Systematic combined noncontrast CT–CT angiography in the management of unexplained nontraumatic coma

Esquevin, Aurore; Raoult, Hélène; Ferré, Jean–Christophe; Ronzière, Thomas; Stamm, Aymeric; Perennes, Mathieu; Bellou, Abdelouahab; Gauvrit, Jean‐Yves

doi:10.1016/j.ajem.2012.09.024

Cited by 8 publications

(9 citation statements)

References 44 publications

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“…[ 6 ] In our study group, the 2 nd most common diagnosis was intoxication ( Table 1 ). Concerning visual assessment of the HBAS on NECT our findings are similar to previous studies reporting a low sensitivity ranging from 57–71%[ 5 , 6 , 13 ] and a high specificity (71%-98%). [ 5 , 6 , 13 ] In screening for BAO, a high sensitivity is more important than a high specificity as missing the diagnosis would have dramatic consequences.…”

Section: Discussionsupporting

confidence: 90%

Sensitivity of Hyperdense Basilar Artery Sign on Non-Enhanced Computed Tomography

et al. 2015

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PurposeThe hyperdense basilar artery sign (HBAS) is an indicator of vessel occlusion on non contrast-enhanced computer tomography (NECT) in acute stroke patients. Since basilar artery occlusion (BAO) is associated with a high mortality and morbidity, its early detection is of great clinical value. We sought to analyze the influence of density measurement as well as a normalized ratio of Hounsfield unit/hematocrit (HU/Hct) ratio on the detection of BAO on NECT in patients with suspected BAO.Materials and Methods102 patients with clinically suspected BAO were examined with NECT followed immediately by Multidetector computed tomography Angiography. Two observers independently analyzed the images regarding the presence or absence of HBAS on NECT and performed HU measurements in the basilar artery. Receiver operating characteristic curve analysis was performed to determine the optimal density threshold for BAO using attenuation measurements or HU/Hct ratio.ResultsSensitivity of visual detection of the HBAS on NECT was relatively low 81% (95%-CI, 54–95%) while specificity was high 91% (95%-CI, 82–96%). The highest sensitivity was achieved by the combination of visual assessment and additional quantitative attenuation measurements applying a cut-off value of 46.5 HU with 94% sensitivity and 81% specificity for BAO. A HU/Hct ratio >1.32 revealed sensitivity of 88% (95%-CI, 60–98%) and specificity of 84% (95%-CI, 74–90%).ConclusionIn patients with clinically suspected acute BAO the combination of visual assessment and additional attenuation measurement with a cut-off value of 46.5 HU is a reliable approach with high sensitivity in the detection of BAO on NECT.

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Section: Discussionsupporting

confidence: 90%

Sensitivity of Hyperdense Basilar Artery Sign on Non-Enhanced Computed Tomography

et al. 2015

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“…Reported prevalence of structural coma varied between 28-64% and non-structural coma between 37-75% of patients presenting with non-traumatic coma [ 6 , 9 , 11 , 14 - 17 ]. Of note, Weiss et al only reported a structural coma prevalence of 9% (cerebrovascular accidents and infections of the central nervous system) [ 18 ].…”

Section: Resultsmentioning

confidence: 99%

“…This is due to the differences in hospital settings (academic versus urban and the differences in physical setting within the hospital), differences in location (Western world versus Africa) and differences in in- and exclusion criteria for causes of NTC. The latter is illustrated by the exclusion of patients with an intoxication as cause of NTC in some studies, while in other intoxications appeared to be a major contributor to NTC [ 6 , 9 , 12 , 14 , 15 , 17 - 19 ]. This explains the very low prevalence of drug intoxication and metabolic causes of coma in the SUPPORT cohort of Hamel et al Even so, within studies including intoxication as cause of NTC, there was a large difference in poisoned patients as a cause of NTC.…”

Section: Discussionmentioning

confidence: 99%

“…Inclusion criteria were retrospective or prospective observational studies on NTC. For the purpose of this review, NTC was defined as a GCS of 10 or less based on several studies included in this review [ 3 , 6 - 9 ]. Studies were selected if etiological data and/or prognostic data or mortality rates of patients presenting with NTC at the emergency department or ICU were provided.…”

Section: Methodsmentioning

confidence: 99%

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The etiology and outcome of non-traumatic coma in critical care: a systematic review

et al. 2015

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BackgroundNon-traumatic coma (NTC) is a serious condition requiring swift medical or surgical decision making upon arrival at the emergency department. Knowledge of the most frequent etiologies of NTC and associated mortality might improve the management of these patients. Here, we present the results of a systematic literature search on the etiologies and prognosis of NTC.MethodsTwo reviewers independently performed a systematic literature search in the Pubmed, Embase and Cochrane databases with subsequent reference and citation checking. Inclusion criteria were retrospective or prospective observational studies on NTC, which reported on etiologies and prognostic information of patients admitted to the emergency department or intensive care unit.ResultsEventually, 14 studies with enough data on NTC, were selected for this systematic literature review. The most common causes of NTC were stroke (6-54%), post-anoxic coma (3-42%), poisoning (<1-39%) and metabolic causes (1-29%). NTC was also often caused by infections, especially in African studies affecting 10-51% of patients. The NTC mortality rate ranged from 25 to 87% and the mortality rate continued to increase long after the event had occurred. Also, 5-25% of patients remained moderately-severely disabled or in permanent vegetative state. The mortality was highest for stroke (60-95%) and post-anoxic coma (54-89%) and lowest for poisoning (0-39%) and epilepsy (0-10%).ConclusionNTC represents a challenge to the emergency and the critical care physicians with an important mortality and moderate-severe disability rate. Even though, included studies were very heterogeneous, the most common causes of NTC are stroke, post anoxic, poisoning and various metabolic etiologies. The best outcome is achieved for patients with poisoning and epilepsy, while the worst outcome was seen in patients with stroke and post-anoxic coma. Adequate knowledge of the most common causes of NTC and prioritizing the causes by mortality ensures a swift and adequate work-up in diagnosis of NTC and may improve outcome.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-015-0041-9) contains supplementary material, which is available to authorized users.

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“…Davon entfallen etwa zwei Drittel auf zerebrovaskuläre Erkrankungen [10]. Mittels CT-Angiographie konnte in 11 % der Fälle ein ursächlicher Basilarisverschluss nachgewiesen werden [11].…”

Section: » Bewusstseinsstörungen Müssen Initial Neurologisch Beurteilunclassified

Brennpunkt Notaufnahme

2016

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The number of patients treated in hospital emergency departments in Germany has risen in recent years to approximately 20 million. This escalation also applies to the increasing numbers of patients presenting with neurological symptoms and diseases, which occur in approximately 20 % of emergency patients. In addition to patients with stroke, inflammatory or degenerative central nervous system (CNS) and peripheral nervous system (PNS) disorders who need urgent treatment, more and more patients with nonspecific complaints or conditions attend emergency departments for elective treatment, not least because timely appointments with specialist neurologists in practices could not be obtained. Neurological expertise and presence in emergency departments at the level of specialist standard are therefore indispensable for providing a professional level of treatment, which also corresponds to current legal requirements. The implementation of a generalist emergency physician in Germany, as introduced in some European countries, would mean a retrograde step for neurological expertise in emergency admission management. The discipline of neurology must work together with other emergency disciplines to improve the financing of emergency departments and provide neurologists working there with a substantive curriculum of further and continuing education in emergency-related aspects of neurology. The discipline of neurology has a responsibility to emergency patients within its range of competencies and must, therefore, strengthen and improve its role in healthcare politics and concerning organizational and personnel aspects of neurological emergencies.

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Systematic combined noncontrast CT–CT angiography in the management of unexplained nontraumatic coma

Cited by 8 publications

References 44 publications

Sensitivity of Hyperdense Basilar Artery Sign on Non-Enhanced Computed Tomography

Sensitivity of Hyperdense Basilar Artery Sign on Non-Enhanced Computed Tomography

The etiology and outcome of non-traumatic coma in critical care: a systematic review

Brennpunkt Notaufnahme

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