蛛网膜下腔出血(SAH)和穿刺损伤出血(Traumatic LP,TLP)的鉴别
李子孝
首都医科大学北京天坛医院神经内科
Shah KH, Edlow JA (2002). Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J Emerg Med 23, 67-74.
CT在SAH的24h内有95%的敏感性,随着间隔时间的延长敏感性下降,1周后降至50%(注意患者的血常规,是否贫血)
CT阴性结果,推荐行腰穿检查
穿刺的时间影响CSF结果
红细胞至黄变受到出血量和分析的方法
Uncal or tonsillar herniation Reversible tonsillar descent Spinal coning in patients with rostral subarachnoid block Postdural puncture headache Cranial neuropathies Nerve root irritation, herniation, and transection Low back pain Implantation of epidermal tumors Infections plications Intracranial bleeding Traumatic lumbar puncture Spinal hematomas plications Vasovagal syncope Cardiac arrest Seizures Subarachnoid cyst Low pressure state in children with ventriculoperitoneal (V-P) shunt Pseudo-pseudotumor cerebri (incorrect measurement of opening pressure) Incorrect lab analysis of cerebrospinal fluid
穿刺损伤发生率10%-20%
SAH与穿刺损伤出血(TLP)误诊后果:
SAH误诊为TLP使致残率和致死率↑
TLP误诊为SAH可能进一步行不必要的DSA(正常人中1-2%存在动脉瘤),可能采取不必要的外科干预
区分SAH和TLP要点
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