This Article Full Text Full Text (PDF) All Versions of this Article: 39/4/1392    most recent STROKEAHA.107.503151v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Savitz, S. I. Articles by Edlow, J. Search for Related Content PubMed PubMed Citation Articles by Savitz, S. I. Articles by Edlow, J. Pubmed/NCBI databases Medline Plus Health Information CT Scans Headache Related Collections CT and MRI

(Stroke. 2008;39:1392.)
© 2008 American Heart Association, Inc.

Controversies in Stroke

Thunderclap Headache With Normal CT and Lumbar Puncture

Further Investigations Are Unnecessary: For

Sean I. Savitz, MD Jonathan Edlow, MD

From the Department of Neurology (S.I.S.), University of Texas Houston Medical School, Houston, Tex and Department of Emergency Medicine (J.E.), Beth Israel Deaconess Medical Center, Boston, Mass.

Correspondence to Sean I. Savitz, University of Texas Houston Medical School, Department of Neurology, 6431 Fannin Street, Houston, TX 77030. E-mail sean.i.savitz@uth.tmc.edu

Stephen M. Davis MD, FRACP Geoffrey A. Donnan MD, FRACP Section Editors:

Key Words: CT • headaches

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Thunderclap headache (sudden and severe headache, maximum in intensity at onset) should raise concern for several life-threatening conditions, including subarachnoid hemorrhage (SAH). The traditional work-up for SAH is a noncontrast head CT followed by a lumbar puncture (LP) if the CT shows no apparent diagnosis. Patients with thunderclap headache and a normal examination, CT and cerebrospinal fluid analysis do not require angiography or other studies to exclude SAH.

Several cases^1–3 suggest otherwise and have reported patients with thunderclap headache and normal CT and LP results who are subsequently found to have aneurysms on digital subtraction angiography. These reports raise the point that some aneurysms cause headache by expansion, dissection or thrombosis and that angiography is important even after a negative standard work-up out of concern for incipient aneurysmal rupture.

However, headache is a very common symptom and aneurysms detected on angiography do not necessarily imply that they are symptomatic. Approximately 2% to 6% of the general population harbors asymptomatic aneurysms. Therefore, another interpretation is that these cases detected incidental aneurysms in patients with thunderclap headache. Other conditions may have explained the clinical features. For example, in one report,¹ angiography also found diffuse cerebral vasospasm which suggests a cerebral vasoconstriction syndrome such as Call-Flemming. A different case reported throat and shoulder pain which unlikely would be explained by their finding of a 7-mm middle cerebral artery aneurysm.² In yet another case, surgical exploration during aneuysmal clipping found no evidence for hemorrhage.³

In support of our interpretation, 6 different consecutive, longitudinal case . . . [Full Text of this Article]