Computed Tomographic Angiography for the Evaluation of Aneurysmal Subarachnoid Hemorrhage

Carstairs, Shaun D.; Tanen, David A.; Duncan, Timothy D.; Nordling, Olaf B.; Wanebo, John E.; Paluska, Thomas R.; Theodore, Nicholas; Riffenburgh, Robert H.

doi:10.1197/j.aem.2005.12.010

Cited by 35 publications

(28 citation statements)

References 38 publications

(58 reference statements)

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“…22 A single prospective study of patients with clinical presentations suggestive of SAH has been performed directly comparing CT/CTA with CT/ LP in 106 patients. 6 Based on strict criteria, 2 patients had positive results of LP, and in both cases aneurysms were revealed by CTA and confirmed by DSA. In 100 patients, the results of both LP and CTA were negative, and it is unknown if any of these patients suffered subsequent bleeds.…”

Section: Discussionmentioning

confidence: 99%

“…2,18,27 Multidetector CTA is considered to be excellent in the detection of aneurysms 1,9,13,34 and has been estimated to have a sensitivity of 99.4% in detecting ruptured aneurysms compared with intraoperative findings. 24 CTA can sometimes detect aneurysms missed by CT/LP 6 and digital subtraction angiography (DSA). 3 We hypothesized that acute headache patients with negative findings on noncontrast head CT and an LP positive for CSF RBCs who have no aneurysm or neurovascular lesion on cerebrovascular imaging are at low risk for subsequent catastrophic SAH.…”

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confidence: 99%

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Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging

Thomas

Czuczman

Boulanger

et al. 2014

JNS

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Object When patients present to the emergency department (ED) with acute headache concerning for subarachnoid hemorrhage (SAH) and a lumbar puncture (LP) shows blood in the CSF, it is difficult to distinguish the results of a traumatic LP from those of SAH. CT angiography (CTA) is often performed, but the long-term outcome for patients with a positive LP and normal neurovascular imaging remains uncertain. The primary objective of this study was to determine whether patients who presented to the ED with acute headache and had red blood cells (RBCs) in their CSF on LP but negative cerebrovascular imaging suffered subsequent SAH. Methods A case series study of consecutive adult ED patients who incurred charges for LP between 2001 and 2009 was performed from 2010 through 2011. Inclusion criteria were: headache, > 5 RBCs/mm3 in CSF, noncontrast head CT with no evidence of hemorrhage, and cerebrovascular CTA or MRA without aneurysm or vascular lesion within 2 weeks of the ED visit. Patients with less than 6 months of available follow-up were excluded. The primary outcomes were 1) subsequent nontraumatic SAH and 2) new vascular lesion. Secondary outcomes were complications related to SAH, or LP or angiography. Results Of 4641 ED patients billed for an LP, 181 patients (mean age 42 years) were included in this study. Over a median follow-up of 53 months, 0 (0%) of 181 patients (95% CI 0%–2.0%) had a subsequent SAH or new vascular lesion identified. Although not the primary outcome, there was 1 patient who was ultimately diagnosed with vasculitis. Eighteen (9.9%) of 181 patients (95% CI 6.0%–15.3%) had an LP-related complication and 0 (0%) of 181 patients (95% CI 0%–2.0%) had an angiography-related complication. Conclusions Patients who present to the ED with acute headache concerning for SAH and have a finding of bloody CSF on LP but negative findings on cerebrovascular imaging are at low risk for subsequent SAH and thus are likely to be safe for discharge. Replacement of the CT/LP with a CT/CTA diagnostic algorithm merits further investigation.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging

Thomas

Czuczman

Boulanger

et al. 2014

JNS

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“…The only study on ED patients with headache who underwent CTA showed an aneurysm prevalence of 5% (5 ⁄ 106), with 3% (3 ⁄ 106) being culprit lesions, one being potentially symptomatic (1 ⁄ 106), and one being most likely incidental (1 ⁄ 106). 21 The clinical utility of the CT ⁄ CTA approach may be determined by the true prevalence of these nonbleeding aneurysms and the implications for patient management and follow-up. Discovering ''incidental'' aneurysms may subject the patient to additional risk from subsequent testing and interventions.…”

Section: Discussionmentioning

confidence: 99%

“…Based on the current literature, the prevalence is between 3% and 16% (Table 1). 1,[19][20][21][22] We have conservatively estimated the prevalence of SAH in an ED patient complaining of an acute-onset headache with an intact neurologic exam as 15%. Although the actual prevalence may be lower, assuming a higher prevalence in a probability model will maximize the number of potential missed cases and reveal weaknesses in the model.…”

Section: Sah Prevalencementioning

confidence: 99%

Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

McCormack

Hutson

2010

Academic Emergency Medicine

131

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Objectives: The primary goal of evaluation for acute-onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT ⁄ CTA versus CT ⁄ LP in the diagnostic workup of acute-onset headache.Methods: This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT ⁄ LP and CT ⁄ CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT ⁄ CTA strategy.Results: SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT ⁄ CTA was 99.43% (95% CI = 98.86% to 99.81%).Conclusions: CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute-onset headache without significant SAH risk factors, CT ⁄ CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT ⁄ CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%.ACADEMIC EMERGENCY MEDICINE 2010; 17:444-451 ª

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“…The clinical examination findings were not reported in any patients. One of the patients with an middle cerebral artery aneurysm refused surgical treatment and had no reported adverse events in a 1-year follow-up, 10 suggesting that the aneurysm was incidental. In fact, the number of aneurysms detected is exactly what one would expect in an unselected population.…”

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confidence: 99%

Thunderclap Headache With Normal CT and Lumbar Puncture

Savitz

Edlow

2008

Stroke

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Computed Tomographic Angiography for the Evaluation of Aneurysmal Subarachnoid Hemorrhage

Abstract: In this pilot study, CTA was found to be useful in the detection of cerebral aneurysms and may be useful in the diagnosis of aneurysmal SAH. A larger multicenter study would be useful to confirm these results.

Cited by 35 publications

References 38 publications

Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging

Low risk for subsequent subarachnoid hemorrhage for emergency department patients with headache, bloody cerebrospinal fluid, and negative findings on cerebrovascular imaging

Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

Thunderclap Headache With Normal CT and Lumbar Puncture

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