Aneurysmal Subarachnoid Hemorrhage: Update for Emergency Physicians

Edlow, Jonathan A.; Malek, Adel M.; Ogilvy, Christopher S.

doi:10.1016/j.jemermed.2007.10.003

Cited by 105 publications

(80 citation statements)

References 182 publications

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“…This is consistent with existing literature that describes the high miss rate of these diagnoses and the difficulty clinicians face when making these diagnoses [7,[27][28][29]. All cases of missed cerebellar strokes in our study were due to cognitive errors or knowledge gaps, which further supports the need for increased education on this diagnosis.…”

Section: Case Errorsupporting

confidence: 91%

“…All cases of missed cerebellar strokes in our study were due to cognitive errors or knowledge gaps, which further supports the need for increased education on this diagnosis. While radiology misreads accounted for several cases of missed cerebrovascular pathology, it is also important for clinicians to understand the limitations of even the most advanced neuroimaging tests in making these diagnoses, particularly in the early hours after an event [27][28][29][30].…”

Section: Case Errormentioning

confidence: 99%

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Types of diagnostic errors in neurological emergencies in the emergency department

et al. 2014

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Background: Neurological emergencies often pose diagnostic challenges for emergency physicians because these patients often present with atypical symptoms and standard imaging tests are imperfect. Misdiagnosis occurs due to a variety of errors. These can be classified as knowledge gaps, cognitive errors, and systems-based errors. The goal of this study was to describe these errors through review of quality assurance (QA) records. Methods: This was a retrospective pilot study of patients with neurological emergency diagnoses that were missed or delayed at one urban, tertiary academic emergency department. Cases meeting inclusion criteria were identified through review of QA records. Three emergency physicians independently reviewed each case and determined the type of error that led to the misdiagnosis. Proportions, confidence intervals, and a reliability coefficient were calculated. Results: During the study period, 1168 cases were reviewed. Forty-two cases were found to include a neurological misdiagnosis and twenty-nine were determined to be the result of an error. The distribution of error types was as follows: knowledge gap 45.2% (95% CI 29.2, 62.2), cognitive error 29.0% (95% CI 15.9, 46.8), and systems-based error 25.8% (95% CI 13.5, 43.5). Cerebellar strokes were the most common type of stroke misdiagnosed, accounting for 27.3% of missed strokes. Conclusions: All three error types contributed to the misdiagnosis of neurological emergencies. Misdiagnosis of cerebellar lesions and erroneous radiology resident

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Section: Case Errorsupporting

confidence: 91%

Section: Case Errormentioning

confidence: 99%

Types of diagnostic errors in neurological emergencies in the emergency department

et al. 2014

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“…Many of these studies, however, relied on experienced neuroradiologist interpretations, where most CTs are actually read by general radiologists, emergency physicians, or neurologists (43). Additionally, many of these studies are limited by spectrum bias, whereas the pretest probability of SAH may be higher than the average population of awake and alert patients being evaluated (31,44,45). Recommendation: There is insufficient evidence at this time to support the use of NCCT alone in the evaluation of SAH, even if the NCCT is performed within the first 6 h.…”

Section: Ncct Alonementioning

confidence: 99%

“…A major drawback to vascular imaging is the discovery of aneurysms that are not the cause of the headache, with the consequent exposure of the patient to the risks of additional testing and potentially unnecessary procedures (31). CTA also exposes the patient to approximately 2-4 mSv of radiation, as well as possible harm from the administration of intravenous contrast (nephrotoxicity, allergic reactions) (48).…”

Section: Ct/ctamentioning

confidence: 99%

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Meurer

Walsh

Vilke

et al. 2016

The Journal of Emergency Medicine

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, Abstract-Background: Subarachnoid hemorrhage (SAH) is frequently caused by the rupture of an intracranial aneurysmal vessel or arteriovenous malformation, leading to a cascade of events that can result in severe disability or death. When evaluating for this diagnosis, emergency physicians have classically performed a noncontrast computed tomography (NCCT) scan, followed by a lumbar puncture (LP). Recently, however, as CT technology has advanced, many studies have questioned the necessity of the LP in the SAH diagnostic algorithm and have instead advocated for noninvasive techniques, such as NCCT alone or NCCT with CT angiogram (CTA). Objective: The primary goal of this literature search was to determine the appropriate emergency department (ED) management of patients with suspected SAH. Methods: A MEDLINE literature search from October 2008 to June 2015 was performed using the keywords computed tomography AND subarachnoid hemorrhage AND lumbar puncture, while limiting the search to human studies written in the English language. General review articles and single case reports were omitted. Each of the selected articles then underwent a structured review. Results: Ninety-one articles were identified, with 31 papers being considered appropriate for analysis. These studies then underwent a rigorous review from which recommendations were developed. Conclusions: The literature search supports that NCCT followed by CTA is a reasonable approach in the evaluation of ED patients with possible SAH. Ó 2016 Elsevier Inc.

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“…The mean GCS score just before entering surgery was 12.5±2.5 (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15). When the patients were evaluated, 21 patients were WFNS grade 1, 5 patients were grade 2, 4 patients were grade 3, 3 patients were grade 4 and 5 patients were grade 5.…”

Section: Discussionmentioning

confidence: 99%

Microsurgical clipping of anterior circle of willis aneurysms: a retrospective study

Eren¹,

Güzey²,

Yücel³

et al. 2017

Bagcilar Medical Bulletin

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Objective: The surgical outcomes of anterior circle of Willis aneurysms were evaluated. Material and Methods: Between March 2015 and December 2016, 38 patients were operated and followed up for aneurysms. There were 15 female and 23 male patients with a mean age of 47 years (range: 17-78). Of the patients, 35 were diagnosed with subarachnoid hemorrhage (SAH). Of these patients, 54.2% (n=19) were operated within the first 24 hours. All patients were operated by the same surgeon with sylvian dissection. All clinical data in the hospital charts and outpatient records and radiological investigations stored in the archive were evaluated retrospectively. Results:The most commonly seen aneurysm was on the anterior communicating artery (44.8%). After that, aneurysms on the middle cerebral artery (31.6%), posterior communicating artery (13.2%), internal cerebral artery bifurcation (7.8%), and distal anterior cerebral artery were seen, respectively. There was a significant correlation between the location of the aneurysm and the mean age (p=0.009). All patients were followed in the intensive care unit after operation. After surgery, vasospasm was observed in 26.3% of patients. Patients with high SAH grade developed vasospasm significantly more frequently (p=0.03). Neurological examinations at discharge were normal in 17 patients with SAH and 3 patients without SAH. Four patients were discharged with minimal neurological deficit and 2 patients with severe deficit. Eight patients with World Federation of Neurosurgical Societies (WFNS) grade 4-5, 2 patients with grade 3, and 2 patients with grade 1-2 were lost. Postoperative Glasgow Coma Scale and SAH WFNS grades were found to be determinants for dying. Conclusion: Despite the development of endovascular techniques in the treatment of aneurysm, microsurgical clipping remains the first choice method to treat anterior system aneurysms. Closure of the aneurysm is the treatment priority. It is well known that early surgery reduces mortality and morbidity. Keywords: aneurysm, clip, aneurysm surgery, microsurgical clipping, subarachnoid hemorrhage, circle of Willis ÖZET Willis poligonu anterior dolaşım anevrizmalarının mikroşirurjikal yöntemle klipslenmesi: Retrospektif çalışmaAmaç: Willis poligonu anterior sistem anevrizmalarının cerrahi sonuçlarının değerlendirilmesi. Yöntem ve Gereçler: Mart 2015-Aralık 2016 arasında intrakranyal anevrizma nedeniyle kliniğimizde ardı ardına 38 hasta ameliyat edildi. On beş kadın ve 23 erkek hastanın yaş ortalaması 47 (aralığı: 17-78) idi. Otuz beş hastada subaraknoid kanama (SAK) vardı ve bunların %54,2'si (n=19) ilk 24 saatte ameliyata alındı. Hastalar aynı cerrah tarafından silviyan diseksiyon yöntemi kullanılarak opere edildi. Çalışmamız klinik kayıt ve radyolojik görüntü arşivleri kullanılarak retrospektif olarak gerçekleştirildi. Bulgular: En fazla anterior komminikan arter anevrizması görüldü (44.8%). Sonra sırasıyla middle serebral arter (31.6 %), posterior komunikan arter (13.2 %), internal serebral arter (7.8%) ve distal anteri...

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Aneurysmal Subarachnoid Hemorrhage: Update for Emergency Physicians

Cited by 105 publications

References 182 publications

Types of diagnostic errors in neurological emergencies in the emergency department

Types of diagnostic errors in neurological emergencies in the emergency department

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Microsurgical clipping of anterior circle of willis aneurysms: a retrospective study

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