Clinical Review

Lesson of the week: Lumbar puncture still has an important role in diagnosing subarachnoid haemorrhage

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7122.1598 (Published 13 December 1997) Cite this as: BMJ 1997;315:1598
  1. Jonathan Wasserberg, senior registrara (jwasserberg@compuserve.com),
  2. Philip Barlow, consultant neurosurgeona
  1. a Department of Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF
  1. Correspondence to: Mr Wasserberg
  • Accepted 26 August 1997

Introduction

An early diagnosis of subarachnoid haemorrhage is essential if patients are to undergo appropriate investigation and treatment. It is increasingly common for patients with suspected subarachnoid haemorrhage to initially undergo computed tomography. Although the procedure is sensitive and non-invasive, it does not detect every instance of subarachnoid haemorrhage. Lumbar puncture should be considered in patients who have an acute onset of headache and who are fully conscious but have a normal scan or when the hospital does not have access to a computed tomographic scanner. We report on two patients in whom an early diagnosis of subarachnoid haemorrhage was missed because they did not undergo lumbar puncture.

Case reports

Case 1—A 58 year old man had lost consciousness for one minute. On recovery he had a severe headache and bloodstained vomitus. He was admitted to hospital and given intramuscular opiates for pain relief. Haematemesis was provisionally diagnosed. His initial symptoms were attributed to possible alcohol withdrawal and treatment with diazepam was started. Two days later his headache had not improved. Subarachnoid haemorrhage was suspected, and he was booked in for a routine computed tomography, the earliest appointment being two days later. On the next day, however, he became unconscious and had a fixed, dilated …

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