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.

Study on Role of Computed Tomography in Diagnostic Workup of Headache at a Tertiary Care Hospital

To determine the etiology of headache in patients undergoing computed tomography (CT) scan of brain without having prior neurologic abnormality and to know the age incidence and the sex incidence of the headache. Methods: A prospective study of one year duration was carried out at tertiary care hospital from Aug 2018 to Aug 2019. It included 1250 patients who underwent brain CT for headache. CT findings of patients were recorded and analyzed. Results: These etiologies were sinusitis (8.8%), followed by tumor (6.8%), infarct (6.4%), hematoma (4.4%), encephalitis (3.8%), abscesses (3.2%) and hydrocephalus (1.2%). Headache is more common in females (55%). Most common age group affected is 40-60 years (37.2%). Conclusions: CT of brain has revealed in 65.1% of cases as normal and detected the various causes in rest of the cases.

Role of Computed Tomography in detecting the cause of Headache in Patients Admitted to a Tertiary Care Hospital in South Odisha

To determine the etiology of headache in patients undergoing computed tomography (CT) scan of brain both with or without neurologic abnormality in South Odisha. Methods: A prospective study of six months duration was carried out at the M. K. C. G Medical College & hospital. It included 200 patients who underwent a brain CT for headache. CT findings of patients were analyzed. Results: The total number of our patients was 200. These etiologies were stroke (15%), followed by tumor(11%),sinusitis(7.5%),trauma (7.5%), abscesses(5%) and encephalitis (4%). Conclusions: CT of brain has revealed in 62.5% of cases as normal and detected the various causes in rest of cases.

The use of brain CT Scan in craniocerebral trauma with Glasgow coma scale scores of 13 – 15 in Dr. Cipto Mangunkusumo Hospital 1999-2001.

There is still a controversy among the neurologists whether brain CT scan must be performed on the mild head trauma patients. This study was executed to find out the correlation between the brain CT scan image findings and its clinical impairment among the mild head trauma patients with Glasgow coma scale (GCS) score of 13 to 15. The study was a retrospective study by analyzing the uniform medical records of the head trauma patients hospitalized at the Neurology ward of Dr. Cipto Mangunkusumo Hospital within the period of 1999 to 2001. During that period 1,663 patients were hospitalized due to head trauma, and 1,166 of them (70.1 %) were suffered from mild head trauma patients with GCS score of 13-15. Among those with brain CT scan examinations (N: 271), the neurological abnormalities were found on 144 (53.1%) of patients, consisted of cerebral edema (11,4%), intracerebral hemorrhage (5.5%), epidural hemorrhage (16.2%), subdural hemorrhage (18.1%), subarachnoid hemorrhage (5.5%), and combination (13.8%). The further analysis showed that cranial nerves disturbance, amnesia, loss of conciousness for more than 10 minutes, and vomiting are significantly correlated to the brain CT scan abnormality. Combination of the above four clinical signs and symptoms have sensitivity of 90 % in predicting brain insults. This findings may be used as a simple set of clinical criteria for identifying mild head trauma patients who need undergo CT scan examination.

Intracranial Hemorrhage in Late Hemorrhagic Disease of the Newborn: Brain Computed Tomographic Findings / 대한소아신경학회지

PURPOSE: This study is to evaluate the Brain CT manifestations of late hemorrhagic disease of the newborn. METHODS: We evaluated 13 cases with late hemorrhagic disease of the newborn, for whom brain CT scans were performed. Clinical indications for brain CT scan were mental changes(n=5), vomiting(n=2), irritability(n=2), seizure(n=3), and lethargy(n=1). We analyzed the result of the brain CT findings with attention to anatomic locations of hemorrhage and characteristics of hemorrhagic manifestations. RESULTS: Only one patient in 13 patients was normal on brain CT scan, and 12 patients showed hemorrhagic lesions. Among 12 patients, 5 cases had single hemorrhagic lesion(3 subdural hemorrhages and 2 intracerebral hemorrhages, and 7 cases had multiple lesions, in which subdural hemorrhage and subarachnoid hemorrhage were common respectively. The other common brain CT findings except hemorrhagic lesion were the mass effects with ventricle compression(n=11), midline shifting(n=6), ventricular dilatation(n=7), and fluid-fluid levels in hemorrhagic lesion(n=9). CONCLUSION: The common intracranial hemorrhages of late hemorrhagic disease of the newborn were subdural and subarachnoid hemorrhages. The associated CT findings were mass effect and fluid-fluid levels. Intracranial hemorrhage in late hemorrhagic disease of newborn could massively occurr. Thus brain CT scan should be done if any symptom for neurologic abnormality was present.

The Role of ELISA in Prediction of the Prognosis after Treatment of Neurocysticercosis

The diagnosis of neurocysticercosis is relatively easy with brain computed tomo-grarhy(CT) and/or magnetic resonance imaging(MRI) and ELISA test of serum and cerebrospinal fluid(CSF). The clinical manifestation of the disease are varied and correlated with the infection sites. The use of praziquantel and/or surgical excision are effective in treatment of the disease. The effect of treatment has been evaluated with imaging studies and changes of clinical manifestation. The authors reviewed 97 neurocysticercosis patients to evaluate the prognostic predictability of serum and CSF ELISA titers after treatment . We classified the patients into two groups. Rebound group was patients which showed higher ELISA titers after praziquantel medication than pretreatment. The responses to treatment were evaluated with the changes on brain CT or MRI. The Initial ELISA titers were lower in rebound group than those of nonrebound group, but three month after treatment, rebound group showed higher titers. The changes of ELISA titers in rebound group were greater in CSF than those in serum. The reduction of cyst on brain CT or MRI was more remarkable in rebound group than in nonrebound group and the prognosis of rebound group was better. Changes of ELISA titers was valuable in predicting the effect of treatment and prognosis.

Delayed Traumatic Intracranial Lesion

A retrospective analysis of 33 cases with operated delayed intracranial lesion who were admitted to EU1 Ji General Hospital from January 1990 to December 1992 was made according to their age and sex, etiology, lesion site, time interval to finding delayed intracrainal lesion, brain CT findings, relationship of GCS in initial and delayed lesion, associated injuries, treatment and prognosis(GOS). The results were follows : 1) The young males on first to second decade were most frequently affected. 2) The most common caused was pedestrian accident by motor vehicle, followed by fall down. 3) The most common associated injury was skull fracture, followed by skeletal injury of extremity. 4) The most common delayed intracranial lesion was delayed epidural hematoma on youth. 5) The most frequent time interval when the delayed intracranial lesion may be occurred was from 12 hr to 24 hr after admission. 6) The most possible intial lesion which the delayed epidural hematoma may be occurred was scanty hematoma with pnumocephalus or CSF leakage. 7) The GOS(Glasgow Outcome Scale) of analysed 33cases were good in 60% and poor in 40%, i.e good recovery(42%), moderate disability(18%), severe disability(15 %), vegetative state(12%), death(12%).

Clinical Analysis of Traumatic Intracerebral Hemorrhage

This retrospective analysis shows 87 patients who were admitted to our department of neurosurgery due to traumatic intracerebral hemorrhage(TICH) from June, 1990 to May, 1992. Our analyses were performed according to the patients's age, sex, operation, initial GCS, serum glucose level, platelet counts, mean arterial blood pressure, srterial CO2 and O2 level. Follow-up CT scans were performed post-operatively 1 day, and 2 weeks after the operation and in the cases that newly neurologic deficit were developed or developed or patients were not improved neurologically. The TICHs were located mainly on the frontal and/or temporal lobe(74%), and increased after craniotomy(68.6%). Other risk factors increasing the hematoma volume were poor neurologic status(GCS, or = 45 mmHg) level. The remaining factors, such as serum glucose level, number of platelets and mean arterial blood pressure did not influence the change of intracerebral hemorrhage.

Non-Operative Management of 20 Extradural Hematomas

The authors presented an analysis non-operative management on 20 epidural hematomas(EDH's) management who had been admitted from June, 1986. to May, 1988. The results were summarized as follows: 1) A number of EDH patients(17/20) with neurologically minor deficits could be successfully managed by conservative management, whereas we underwent surgical evacuation on 3 other cases with clot volume over 50cc. 2) Serial Brain CT scans on 20 patients revealed mostly two types of resolution pattern: One with an intervening expansile phase preceding net resorption(5 cases; 25%), and the other without this phase(15 cases; 75%). 3) All of patients presented mild symptoms and signs(Glasgow Coma Score>13). However, the common complaints were headache and vomiting. 4) The mean period from admission to discharge was 5.6 weeks, and the mean number of followup CT scan was 4.2 times.

Gas Containing Brain Abscesses(Case Report)

Most of the reported cases of pneumocephalus are related to head trauma but gas containing brain abscess is a rare condition. Three cases of intra parenchymal gas containing brain abscesses have recently been experienced. All of three cases were otogenic origin, but causative organisms could not be found in bacteriological studies. Two cases were improved by pus drainage and total extirpation of abscess cavity with administration of broad spectrum antibiotics, but one case died suddenly during initial stage of brain abscess formation.

Clinical Study of Intracranial Meningioma

To provide a guideline of accurate diagnosis and proper methods of treatment of meningioma, the most common benign intracranial tumor, the author studied 57 cases of meningioma who had been diagnosed and operated at the Department of Neurosurgery, Inje Medical College, Paik Hospital, Pusan from July, 1983 to June, 1988. The results were as followings. 1) The ratio of male to female was 1 to 2.2 and 31.6% of the 57 patients were in the 5 th decade of age and 29.8% in the 6 th decade. 2) The predilection sites were parasagittal and falx(33.3%), convexity(26.3%) and sphenoid ridge (21.1%) areas. The most frequent histological type was meningotheliomatous type(47.4%) which was followed by transitional(15.8%) and fibroblastic(10.5%) type. 3) The common initial clinical features were headache(29.3%), visual disturbance(24.6%), seizure(22.8%) and motor weakness(10.5%). In radiologic diagnostic tests, there were abnormal findings in 47.4% on plain skull X-ray, the possibility of diagnosis as the meningioma was 91.2% by means of brain CT scan only, which was regarded as the most accurate and safe method. 4) The extent of operation were total(84.2%), subtotoal(12.3%) and partial(3.5%) removal, The surgical outcome were excellent(49.1%) and good(29.8%). 5) The preoperative embolization of feeding artery was effective to reduce the operative bleeding, and the CO2 laser was thought to be effective surgical tool to remove the meningioma, with its unique properties of non-mechanical bloodless evaporation of tumor and minimalizing of brain edema.

Outcome Following Severe Head Injuries in Children

Accidents cause more than half of all childhood deaths, despite early diagnosis and proper treatment. It has showed still high mortality and morbidity. We analyzed the results of treatment of 50 severely head injured children who were admitted to the department of neurosurgery. Wonkwang University Hospital from January, 1984 to March, 1988 and evaluated prognostic factors affecting the outcome. Our conclusions are as follow: 1) We experienced the high mortality in children no more than five years of age. 2) The Glasgow coma scale on admission was a reliable indicator predicting the outcome in severe head injury. 3) The neurological features such as papillary light reflex, oculocephalic reflex and motor respons were good indicators of outcome. 4) Therer was no significant difference in outcome between diffuse brain injury and intracranial mass lesion. 5) The diffuse brain swelling on brain CT scan worsened the outcome. 6) The mortality rate increased in children associated with viscus rupture in head inujury. 7) The overall outcome showed 38% of good recovery, 20% of moderate disability, 10% of severe disability, 4% of vegetative state, and 28% of death.

Delayed Traumatic Cerebral Infarction(Case Reports)

Delayed traumatic cerebral infarction appears to occur more frequently than previously expected. We have experienced two cases of this clinical entity whose initial neurological condition were good except headache and/or mental confusion. However, their initial Brain CT scans showed no specific abnormalities. The detailed neurological examination and follow up Brain CT scans were prerequisite choices of strategy against this type of lesion. However, additional studies regarding intracranial pressure(ICP), cerebral blood flow(CBF), multimodality evoked potential(MMEP) and magnetic resonance imaging(MRI) should be considered as an alternative armamentarium for further elucidation of vascular insults to already injured brain.

Correlation Between Tumorous CT Finding and Histology in 41 Patients with CT - Guided Stereotactic Biopsy

CT guided stereotactic biopsies were carried out in 41 patients with tumorous CT findings during past 2 years. In 27 tumorous CT conditions impressed glioma, meningioma, metastatic ca, chondroma, germinoma and craniopharyngioma, 16 cases were disclosed correctly in preoperative cinicalradiological diagnosis comparing with pathological diagnosis confirmed by means of stereotactic biopsy, but other 11 cases, showed the preoperative diagnostic error which pathological diagnosis were infarction, cryptical AVM, abscess, granuloma, and tumors such ad lymphoma, oligodendroglioma, GBM, chordoma. Among 12 granulomatous CT lesions 3 cases showed preoperative diagnostic error, which were, confirmed infarction, multiple sclerosis by pathological diagnosis. The pathological findings of 2 vascular lesions that were impressed as infarction and old hematoma were confirmed as granuloma and GBM. The error of preoperative clinical - CT diagnosis was 39% of total 41 patients. The advantage of preoperative stereotactic biopsy is to confirm the correct histological diagnosis, while it can help the patient and surgeon for the planning of further proper therapy.

Primary Malignant Lymphoma of the Brain

The authors have studied six patients with histologically proven primary malignant lymphoma of the brain which is still a rare primary brain tumor. The clinical, radiological and pathological findings with results of the treatment are presented. All cases showed a good response to radiation therapy. Therefore, the early diagnosis by computerized tomography scan followed by biopsy or excision is considered to be very important for the BEST results in the treatment. Related reports are discussed briefly.

Clinical Study of Normal Pressure Hydrocephalus

Since the discovery of CT scan for brain, the detection of hydrocephalus became easier than before. Of those hydrocephalus, non-parenchymatous in origin, in order words, normal pressure hydrocephalus can be differentiated by RISA cisternography. The etiology, symptomatology and surgical outcome of 16 cases of normal pressure hydrocephalus were presented. Followings are the results. 1) All of the cases revealed ventriculomegaly in brain CT scan and prolonged ventricular retention of dye in RISA cisternogram. 2) Ventriculoperitoneal shunt was done on all of the patients and outcome was excellent:3, good:6, fair:3 and poor:4. 3) It is thought that the prognosis is much related duration of clinical manifestation; the earlier surgery, the better outcome.

CT Guided Stereotaxic Biopsy for the Differential Diagnosis of Brain Lesions

Some intracranial masses are usually treated following a presumptive diagnosis based on the clinical picture and neurological studies but in some instances a proven histological diagnosis might alter the method of treatment as well as affect the prognosis. Open surgical biopsy however might cause serious neurological deficit in many of these patients however a stereotaxic approach might avoid such problems. For the correct three dimensional target localization on CT scan we developed nearly artifact free simplified CT interface frame that accurately interface between the CT scanner and the stereotasic instrument makes it possible to take biopsies at exact and with low risk. In 10 patients CT interfaced stereotaxic biopsy of brain lesions were performed. 100% accurate histological diagnosis was obtained and helped considerably in planning further therapy. The localization error was less than 0.04mm and no significant complications occured in these patients.

Clinical Analysis of Metastatic Brain Tumors

The author analyzed 153 cases of metastatic brain tumors, including diagnostic and therapeutic aspects, who had been admitted to Yonsei University College of Medicine and Jeonju Presbyterian Medical Center from January, 1976 to August, 1983. Results obtained are as follows: 1) Metastatic brain tumors constituted 16.5% of all brain tumors. 2) The majority of patients was in the age range of 41 to 60 years. 3) The most common primary tumor with brain metastasis was lung carcinoma(45.1%). 4) Headache was the single most common presenting symptom of cerebral metastasis. 5) The most frequent intracranial locations of metastatic brain tumors were parietal and frontal lobe. 6) The computed tomographic scan has become the single most valuable and accurate diagnostic tool for investigation of metastatic brain tumor. It was also important study in evaluating the effect of treatment. Multiplicity of lesions was an important diagnostic feature. Also densely enhancing, and homogeneous cortical mass surrounded by edema with finger-like projections was a common characteristic feature. 7) Combined therapy-surgical excision followed by whole brain radiotherapy and/or chemotherapy-had been shown to result in better prognosis than either modality alone. The 6 months survival rate of combined therapy was 66.7% and it was more efficient in prolonging the patient's quality of life than the other methods currently available. In some instances, admittedly rare, long-term survival could be achieved. When the metastatic mass was producing wevere neurological disability because of its location, and the prognosis was otherwise reasonable, significant palliation and improvement in the patient's neurological status could be secured by surgical removal.

Clinical Analysis of Treatment of Chronic Subdural Hematoma

The authors analyzed 103 cases of chronic subdural hematoma(SDH) treated in the department of Neurosurgery, Yonsei University Hospital from January 1976 to September 1983. All of the cases were operated on except a single case, which was treated conservatively. The results of the analysis are summarized as follows: 1) The chronic SDH occurred most frequently in the 5th decade, and 71.8% of the patients were older than their 4th decade. The chronic SDH were far more common in men(84.5%) than women(15.5%). 2) Seventy two patients(79.6%) had a history of previous head injury. Chronic alcoholism was noted in thirteen patients(12.6%). 3) Presenting symptoms and signs in decreasing order were headache(76.9%), motor weakness(44.7%), mental disturbance(43.7%), papilledema(42.7%), and vomiting(35%). 4) Brain CT scan was not only the most accurate diagnostic procedure but also important for planning operative intervention as well as evaluating the prognosis. Four patterns of CT densities were noted in chronic SDH;hypodense(43.3%), isodense(37.8%), hyperdense(13.5%), and mixed density(5.4%). Cerebral expansion rates decreased with age, which was less than 80% in patients over their 40s. The chronic SDH was found on the right side in 45.6% of cases and 41.8% on the left, while 12.6% of chronic SDH were bilateral. 5) Operative procedures in 102 cases, were as follows; 32 Simple burr hole closed drainage, 31 Simple burr hole open drainage, 31 craniotomy and membranectomy, and 10 craniectomy and membranectomy. In conclusion, simple burr hole closed system drainage is the most effective and the least invasive procedure for the treatment of chronic SDH. Membranectomy with craniotomy or craniectomy should be reserved for such cases as recollection of SDH, failure of brain expansion, solid hematoma, and extensive swelling of the white matter subjacent to the hematoma.

Clinical Observation, of Chronic Subdural Hematomas (Burr hole, Drainage and Craniotomy, Membranectomy)

The authors have presented 44 cases of chronic subdural hematoma which were diagnosed by brain computerized tomographic (CT) scan at the Department of Neurosugery, Keimyung University, School of Medicine from May 1980 to July 1982. There were 42 men and 2 women. The common incidence of age was between fourth and fifth decade. Most of the cases(80%) had a history of head injury and nearly all cases complained headache(93%). The most common sign was papilledema(71%) in relatively young age patients and mental change(62%) in old age patients. All cases performed brain CT scan, which showed hypodense(41%), isodense(21%), hyperdense(21%) and mixed dense(18%) lesion. The thickness of hematoma which was measured by brain CT scan revealed 10 mm-30mm in most cases and showed the tendency of increase in old age patients. Of 44 cases, 23 cases were treated with craniotomy and membranectomy, 18 cases with burr hole and drainage, and 3 cases which were bilateral lesion with both methods. There was not any different result in both methods and most of all cases showed good postoperative course except 3 cases of poor preoperative state.