Aneurysmal Subarachnoid Hemorrhage
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The article by Dr. Suarez and colleagues (Jan. 26 issue)1 includes the statement that "a good-quality head CT scan will reveal subarachnoid hemorrhage in 100 percent of cases within 12 hours after the onset of symptoms and in more than 93 percent of cases within 24 hours." One of us was a coauthor of the study cited in support of this statement,2 and we believe its findings were misrepresented. Although their study certainly supports this observation, its authors did not analyze or report sensitivity within 12 hours. We are not aware of data supporting a 100 percent sensitivity for any CT scanning within 12 hours.
Although the algorithm of the authors clearly indicates the need for lumbar puncture after a negative CT scan, the sentence quoted above could be misinterpreted to mean that further testing (lumbar puncture, CT angiography, or cerebral angiography) is not indicated after a negative CT scan within 12 hours after the onset of symptoms.
Alan B. Storrow, M.D.
Keith Wrenn, M.D.
Vanderbilt University Medical Center
Nashville, TN 37232-4700
alan.storrow@vanderbilt.edu
References
Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med 2006;354:387-396.
Sames TA, Storrow AB, Finkelstein JA, Magoon MR. Sensitivity of new-generation computed tomography in subarachnoid hemorrhage. Acad Emerg Med 1996;3:16-20.
To the Editor: In their review on aneurysmal subarachnoid hemorrhage, Suarez et al. recommend several diagnostic and treatment procedures that are not in accordance with current evidence. On the basis of data from a retrospective study,1 the authors conclude that a good-quality CT scan within 12 hours will reveal subarachnoid hemorrhage in 100 percent of cases. However, such a statement might lead readers not to perform a diagnostic lumbar puncture. A prospective study clearly demonstrated that 2 percent of cases will be missed by relying on a CT scan only.2 The authors also recommend the four-tube method for the red-cell count to differentiate between a traumatic tap and a subarachnoid hemorrhage, but this test has proved to be obsolete.3
Koen de Gans, M.D.
Mervyn D. Vergouwen, M.D.
Yvo B. Roos, M.D., Ph.D.
Academic Medical Center
1105 AZ Amsterdam, the Netherlands
k.degans@amc.uva.nl
References
Sidman R, Connolly E, Lemke T. Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal. Acad Emerg Med 1996;3:827-831.
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? J Neurol Neurosurg Psychiatry 1995;58:357-359.
Buruma OJ, Janson HL, Den Bergh FA, Bots GT. Blood-stained cerebrospinal fluid: traumatic puncture or haemorrhage? J Neurol Neurosurg Psychiatry 1981;44:144-147.
To the Editor: Recent studies1,2 have shown that dysfunction of the hypothalamic–pituitary axis is common after subarachnoid hemorrhage, with corticotropin deficiencies occurring in 2.5 to 40 percent and growth hormone deficiency occurring in 20 to 25 percent of subjects tested 3 to 66 months after subarachnoid hemorrhage. Untreated corticotropin and growth hormone deficiency have important implications3 that may hinder recovery from subarachnoid hemorrhage.
The case of a patient we encountered who had hyponatremia (plasma sodium level, 122 mmol per liter) and hypotension that developed six days after subarachnoid hemorrhage illustrates the clinical significance of post-aneurysmal hypopituitarism. The serum cortisol level was less than 5 μg per deciliter, and corticotropin was undetectable despite acute illness and hypotension. Treating the acute corticotropin deficiency with intravenous hydrocortisone resulted in rapid normalization of blood pressure and the plasma sodium concentration. Hypopituitarism is an underdiagnosed cause of complications after subarachnoid hemorrhage that must be recognized and treated.
Mark Sherlock, M.B.
Amar Agha, M.D.
Christopher J. Thompson, M.D.
Beaumont Hospital
Dublin D9, Ireland
Dr. Sherlock reports having received research support from Pfizer; and Drs. Agha and Thompson, research support from Pfizer and Novo Nordisk.
References
Aimaretti G, Ambrosio MR, Di Somma C, et al. Traumatic brain injury and subarachnoid haemorrhage are conditions at high risk for hypopituitarism: screening study at 3 months after the brain injury. Clin Endocrinol (Oxf) 2004;61:320-326.
Kreitschmann-Andermahr I, Hoff C, Saller B, et al. Prevalence of pituitary deficiency in patients after aneurysmal subarachnoid hemorrhage. J Clin Endocrinol Metab 2004;89:4986-4992.
Vance ML. Hypopituitarism. N Engl J Med 1994;330:1651-1662.
To the Editor: In their review article on aneurysmal subarachnoid hemorrhage, Suarez et al. mention hyponatremia as a possible complication, but they do not mention pituitary dysfunction. Diabetes insipidus has been reported in patients after the clipping of an anterior communicating aneurysm with or without previous hemorrhage.1,2 Such patients frequently have hypodipsia or adipsia as a result of damage to the hypothalamic osmoreceptors and are at risk for life-threatening hypernatremia, since increasing their fluid intake does not compensate for the polyuria caused by diabetes insipidus. Timely recognition of this complication is critical and should lead to therapy with desmopressin, a prescription for scheduled fluid intake, and close monitoring of the volume and electrolyte status to maintain euvolemia.
In addition, anterior hypopituitarism has been detected in varying degrees in 47 to 55 percent of patients who survive aneurysmal subarachnoid hemorrhage.3,4 Evaluation of anterior pituitary function followed by replacement therapy as appropriate should be performed routinely to minimize excess morbidity and mortality associated with hypopituitarism.
Nicholas A. Tritos, M.D., D.Sc.
Lahey Clinic Medical Center
Burlington, MA 01805
nicholas.a.tritos@lahey.org
References
McIver B, Connacher A, Whittle I, Baylis P, Thompson C. Adipsic hypothalamic diabetes insipidus after clipping of anterior communicating artery aneurysm. BMJ 1991;303:1465-1467.
Nguyen BN, Yablon SA, Chen CY. Hypodipsic hypernatremia and diabetes insipidus following anterior communicating artery aneurysm clipping: diagnostic and therapeutic challenges in the amnestic rehabilitation patient. Brain Inj 2001;15:975-980.
Dimopoulou I, Kouyialis AT, Tzanella M, et al. High incidence of neuroendocrine dysfunction in long-term survivors of aneurysmal subarachnoid hemorrhage. Stroke 2004;35:2884-2889.
Kreitschmann-Andermahr I, Hoff C, Saller B, et al. Prevalence of pituitary deficiency in patients after aneurysmal subarachnoid hemorrhage. J Clin Endocrinol Metab 2004;89:4986-4992.
The authors reply: Two of these letters question the sensitivity that we cited for the CT scan of the head for the diagnosis of subarachnoid hemorrhage. We agree with Storrow and Wrenn that their study did not address head CT-scan sensitivity within 12 hours after the onset of symptoms.1 Rather, Sidman et al.2 reported that a head CT scan performed within 12 hours after presentation would detect subarachnoid hemorrhage in all patients. We apologize for this misrepresentation.
Storrow and Wrenn, as well as de Gans et al., also argue that our interpretation of the sensitivity of the head CT scan might lead readers to believe that no further testing would be needed to complete the diagnostic investigation. We disagree. As clearly stated in our diagnostic algorithm and in the text of our article, we recommend that in the presence of a history suggestive of typical or atypical subarachnoid hemorrhage, all patients with a normal head CT scan should undergo a lumbar puncture. We have also indicated that cerebrospinal fluid findings that are suggestive of subarachnoid hemorrhage include elevated opening pressure, xanthochromia, and an elevated red-cell count that does not diminish from tube 1 to tube 4. Practitioners should carefully determine the presence or absence of all these abnormalities in light of the clinical presentation before deciding on further diagnostic testing.
We disagree with de Gans et al. with respect to the four-tube method. This test can still be useful within the first few hours after subarachnoid hemorrhage, when xanthochromia has not yet developed.
We thank Sherlock et al. and Tritos for pointing out the importance of dysfunction of the hypothalamic–pituitary axis in patients after subarachnoid hemorrhage. We agree that recognizing and treating endocrinologic abnormalities may be important. As we mentioned in the text, virtually every patient has medical complications, which may be severe in 40 percent of cases. Such complications include hypopituitarism. Because of space limitations, we commented on the most common medical issues only.
Jose I. Suarez, M.D.
Robert W. Tarr, M.D.
Warren R. Selman, M.D.
University Hospitals of Cleveland
Cleveland, OH 44106
jose.suarez@uhhs.com
References
Sames TA, Storrow AB, Finkelstein JA, Magoon MR. Sensitivity of new-generation computed tomography in subarachnoid hemorrhage. Acad Emerg Med 1996;3:16-20.
Sidman R, Connolly E, Lemke T. Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal. Acad Emerg Med 1996;3:827-831.
Although the algorithm of the authors clearly indicates the need for lumbar puncture after a negative CT scan, the sentence quoted above could be misinterpreted to mean that further testing (lumbar puncture, CT angiography, or cerebral angiography) is not indicated after a negative CT scan within 12 hours after the onset of symptoms.
Alan B. Storrow, M.D.
Keith Wrenn, M.D.
Vanderbilt University Medical Center
Nashville, TN 37232-4700
alan.storrow@vanderbilt.edu
References
Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med 2006;354:387-396.
Sames TA, Storrow AB, Finkelstein JA, Magoon MR. Sensitivity of new-generation computed tomography in subarachnoid hemorrhage. Acad Emerg Med 1996;3:16-20.
To the Editor: In their review on aneurysmal subarachnoid hemorrhage, Suarez et al. recommend several diagnostic and treatment procedures that are not in accordance with current evidence. On the basis of data from a retrospective study,1 the authors conclude that a good-quality CT scan within 12 hours will reveal subarachnoid hemorrhage in 100 percent of cases. However, such a statement might lead readers not to perform a diagnostic lumbar puncture. A prospective study clearly demonstrated that 2 percent of cases will be missed by relying on a CT scan only.2 The authors also recommend the four-tube method for the red-cell count to differentiate between a traumatic tap and a subarachnoid hemorrhage, but this test has proved to be obsolete.3
Koen de Gans, M.D.
Mervyn D. Vergouwen, M.D.
Yvo B. Roos, M.D., Ph.D.
Academic Medical Center
1105 AZ Amsterdam, the Netherlands
k.degans@amc.uva.nl
References
Sidman R, Connolly E, Lemke T. Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal. Acad Emerg Med 1996;3:827-831.
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? J Neurol Neurosurg Psychiatry 1995;58:357-359.
Buruma OJ, Janson HL, Den Bergh FA, Bots GT. Blood-stained cerebrospinal fluid: traumatic puncture or haemorrhage? J Neurol Neurosurg Psychiatry 1981;44:144-147.
To the Editor: Recent studies1,2 have shown that dysfunction of the hypothalamic–pituitary axis is common after subarachnoid hemorrhage, with corticotropin deficiencies occurring in 2.5 to 40 percent and growth hormone deficiency occurring in 20 to 25 percent of subjects tested 3 to 66 months after subarachnoid hemorrhage. Untreated corticotropin and growth hormone deficiency have important implications3 that may hinder recovery from subarachnoid hemorrhage.
The case of a patient we encountered who had hyponatremia (plasma sodium level, 122 mmol per liter) and hypotension that developed six days after subarachnoid hemorrhage illustrates the clinical significance of post-aneurysmal hypopituitarism. The serum cortisol level was less than 5 μg per deciliter, and corticotropin was undetectable despite acute illness and hypotension. Treating the acute corticotropin deficiency with intravenous hydrocortisone resulted in rapid normalization of blood pressure and the plasma sodium concentration. Hypopituitarism is an underdiagnosed cause of complications after subarachnoid hemorrhage that must be recognized and treated.
Mark Sherlock, M.B.
Amar Agha, M.D.
Christopher J. Thompson, M.D.
Beaumont Hospital
Dublin D9, Ireland
Dr. Sherlock reports having received research support from Pfizer; and Drs. Agha and Thompson, research support from Pfizer and Novo Nordisk.
References
Aimaretti G, Ambrosio MR, Di Somma C, et al. Traumatic brain injury and subarachnoid haemorrhage are conditions at high risk for hypopituitarism: screening study at 3 months after the brain injury. Clin Endocrinol (Oxf) 2004;61:320-326.
Kreitschmann-Andermahr I, Hoff C, Saller B, et al. Prevalence of pituitary deficiency in patients after aneurysmal subarachnoid hemorrhage. J Clin Endocrinol Metab 2004;89:4986-4992.
Vance ML. Hypopituitarism. N Engl J Med 1994;330:1651-1662.
To the Editor: In their review article on aneurysmal subarachnoid hemorrhage, Suarez et al. mention hyponatremia as a possible complication, but they do not mention pituitary dysfunction. Diabetes insipidus has been reported in patients after the clipping of an anterior communicating aneurysm with or without previous hemorrhage.1,2 Such patients frequently have hypodipsia or adipsia as a result of damage to the hypothalamic osmoreceptors and are at risk for life-threatening hypernatremia, since increasing their fluid intake does not compensate for the polyuria caused by diabetes insipidus. Timely recognition of this complication is critical and should lead to therapy with desmopressin, a prescription for scheduled fluid intake, and close monitoring of the volume and electrolyte status to maintain euvolemia.
In addition, anterior hypopituitarism has been detected in varying degrees in 47 to 55 percent of patients who survive aneurysmal subarachnoid hemorrhage.3,4 Evaluation of anterior pituitary function followed by replacement therapy as appropriate should be performed routinely to minimize excess morbidity and mortality associated with hypopituitarism.
Nicholas A. Tritos, M.D., D.Sc.
Lahey Clinic Medical Center
Burlington, MA 01805
nicholas.a.tritos@lahey.org
References
McIver B, Connacher A, Whittle I, Baylis P, Thompson C. Adipsic hypothalamic diabetes insipidus after clipping of anterior communicating artery aneurysm. BMJ 1991;303:1465-1467.
Nguyen BN, Yablon SA, Chen CY. Hypodipsic hypernatremia and diabetes insipidus following anterior communicating artery aneurysm clipping: diagnostic and therapeutic challenges in the amnestic rehabilitation patient. Brain Inj 2001;15:975-980.
Dimopoulou I, Kouyialis AT, Tzanella M, et al. High incidence of neuroendocrine dysfunction in long-term survivors of aneurysmal subarachnoid hemorrhage. Stroke 2004;35:2884-2889.
Kreitschmann-Andermahr I, Hoff C, Saller B, et al. Prevalence of pituitary deficiency in patients after aneurysmal subarachnoid hemorrhage. J Clin Endocrinol Metab 2004;89:4986-4992.
The authors reply: Two of these letters question the sensitivity that we cited for the CT scan of the head for the diagnosis of subarachnoid hemorrhage. We agree with Storrow and Wrenn that their study did not address head CT-scan sensitivity within 12 hours after the onset of symptoms.1 Rather, Sidman et al.2 reported that a head CT scan performed within 12 hours after presentation would detect subarachnoid hemorrhage in all patients. We apologize for this misrepresentation.
Storrow and Wrenn, as well as de Gans et al., also argue that our interpretation of the sensitivity of the head CT scan might lead readers to believe that no further testing would be needed to complete the diagnostic investigation. We disagree. As clearly stated in our diagnostic algorithm and in the text of our article, we recommend that in the presence of a history suggestive of typical or atypical subarachnoid hemorrhage, all patients with a normal head CT scan should undergo a lumbar puncture. We have also indicated that cerebrospinal fluid findings that are suggestive of subarachnoid hemorrhage include elevated opening pressure, xanthochromia, and an elevated red-cell count that does not diminish from tube 1 to tube 4. Practitioners should carefully determine the presence or absence of all these abnormalities in light of the clinical presentation before deciding on further diagnostic testing.
We disagree with de Gans et al. with respect to the four-tube method. This test can still be useful within the first few hours after subarachnoid hemorrhage, when xanthochromia has not yet developed.
We thank Sherlock et al. and Tritos for pointing out the importance of dysfunction of the hypothalamic–pituitary axis in patients after subarachnoid hemorrhage. We agree that recognizing and treating endocrinologic abnormalities may be important. As we mentioned in the text, virtually every patient has medical complications, which may be severe in 40 percent of cases. Such complications include hypopituitarism. Because of space limitations, we commented on the most common medical issues only.
Jose I. Suarez, M.D.
Robert W. Tarr, M.D.
Warren R. Selman, M.D.
University Hospitals of Cleveland
Cleveland, OH 44106
jose.suarez@uhhs.com
References
Sames TA, Storrow AB, Finkelstein JA, Magoon MR. Sensitivity of new-generation computed tomography in subarachnoid hemorrhage. Acad Emerg Med 1996;3:16-20.
Sidman R, Connolly E, Lemke T. Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal. Acad Emerg Med 1996;3:827-831.