Clinical scoring system may improve yield of head CT of non-trauma emergency department patients

Bent, Chris; Lee, Paul S.; Shen, Peter Y.; Bang, Heejung; Bobinski, Matthew

doi:10.1007/s10140-015-1305-x

Cited by 35 publications

(58 citation statements)

References 10 publications

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“…As an example, studies of positive rates of non-trauma head CTs found abnormalities ranging from 10% to 39%; trauma head CT rates were ~29%. [20][21][22] For non-trauma and trauma head scans, abnormal findings in this study were 53.8% and 45.1%, respectively, which were also higher than most. A study done in Malaysia reported a positive rate of 70.5%.…”

Section: Researchmentioning

confidence: 84%

High positive computed tomography yields in the emergency department might not be a positive finding

Swartzberg

Goldstein

2018

S Afr Med J

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Background. There is growing pressure to reduce unnecessary computed tomography (CT) imaging requests that the radiology department receives from the emergency department (ED); however, information on acceptable usage rates and diagnostic yields remains scanty. Objectives. To describe the indications, clinical categories and positive yield rates of patients receiving CT scans in the ED. Methods. A retrospective record review was done of all patients who received CT scans at an urban, adult academic ED during a 4-month period. Primary outcomes were to establish CT scan usage and positive yield rates. Other outcomes included analysis of indications, demographics and anatomical areas scanned. Results. Scans (n=1 010) were analysed. The median age of patients was 36 (range 4 -93) years. Male patients received 64.3% of all scans, as well as 75.7% of the scans performed for trauma. The majority of the scans were for trauma patients. However, non-trauma patients had a higher positive yield; the non-trauma positive yield rate was 61.8% compared with the trauma positive yield rate of 47.1% (p<0.001). The majority of scans performed were of the head (58%) and neck (20%), with lowest positive yield rates of 48.9% and 17%, respectively. The overall CT scan usage rate was 4.6% and overall positive rate 53.8%. Conclusion. A negative CT scan does not necessarily mean that the test was not indicated. Higher positive yield rates may reflect insufficient use of CT scanning by the ED. Local guidelines should be established to ensure judicious and effective clinical use of CT scans.

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Section: Researchmentioning

confidence: 84%

High positive computed tomography yields in the emergency department might not be a positive finding

Swartzberg

Goldstein

2018

S Afr Med J

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“…Some have advocated for specific clinical decision rules for determining who should receive neuroimaging for acute headache, especially when the differential includes subarachnoid hemorrhage [7]. Others have suggested using clinical risk factors to stratify patients' overall risk for actionable CT results [8] or using online clinical decision support tools to ensure that only those patients who meet certain criteria will receive appropriate use of resources [9]. While CT assessment is an important tool in assessing cranial pathology in the emergency department (ED), appropriateness criteria should be utilized to ensure that the potential benefits outweigh the harms [10].…”

Section: Introductionmentioning

confidence: 98%

Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis

et al. 2015

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The purpose of this study was twofold: (1) to determine the incidence of positive computed tomography (CT) findings in patients presenting to the emergency department (ED) with non-traumatic headache at our institution and (2) to examine follow-up exams, including lumbar puncture, non-enhanced CT, CT angiogram, CT venogram, and magnetic resonance imaging (MRI), to see how often the use of further testing changes the diagnosis. With IRB approval, 865 patients were identified through ED requisitions for CT head with the indication of headache during the calendar year 2011. Exclusion criteria included head trauma, prior intracranial surgery, focal neurologic symptoms, and known intracranial mass. CT results were divided into three categories: P0, P1, and P2. Negative studies were graded as P0. Positive studies were subdivided into clinically insignificant or P1 and clinically significant or P2. Clinically significant was defined as requiring medical treatment. Subsequently, the electronic medical records and picture archiving and communication system (PACS) were reviewed to determine the incidence of follow-up exams, including lumbar puncture or imaging. The secondary tests were divided into the same P0, P1, and P2 categories. There were 254 positive studies: P1 clinically insignificant (27.1 %, 235/865) and P2 clinically significant (2.2 %, 19/865). Of 257 follow-up exams performed, the majority were lumbar punctures (36.0 %) or CT angiograms (29.5 %). In 19/257 exams or 7.4 %, the additional testing changed the clinically insignificant (P0/P1) diagnosis to a significant (P2) result. At our institution, there was a 2.2 % incidence of significant positive CT findings in patients presenting to the ED with non-traumatic headache. Follow-up testing was variable and resulted in a 7.4 % increase in the severity of diagnosis compared to the initial negative CT scan.

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“…Unfortunately, the CDRs proposed in the past for NTBI have received little attention and validation. These criteria include those by Rothrock et al , Harris et al , Wang and You and Bent et al (Table ). In particular, the Rothrock and Harris criteria have both been validated previously, and their initial, high sensitivities and scan reduction rates have not been reproducible …”

Section: Introductionmentioning

confidence: 99%

“…The data were clearly defined and were either categorical, such as headache (yes or no), or continuous, such as heart rate or temperature. Coagulopathy was defined as thrombocytopenia, clotting factor variant or deficiency or bleeding disorders such as haemophilia or disseminated intravascular coagulopathy . The researchers were not blinded to the study objective.…”

Section: Introductionmentioning

confidence: 99%

“…Multiple variables were used to check possible risk factors for NTBI. These variables were chosen based on previous published studies regarding NTBI, as well as vital signs, risk factors for cerebrovascular diseases, neurological signs and symptoms. The CDR was developed by using the χ 2 ‐test to determine which particular variables were associated with statistically significantly increased odds ratios (ORs) of positive CTB findings as defined by OR and 95% confidence interval (CI) >1.…”

Section: Introductionmentioning

confidence: 99%

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Clinical decision rule for non‐traumatic computed tomography of the brain

Scott-King

Tieu

Chiew

et al. 2019

Emerg Medicine Australasia

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Objective: The aims of the present study were to derive and validate a clinical decision rule (CDR) to rule out the need for computed tomography of the brain (CTB) in nontraumatic patients who present to the ED. Methods: This is a retrospective review of non-traumatic patients who presented to the EDs in two urban hospitals and received CTB from January 2014 to December 2016. Data from one hospital were used to develop a CDR for clinically significant CTB findings. Clinically significant CTB findings were defined as acute infarction, intracranial neoplasm, intracranial haemorrhage, acute hydrocephalus, cerebral oedema and intracranial infection. Patients from another hospital were used as a validation cohort to evaluate the CDR and compare it to four previously derived CDRs.Results: There were 5296 cases in the derivation cohort, with 345 (6.5%) clinically significant CTB findings. Identified risk factors were: focal neurological deficit (adjusted odds ratio [OR] 3.4, 95% confidence interval [CI] 2.6-4.4), Glasgow Coma Scale <15 (adjusted OR 3.5, 95% CI 2.6-4.6), history of malignancy (adjusted OR 3.2, 95% CI 2.4-4.2), nausea and/or vomiting (adjusted OR 1.6, 95% CI 1.1-2.1), headache (adjusted OR 1.1, 95% CI 0.9-1.5) and coagulopathy (adjusted OR 9.2, 95% CI 2.1-41.5). These criteria and four pre-existing CDRs were applied to the validation cohort of 5098 patients from the second hospital, which had 338 (6.6%) clinically significant CTB findings. Our criteria were found to have a sensitivity of 99.7% (95% CI 99.1-100.0) and a specificity of 11.0% (95% CI 10.1-11.9). The risk of having a clinically significant CTB finding is 0.3% if patients do not meet any of the criteria. Conclusion: The CDR derived in the present study achieved the highest sensitivity and a moderate specificity when compared with four other pre-existing CDRs for nontraumatic brain injury patients.• Create a useful CDR for clinicians to identify low-risk patients for non-traumatic brain injury. • Hence decrease harmful, costly, over-scanning of patients with CT brain.

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Clinical scoring system may improve yield of head CT of non-trauma emergency department patients

Cited by 35 publications

References 10 publications

High positive computed tomography yields in the emergency department might not be a positive finding

High positive computed tomography yields in the emergency department might not be a positive finding

Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis

Clinical decision rule for non‐traumatic computed tomography of the brain

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