA, et al. Intracranial aneurysms in patients with subarachnoid hemorrhage: CT angiography as a primary examination tool for diagnosis—systematic review and meta-analysis. Radiology . 2011 Jan;258[1]:134–45.

  34. Van Der Wee N, Rinkel GJ, Hasan D, Van Gijn J. Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan? Journal of Neurology, Neurosurgery & Psychiatry . 1995 Mar 1;58[3]:357–9.

  35. Ohashi Y, Horikoshi T, Sugita M, Yagishita T, Nukui H. Size of cerebral aneurysms and related factors in patients with subarachnoid hemorrhage. Surgical Neurology . 2004 Mar;61[3]:239–45.

  36. Sailer AMH, Wagemans BAJM, Nelemans PJ, De Graaf R, Van Zwam WH. Diagnosing intracranial aneurysms with MR angiography: Systematic review and meta-analysis. Stroke . 2014 Jan;45[1]:119–26.

  37. Ward MJ, Bonomo JB, Adeoye O, Raja AS, Pines JM. Cost-effectiveness of diagnostic strategies for evaluation of suspected subarachnoid hemorrhage in the emergency department: Cost-effectiveness of diagnosing SAH. Academic Emergency Medicine . 2012 Oct;19[10]:1134–44.

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