When is the last time you LP'd somebody specifically looking for occult SAH after negative CT (taking all comers, not just <6 hrs post onset)? I order a lot less CTs on non traumatic headaches than I used to (I think this is d/t experience and more comfort with H&P) but still I can't remember the last time I tapped somebody looking for SAH and want to get a feel on the trends. FTR I am pretty confident my partners also rarely/never do this.
Last time you LP'd to look for SAH?
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I know at least one encounter at my hospital in the past year or two that was essentially a negative CT, positive LP. Ended up getting d/c'ed home bc it was thought to be a 'traumatic tap.' Came back with a bad outcome with a rebleed...
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I do a lot more than I would like, but it's ritual at my shop. We even had one case where the CT, CT angiogram, and LP were all negative, but the person returned with a massage SAH. CT angiograms can miss aneurysms because of vasospasm. Even with a negative CT angiogram in the setting of a positive LP, we often admit them for observation. I'm at a comprehensive stroke center that does a lot of aneurysm repairs. So I may be tainted, and I will say that my LP numbers have increased since we started repairing aneurysms.
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I'm glad someone posted this thread. I was thinking about this lately - as I had a case where a lady was a bounceback headache who was being seen by an MLP who refused the CT/LP pathway both to the MLP and to me (once I suggested it to her).
I state very clearly in my ROS (verbatim): "Care was taken during H&P to elicit signs/symptoms to suggest SAH or other more serious etiology of headache; but patient denies any sudden-onset "thunderclap" headache, "worst headache of life", or family history of aneurysm." I write a rather descriptive head and neck exam, as well.
People just don't like to be LP'ed here.
I state very clearly in my ROS (verbatim): "Care was taken during H&P to elicit signs/symptoms to suggest SAH or other more serious etiology of headache; but patient denies any sudden-onset "thunderclap" headache, "worst headache of life", or family history of aneurysm." I write a rather descriptive head and neck exam, as well.
People just don't like to be LP'ed here.
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I offer it a lot in cases where it may be necessary. Haven't had one person consent for evaluation of either SAH or meningitis in at least a year.
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Do you make them sign out AMA or sign refusal of procedure form, or just document you discussed and dc?
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In 9 years, I've never had a negative CTH, positive LP that was a SAH.
I have "shared decision making" conversations with patients after the CTH. It's been about 3 years since any patient was willing to undergo the LP.
I have "shared decision making" conversations with patients after the CTH. It's been about 3 years since any patient was willing to undergo the LP.
D
deleted547339
I had one I admitted recently. Neg CT. Clearly traumatic tap. Hedge read on CTA. Went to the OR with nsgy for a angio....
Ended up being negative, but had a great story.
Ended up being negative, but had a great story.
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I probably do one every other month. I've never found a CT-occult SAH. The problem is that while I think the studies on CT-only SAH rule out are encouraging, all the CTs were read by neuroradiology attendings. At my shop, we only have residents overnight, and the attending over-read rate is unacceptably high. On top of that, I don't trust that I'd be able to reach a patient in the event of an over-read or that the patient would come back (obviously this is location-specific).
Plus, I like LPs and don't think we do enough of them.
Plus, I like LPs and don't think we do enough of them.
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NNT= 700. I sure hope they become less common. I haven't done one in about 2 years. Whenever I'm contemplating it I'm usually able to talk the patient out of it.
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That number came to mind, but I couldn't quote it concretely. Glad you reaffirmed that my Aricept is working!!
Fox, I think most people don't like being LP'd. If I had a negative CT and CT angiogram, I certainly wouldn't want the LP. I would take my risk of a 1 in 10 or 20,000 chance of it being a very small aneurysm.
I never have a patient sign AMA. I just document that I had a clear discussion with them and usually get the nurse to witness and also document their refusal to have the LP performed.
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I haven't LP'd anyone for SAH since residency.
A tiny handful of LPs for meningitis/GB/eval ICP.
Just did an interview for EMN discussing the Sayer article. The numbers for SAH evaluation right now just stink. 2000 LPs to find 8 cases of blood + aneurysm? 15% procedural failure rate? Another 200+ indeterminate or false-positives? Everyone I've discussed the procedure with has always recoiled in horror faced with such a low-yield, painful, and time-consuming evaluation.
Hard to say the best current strategy. CT + CTA seems reasonable, but isn't well-described re: false-positives/true-positives compared with any sort of gold-standard. Also not cheap, can be a bit of extra radiation.
A tiny handful of LPs for meningitis/GB/eval ICP.
Just did an interview for EMN discussing the Sayer article. The numbers for SAH evaluation right now just stink. 2000 LPs to find 8 cases of blood + aneurysm? 15% procedural failure rate? Another 200+ indeterminate or false-positives? Everyone I've discussed the procedure with has always recoiled in horror faced with such a low-yield, painful, and time-consuming evaluation.
Hard to say the best current strategy. CT + CTA seems reasonable, but isn't well-described re: false-positives/true-positives compared with any sort of gold-standard. Also not cheap, can be a bit of extra radiation.
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For this I probably do one every 1-2 months if they have a good story. I've seen a high amount of meningitis cases in the past year at my new job though so my threshold has been generally fairly low for HA if they have any other concerning symptoms
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This diagnostic pathway is not as well described in the NSG literature. At least not by my review.
If the LP is positive, you need a CTA anyway.
The person has to have a really good story for me to bring up an LP.
If the LP is positive, you need a CTA anyway.
The person has to have a really good story for me to bring up an LP.
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If you are documenting all the reasons they don't need an LP, why are you recommending an LP?
maybe i didn't understand correctly?
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I just document it.
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For the lawyers
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Yeah, it was poorly worded on my part. When I don't recommend CT/LP, that's my script.
The patient encounter was more of an anecdote.
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i do shared decision, have the discussion regarding risk factors, offer it anyways and document if they want it or not.
Had one several months ago. Classic story, CT read as neg within 2 hours of onset. Pt refused the LP. Had high suspicion so convinced her to stay for CTA. 10mm aneurysm. Per rad read on CTA, "looking back at the noncontrast CT, minimal blood seen adjacent to aneurysm".
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You had a "classic story" though which I think most of us would consider doing LP and CTA in that case. The conundrum is what to do with all of these chronic migraine patients who come in every day, but TODAY is the worst headache of their life and "completely different" from their prior migraines. Of course every day they come in is the worst headache of their lives......
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thats's what i thought. thanks
Depends on if your a CT/LP doc or a CT/CTA. The CT/LP doc would have sent the pt home AMA or documented refusal. Regardless, I wouldn't want to deal with the fallout if the pt ended up having a bad outcome. The other point was the radiologist missed the bleed on the noncontrast CT. That doesn't give me much confidence in the reliability of a CT performed less than 6 hour from onset.
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Ive had 1 positive lps for sah and 2 positive for meningitis in the past 4 months. All with good stories, ive done 8 taps total during that time. Poor story and if i did order a ct, most likely not im not going tobtap. Marginal story depends on gesalt, return and discussion with the patient. I usualy offer it in these situations and they always refuse
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